EBERE OKEREKE: In this module, we will go through a brief definition of a health system and explore the role of a health system in outbreak preparedness and response and control, and discuss some of the challenges in low and middle-income countries and opportunities for addressing these. So what is a health system? The World Health Organization defines health systems as all organisations, people, and actions whose primary intent is to promote, restore, or maintain health. WHO developed a framework to promote a common understanding of what a health system is to underpin its objective to strengthen them. The framework describes the attributes of a health system and provides a means for identifying gaps for investment. The six interconnected building blocks
include: effective leadership and governance; adequate financing; a well-trained and performing health workforce; essential medicines, vaccines and health products; a functional health information system; and service delivery, health facilities, including health centres, clinics, hospitals etc.; and finally, research to provide the evidence base for the health interventions required.
Access to a safe and quality assured health system is essential to achieve the desired outcomes of improved health, reducing mortality and morbidity, improved efficiency and value for money in the face of increasing health system costs.
Financial and social risk protection: this is that individuals and communities should not be overburdened in order to access health. So you shouldn’t be bankrupt just because you need to go to the doctors.
Responsiveness: a system needs to be able to anticipate, respond, and adapt to changed needs, new risks, and demands. This is particularly relevant to this topic of outbreaks. The health system needs to be perceived as of an acceptable quality and to be seen as safe to gain the trust of the communities served. Because the health system does not function if the communities for whom it is intended do not use it.
So what are the specific health system challenges in low- and middle-income countries? The interface between health system and the community it serves is essential for outbreak control. That’s a given. So underfunded health systems with poor governance are a major challenge in low- and middle-income countries - most, not all. Thus, the systems are limited in their ability to detect and respond to outbreaks. Limited access due to low coverage, high cost, are a major barrier to patient engagement. Studies have shown that out-of-pocket costs have been estimated to be up to 70% in many low-income countries. This limits access and utilisation, and therefore makes surveillance systems that are dependent on patient utilisation incomplete, inaccurate, and thus ineffective for outbreak detection.
Poor quality services compound this situation, leading to a lack of trust in the system. And thus, communities are less likely to comply with health protection advice or behavioural change interventions required for outbreak control. A stark example of this was the response to the Ebola outbreak in West Africa, 2013 to 2016, where advice on handling bodies was ignored due to a lack of trust in the health system. Limited local financing and poor governance of health systems in low and middle-income countries results in a multiplicity of vertical health programmes with parallel funding, parallel governance, and infrastructure. This is not only inefficient, but limits the potential for system-wide learning.
It skews capacity building in terms of workforce and infrastructure towards the priorities of the funders, but in an outbreak situation, presents additional complexities of governance and coordination leading to delays and sometimes conflicting approaches to outbreak control. Again, the early response to the West African Ebola outbreak demonstrated the impact of the absence of a health system-wide governance and coordination mechanism. Thus, access to the health system is a challenge that needs to be addressed for appropriate outbreak detection and response.
Now let’s look at another perspective of health systems: public health functions. An effective health system includes the ability to deliver the essential public health functions. The 10 essential public health functions as defined by the WHO
are listed above in this slide: surveillance; response to emergencies; health protection; health promotion; disease prevention; governance; workforce; finance; communication and social mobilisation; and research. Note the recurring patterns. There are similar headings in the essential public health functions, as I included within the health system building blocks. Health systems have traditionally focused on the delivery of health care, about the focusing on the individual. This has been particularly so in low- and middle-income countries, where dependence on donor funding has prioritised vertical programmes focusing on single conditions; so HIV, malaria programmes, TB. Even when these vertical programmes have included public health functions, their development in parallel to the health system has led to a lack of sustainability.
This continues to be the case in many settings. Most relevant at this time would be the Polio Eradication Programme, for example.
The essential public health functions are most effectively delivered through an integrated approach embedding them into the health system. In developing a resilient health system, public health functions should not only be integral, but should be link directly to the health system building blocks, and driven by the same enablers.
The interconnectivity between the health system, public health functions, and the desired health outcomes, including outbreak prevention and control, is illustrated in this diagram highlighting the enabling factors for positive health outcomes.
As previously mentioned, effective prevention and control of outbreaks requires continuous interaction between the health system and the population it serves. A systematic approach to outbreak control based on all hazards preparedness, requires a health system that is able to detect and respond to all potential hazards and to adapt lessons from past experience to improve health system resilience. Outbreak preparedness starts with governance, coordination and relevant legislation and policies outlining roles and responsibilities to prevent and respond to outbreaks. This is a function of the governance block in the health system. Surveillance and risk assessment inform priorities for investment, for workforce development, and for infrastructure.
A core part of outbreak preparedness is establishing enablers, such as the legislation, the policy and coordination, and training the workforce. All of these are core aspects of a functional health system. Therefore, effective outbreak preparedness cannot be separated from health system development.
Outbreak detection: outbreak detection requires an effective surveillance system; diagnostic capability; an infrastructure; and a trained workforce. Surveillance has been covered in another module in this course so will not be discussed in detail here. Information is a core health system function and both indicator-based and event-based surveillance, necessary for outbreak detection, rely on a functional health system to generate, analyse, and interpret information on which a response will be based. Absence of or poor quality surveillance information, not only leads to delayed detection, but can also be misleading of the impact of intervention and control measures.
The recent HIV seroprevalence survey in Nigeria, for example, was necessary in order to assess the impact of the control programme due to a lack of reliable surveillance information.
The interface between the population-at-risk from an outbreak and the health system is a trained and adaptive workforce trained to communicate the risk generated from a robust evidence base and engaging with a receptive population. As previously mentioned, a receptive population is determined by the level of trust in the system, and the level of trust in the system is determined by the perceived quality and safety of the system and accessibility. Effective outbreak response is informed by an understanding of the epidemiology of the disease in that population, but also by the social-cultural factors and the effective behavioural change approaches for outbreak control in that particular context. Research into effective interventions should inform the availability of appropriate medical countermeasures to support the outbreak response.
A health system must learn from outbreaks so that it can evolve and improve. This is essential. After Action Reviews, simulation exercises, outbreak reports provide an opportunity to understand what happened and what resources worked in order to strengthen the response to future outbreaks. These also provide an opportunity for system-wide learning and improvements, not just in response to the specific cause of the most recent outbreak. Health systems should have mechanisms for disseminating such learning to the workforce through training, as well as adapting policy, legislation, and coordination mechanisms to reflect learning from the last outbreak response. By so doing, outbreaks can lead to health system improvements.
The vicious cycle of weak health systems and outbreaks was perfectly demonstrated by the recent West Africa Ebola outbreak. The affected countries are fragile states, some just emerging from civil war. All have significantly underdeveloped, limited, and poor quality health systems. This fueled the impact of the outbreak and contributed to its spread. The population did not engage with the health messages from a system they did not trust. In turn, the outbreak further weakened the health system. Not just through direct impact on health workers, but also by diverting the limited resources that were available to the outbreak response. Deaths from factors associated with pregnancy in childbirth, for example, and from malaria, increased during the outbreak of Ebola in West Africa.
The ineffectiveness of the poorly developed system further fueled distrust in the population, aiding further outbreak spread.
But can outbreaks lead to a virtuous cycle of health system strengthening? Most public health specialists will say “Never let an outbreak go to waste.” The dramatic nature of outbreaks tends to draw the attention of policymakers, politicians, and those in charge of financial systems. This focus in the wake of an outbreak, if harnessed effectively, can be leveraged to strengthen the core capacities for outbreak prevention and control, not just limited to the particular disease in question. So from immunisation to surveillance to diagnostics and to treatment measures, thus strengthening the health system to be better equipped to prevent, detect, and respond to the next outbreak, whatever its course.
It is important that the opportunity presented by an outbreak is not just used to enhance preparedness for the most recent incident, preparing for the last one, but focusing on core capabilities of the health system itself to be better prepared for any other event.
To summarise, outbreaks are prevented by planning and contained by early detection and response. Outbreak control measures should be available as close to the community they serve as possible in order to detect early and limit spread.
To embed outbreak preparedness into the health system, it must be considered as an integral part of the system. It needs to be generic, taking an “all hazards”, “One Health” approach, not responding to the last disease. It must be multi-sectoral with cross-government commitment. Outbreak prevention and control is everybody’s business, but the workforce is key. This diagram summarises the interconnectivity between health system resilience and outbreak preparedness and response.
The development of public health capabilities and capacity has been limited by the historical separation of public health function from health system planning. There is a need to reintegrate public health functions into health system planning at local, national, and international levels, and the current focus on health security presents such an opportunity. To do this requires leadership at country level adapted to that country’s specific context. The approach needs to be “One Health”, “all hazards”, multi-sectoral. As previously stated, health is the business of all parts of government. In order to ensure sustainability, any health security plans must align with existing related health plans and integrated into the national health plan.
Global health security is essentially about stopping outbreaks from becoming international concerns. Following initial proposals by the United States via their global health security agenda, health security has now been adopted as an international priority. The International Health Regulations (2005) are central to global health security, and outline the responsibilities of all member states to prevent, protect against, detect, and respond to Public Health Threats of International Concern. The International Health Regulations are intended to prevent the spread of diseases across borders and outline the minimum requirements for functional public health systems that allow countries to quickly detect and respond to disease outbreaks in their communities.
Countries are required to promptly notify the World Health Organization of Public Health Emergencies of International Concern, which allows the World Health Organization to coordinate a global response and minimise unnecessary interference to trade or travel. The current International Health Regulations (2005) entered into force in June 2007. Meeting the requirements for compliance with International Health Regulations (2005), means that countries must also develop capacity and capabilities to respond to internal outbreaks, not just those of international concern.
Therefore, International Health Regulation compliance provides a mechanism for linking health system strengthening to health security, and thus preventing outbreaks. However, despite being legally binding, core capacities required for compliance with International Health Regulations remain underdeveloped in many low- and middle-income countries. Assessments of compliance with International Health Regulations through the WHO coordinated Joint External Evaluation, shows that most countries are not ready to prevent outbreaks with scores lowest in the capacities that rely on a resilient health system. Therefore, global health security cannot be sustainably achieved without building sustainable health systems, and there is a recognition that International Health Regulations compliance requires not just international, outward-looking, but internal, inward-looking, national, bottom-up health systems strengthening.
National Action Planning for Health Security: this is the main instrument used by the World Health Organization and adopted by its member states to ensure compliance with International Health Regulations. It ensures that investment in capabilities and capacity for health security is coordinated, driven by local needs, risks, and priorities. It ensures that planning is multi-sectoral and takes an “all hazards” approach. But most importantly, the process is owned by the national government, thus ensuring long-term sustainability. International Health Regulations and its associated processes are covered elsewhere in this course, and so we will not go into further detail here.
In conclusion, essential public health functions are an integral part of the health system. Ensuring public health functions are built into the health system is key to sustainable and effective outbreak preparedness and response.