Introduction

It is impossible to achieve a healthy future without placing the health and well-being of the population at the heart of public policy.

A person’s economic prospects are affected by their health throughout their lifecycle. Ill health can affect the ability of young children and infants to accumulate human capital. For adults, it lowers their quality of life, as well as their labor market outcomes. This disadvantage is compounded over a lifetime.

Surprisingly, despite all the evidence that good health benefits economies and societies, health systems worldwide struggled to maximize their populations’ health, even before the COVID-19 Pandemic. This crisis has exposed the weaknesses and stresses of our health system. These weaknesses must be addressed to make the population healthier and more resilient.

At least once, we have all been frustrated by the care that is inflexible and impersonal. These individual experiences can add up to poor coordination, inefficiency, and poor safety at the system level. This results in millions of deaths and huge costs to society.

This situation contributes to a slowdown in achieving the Sustainable Development Goals that all societies have set, regardless of the level of their economic development.

Many conditions in place make change possible. There is ample evidence that investment in primary prevention and public health can have significant economic and health benefits. Digital technology has also made many products and services across various sectors more efficient, safe, and convenient. With the right policies in place, there is no reason that this cannot also happen within health systems. Imagine, for instance, the possibility of providing high-quality and specialized healthcare to previously underserved populations. COVID-19 has increased the use and development of digital health technology. It is possible to use digital health technologies to enhance public health, disease surveillance, clinical treatment, research, and innovation.

The Global Future Council on Health and Health Care developed a series of stories to encourage reform in health systems towards those more resilient and better centered around what people want and need and sustainable for the long term. These stories illustrate why change is necessary and why it’s possible now. The COVID-19 crisis challenges the health system in many ways, but we can achieve a healthy future with suitable investments.

Five Changes To Sustainable Health Systems That Place People First

The COVID-19 Crisis has caused severe suffering and death in more than 188 nations and regions worldwide. The COVID-19 crisis is a severe threat to global economic growth, as it has caused a drop in employment, consumption, and activity worse than the one seen during the financial crisis of 2008. COVID-19 also revealed weaknesses in our healthcare systems, which must be addressed. How?

First, a more significant investment in the health of populations would increase resilience to health risks, especially among vulnerable groups. The health and socio-economic effects of the virus will be felt more strongly by disadvantaged groups, straining a social fabric already challenged with high levels of inequality. The crisis shows the negative consequences of inadequate investment in wider social determinants, such as poverty, low levels of education, and unhealthy lifestyles. Even though health promotion is a hot topic, only 3% of all health expenditures are devoted to prevention in the wealthiest OECD countries. Focusing more on social protection and solidarity is necessary to build resilience in populations to address structural inequalities.

Health systems need to be strengthened, not only for the sake of creating greater resilience among populations but also to enhance them.

Universal health coverage is of paramount importance. The high cost of health services and goods for households discourages people from seeking treatment and early diagnosis when they are most in need. Faced with the COVID-19 crisis, many countries have improved access to healthcare, including diagnostic testing coverage. Others need robust UHC arrangements. The pandemic has reinforced the importance that international fora such as the 2018 High-Level Meeting on Universal Health Coverage have placed on a deliberate focus on high-quality UHC. These systems are designed to protect the public from threats such as health expenditures and sudden surges in demand.

Secondly, primary care and eldercare must be strengthened. COVID-19 is a double-edged sword for those with chronic illnesses. COVID-19 not only puts them at higher risk for severe complications and even death, but it can also cause unintended harm to their health if they don’t receive the usual care. This could be due to service disruptions, fears of infection, or concerns about burdening the healthcare system. These groups benefit from vital primary care that maintains continuity of care. The elderly care sector is particularly vulnerable to COVID-19, which causes 94% of deaths among those aged 60 and older in high-income nations. This calls for increased efforts to control infections, protect and support care workers, and coordinate medical and social services for frail elders.

Third, this crisis shows the importance of equipping the health system with reserve capacity and agility. There has been a historic underinvestment of health workers, with an estimated global shortage of 18 million professionals. In addition to the sheer number of health workers, rigid labor markets in this sector make it hard to react quickly to supply and demand shocks. A “reserve arm” of healthcare professionals who can be rapidly mobilized is one way to combat this. Some countries allowed medical students to begin working in their final year of training, accelerated licenses, and provided excellent training. Some countries have mobilized care assistants and pharmacists. Keeping a stock of personal protection equipment and care beds easily convertible into critical care beds is also essential.

Fourth, we need more robust systems for health data. The crisis has led to the development of innovative digital solutions, including smartphone applications for monitoring quarantine, robotics, and artificial Intelligence to track and predict where the virus may appear next. Telemedicine is now more accessible. Much more can be done to use standardized national electronic records for disease surveillance, clinical trial management, and health system administration. The barriers to telemedicine deployment, lack of real-time information, interoperable data from clinical documents, data sharing between health and other sectors, and the lack of data linking capability must be addressed.

The only way to exit the situation is through an effective vaccine and the successful vaccination of all populations worldwide. There is no guarantee of success, and many policy questions must be addressed. International cooperation is essential. Multilateral agreements to pay for the successful candidates give manufacturers the confidence to scale up production and have vaccine doses ready quickly after marketing authorization. It could also ensure that vaccines are sent to areas where they will be most effective to end the pandemic. While leaders are under political pressure to prioritize the health of their people’s health, distributing vaccines according to need is more effective. Multilateral access mechanisms that include licensing commitments are needed, ensuring intellectual property is not a barrier to access and allocating scarce doses according to need.

The pandemic presents an excellent learning opportunity about health system resilience and preparedness. Future norms will include:

  • A greater focus on anticipating reactions.
  • More solidarity between and within countries.
  • Better agility in managing response.
  • A renewed commitment to collaborative action.

In The Face Of Covid-19, Improving Population Health And Creating Healthy Societies Is Essential.

COVID-19 has served as a stark reminder of the fragility of population health worldwide. At this time, over 1,000,000 people had died of the disease. COVID-19 has been a major cause of death for disadvantaged communities and populations. Inequalities rooted deep in society have negatively impacted people’s health within and across countries. In addition to the direct and indirect impacts on the health of COVID-19 and the decimation of health systems, restrictions to population movement and lockdowns implemented to combat the pandemic will have economic and social consequences at an unprecedented scale.

To address the COVID-19 consequences, population health is improving physical and mental well-being and outcomes of local, regional, and national populations and reducing health disparities.1 There is also increasing recognition of societal and environmental factors such as climate change and food security that can influence the population’s health.

Maria, David, and Ruben’s experiences – as reported by Spanish public broadcaster RTVE exemplify real challenges faced by people in densely populated cities when exposed to COVID-19.

Maria: A Mexican immigrant from Connecticut, has recently returned to the Bronx. Her partner Jorge passed away in Connecticut due to COVID-19. She has no income now and is searching for an apartment to house herself and her children. She took Jorge to the hospital when he became sick, but they refused to admit him. Maria and their children sent him home to be taken care of. It was already too late when an ambulance finally took him to the hospital. He died alone that night in the hospital. She believes he has diabetes but was never diagnosed. The income was only enough to cover the basics. Maria is alone and depressed. She knows that she must continue to support her children. Her 10-year-old child tells her he will work if she can help him. After three months, she finds an apartment.

David: A hairdresser who takes the overcrowded train from Leganes in Madrid to Chamberi daily. He lives in San Nicasio in one of Madrid’s poorest working-class areas, with the highest percentage of older adults. David’s apartment is tiny, making it hard to confine yourself. All of David’s neighbors have heard of someone who was a victim of COVID-19. His father worked as a hairdresser. David’s dad was not feeling good; he was taken by ambulance to the hospital and died three days later. David did not have the chance to say goodbye to their father. The unemployment rate has increased; local small shops are losing customers, and more people expect to lose jobs.

Ruben: A resident of Iztapalapa, Mexico City. He has three children, five grandchildren, and a daughter-in-law. The apartment is small and has no running water in the evening. He walks 45 minutes daily with his mobile stall, selling fruit juices near the hospital. The family survives on his daily earnings. He takes a dirty, crowded bus to the central market to buy fruits. He believes the city’s primary need was contaminated when the pandemic began but couldn’t be closed because it is the country’s primary food source. He has diabetes and has no insurance. The medication he needs to treat his condition is also too expensive. He is forced to go to the office daily because “we die from COVID or hunger.”

These real-life stories illustrate the need to address persistent health inequalities and improve health outcomes by focusing on the population. Maria, David, and Ruben’s reports show the devastating effects COVID-19 had on people who live in poverty, social deprivation, and older people. They also illustrate how COVID-19 affects people with co-morbidities or pre-existing conditions. All three live in densely-populated urban areas with substandard housing and must travel long distances on overcrowded transport. Maria’s income loss has affected her housing, access to health care, and health insurance. This will likely result in worse health conditions for her and her kids. All three also experienced high levels of stress. This is magnified by the fact that Maria and David were absent at their loved one’s death.

Citizens around the globe are calling for the strengthening of health systems and the protection of vulnerable populations by governments. Leadership that carefully considers long-term economic, social, and health policies is needed to create a better future.

Three prerequisites are necessary to develop and implement policies that promote population health. It is essential to understand better the factors that affect health inequalities and the connections between economic, social, and health impacts. Second, broader policies should be considered in the health sector and other sectors, such as education and employment, transport, infrastructure, agriculture, and water and sanitation. Third, policies should be developed by involving the community and vulnerable groups. They also need to foster inter-sectoral partnerships and encourage action.

In the UN’s Agenda 2030, Sustainable Development Goal 3 lays out a strategy to achieve wholesome lives and well-being. The 17 interdependent Sustainable Development Goals (SDGs) offer an opportunity to create healthier, more fair, and equitable societies that benefit communities and the planet.

1. Imagine a system of ‘well-care,’ which invests in people’s health.

Imagine Emily, a patient. Emily is 32 years old, and I am her doctor.

Emily was pre-diabetic, had high cholesterol, and was 65lb over her ideal weight. In a 15-minute appointment, I gave Emily advice on diet and exercise. This is what doctors usually do when they are under time pressure. I had no other resources, incentives, or support systems to help me or Emily change her lifestyle.

Eight months later, I saw Emily, not in my office but at the hospital ER. She was baffled, weak, and vomiting. Her husband was with her. She was diagnosed with type 2 diabetes and admitted to the intensive-care unit. She was hooked up to an insulin drip to lower her blood glucose. When I spoke to Emily, I stressed that the new diabetes medications would only reduce sugars. She still had time to change her lifestyle. A nutritionist gave her further advice.

Emily gained weight over the years and needed higher doses of her diabetes medication. Emily was forced to visit the emergency room for more high blood sugars, developed skin and foot infections, and eventually developed kidney disease due to uncontrolled diabetes. Emily is now 78lb, 35kg over her ideal weight. She is blind and can’t feel her feet because of nerve damage caused by high blood sugar. Her kidneys are failing, and she will need dialysis soon. Emily’s declining health has cost her and the healthcare system a lot of money. Our interventions have saved and prolonged her life, but every interaction with the healthcare system has been costly – and these costs will continue to rise. We have failed Emily as well by allowing Emily’s diabetes to worsen. We know what to do but have not made the right investments or provided incentives.

Emily could have easily been one of my patients. All doctors who treat chronically ill people will know her sad story. Unfortunately, health systems around the world are neglecting patients like Emily. Chronic disease burden is rising at alarming rates. Across the OECD, nearly 33% of people over 15 live with at least one chronic condition. This rises to 60% in those over 65. About 50% of chronic disease deaths can be attributed to cardiovascular disease. In the next decade, obesity will kill 92 million people in the OECD, while illnesses related to obesity will reduce life expectancy by three years by 2050.

Primary prevention is a method that focuses on vaccinations, lifestyle changes, and the regulation of unhealthy substances. Prevention interventions have proven to be effective. To combat obesity, many countries have used public awareness campaigns, training for health professionals, and encouragement of dietary changes (such as taxes, limiting unhealthy food, and nutrition labeling).

COVID-19 is a crisis that provides the most significant incentive to prevent chronic diseases. COVID-19 is a deadly virus that kills most people with chronic conditions, such as obesity, CVD, or diabetes. These are all preventable by adopting a healthy lifestyle. COVID-19 highlighted structural weaknesses within our healthcare systems, such as the lack of focus on prevention and primary healthcare.

Primary prevention’s utility is well understood, and an increasing body of evidence supports its effectiveness. However, it has yet to be implemented due to chronic underinvestment. This indicates a need for societal and government prioritization. OECD countries invest only 2.8% of their health budgets in prevention and public health. Several factors contribute to this, including a decrease in funding for prevention research, a lack of awareness among populations, the belief long-term prevention is more expensive than treatment, and lacked commitment and incentives from healthcare professionals. Public health is also often seen as a separate component of the health system rather than an integral part.

Aside from the health benefits, investing in primary prevention is a sound economic decision. Obesity, for example, contributes to many diseases’ treatment costs: 70% for diabetes, 23% for CVD, and 9% for cancer. The economic losses are also reflected in absenteeism and a decrease in productivity.

Worldwide, healthcare systems are dominated by fee-for-service payment models, which pay physicians according to the number of sick people they treat, regardless of the outcome and quality. Primary prevention requires a payment system to reimburse healthcare professionals and patients who take preventive measures. Ministers of health and government leaders must challenge the skepticism surrounding preventive interventions and realign incentives to encourage preventive actions. Primary prevention can reduce the chronic disease burden on the healthcare system.

Reflecting on Emily’s life, I wonder if our healthcare system has done anything differently. What if our healthcare system was more of a healthcare system than a sick-care one? Imagine that Emily, a pre-diabetic 32-year-old, could access a nutritionist, exercise coach, and a nurse who closely followed her at her first appointment with me. Imagine Emily joining group exercise classes and learning how to prepare healthy food. She could also have access to places to exercise and be active. Imagine Emily becoming more educated about diabetes and empowering her to take charge of her health and well-being. It is more complex than that, but it could have been different if the healthcare system had started to invest in prevention, rewarded Emily’s weight loss, and for making healthy lifestyle changes. Imagine Emily continuing to contribute and be active in society while losing weight. Imagine investing in people’s health rather than letting them get sick and then treating it. Imagine a system of well-care.

2. Early detection and diagnosis are essential.

The world’s healthcare systems share a simple and common goal: to provide affordable, high-quality care. However, they differ significantly and are becoming more expensive to deliver due to the aging population, chronic disease burden, and cost of new technologies.

The challenge for governments is to find the best way to care for their population and to make their system sustainable. There is no solution to the problem. Neither universal healthcare, single-payer, hybrid, or other methods are used in the US. Those systems ranked highly in many studies, including a report from the Commonwealth Fund for 2017, are usually those with robust early detection and prevention programs. It does not, however, guarantee that the outcome will be positive regarding a healthy or long life expectancy. However, there is no doubt that early detection and prevention can help create a sustainable system. They can reduce the risk of severe disorders or diseases.

It is essential to understand the activities and scope of early detection before you can discuss it constructively. Early detection can include pre-symptomatic testing and treatment as soon as the first symptoms of a disease are detected. Programs can target a specific condition, such as HIV/AIDS or breast cancer. Or they can be more general. This blog does not focus on prevention but can be defined as any activity undertaken to prevent diseases.

During the global financial crisis of 2008, many countries cut preventive spending. In recent years, several countries have implemented reforms that strengthen and promote early detection and prevention. In recent years, the Affordable Care Act in the US was the most notable example. It focused on providing an extensive range of screening and preventive services. The list includes 63 services covered by the Affordable Care Act without copayments, coinsurances, or deductibles.

While logic would suggest that early detection is a good investment, there are some challenges and hurdles to overcome. Here are some essential requirements and criteria for a successful early detection program.

  • Accessibility

The healthcare system needs to ensure a balance of doctors, both geographically and by specialization. Patients should have access to the system quickly, without long waiting periods for diagnostics or elective treatment. This can help mitigate diseases or conditions that have already advanced or been developing for months or years prior to a clinical diagnosis. Telehealth is an important innovation to mitigate access deficiencies. Telehealth should make it easier for people to access health services. This is not just in the case of illness but can complement primary care.

  • Early symptoms and initial diagnoses

Initial diagnoses that are inaccurate or delayed can harm patients’ health, lead to unnecessary or inappropriate testing and treatments, and represent a large portion of the total healthcare expenditures. Medical second opinions, particularly of severe diagnoses that can be performed remotely, can improve healthcare outcomes.

Studies show that an early and accurate diagnosis can lead to a broader range of treatment options and reduce costs. For colon cancer, the stage-four treatment expenses are multiples of the stage-one costs.3

  • New Technology

Early detection of symptoms and diseases can be improved with new technologies.

i. The advancements in medical monitoring and wearable technology, including ECG, blood pressure, and biosensors, allow patients to be more aware of their health and condition. This trend will positively impact the early detection of diseases such as atrial fibrillation, Alzheimer’s, and other conditions.

ii. Diagnostics tools using new biomarkers, such as liquid biopsy, volatile organic compounds, and machine learning, can play a growing role in areas like oncology and infectious diseases.

  • Regulation and Intervention

It will take government regulation and intervention to establish normality ranges, prohibit or discourage excessive diagnosis and reduce the incentives for healthcare providers to overtreat or follow inappropriate patient requests. Some countries, like the US, have seen some success with capitation models and value-based care.

The government may also have to intervene to de-risk innovation, so private capital providers feel more comfortable investing in new detection technologies and proven business models for novel therapeutics.

The Business Case For Investing In Health Care For All

Faith, a mother of two, just lost another client. In a small South African town, some households she cleans are unaware of her medical condition. This Zimbabwean woman, who has type 2 diabetes, visits the public clinic regularly and sometimes at short notice. After waiting in line for hours, the woman was told at her last appointment that a doctor could not see her. She went to her local general practitioner for a prescription to avoid missing another day at work. The consultation and medication cost more than three days’ wages. This fictional character sadly reflects the reality of many people living in middle-income nations.

The UN Sustainable Development Goal of universal health coverage is in danger. The World Bank has identified a $ 176 billion funding gap. This gap is increasing each year as a result of the aging of the population and the shift in health burden to non-communicable diseases (NCDs), which are now the leading cause of death for emerging markets—the traditional sources of funding for healthcare need to raise budgets enough to cover this gap. Only 4% of private investments in health care are focused on diseases that primarily affect countries with low and middle incomes.

Private investors in middle-income countries often concentrate on expanding existing businesses, such as developing private hospital capacities, and target consumers who already receive quality healthcare. Ultimately, more than private capital invested in healthcare systems is required.