I recently had the honor of serving as a panelist in plenary session 5 “Health systems fit for the future: promoting better health, economic growth, and social cohesion”, that was held virtually as part of the 16th World Congress on Public Health: “Public health for the future of humanity: analysis, advocacy and action”, on October 15th, 2020. 

While all the participants in the Congress regretted not having been able to travel to Rome, the Eternal City, and participate in person due to the COVID-19 pandemic, the organization of the virtual event was flawless.  So, our sincere congratulations are conveyed to the organizers for a job well done!

My session was chaired by Prof. Walter Ricciardi and Prof. Sheila Dinotshe Tlou, Co-chairs of the  16th World Congress on Public Health, and included as my fellow panelists Natasha Azzopardi Muscat, Director for Country Health Policies and Systems at the WHO Regional Office for Europe and Immediate Past President of the European Public Health Association (EUPHA); Sara Cerdas, a Portuguese medical doctor and since July of 2019 a Member of the European Parliament; Katie Gallagher, Senior Policy Adviser, European Patients’ Forum; Rüdiger Krech, Director, Department of Health Promotion, World Health Organization; and Gita Sen, Director of the Ramalingaswami Centre on Equity and Social Determinants of Health at the Public Health Foundation of India and Adjunct Professor of Global Health and Population at the Harvard T. H. Chan School of Public Health.

In my presentation, I conveyed three action points to address the overarching questions guiding the discussion in the session.  These were:

Question 1:  How can we improve health, wealth, and societal well-being by investing in health systems?

Action 1:  Prevent, detect, and respond to the threat posed by zoonotic diseases and strengthen national systems for public health preparedness

The worldwide spread of COVID-19 is demonstrating the impact that infectious diseases of animal origin can exert on global health and development.  More than 70% of new infectious diseases are zoonotic.  The COVID-19 pandemic is currently affecting 188 countries and territories across all regions.  As of mid-October 2020, more than 37 million confirmed cases and more than 1 million confirmed deaths have been reported.

Besides growing numbers of infected people and loss of life, the pandemic has caused an economic free-fall not experienced since World War II.  International Monetary Fund (IMF) estimates show that 170 countries will see income per capita go down.  And  World Bank Group projections suggest that rising unemployment and loss of income, including in some countries a significant drop in remittances, could push between 88 million and 115 million people back into extreme poverty as a result of the pandemic, with an additional increase of between 23 million and 35 million in 2021, potentially bringing the total number of new people living in extreme poverty to between 110 million and 150 million. 

The pandemic is also putting at risk the past decade's progress in building human capital, including gains in health, survival rates, school enrollment, and reduced stunting. The economic impact of the pandemic has been particularly deep for women and for the most disadvantaged families, leaving many vulnerable to food insecurity and poverty.

The COVID-19 pandemic, therefore, is a stark remainder of the ongoing challenge of emerging and reemerging infectious diseases and the need for constant disease surveillance, prompt diagnosis, and robust research to understand the basic biology of new organisms and our susceptibilities to them, as well as to develop effective countermeasures to control them.

A critical long-term aspect of the response is strengthening and building a resilient health system able to manage similar future health system shocks by supporting the realization of the universal health coverage (UHC) agenda, which includes timely access to health care when needed, financial protection, and disease prevention and preparedness. To this end, the universal health coverage agenda needs to strengthen its focus on prevention to help guide investments, identify and prioritize the biggest risks, and promote pandemic preparedness for future outbreaks building upon the One Health Strategy.

Question 2: Which investments inside and beyond the health system should be performed to increase quality and reduce inequities? 

Action 2:  Avoid the false dichotomy between physical health and mental health

In this midst of a global pandemic, this year’s World Mental Health Day campaign called for greater investment in mental health. This is timely and justified. Recent estimates suggest that most low- and middle-income countries spend less than $2 per person on the treatment and prevention of mental and substance use disorders – and this was prior to the global outbreak of the novel coronavirus.

A fundamental rethinking is needed to overcome the false dichotomy between physical health and mental health in health services. Mental health parity must be placed at the core of human capital development.  The social cost of mental illness and substance use disorders – which compound the impact of poor physical health – are terribly high for individuals, families, communities, and the economy. Yet the cost of effective treatments is surprisingly low.

We must be wary of siloed approaches to increased mental health funding. Rather, governments can mobilize new resources and leverage existing funding streams by integrating mental health interventions into existing service delivery platforms across sectors.

There are numerous potential cross-sectoral entry points that would align funding, service provision, and population needs:

(i) Integrating mental and physical health services at primary health care and community levels

(ii) School-based and youth interventions are critically important because 75 percent of mental and substance use disorders begin before age 25, and suicide is a leading cause of death among youth

(iii) Integrating mental health into wellness programs in the workplace can mobilize private companies to invest in health promotion activities

 (iv) Programs in fragile and conflict-affected settings can be leveraged to mainstream integrated physical and mental health interventions alongside other social services to address the needs of displaced populations and refugees

(v) Microcredit schemes to provide low-interest, small business loans, training, and mentorship to entrepreneurs with a history of mental health or addiction challenges (including former prisoners), facilitate reintegration into the community

Question 3: How can we guarantee that health systems are sustainable, resilient, and accessible?

Action 3: Pro-health taxes reduce health risks, expand fiscal space for universal health coverage, and enhance equity

Taxes on tobacco, alcohol, and sugar-sweetened beverages are effective but underused policies of disease prevention and health promotion, that could also help mobilize additional government revenue to fund investments and programs that benefit the entire population and enhance equity.

Raising taxes on tobacco, in particular, can do more to reduce premature mortality than any other single health policy. The evidence across a wide range of countries shows that a 50% increase in cigarette price typically leads to a 20% decline in cigarette consumption. Lowering consumption reduces tobacco-attributable sickness and death: about half of this effect comes from current smokers quitting and the other by reducing smoking initiation among young people.  Taxing alcohol and sugar-sweetened beverages helps to reduce consumption and prevent the onset of related chronic diseases such as cardiovascular diseases, cirrhosis of the liver, obesity, and diabetes. Moreover, taxation to increase the price of alcohol products, along with strict enforcement of drunk-driving laws, can help reduce the high human and economic cost of road traffic injuries, fatalities, and domestic violence. 

Emerging evidence shows positive health impacts from sugar-sweetened beverages taxes by reducing consumption and hence helping to control the growing obesity epidemic and its impact on NCDs.
Tobacco, alcohol, and sugar-sweetened beverage taxes can substantially boost government revenues.  This is of critical importance during COVID-19, as policymakers must maintain their public health responses while also mobilizing domestic revenue for investment in future pandemic preparedness and other essential health services.

These health tax increases would have the additional advantage of reducing future health care costs by curbing the growth of the non-communicable diseases that tobacco, alcohol, and sugar-sweetened beverages can cause.  Elimination of fossil fuel subsidies, which impose large fiscal costs while adding to negative environmental and health impacts, could also help expand fiscal space for health. 

Projections presented in a World Bank Group report for the G-20 meeting in Osaka, Japan in 2019 showed that the substantial UHC financing gap in low- and lower-middle-income countries (now exacerbated by COVID-19), can be attenuated by excise tax increases on tobacco, alcohol, and sugar-sweetened beverages. These calculations showed that a 50% increase in prices for these products could generate additional revenues of approximately $24.7 billion in 54 low- and middle-income countries by 2030.  Importantly, the revenue raised can additionally benefit poorer households when it is used progressively.

Take Away Message

As voiced by my fellow panelists during the session, it should be clear to all going forward that high-quality health systems include not only the right to quality health care but also equity. Evidence-based, cost-effective investments and rigorous assessment are key to guarantee high quality health systems for all.