“… there is a very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen killing 50 to 80 million people and wiping out nearly 5% of the world’s economy. A global pandemic on that scale would be catastrophic, creating widespread havoc, instability and insecurity. The world is not prepared.” Global Preparedness Monitoring Board, A World at Risk: Annual report on global preparedness for pandemic emergencies, September 2019, World Health Organisation, p6.

“Governments and health ministries should ensure their healthcare systems are sustainable, reliable, comprehensive, resilient, and based on inclusive approaches.” Independent Commission on Multilateralism, Global Pandemics and Global Public Health, 2017, p2.

“Sadly, I wrote a ‘just in case’ letter to my husband and sons in case Mummy is one of the unlucky healthcare professionals who doesn’t make it home.” National Health Service doctor on writing to her family about the lack of protective equipment amidst the COVID-19 pandemic, March 2020.

News of the UK’s NHS healthcare workers writing farewell letters to their families in anticipation that they may die from COVID-19 infections is a tragic example of our collective failure to develop resilient health systems around the world.

NHS staff in the UK reportedly felt the need to protect their families by documenting the lack of available personal protective equipment for them in Britain’s health system.

Global failure to prepare
But the story of the health system being completely overwhelmed by the COVID-19 outbreak is not unique to the United Kingdom.
From Wuhan to Washington, from Lombardy to London, from Madrid to Manhattan, the world is awash with tragic stories of health systems not coping with a new virus that has spread around the world in since December.

Our health systems have been tested in the last few months and in many cases have failed, often spectacularly.

We have neglected to invest in the resilience and effectiveness of our health systems on a systematic scale.

Instead, health systems in many countries have been shown up as being quite fragile.

Scenes of mass burials, overflowing morgues, gross shortages of ventilators and PPE, catch-up development of treatments and vaccines and economic collapse are all signs that our health systems do not have built in excess capacity to deal with a pandemic like COVID-19.

The obvious question is: why?

Not enough investment in healthcare
Even as an expert in health policy and economics, I was genuinely shocked when I looked at the OECD data on health spending again the other day and saw that growth in health spending as a share of GDP in OECD countries has stagnated since the Global Financial Crisis.

Across the OECD health spending has been stuck at around 8.8% of GDP for the last decade ever since the GFC precipitated widespread cost cutting in healthcare systems across the developed world.

This defies the previous trend going back half a century or more of OECD countries all gradually investing more of their income in health as their economies grew.

While varying from country to country, over the last decade governments across the developed world have jammed the brakes on health spending even as their populations grew and aged.

All the talk of ‘efficiency’, ‘cost management’ and ‘budget blowouts’ has focused payers’ minds on saving money in the here and now and not on investing in the long-term resilience of health systems.

A decade of prioritising cost saving after the GFC has left our health systems in a fragile state, teetering on the edge of just making do each day without the built-in excess capacity needed to deal with shocks like COVID-19.

Similarly, we know that low- and middle-income countries have not invested sufficiently either. For years the World Health Organisation and the World Bank have been urging governments and payers in these countries to adequately fund their health systems.

These organisations were warning even before COVID-19 that health systems around the world were at risk of not meeting their SDG targets to develop effective health systems.

It remains to be seen how these countries will deal with COVID-19 going forward, but there are grave fears for how low- and middle-income countries and their people will manage.

Whether it is the world’s poorest countries or richest countries, right now we are seeing the results of years of cost cutting and insufficient investment in the strength and resilience of our health systems.

A combination of fiscal cutbacks and lack of priority attached to health have come home to roost in the form of the COVID-19 outbreak.

Ignoring the warning signs
But, to be honest, what is happening now with COVID-19 should not be a surprise.

There have been warnings for years that we needed to get better prepared for major pandemics. COVID-19 is not a ‘Black Swan’ moment that no one could see coming. We have had:

  • lessons learned from the 1918 Spanish Flu pandemic barely a century ago
  • years of recommendations coming out of meetings in Geneva reviewing the International Health Regulations after previous pandemics like H1N1 or Ebola
  • warnings from people like Bill Gates and Barack Obama that we need to be prepared for future global pandemics
  • the WHO last year listing global pandemics as a top 10 threat to global health
  • reports by the Global Preparedness Monitoring Board also from last year warning governments of the “very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen killing 50 to 80 million people and wiping out nearly 5% of the world’s economy”
  • warnings from the Centre for Epidemic Investment Preparedness for nations to invest in preparing for ‘Disease X’ as a potential threat; and
  • even academic studies from 2007 warning of the emergence of deadly new SARS-like coronaviruses.

We have known those threats were there.

And yet we have not sufficiently acted on those warnings.

Our health systems have not been sufficiently developed, strengthened and prepared to deal with the shocks we knew were likely to come.

One example of some countries’ inability to follow the World Health Organisation’s recommendation to ‘test, test, test’.

Just as an example, Germany has adopted testing at a much higher and faster rate than the UK and has a lower number of COVID-19 deaths and a lower death rate compared to the UK.

Lack of priority
The truth is that giving our health systems the scale, scope, and capacity to deal with shocks of the COVID-19 variety has just not been a priority for the world.

Many a health system today is being dramatically tested in its ability to cope with a surge in infectious disease whilst still delivering normal health care services and has been found wanting.

Multiple governments have even said that one of the key reasons to ‘flatten the curve’ of COVID19 cases is to take pressure off the health system – an admission that there is little built in redundancy and excess capacity to cope with shocks.

Over the years, health spending has been regarded as a cost to be managed, cut and assessed with razor-like efficiency within a set budget envelope with little attention to the question of whether the envelope should grow.

The result is a global economic recession resulting from the COVID-19 lockdown that the International Monetary Fund has said will be the worst recession since the Great Depression of the 1930s. It expects the global economy to shrink by 3% this year instead of its previous forecast for 2020 of 3.3% growth.

The low priority attached to dealing with pandemics and health care system resilience is also revealed when one realises that there actually is a United Nations Sustainable Development Goal 3.D to “Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks”. But the main metric to track its progress is the implementation of the International Health Regulations which are often ignored.

Investing in the resilience of our health systems is a priority
If the COVID-19 outbreak shows us anything, it is the urgent need to re-invest in the effectiveness and resilience of our health systems.

For too long, perhaps in the wake of the GFC, governments and payers around the world have recanted the mantra of efficiency, making do and austerity in health care on the pretext that the budget cannot afford it.

This needs to end.

The economic costs of not doing this have been laid bare in the broken supply chains, long unemployment queues and idle factories created by a microscopic virus that cannot survive 20 seconds of handwashing with soap and water.

In the aftermath of the COVID-19 outbreak, when governments are trying to work out how to pay for the trillions of dollars in support they have provided, it would be a mistake of extraordinary proportions to think that the remedy was to cut back further in health spending.

If anything, the opposite is true.

The failure of health systems to manage the COVID-19 crisis in rich and poor countries alike is evidence of that.

In the inevitable post-mortem reviews of how our health systems coped with COVID-19 the issue of our failure to build sufficiently resourced health systems for the 21st century should be one key area for review.

We owe it to the people working in health systems today, we owe it to ourselves and we owe it to future generations.

Brendan Shaw is principal of Shawview Consulting