Systems Thinking and Global Health Governance

• Citation: Vol. 49 No. 3
• Publication year: 2021

Systems Thinking and Global Health Governance

Elsie Hayford^* & Marice Ashe^**

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Table of Contents

I. introduction................................................................. 565

II. Global Health Treaties and Governance..........................565

III. WHO Systems Building Blocks.......................................566

IV. Healthcare Worker Rights........................................... 567

V. Disparities in National COVID-19 Responses......................569

A. France and New Zealand..................................................569
B. Democratic Republic of Congo and Rwanda....................570

VI. Law as a Tool for Improved Pandemic Response................570

VII. Domestic Health Policy................................................571

VIII. The Health Impact Pyramid and the Drivers of Health Equity......................................................................571

IX. Health in All Policies................................................... 575

X. Case Study: Health in All Policies in Richmond, California. 576

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XI. Case Study: Equity in All Policies in Seattle, Washington..............................................................578

XII. Case Study: Bloomberg Philanthropies Data for Health... 581

XIII. Moving Forward........................................................582

XIV. Conclusion............................................................... 583

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I. Introduction

The novel coronavirus (COVID-19) has exposed the governance failures within health systems across the globe, leading to the deaths of over two million people.¹ Despite the debilitating effects of previous outbreaks such as MERS, SARS, and EBOLA on some countries, many others were unprepared for the onslaught of COVID-19. Essentially, many countries had the capacity to respond but were simply unprepared to do so.

The rapid development and current global patronization of COVID-19 vaccines although laudable, are not magic wands that will wave the virus away. Vaccines form part of pandemic response strategies and do not guarantee mass protection particularly in this era of misinformation and the right to choice. As a result, countries must prioritize and heavily invest in pandemic preparedness to respond effectively to "serious national and global security threats."² This can only be achieved by building trust, cross-sector international collaboration, and strong yet compassionate leadership. In the words of Noah Harari, "[t]o defeat an epidemic, people need to trust scientific experts, citizens need to trust public authorities, and countries need to trust each other."³

II. Global Health Treaties and Governance

There is a plethora of global treaties and standards that were enacted to encourage trust, collaboration, and leadership—some binding and others merely normative. Key amongst them in this era of infectious disease outbreaks are the International Health Regulations (IHR).⁴ The IHR, an international treaty, are legally binding on all member states of the World Health Organization [WHO]

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and were adopted after the SARS outbreak.⁵ Their aim is to provide a system of preparing for, monitoring, and reporting international health threats and improve coordination without interference of trade and travel.⁶ Consequently, countries agreed to ensure the development of core capacities such as legislation and pandemic planning to implement the regulations.⁷ Article 3(1) of the IHR also clarifies that countries must have regard for the "dignity, human rights, and fundamental freedoms of persons" in implementing the regulations.⁸

The Universal Declaration of Human Rights,⁹ WHO Constitution,¹⁰ and the International Covenant of Economic, Social and Cultural Rights¹¹ all indicate that everyone has a right to health. The full extent of this right is expatiated on in the Committee on Economic, Social and Cultural Right's General Comment No. 14, and includes state responsibility to provide healthcare, combat infectious diseases, and ensure access for all to the underlying determinants of health.¹² Thus, there is impetus for the change required to improve pandemic preparedness outside the IHR framework. Whilst discussions on IHR reform are ongoing, there are many actions countries can take at the national level to improve pandemic response.

III. WHO Systems Building Blocks

In 2010, the WHO published an analytical framework to describe health systems by disaggregating them into six core components.¹³ As shown in Figure 1, these core components are health service delivery, health workforce, health information systems, access to essential medicines, health systems financing, and leadership and governance.¹⁴ No health system can thrive without these

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foundational blocks. It is also important for each component to be underpinned by implementable laws and policies which clearly define rights, duties, and responsibilities and the extent of each.

Figure 1: WHO Systems Building Blocks¹⁵

Countries that adopted this six-component framework or some variation of it have fared better than those that have not actualized one or more of the blocks within their health systems.¹⁶ Most glaringly, the pandemic has highlighted the utmost importance of the interrelated leadership and governance, health workforce, and service delivery blocks—a failure in one area has a domino effect on the others.

IV. Healthcare Worker Rights

Healthcare workers (HCWs) form an integral part of emergency healthcare delivery yet leadership failures have led to the deaths of thousands of HCWs

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globally as shown in Figure 2.¹⁷ These numbers will continue to rise without adequate logistical support and well-documented protections for HCWs.¹⁸

Figure 2 : HCW Deaths, Statistica, September 2020¹⁹

The enforcement of occupational health standards and infection prevention and control policies must be prioritized. In order for health systems not to crumble due to a lack of manpower, employers should provide HCWs with hazard pay and benefits, enhanced insurance and liability protections, and clear guidance on crisis standards of care. The government must also be protected from community attacks driven by stigma, fear, and misinformation.²⁰

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V. Disparities in National COVID-19 Responses

A. France and New Zealand

As aptly indicated by Dr. Larry Brilliant, outbreaks are inevitable but pandemics are not.²¹ How do we prevent outbreaks from becoming pandemics? New Zealand has demonstrated that it takes strong, decisive leadership, early action, strict temporary measures, mass testing, isolation of imported cases, and a sense of ownership to prevent a pandemic from occurring.²² Repeatedly, all five million inhabitants of New Zealand were collectively and individually encouraged to work as a team to defeat the virus.²³

Conversely, France responded slowly to reports of the first set of cases and took its time to lock down.²⁴ France failed to contain the virus for a number of reasons including lack of logistical support for mass testing.²⁵ Unfortunately, the recently-developed vaccine may not completely eradicate the virus within the country because 33% (the highest percentage worldwide) of French nationals do not trust vaccines according to the Wellcome Global Monitor on attitudes to vaccines.²⁶

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B. Democratic Republic of Congo and Rwanda

The Democratic Republic of Congo [DRC] and Rwanda are two examples of African countries with histories of conflict which now have contrasting health systems. In the DRC, years of conflict have completely decimated trust for institutions—especially within the health sector.²⁷ Consequently, efforts to control the Ebola outbreak were met with violence as treatment centers were attacked and many HCWs lost their lives.²⁸

During the Rwandan genocide, 800,000 people lost their lives in 100 days and yet the government consistently made the effort to build up the trust of communities in health authorities.²⁹ Today, Rwanda's secret weapon against COVID-19 is trust.³⁰ Ninety-seven percent of Rwandans trust their health authority.³¹ Building the trust of a nation takes time—however, this process should not be taken for granted if we want to move forward.

VI. Law as a Tool for Improved Pandemic Response

Law and policy have a major role to play in shaping health systems and their response to infectious disease outbreaks. The body of public health emergency laws of every country must seek to achieve each of the following objectives:

• Define triggering events
• Address the complete lifecycle of emergencies
• Balance strong and agile decision-making with meaningful oversight
• Fund health and allied sector activities adequately
• Equip authorities with all relevant public health tools
• Fulfill IHR obligations³²
• Protect human rights

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• Integrate functioning health strategies
• Ensure secure and timely flow of health data across all levels of governance
• Enforce the rules without imposing unjust penalties
• Promote transparency³³

Accomplishing these objectives will foster trust, cross-sector cooperation, and leadership, making us better prepared at the national and global levels.

VII. Domestic Health Policy

Lack of trust, poor collaboration between levels of government, and a dearth of effective leadership from at least the Trump administration contributed to the dismal U.S. experience in battling COVID-19 throughout 2020.³⁴ Thankfully that trend was reversed with the introduction of effective vaccines and a change in federal leadership.

VIII. The Health Impact Pyramid and the Drivers of Health Equity

The now-classic work of former CDC director Thomas Frieden, The Health Impact Pyramid,³⁵ (see Figure 3) shows that the most effective public health interventions—those addressing socioeconomic factors—have the broadest and most powerful population-level impact.³⁶ Interventions to alleviate poverty, boost educational attainment, and secure essential infrastructure such as quality...