Health Systems Governance, Essential Public Health Functions and the COVID-19 Pandemic

In November 2020, the World Health Organization’s (WHO) Health System Governance and Financing team, along with the Health System Governance Collaborative and Middle East and North Africa Policy Forum, hosted the webinar: “Governance in support of Common Goods for Health: Regional and country perspectives”. This session brought together health system experts from WHO, government leadership (e.g., ministries of health, parliament) and academia to discuss the importance of governance arrangements to support common goods for health and essential public health functions in the time of COVID-19. This blog is a continuation of the rich discussions and reflections on how to move this health agenda forward in countries.

The rise of globalization has led to unprecedented levels of interconnectedness, economic growth and development, shined the light on poverty and illness, and increased solidarity in the call for universal health coverage (UHC) and global health security. In September 2019, at the inaugural United Nations High-Level Meeting on UHC, a political declaration was adopted that all people have access to quality health services and do not suffer financial hardship paying for them. This declaration was preceded by several international health agreements pledging to strengthen health and well-being in countries and address international health security risks, including the Astana Declaration (2018), Sustainable Development Goals (2015), and Sendai Framework (2015). However, despite great progress and these international commitments, COVID-19 still exposed significant health system vulnerabilities and public health response gaps at global, regional and national levels.

Common Goods for Health, Essential Public Health Functions and COVID-19

“Common goods for health are the step zero in achieving UHC” – Dr. Agnes Soucat, Director of Health Governance and Financing at WHO Headquarters.

Common goods for health (CGH) are the “core population-based functions that serve as the foundation for health security on the road to Universal Health Coverage”. They occupy an important place on the Global Health Agenda, as illustrated by the Health Systems & Reform special issue on “Financing Common Good for Health”, which brought together leading experts and policymakers to discuss the economic and technical rationale for financing CGH. More recently, including at the above-mentioned WHO webinar, many international public health experts have generally agreed that CGH and essential public health functions (EPHFs) are practically consistent from a health financing and public health perspective. EPHFs, as defined by WHO, are the “indispensable set of actions, under the primary responsibility of the state, that are fundamental for achieving the goal of public health which is to improve, promote, protect and restore the health of the population through collective action”. In this respect, and drawing from COVID-19 lessons learned, health system experts are advocating for governments to provide stronger leadership, sustained investment and more responsive governance for CGH/EPHFs going forward.

“If we want to promote government leadership in policy development and implementation along with supportive regulation, surveillance, public health programs, then we need to strengthen health system governance arrangements in support of EPHFs for better accountability, transparency, effective and equitable health systems response.” – Dr Sameen Siddiqi, Professor/Chair, Aga Khan University and former Director of Health System Development at WHO’s Eastern Mediterranean Regional Office.

Tragically, the COVID-19 pandemic brought massive loss of lives and livelihoods. It was clear that countries were not adequately prepared to respond to a public health emergency of this magnitude. However, this pandemic has also put health at the center of the global, regional and national discussion on development. World leaders, heads of state and the general public are suddenly calling for a whole-of-government and whole-of- society approach to promote public health and health system responses. This has created an opportunity for experts and decision-makers to join forces and better engage with the community in priority setting and health decision making. Based on the above, we have focused on the following areas in protecting and promoting EPHFs: Governance Arrangements and Collective Action.

Governance arrangements to promote and protect EPHFs

Governments often use investment in health for short term political gain. They prefer visible investments (e.g. a new hospital) or quick fixes (e.g., individual clinical services), instead of investment in supportive public health institutional set-ups and capacities (e.g., EPHFs) to improve health system performance. However, it became clear early in the COVID-19 pandemic that the response required coordinated contributions from all eight EPHFs. When governments rushed to provide EPHFs without adequate institutional arrangements supporting their coordination and oversight, the response was fragmented, and health systems became overwhelmed.

Since CGH/EPHFs are ‘step zero’ to advance UHC and health security, governments must take the lead in ensuring their provision through oversight, regulation, coordination as well as financing , taking in account the evolving role of ministries of health. This requires special focus on governance institutional arrangements and capacities to develop and implement national and sub-national policies and plans. “Governments need to invest in EPHF, strengthening their institutional arrangements, power relations and capacities to avoid further political and economic loss and more importantly promote and protect people’s quality of life and right to health care.” – Dr. Hala Abou-Taleb, Regional Adviser, Health Systems Governance, WHO/EMRO.

When COVID-19 gripped hold in countries, it became clear that health systems suffered from chronic lack of investment in EPHFs, governance arrangements that were not ‘fit for purpose’, and a power imbalance hindering collective action. It also showed us that quick fixes do not work and the cost of providing EPHFs during a pandemic is significantly higher, less efficient and more difficult. Going forward, governments must step in to provide leadership and oversight to coordinate collective action and ensure EPHFs are not left to the market interests.

Collective action for building trust and collective accountability

“If we refer to the WHO health system governance arrangements , the essence of collective action is the people, its citizens. We need build institutions and promote mechanisms that enable the community to effectively participate in social dialogue and health decision making e.g. national health assemblies” – Dr. Agnes Soucat.

In the Eastern Mediterranean Region, many heads of state led the early COVID-19 pandemic response in a top-down authoritative-like process (e.g., curfews, lockdowns, movement restrictions). This was initially successful in some contexts, even containing the COVID-19 spread, but not for long. As the pandemic progressed, weak engagement with the community (e.g., civil society, private sector, academia, etc.) in the health decision making and implementation processes had a negative impact on their success, and proved to be a missed opportunity to build trust between governments and broader populations. This was demonstrated in many countries through noncompliance with public health prevention and promotion measures, subsequent increase in the number of cases, and escalating negative economic impacts of the pandemic.

In line with the above, engaging with civil society, including academia, private sector and others, throughout the decision-making process helps governments avoid imposing overly drastic, poorly timed measures and exacerbating inequities. Furthermore, it is especially important to provide equal opportunities for participation and pay special attention to often underrepresented groups (e.g., women, minorities, low-income populations). Lastly, supportive governance institutional arrangements, policy and regulatory frameworks are needed to ensure engagement and build partnerships within and across health sectors. As endorsed in the  political declaration on UHC, world leaders committed to “…engage all relevant stakeholders, including civil society, the private sector and academia, as appropriate, through the establishment of participatory and transparent multi-stakeholder platforms and partnerships”. More than ever, now is the time to stand by this commitment.

Final thought

In conclusion, we must seize the opportunity to engage world leaders and head of states to strengthen health governance arrangements in support of EPHFs and building the reset. This entails a whole-of-government and whole-of-society approach, with a renewed emphasis on collective action for collective accountability!

“EPHFs are essential to inform the development of the health policies and produce the necessary health system changes, including the commitment for inclusive participation, accountability and collective action” – Dr Maha El Rabbat, Executive Director of Middle East and North Africa Policy Forum and Special Envoy on COVID-19 for WHO Director General.