Strategies to Promote Health System Strengthening and Global Health Security at the Subnational Level in a World Changed by COVID-19

"Achieving strong, resilient health systems that reach both global health security and universal health coverage goals requires a unified approach to how we work across the system."

As the COVID-19 pandemic illustrates, infectious disease outbreaks often lead to a short-term breakdown of health systems, which then result in long-lasting reversals of public health gains. In the wake of COVID-19, this article illustrates some of the health systems challenges at the district level and discusses problems associated with alignment, integration, and coordination. It offers potential solutions on how to align national and local priorities and policies to support countries to build health systems that are strong and resilient.

As outlined here, building health systems resilience capacities can help low- and middle-income countries (LMICs) absorb, adapt to, and transform in the face of shocks and stressors to maintain delivery of quality essential health services outlined by universal health coverage (UHC) and global health security (GHS) goals. For example, before 2019, with the support of international donors, Indonesia worked to strengthen the human resources needed to manage their health information system and ecosystem to provide real-time high-quality data for strategic use, such as the development of policy that addressed challenges to the health workforce. These investments proved to be crucial for supporting healthcare workers during COVID-19 and permitted the Indonesian Ministry of Health to undertake rapid development and deployment of data dashboards on the health workforce that facilitated decision making during response planning, which is a key element of adaptive capacity.

For UHC and GHS initiatives to work in synergy and create an effective response to any public health threat, health system strengthening (HSS) programming at the district level needs to include the implementation of governance and management structures for sharing resources and knowledge across public, private, and nonprofit sectors. For example, 6 years before Uganda's 2000 Ebola outbreak, Uganda initiated the process of decentralising healthcare administration, which allowed a range of stakeholders who had a role to play in health efforts to come together; as a result, the district health system was adequately resourced and empowered to fulfill the necessary actions to contain the Ebola outbreak and ensure minimal disruption to routine and essential service delivery. In addition, district health management teams (DHMTs) closely coordinated with other ministries that might otherwise be perceived as outside their scope and mandate, such as agriculture and environment ministries under the One Health approach (intersection of human health, animal health, and environmental health). However, there are challenges in such cases - for example: "Conflicts between the demands for central control and local discretion, limited institutional capacity, and political and cultural influences over their roles as district managers are common."

To achieve the goals of strong, resilient health systems that incorporate both GHS and UHC, the article recommends the following:

1. Strengthen investments in cross-cutting aspects of health systems that promote public health at the subnational level - That is, district planners must understand how various public health programmes come together within their communities, the range of stakeholders who have a role to play in health efforts, and how public and private funding and information systems can be leveraged at the local level to achieve their objectives. They should pay ongoing attention to contextual issues, governance, and power structures, while identifying and addressing gaps in implementation.
2. Support flexibility of district health systems to break the silos of vertical programmes, and take on new roles as circumstances warrant - For example, countries need to consider the roles played by additional stakeholders within the system, including the private sector, the nonprofit sector, and communities who are critical to ensuring health systems can prevent, detect, and respond to infectious disease threats and day-to-day disruptions. The objectives focused on creating this synergy at the subnational level must be clear and explicit.
3. Use the roll-out of COVID-19 interventions as an opportunity to address management, coordination, and integration challenges at the district level - These approaches might leverage in-house capacity and experiences from other clusters. For example, assets provided by the polio eradication programme that promote sustainability and early mobilisation of both human and financial resources might be used to initiate readiness activities in priority countries. Efforts to vaccinate the entire population against COVID-19 may require combining with or leveraging other health campaigns to optimise the use of resources to meet the demand. DHMTs may also consider opportunities to formally link communities to the health system (e.g., social media listening, rumour monitoring, and response systems) to understand and address issues related to vaccine access, demand, confidence, and misinformation. The capacity to deliver routine immunisations and conduct regular testing over a wide coverage area that reaches vulnerable populations is an example of the integration of GHS and UHC. "Missing this opportunity would severely limit the health system's ability to bounce back effectively and build stronger systems in the future."

Next, the article examines how to improve synergy between HSS and GHS in LMICs. "Future investments toward HSS may...require robust and updated evidence on strategies to facilitate the integration of UHC and GHS initiatives in a way that would result in improved health outcomes and greater efficiencies." For instance, many public health programmes have adopted community engagement strategies to improve access and expand coverage. "The increased use of community-based approaches may serve to enhance ownership in PHC [primary health care] and increase access to and utilization of health services by all for both communicable and noncommunicable diseases. Nonetheless, there remain great gaps in our knowledge as to how to understand and evaluate implementation strategies used for these approaches..."

Further research and learning efforts can shed light on these issues through a systems-based approach that involves engaging multiple stakeholders, including beneficiaries of the health system. Some key questions include: (i) How can numerous parallel community activities be integrated into one sustainable community-based health package? (ii) How can different stakeholders at the subnational level (e.g., health system managers, health workforce members, and private sector institutions and communities) be drawn together to advise policymakers on how to ensure that HSS addresses GHS and UHC needs?

In conclusion: "Urgent support is needed at the subnational level of LMICs to integrate isolated programs and to facilitate the appropriate distribution of resources to ensure better integration of HSS and health security to advance progress toward UHC."