Re-imagining health leadership beyond the pandemic
By Tim Mastro & Dylan Edwards
The world is beginning to move into a new phase of the COVID-19 response. This new phase is characterised less by emergency response (how do we get masks, test kits and ventilators to where they need to be?) and more by the changes that we need to make to health systems globally (how do we prevent this from happening again and protect the health of everyone, everywhere?).
Health leaders around the world are increasingly talking about the imperative to “build back better”, a phrase borrowed from the disaster management community to refer to recovery, rehabilitation and reconstruction efforts after a disaster aimed at increasing the resilience of affected communities. Some are also talking about the opportunity to “re-imagine” the health system in a post COVID-19 world.
It is important to bear in mind that COVID-19, as devastating as it has been - and we are early in this pandemic - is only one disease. We cannot allow the dream of creating a more resilient, more equitable and more sustainable health system to also become a casualty of this pandemic.
At the local level, we must ensure that capable managers are empowered with the skills and resources to build back better. At the global level, leaders must set out a cohesive vision for what a re-imagined global health system might look like beyond the pandemic. To do this successfully, these leaders will have to consider global forces that will give shape to health systems of the future. In this article we outline five megatrends which we believe leaders in global health must take into consideration as they chart a visionary path forward.
Trend one: Shifts in geo-politics and health governance
The threatened withdrawal of the United States from the World Health Organisation (WHO) poses a significant threat to the current world order. At the same time, countries like China have been extending support to low- and middle-income countries in the form of funding and technical assistance. Jack Ma, the billionaire founder of the Chinese tech giant Alibaba has emerged as a major figure in global philanthropy by buying and distributing plane loads of personal protective equipment for several African countries.
A complicating factor is that the COVID-19 pandemic has highlighted the vulnerability of systems that rely on global supply chains and just-in-time delivery. The closing of international ports and interruptions of air travel have cut off countries from supplies of protective equipment, testing equipment and reagents, and medicines. In the coming months and years, we are likely to see the localisation of manufacturing and supply chains, particularly for health commodities.
However, leaders in global health should not let this need to act locally cloud out the imperative to cooperate and think globally. The collective effort required to rebuild and reimagine our health systems will require a collective effort from teams that have bought into a shared vision.
It is likely, for example, that safe and effective COVID-19 vaccines will play a key role in ending the current pandemic. But vaccines will be most effective if they are available for everybody at an affordable price. Achieving this will require large scale international cooperation on financing, manufacturing, distribution and intellectual property. Without this we risk “vaccine nationalism” driving up prices and leaving large parts of the world unprotected.
At the same time, vaccination programmes require capable managers to oversee enormous distribution, communication, and community engagement efforts. It is therefore vital to invest in developing the skills of both the leaders who will set the vision for future health systems and the teams that will have to execute on this vision.
Trend two: Population dynamics
In the next thirty years, the global population is projected grow from 7.8 billion people to 9.7 billion people. Half of the almost 2 billion additional people are anticipated to live in Africa, most of them in cities.
The pace of urbanisation in Africa is unprecedented. According to one estimate, the population of Lagos (Africa’s most populous city) is growing at a rate of 77 people every hour. By 2025, there will be more than 100 African cities with populations of more than 1 million people.
This process of urbanisation could offer billions of people access to better economic opportunities and health services. However, national governments and city leaders face enormous challenges in addressing the infrastructure, health, and environmental challenges of rapidly growing cities. Air pollution, unsafe drinking water, high incidences of HIV and tuberculosis, and a growing burden of non-communicable diseases that are often associated with urban lifestyles are just some of the health concerns that these leaders will have to confront. Urban planning decisions must be informed by science and the health needs of the population, which will require greater inter-sectoral collaboration.
In contrast to the rapidly growing, young, and mostly urban African population, many developed countries will be characterised by shrinking, aging populations. Soon, many developed countries will come to rely on immigration to sustain economic growth. The policy implications of this run counter to the trend in recent years of tightening immigration policies across the global north.
Trend three: Pandemic preparedness
We know that countries that were hardest hit by H1N1 flu, SARS and MERS have generally invested more in pandemic preparedness, and, as a result, were better equipped to put measures in place to curb the spread of SARS-COV-2.
However, in 2019, the total amount of development assistance for health applied toward pandemic preparedness came to less than 1 percent of all development assistance. That figure is likely to increase as bilateral and multilateral funders prioritise pandemic preparedness in the coming years.
There will need to be greater attention on the Global Health Security Agenda and building capacity for all countries to fully adhere to WHO’s International Health Regulations (adopted by the World Health Assembly in 2005), which were intended to prevent the international spread of disease but have been woefully under-implemented in the majority of countries. These fundamental frameworks will likely be reviewed and updated.
There must also be increased investment to better characterize the viruses and other potential pathogens living in our global ecosystem to prevent “spill-over” events from animals to humans, as we’ve seen with COVID-19, MERS, SARS, Ebola, HIV and many others. Unfortunately, US government funding for this kind of work was drastically cut in the 2019 budget, leading to the shutting down of programmes that focussed on the discovery and surveillance of dangerous animal viruses that someday may infect humans.
Trend four: Technological change
The restrictions on travel and public meetings that have been introduced to slow the transmission of the coronavirus have forced many organisations to accelerate the adoption of technology to facilitate their work. This applies to everything from video-conferencing replacing in-person staff meetings, to an increase in cashless and contactless payments, to a greater uptake in telemedicine, to apps that support contact tracing.
With the scale of investment in responding to COVID-19, we anticipate seeing an explosion in technology to support rapid, point-of-care diagnostics, disease surveillance and vaccine science. These innovations will likely include new devices, processes, and software as well as the re-purposing of existing technology to support health care efforts.
All these innovations have the potential to contribute to building stronger and more resilient health systems for the future. They could allow countries not only to respond more effectively to COVID-19 and future epidemics, but also contribute to the achievement of the health-related Sustainable Development Goals and improved health outcomes.
However, there is a risk that if these innovations do not become institutionalised, they will fail to have a lasting impact beyond COVID-19 particularly in low-resource settings. Even before the current pandemic, a review of digital health projects identified “pilot fatigue” – the expansion of numerous pilot digital health projects that rarely reach scale and fail to connect to a national strategy – as one of the limitations of the impact of technology in advancing progress in global health.
With these new technologies, there will also be new concerns about privacy and who is able to access health information. Around the world, governments have a track record of introducing new powers in response to specific emergencies that they are reluctant to surrender once the crisis has passed. Data that are surrendered temporarily during a crisis can become very difficult to get back. Leaders and policymakers will have to balance the use of these innovative technologies with the protection of personal information.
While the transformative potential for technology in healthcare is tremendous, especially in difficult-to-reach area, it is not a panacea for all health challenges. Too often, the conversation around digital health is focused only on the technology, rather than on the people this technology is meant to serve. Effective managers in health care will need to have the skills to navigate these new technologies and the privacy and governance concerns that come along with them. We must invest in developing these skills in teams working on the frontlines of public health.
Trend five: Climate change
Climate change will bring forth a complex set of challenges that will affect everything that we do in global health. Climate change is already contributing to declining crop yields, increased loss of life due to extreme weather events, and increases in vector-borne diseases like Zika, malaria and dengue as they make their way to new places as rainfall patterns and temperatures change.
The WHO estimates that between 2030 and 2050 climate change will cause approximately 250,000 additional deaths every year as a result of malnutrition, malaria, diarrhoea and heat stress. Water shortages will increase in intensity in multiple locations and will be exacerbated by population growth in vulnerable settings, most notably the Sahel region of sub-Saharan Africa.
Poorer countries, particularly those in equatorial regions, will be hit hardest by climate change. These countries also tend to have weak public health infrastructure and will be least able to cope with the impact of climate change on the health of their populations.
Preparing to deal with the effects of climate change will require leaders in health to look beyond their own sector and manage a broad range of stakeholder relationships. As we re-imagine health systems beyond the current pandemic, we must invest in building the skills of these leaders so that they can manage the complex effort to build systems that are resilient to effects of climate change and can address the intersections with population dynamics and emerging infectious diseases.
Conclusion: Reimagining leadership and management
COVID-19 has not created weaknesses in our health system so much as highlighted the weaknesses that were already there. It has revealed the precariousness of even the most advanced health systems and illustrated how the inequities in health systems can affect us all. In the words of Dr Tedros Ghebreyesus, Director-General of the WHO, “Global health security is only as strong as its weakest link. No-one is safe until everyone is safe.”
Re-imagining health systems for the future requires us to re-imagine leadership and management of these systems. The five megatrends outlined in this article will shape the future of global health, and it is imperative that the people working in health systems of the future have analytical and problem solving skills to adapt to the challenges that these trends will bring, and feel empowered to make decisions based on the best available information.
Armed with stronger skills across these critical domains, teams – and the individuals that comprise them -- will be better poised to respond to emergency health crises more rapidly and strategically; engage new and non-traditional partners to identify and implement novel solutions and catalyse more domestic resources for health; and make better tactical decisions informed by real-time data to improve public health and save lives.
This will require significant investment in leadership and management skills for government employees, development agencies, the private sector and civil society. It is these teams, after all, that we will rely on to make our re-imagined health systems a reality.
Tim Mastro (@DrTimMastro) is the Chief Science Officer at FHI 360, Durham, North Carolina. Dylan Edwards is Deputy Director for Strategic Communication at AMP Health. This article is adapted from a roundtable discussion on leadership and management in response to COVID-19 hosted by AMP Health.