It was a workday in late June when Hasfat Alkali Yerima heard a rumor: A COVID-19 patient was on the way to her hospital. This was in Damaturu, the capital of Yobe State in northeastern Nigeria, where she had been employed for four years as a health worker.
Like all health workers, Yerima is a core functionary of the country’s primary health care system, one of the frontline workers who perform the basic, essential tasks: Giving children vaccines, treating people for malaria, or counseling pregnant women for their prenatal checkups. On the day of the rumor, however, there came a point when Yerima was doing none of these things.
Instead, she was watching as the hospital emptied itself of patients. Rumor of an imminent coronavirus case had somehow spread among the wards. Fearing infection, patients ran from their beds and waiting area chairs, out the exits. In the rush, many left behind their “yellow cards,” which serve as a combination medical record and form of identification in the country.
Yerima hasn’t seen a single confirmed case of COVID-19—the rumored patient eventually tested negative—and yet, she said, “some clients still fear to come to our facility.”
A community that avoids the hospital isn’t getting needed care. But that health care problem could also reflect something else. The community didn’t trust that the hospital, its health care workers, or its medical resources could keep them safe from a single, possible, COVID-19 patient, which turned that one-day event into something larger. The lack of trust reveals a health system problem.
COVID-19 has proven to be massive disrupter of health systems of every size, shape, and location. In places like Damaturu, many hospitals are still too empty. In places like Italy, hospitals were overrun with COVID-19 patients in need of oxygen and ventilators. In the U.S., the pandemic has surfaced problems with everything from the supply chain for protective gear to the disparities in care that have caused a disproportionate impact on communities of color. These all reflect health system problems.
But amidst all of the tragedy this pandemic has unleashed, something else is happening, too: By forcing governments and others to really look at health systems, it’s revealing opportunities for change.
What is a health system?
It’s easy to look at health questions narrowly, almost like looking through the lens of a microscope. Someone working in health may consider questions like “Are pharmaceutical companies investing enough in HIV drugs?” Or, “Where are the disease hotspots?” Or, “How soon can we have a COVID-19 vaccine?” There’s great value in this hyper-focus on the diseases themselves. But all of these tangible, very measurable things also depend on an interconnected web of factors collectively called the health system. That’s the focus of people like Jean Kagubare, the deputy director of health systems design at the Gates Foundation. A health system, he says, “is all the elements needed to deliver the entire set of services that improve the health of a population.” If that sounds broad, it’s because it is broad. Further complicating the issue is that no two countries’ situations are exactly alike.
It helps, Kagubare notes, to think about a health system in terms of supply and demand.
The supply side is largely made up of service delivery. The vast majority of a person's experience with a health system revolves around primary health care, which is delivered by doctors, nurses, community health workers, and others, through health centers, hospitals, outreach programs, pharmacies, and telemedicine.
Take one illness: Malaria. In malaria treatment, the supply side would include the malaria drugs, the companies that make the drugs, the companies that make the vials to contain the drugs, the health care workers who prescribe or administer the drugs, the pharmacies that dispense the drugs, the hospitals that treat the sickest patients, the financing the pays for all of that, the data system that tracks which malaria drugs are most effective, and so on.
The demand side includes sick patients, of course, but it's also children in need of vaccines, couples seeking contraceptives to space pregnancies, pregnant women whose outcomes will be much improved by prenatal care, and more. The demand side is shaped to a large extent by trust, which can be increased by making the health system more responsive to client needs and by increasing accountability to the community. The demand side is also shaped by access, which can be increased by things like ensuring care is accessible and convenient or by subsidizing services for the poorest clients. By understanding clients' experience with and perceptions of the health system, providers can better respond to client needs. As Yerima saw in northeastern Nigeria, if trust in the system wavers, there can be lasting consequences.
The machinery of the health system, then, is what transforms pills in a vial to a measurable improvement in public health. It's where science meets patients, where health goals either succeed or fail. You have a breakthrough treatment? The make-or-break is a robust health system.
Here, we’ll focus on just two aspects of that complex health system web: The patients and the people on the ground, delivering care. Which means we’ll be focusing a lot on women.
Patient-centric care is woman-centric care
If you ask public health experts what metrics they use to measure success, they’ll tell you all about mortality rates and Sustainable Development Goals. “But nobody uses mortality rates at the community level,” said Dr. Sridhar Srikantiah, technical director of CARE India. Instead, they’re thinking about the patients themselves.
Understanding a health system from the perspective of its most vulnerable patient is important. In most countries, that patient is a woman. Not only are women 51% of the population with specialized health care needs of their own, they are also the primary caretakers in almost every society. So, when the children need vaccines, it’s almost certainly a woman who is giving up time—and in many countries, walking many miles—to take them to a clinic.
So, what does she need from her health system? In an advocacy campaign called What Women Want, White Ribbon Alliance did something radical: They asked. From 2016 to 2017, they polled 143,000 women in India about what they’d like to see in their health system.
“Most of the women were like, ‘Just let there be a doctor when I go to a public health facility—that’s what I want,’” said Debarshi Bhattacharya, Gates Foundation senior program officer in Bihar, India.
The women’s top “demands” from the Indian health system: access to maternal health care, including supplies and services (36%), dignity and respect (23%), availability of health providers (20%), as well as clean and hygienic health facilities (16%). When the What Women Want campaign spread to 113 other countries, the demands were strikingly similar.
It is perhaps unsurprising that these women’s expectations are so low. Despite the fact that 70% of health workers are women, the parts of health systems that exist primarily to care for women are often the most fragile and poorly funded. What’s worse, in times of crisis, these are often the first services to break down. That not only limits women’s health care; these kinds of breakdowns can sever important connections in the health system’s interconnected web.
When the Ebola virus broke out in Sierra Leone in 2014, for example, regional maternal mortality rates were the lowest they had ever been, thanks to an improved health system that included some level of prenatal care for almost every pregnant woman. After Ebola arrived, fewer expectant mothers risked going to health centers. As a result, in 2014, it’s estimated that more people in Sierra Leone died during or after childbirth than died of Ebola itself.
During the COVID-19 pandemic, gender disparities have already become apparent. Men are dying from the novel coronavirus at a higher rate than women, but the pandemic has threatened women’s lives and livelihoods in profound ways, from increased exposure to violence at home while quarantined to a higher rate of maternal mortality, due to reproductive services being deemed “inessential” care. In fact, modeling by Johns Hopkins suggests that cutting maternal and other health care in low- and middle-income countries could lead to 113,000 additional maternal deaths in this pandemic.
In highlighting health system components that just don’t work for women, COVID-19 could lead to other long-needed changes. For example, in many low-income countries, health systems have long followed a block schedule approach: Mondays are vaccination days. Tuesdays are for prenatal care, and so on. You can see why this doesn’t make sense. Many women need to see a health worker for more than one reason—and few can afford multiple days to do so. As Melinda Gates has noted, block scheduling is especially problematic in a pandemic “when no one should be spending any more time in a crowded waiting area than necessary.”
Even with COVID-19 as the focus, there are opportunities to change this. In the midst of the pandemic, in Bihar, India, health workers began to go door to door in April to collect information about how COVID-19 has been spreading in their state. Within four weeks, they'd reached almost 104 million people. And they used the opportunity to discuss family planning and screen pregnant people for health risks—a simple but crucial overlap of services that could make a huge difference for many local families.
The world needs more health care workers
COVID-19 has been a havoc-wreaker—and also an instructive adversary. “It’s finally putting an emphasis on what I call the ‘software,’” said Usha Kiran Tarigopula, the foundation’s deputy director of Global Health at the India country office. “The software is the people who deliver the care, as well as the organizational culture and work ethos they operate in.”
And yet, Tarigopula said, “It’s the software that gets overlooked the most often.”
In 2013, the WHO estimated there were 43.5 million health care workers globally, but that wasn’t near enough. Each region of the world has its own needs and its own particular shortages, and even within a given country or state, there can be great disparities between, say, rural and urban areas. Overall, the WHO estimates the world needs an additional 18 million health care workers. The shortages are particularly acute in parts of Africa, where their numbers may need to triple to meet population health goals.
Many developing countries put an emphasis on community health workers. Numbering some 5 million, they have less training than doctors and nurses but their portfolio is immense: They provide important preventative care, as well as basic treatment for conditions such as, malaria, diarrhea and pneumonia, and they refer patients further into the health system. They typically come from the community they serve and are among its best advocates.
And they can serve multi-faceted aims. A community health worker in the Kumbotso area of Nigeria, for example, travels door-to-door in villages to attend to basic health care needs. To put families at ease, she introduces herself with a gift: Soap. It’s an offering that both serves the household and the community’s larger health goals. A conversation about vaccines can then be had.
There is strong evidence that the community health worker model works: Patients receive more equitable care and better health outcomes, while community health workers get meaningful work within their own communities. Evidence has suggested that properly trained and equipped community health workers have helped reduce pneumonia death rates and under-five and maternal mortality as well as improve nutrition.
Just look at Rwanda and its response to another kind of crisis. In 1994, its entire health system was in ruins. The country was in the midst of a brutal genocide that claimed the lives of as many as 1 million people, including many of the country’s doctors and health workers. Many others fled. Then came more tragedy: The world’s highest child mortality rate and its shortest life expectancy.
Dr. Agnes Binagwaho spearheaded the rebuilding of Rwanda’s health system after the genocide. One of her first orders of business was to train thousands of community health workers who went from home to home to care for the poorest families. Chosen for the post by their own villages, the workers have built-in trust and accountability. And together, they began the work of rebuilding Rwanda’s health system.
Today, this system is a model for other countries. Infant vaccination rates top 97%—four times what they were in 1994. Everything from child and maternal mortality rates to AIDS, malaria, and tuberculosis deaths have dropped significantly.
As the world fights the novel coronavirus, many countries’ best hope to beat the virus lies in improving their public health system like Rwanda did.
Take India, which has both a public and a private health system. In the face of COVID-19, the former seems to be taking a proactive role.
In Bihar, for example, the private sector includes many mom-and-pop, 15- to 25-bed nursing homes. “The moment that COVID-19 hit Bihar, they shut shop,” said Bhattacharya. “The biggest reason was that their human resources—the people working in those private facilities—were typically semi-skilled at best."
While the public system also faces similar human resource issues, the government is nonetheless taking steps that could create a better system for the future.
“Frontline workers were knocking on people’s doors and asking them, ‘How many people are in your family? Did you have a cough or any symptoms?’" Bhattacharya said. "So very quickly, the government perhaps acquired a lot of public mindspace. What they do with it now is a huge opportunity.”
Caring for the care-givers
The global pandemic has also revealed other weak links in health systems that make it a challenge for workers to deliver care.
For example, women are often delivering the care as nurses, midwives, and community health workers, but it’s men who hold the vast majority of leadership positions within a health system. As a result, women’s perspectives and needs are often shut out of conversations on how to design a health system that works for the people who provide the care. As just one example: Female health workers have complained of ill-fitting respirator masks designed to fit larger (typically male) faces. Masks designed specifically for women just weren’t available.
In the United States, hospital doctors and nurses are protecting their families from COVID-19 by quarantining themselves in mudrooms, garages, or basements. But in low- and middle-income countries, very few homes have extra rooms. Many homes, in fact, are just one room.
The COVID-19 pandemic has made it harder for some health care providers to do their job in other ways, too. In Nigeria, because public transportation is limited, health care workers are forced to find new ways to get to work. For some, this means hiring an expensive dirt bike service that they can’t actually afford. So, health workers are put in an impossible position—forced to decide between going into debt or serving their community.
And right now, many African nations struggle to balance the needs of these workers as governments race to contain the coronavirus. Infections among health workers are spiking on a continent that already has a massive deficit of trained providers. The Washington Post recently reported that Nigerian doctors have gone on strike to demand masks and hazard pay, while Cameroonian nurses are ignoring their own fevers for fear of losing a paycheck.
Caregivers who can’t keep themselves or their families safe; who can’t get to work; who aren’t paid enough to do their job—these problems aren’t just bad for workers. These challenges can undermine entire health systems. Stopgap measures have been employed, but they’re neither sustainable nor strategic—and not just during this short-term crisis. As Dr. Binagwaho wrote of her experience rebuilding the Rwandan health system, “The lesson of the post-genocide period for Rwanda—and for countries around the world hoping for recovery from social upheaval of many kinds—is that a nation’s most precious resource is its people.”
Looking ahead
Right now, everyone wants to know how we get out of this pandemic. But another vital question is, how can we rebuild health systems that are able to confront not only the next pandemic but also any of the more common epidemics we face each day, such as HIV, malaria, and malnutrition?
Health systems experts like the foundation’s Kagubare are focusing on the data, to understand exactly what governments are spending their health dollars on and what they’re getting for their money. Are they investing heavily in community health workers? Are they focused on increasing vaccination rates? Are they improving their supply chains? “If multiple countries have found similar success,” said Kagubare, “we need to know what they’re doing.”
So far, it’s been difficult to pinpoint the exact levers to pull in order to manifest the health outcomes we hope to see. But data can already begin to help us understand which health systems are over- and under-performing. "Using just a simple X-Y axis," Kagubare said, “you can very clearly see which countries are getting the best health outcomes in return for their investments.”
Certainly, beefing up health systems would require major government investment, which can be a hard sell during a global economic crisis. But if it’s wisely spent, it’s a comparatively small investment in long-term well-being. We estimated that if 2% of the money committed to 2020 stimulus packages was devoted to health care, it would bring the world to the level of spending needed for our health systems.
In addition to more health care workers, a good health system requires disease monitoring systems, outreach, and delivery services, along with accessible, high-quality primary care. Improving population health also demands improvements in vaccination rates; better preventative programs such as maternal and child care; improved social circumstances that can affect health, such as safe housing, quality educational opportunities, and solid job prospects; and more.
“We need all of these on the front lines right now,” said Tarigopula, with the global health program. “What COVID-19 has done is help leaders recognize what their health systems don’t have. So, hopefully, this will be the forcing mechanism that will finally get them to put in place some systemic changes.” Already, she said, there are reasons to be hopeful. In 30 years of working in public health, “this is the first time I've seen political and administrative leaders, everybody up and down the chain, paying attention to health as an issue,” she said. “I think COVID-19 shows the incredible potential of even these most fragile systems to solve problems informed by the use of data. There’s an innate capacity that’s not being harnessed.”
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