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Fragmented health systems: The misalignment between global health security and universal health coverage

December 4, 2020

Topics: Quote of the Day

By Arush Lal, M.Sc.; Ngozi A Erondu, Ph.D.; David L Heymann, M.D.; Githinji Gitahi, M.D.; Robert Yates, M.B.A.
The Lancet, December 1, 2020


The COVID-19 pandemic has placed enormous strain on countries around the world, exposing long-standing gaps in public health and exacerbating chronic inequities. Although research and analyses have attempted to draw important lessons on how to strengthen pandemic preparedness and response, few have examined the effect that fragmented governance for health has had on effectively mitigating the crisis. By assessing the ability of health systems to manage COVID-19 from the perspective of two key approaches to global health policy—global health security and universal health coverage—important lessons can be drawn for how to align varied priorities and objectives in strengthening health systems. This Health Policy paper compares three types of health systems (ie, with stronger investments in global health security, stronger investments in universal health coverage, and integrated investments in global health security and universal health coverage) in their response to the ongoing COVID-19 pandemic and synthesises four essential recommendations (ie, integration, financing, resilience, and equity) to reimagine governance, policies, and investments for better health towards a more sustainable future.


National responses to COVID-19 have varied greatly, from swift and proactive at best to haphazard and negligent at worst. That countries have managed the pandemic differently is expected, but COVID-19 has pushed all health systems to their limits, exposing severe gaps in public health infrastructure, even in nations once lauded as the gold standard for readiness. Although much has been discussed about how countries could have been better prepared, these analyses have largely missed a focus on how fragmented governance for health and the resulting silos in financing of health systems (ie, vertical funding streams towards single disease categories, independence of tertiary care from primary care, and differences in domestic health priorities vs global health priorities) continue to hamper response efforts. Analysing the spread of COVID-19 from the perspective of global health security (GHS) and universal health coverage (UHC) offers a useful opportunity to uncover blind spots in fostering health-system resilience moving forward. In this Health Policy paper, we seek to understand how health systems that are heavily influenced by either GHS or UHC policies have initially fared with the shock of the ongoing COVID-19 pandemic, and we conclude with four key recommendations to redesign health systems for a sustainable future.

Health systems with stronger investments in GHS capacities

Despite the USA receiving top ratings for pandemic preparedness in the Global Health Security Index, it has, to date, reported the world’s highest number of COVID-19 cases and deaths. Although the country has an impressive array of public and private laboratories, innovative pharmaceutical and technology companies, and a national public health institute with high capacity, the USA ultimately relies on a greatly fragmented health-care system. Each state funds and operates its own systems for public health and surveillance, and the nation has been reluctant to build a unified health system that is publicly funded. This absence of clear coordination, a crucial IHR (International Health Regulations) core capacity, has so far hindered the country’s ability to accurately estimate and forecast the effect of COVID-19, resulting in delayed response activities, including testing and contact tracing. Additionally, the scarcity of centralised funding has led to chronic misuse and underuse of human and financial resources. Finally, high rates of underinsurance could disincentivise health-care use and discourage citizens from seeking emergency care, leading to untreated chronic diseases, reducing capacity for syndromic surveillance, and undermining overall trust in public services; thus further accelerating the effect of COVID-19. The USA is one of the most prominent examples, showing that reliance on traditional GHS capacities to provide an accurate assessment of health-system readiness does not account for the effect of incoherent coordination and inadequate UHC and political economy during health emergencies.

Health systems that align GHS and UHC investments

Although not mutually exclusive, GHS and UHC tend to have different policies in practice. Thus far, countries with policies that are closely aligned with both frameworks have generally fared better and might be better equipped to recover after COVID-19 compared with nations with health systems that are not aligned to both frameworks, which could struggle to cope with challenges in the long term. Importantly, health systems that successfully integrated GHS core capacities with PHC services have been particularly effective at mitigating the effects of COVID-19.

Reimagining governance, policies, and investments for global health

Although breaking the cycle of panic and neglect, which is necessary for sustained GHS, might be unlikely, re-envisioning UHC as the foundation for solidarity and action, including for health security and healthy societies, offers a necessary path forward in the world after COVID-19. A system with programmes for social protection, cost-effective PHC, inclusive leadership, and adequate public financing can guarantee quality services for all, especially in fragile contexts where poverty, overcrowded housing, and inadequate resources make communities most susceptible. In the recovery from COVID-19, economic fallout and public fear might push countries to favour isolationist approaches to health, favouring privatised health care and quick fixes to provide the illusion of health security. Donors and advocates should be wary of overly securitised or neoliberal solutions that have long restricted both GHS and UHC, instead backing truly universal, publicly financed, and country-owned health systems that promote health equity and upstream determinants of health to leave no-one behind. This expanded implementation of GHS capacities that are embedded and delivered through UHC can be developed along four core recommendations: integration, financing, resilience, and equity.

  • Integration: build robust GHS capacities into comprehensive UHC systems
  • Financing: break narrow funding pathways that prevent unified health systems
  • Resilience: develop and assess health-system resilience
  • Equity: apply a rights-based approach as the necessary foundation for health systems

From the Conclusion

With the effects of additional sociopolitical factors, such as protracted crises, race, gender, climate change, economic status, and differing social contracts between citizens and their governments, the influence of competing priorities in the governance for global health should be integrated into traditional preparedness and response guidance. A reimagined framework for global health that prioritises health-system integration across UHC and GHS domains, innovative and unified health financing, cross-sector resilience indicators, and equity as a core value offers a necessary path ahead. National authorities developing health-system priorities and funders, who control expenditure, agenda setting, and prioritisation of investment, cannot continue business as usual. To rebuild a more sustainable future after COVID-19, embedding the core capacities of GHS into holistic, publicly financed UHC systems is the clear next step forward. We cannot keep jumping from one epidemic to the next while ignoring the political will that is required to invest in the foundations of health for all. In the end, truly universal, comprehensive health systems in all countries, which have integrated core capacities for public health and are aligned across all levels of governance, will be our strongest defence against the next great pandemic.



By Don McCanne, M.D.

In response to the enormous strain placed on countries by the COVID-19 pandemic, the authors recommend rectifying the misalignment between global health security and universal health coverage.

How does this apply to the greatest health care system on earth, er, well, the most expensive one? Our current commitment to global health security is perhaps best represented by our withdrawal from the World Health Organization just at the time or our greatest need – not much of a commitment. Also, of all wealthy nations, ours is the only one that is not fully committed to universal health coverage.

Next month we will have a new administration. President-elect Joe Biden has told us that we will immediately rejoin the WHO, obviously a very important first step toward improving global health security, though much more will need to be done.

Regarding universal health coverage, Biden has already rejected the most efficient and effective model that would achieve that goal – single payer improved Medicare for All. Although he proposes policy patches to our current system, those measures are not adequate to correct the severe dysfunctions in our financing system and will still leave an unacceptable number of us without adequate coverage.

The authors state that we need “a reimagined framework for global health that prioritises health-system integration across UHC and GHS domains, innovative and unified health financing, cross-sector resilience indicators, and equity as a core value.” With our wealth and our renewed pledge for cooperative leadership in the world, the United States should lead the way.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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