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"Two Sides of the Same Coin": Can a Health Systems Lens Inform Health Security Efforts?

This post was originally published on the Global Health Council blog.

The discussions at the 71st World Health Assembly (WHA) have been wide-ranging, from non-communicable diseases (NCDs) and youth engagement to citizen participation and Universal Health Coverage. With the 2018 Ebola outbreak in the Democratic Republic of Congo (DRC), health security, and its link to strong health systems, is at the forefront of the discussion as one of the three strategic priorities in the General Programme of Work. In fact, Dr. Tedros, the Director-General of WHO, has taken to saying that “health security and health systems are two sides of the same coin.” However, it is not yet not clear to me how Dr. Tedros, WHO, or the wider global health community think a health systems lens could add value to the health security discussions.

Sessions on health security have so far focused on metrics and measurement, as 76 countries have conducted Joint External Evaluations (JEEs) to evaluate their own health security capacity. Speakers recognize that these evaluations are necessary, but not sufficient, to ensuring that countries focus their efforts on key health security priorities. To complement the JEEs, a team from Hopkins, the Economist Intelligence Unit, and the Nuclear Threat Initiative is developing a Global Health Security Index to provide regular updates on preparedness efforts. The index should be ready by mid-2019. Additionally, about 25 countries have developed health security action plans, based on the gaps found in the JEEs. Regardless, countries are not seeing the political commitment, at either global or national levels, to ensure that these action plans are adequately funded, implemented, and monitored.

Nonetheless, efforts to advocate for these commitments exist. For example, Resolve to Save Lives, under the direction of former CDC Director Dr. Tom Frieden, has consolidated JEE findings to spur global action on the highest priority areas. During the JEE process, several health systems challenges have emerged, including analyzing surveillance data, training epidemiologists, and coordinating across sectors. Building on the JEE findings, I see three systems approaches that could add value to the health security discussion: contextualization, use of complexity science, and adaptation of existing tools.

First, we know from our experience in health systems and governance that solutions must be contextualized to specific environments.  In the health systems space, we are beginning to use more political economy thinking and adaptive management techniques to inform programmatic design and technical assistance packages.  Health security, through the JEE process, takes a much more normative approach by evaluating the existence of set policies, standards, and processes. Contextualization could include using a political economy lens to understand incentives and motivations for prioritization and/or tailoring action plans to endemic disease patterns, geographic differences, and cultural practices when developing health security action plans.

Second, I wonder to what extent the health security community has embraced the knowledge on complexity science, which seeks to describe systems that have multiple, interconnected elements. In the sessions I have attended, health security is described as a complicated system of widgets (simulation sessions, laboratory diagnostics, reporting procedures, etc) where the effects can be predicted and replicated. We know, however, that systems with interpersonal relationships and various stakeholders are inherently complex.  Understanding and strengthening the complex systems that prevent, detect, and respond to pandemics requires knowledge of the relationships between actors, responding to their interests and motivations, and iterating effective, if not always perfect, solutions.

Third, the health systems community has developed several relevant tools and approaches that could be applied to health security issues. As Ministries of Health seek to finance and implement health security action plans, investment cases, as with those for NCDs or HIV, can influence Ministries of Finance to invest in health security. The Health Systems Assessment Approach takes advantage of the wealth of qualitative data and experience at national and sub-national level. While costing models, such as the OneHealth tool, provide powerful, low-cost ways to collect and analyze country-level data.

So how can we, as a global health community, make use of these systems approaches? The most obvious use is to inform the ongoing development of the Global Health Security Agenda 2024 that will outline how international, multilateral, and country programs can improve health security efforts. Using a health systems lens can also strengthen data use and political analysis that drive resource allocation decisions.

Preventing, detecting, and responding to pandemic threats is at the heart of public health.  When John Snow first removed the handle from the Broad Street pump in 1854, he was responding to an outbreak of cholera.  Though our profession has moved beyond wrenches and bolts, outbreaks of Ebola, measles, yellow fever, and H1N1 keep calling us back to our roots. We should use all the tools at our disposal to create a truly secure and healthy future.