The beating heart of health systems
Health workers are what make a health system resilient – but we cannot test them again in the way they have been tested during the Covid-19 pandemic
The Covid-19 pandemic is severely testing the resilience of health systems the world over – from the first months of the initial onslaught, through the waves that continue to this day.
Health systems are as strong as their component parts, and health workers are the beating heart. Health system resilience is commonly defined as the ability to prepare for, manage and learn from shocks – this is the job of people.
Despite predictions of a new pandemic threat, it was nonetheless a shock when a new virus, reported and acted on too late, had the ability to overwhelm some of the best-equipped hospitals in the world. We watched in horror as nurses and doctors, some wearing garbage bags for lack of gowns, did their utmost to care for increasing numbers of patients. They held dying patients with one hand and a tablet in the other to connect those people to say goodbye to their families. At the end of their shifts, those exhausted health workers pulled off their masks to reveal bruising around their eyes and welts across the backs of their ears. They went home to sleep separately from their families, if they went home at all.
As co-chair of the Independent Panel for Pandemic Preparedness and Response, I heard from front-line health workers from around the world. Many midwives, who provide essential, safe maternal and neonatal care, told us they received no personal protective equipment. They had to buy their own, reuse stock or otherwise improvise. Nurses, already facing a global shortage of more than six million personnel at the outset of the pandemic, told us about their resilience and ability to organise new ways of working almost overnight, and about their mental stress. “Nurses were there and ready to work,” a nurse leader from Ghana told us. “But they also had a lot of fears as there was so little known about the virus.”
Impact on mental health
In one survey from the early phase of the pandemic, almost half of the health workers reported serious psychiatric symptoms, including thoughts of suicide. Health workers also reported an increase in their perception of incidents of violence against them at work, including physical aggression. The World Health Organization estimates up to 180,000 healthcare workers died due to Covid-19 in the first 18 months of the pandemic.
While prioritising Covid-19, health workers had no choice but to let other services take a back seat. Multiple WHO surveys showed disruptions to essential services in most country respondents throughout 2021. Data are beginning to show the longer-term impact: immunisation coverage globally dropped from 86% to 81%; tuberculosis deaths among people living with HIV increased for the first time in 13 years; closures of sexual and reproductive health services led to unplanned pregnancies, unsafe abortions, and preventable illness and deaths of women and children; cancers have been left undetected; and the pandemic has widened the mental health treatment gap. Behind these losses are health staff who were working overtime on Covid-19, and who now face a steep climb to reverse these setbacks.
Health systems in crisis
Today, many countries that were already experiencing health system challenges before the pandemic are in stages of health system crisis. Health workers are speaking out as they continue to battle waves of Covid-19, with decreasing political support and leadership. Too many are understandably burnt out, feel undervalued and are ready to leave professions in which they have invested their lives. We cannot afford to lose them – there is already a predicted shortage of 15 million health workers by 2030. The International Council of Nurses warns that an additional 2.5 million nurses may leave due to the ‘Covid effect’.
A resilient health system begins with its people. One lesson of Covid-19 is that people will do their utmost to stand strong in the face of an immediate shock, but that people cannot be expected to withstand the effects of a pandemic for years. We must care for the carers. Countries must take stock of the impact of this pandemic on their health systems, and in particular on the people at the centre.
The solutions will take time – whether better working conditions, better pay, incentives to work in rural areas, greater and more strategic enrolment of students and their involvement in practice, a more rapid pathway to licensing for people trained abroad, investment in community health workers and mental health supports. Solutions must also focus on the fact that women make up 70% of the health workforce – and that now is the opportunity to provide better pay, better conditions, a harassment-free environment and a place at the decision-making table.
Another solution is to dramatically reduce the risk of a new pandemic shock. A new health threat should not become a raging pandemic, and the Independent Panel found that Covid-19 could be the last pandemic of such devastation.
We recommended that a package of interlinked actionable reforms be implemented globally and nationally, to transform the system for pandemic preparedness and response. These include new finance; modern surveillance systems; a more independent, stronger WHO that has the authority to report global health threats rapidly; an equitable, end-to-end platform for pandemic countermeasures; all guided by a global high-level leadership council that would sustain momentum. Several reforms along these lines are under way – albeit slowly and in a piecemeal fashion.
We also recommended that countries invest in health and social protection to build resilient systems – and that these should be grounded in high-quality primary and community health services, universal health coverage, and a strong and well-supported health workforce, including community health workers.
People are what make a health system resilient. Health workers are some of the most resilient among us. But their resilience should never need to be tested again in the way it has been during this pandemic.
