Rethinking developed nations’ health systems through a social sustainability perspective in the light of the COVID-19 pandemic. A viewpoint

Abstract

This viewpoint paper argues for the need for more socially sustainable care systems that can better contribute to equitable utilization of health care in a post-pandemic era. Health care systems in developed nations need to rethink their role, particularly with regard to the achievement of Sustainable Development Goal 3 (SDG 3) as well as becoming more sustainable societies. Socially sustainable care systems will recognize that systemic factors and processes (social, economic, environmental, cultural) need to be addressed simultaneously in order to achieve health equity. Moreover, these systems are likely to be of paramount importance for post-COVID-19, because of the potential increase in demand for health care due to forgone health care and the increased burden of chronic diseases as spillover effects related to COVID-19 mitigation interventions.

Significance for public health.

The current COVID-19 pandemic is posing a challenge to health care systems in the developed world, as infections and deaths are occurring disproportionately among disadvantaged groups. We argue that in order to achieve health equity and a sustainable public and population health (in the context of Agenda 2030 and SDG3 in particular), health systems post-COVID-19 need to rethink their role and embrace a social sustainability perspective that will also consider the structural and systemic factors affecting health and health care.

Introduction

The COVID-19 pandemic, which started in China in December 2019, has now reached all continents and many countries are currently struggling to curb infection and death rates.¹ Globally, the novel coronavirus has infected 29,032,938 people and 924,831 have died because of the disease.² Up to date some of the most affected countries have been the US, the UK, Spain and Italy.^2,3 The pace of infection and death rates have varied widely and health care systems (and their health care workers) have been at the forefront of these situations so far. However, the pandemic has also exposed various problems affecting health care systems (e.g. reduced bed capacity; insufficient testing systems) across different countries and especially in Europe and the USA.^2,3

As agreed by many, health can be seen as essential for the achievement of sustainable human development (health as a human right)⁴ but also as an important factor for economic development. ⁴ This makes it a measure of the economic development of societies and an adequate measure for any nation’s progress towards sustainable development and achievement of United Nations (UN) Agenda 2030, particularly Sustainable Development Goal 3 (SDG 3), health for all at all ages.^4,5 Furthermore, health has an effect on any country’s development through increased productive employment, promotion of social cohesion and reduction of medical expenses.⁵

In any country, the health care system is expected to provide health care for all individuals, thus contributing to wellbeing and economic prosperity. In addition, the provision of health care should occur without contributing to influencing financial strain, poverty, or to social and health inequity outcomes for individuals and population groups.⁶ However, the COVID-19 pandemic has exposed the failures associated with the type of health care systems prevailing in some countries. Within this context, we can establish a contrast between how the health care systems in Europe and the US responded, and still do today, as the task of controlling the infection is still unfolding. Similar failures were seen across public health systems regarding disease testing, surveillance and contact tracing.^2,3 In European countries, health care is provided through a wide range of different systems run at individual national levels tightly regulated, and competing private health insurance companies, with government subsidies available for citizens who cannot afford coverage. This way, although under pressure as well as facing several other challenges (such as early unpreparedness and lack of personal protective equipment), countries have been able to provide care for all during the pandemic. For instance, Germany health care system is based on a compulsory social insurance that provides comprehensive health coverage to the entire population.⁷ On the other hand, France have a national health insurance system that provides coverage to all legal residents. It is financed by public social security and private health care financing, combined with a public-private mix in the provision of health care services.⁸ Italy health care system – although highly decentralized – provides universal coverage to the whole population through corporate and value-added tax revenues collected by the central government and distributed to the regional governments, which are responsible for delivering care.⁹ Although the above mentioned differences between countries and the challenges they are facing with regard to increased health care costs (due to aging population, increased chronic disease co-morbidity, inequalities in access to care, etc.), European countries have been able to provide universal health care to their citizens during the pandemic.^6,7 By contrast in USA, the Affordable Care Act (ACA) was enacted in 2010 to establish “shared responsibility” between the government, employers, and individuals with the purpose to ensure that all USA citizens have access to affordable and good-quality health insurance. However, as compared to other developed nations, the USA health care system is fragmented; with a myriad of various private and public sources with gaps in rates of insured people across the country. For instance, in 2014, fortyeight per cent of the country health care spending came from private entities, twenty-eight percent from households and twenty percent from private business. In addition, twenty-eight per cent was accounted by the federal government while seventeen percent by state and local government.⁷ During the COVID-19 pandemic the system is experiencing more difficulties than the European systems to care to its citizens, especially as unemployment soared and, with it, massive loss of individual insurance.⁷ According to Schwartz, the US health care system is more an illness profit system in which the first priority is profit.¹⁰ The argument here is that the US care system is primarily an economic system rather than a system aimed to foster individual and social wellbeing, which looks at health as a human right.¹¹ However, exceptions to the above are the Medicare federal program that provides health coverage for those individuals who are 65+ or under 65 and have a disability (no matter their income) and Medicaid (a state and federal program that provides health coverage for those having a very low income).⁷

The differences in the systems of care are likely to be one of the reasons for the observed discrepancies in the rates of infection and death between Europe and the US. However, across both systems we have seen similarities in the degree of inequality of COVID-19 outcomes, being more severe across disadvantaged sections of the population. For instance, in the UK and US, minorities of colour are dying disproportionally from the disease as they are more likely to live in disadvantaged neighbourhoods (with high levels of pollution and crowded living conditions) and also bear the brunt of high rates of chronic co-morbid diseases such as diabetes, hypertension and cardiovascular disease.^12-14 This viewpoint paper argues for the need for more socially sustainable care systems that can better contribute to equitable health care in a postpandemic era.

Health systems sustainability

In recent years and within the context of Agenda 2030, organizations have been challenged to become more sustainable and to undo the impact they have had, and still have, on the planet, economies and people. Sustainability entails three interdependent dimensions: i) economic; ii) environmental; and iii) social, in pursuit of sustainable objectives.^15,16 Health systems sustainability involves a system maintaining itself and constantly adapting to a changing social, economic and environmental context, making sure that limited resources (physical, financial and human) are being used efficiently and responsibly in order to permanently maintain or improve the health and wellbeing of the population as a whole and of each individual.^16,17 Furthermore, a sustainable health system needs to be understood in terms of three important elements: i) accessibility for each individual; ii) mutual acceptance between patients and the nursing, medical and administrative staff; and iii) adaptability, as health systems need to be able to adapt to the socio-economic and demographic changes, to new illnesses, and to scientific discoveries and dynamic technologies needed to remain viable.^16,17

A socially sustainable health care system is one that mobilizes and allocates sufficient, and appropriate, resources (human resources, technology, information and finance) for activities that meet individual and public health needs. In delivering services, health care organizations need to operate in a way that takes into consideration the priorities of their stakeholders and partners so that they can achieve their organizational goals, which is an essential component of being a socially responsible entity.¹⁸ Also, in the context of social sustainability, health care organizations need to promote person-centred care as a provider-client relationship in which the patient has an expectation to receive benefits and/or reduced costs. A mutual belief in social exchange is expected to reduce the barriers to social sustainability.¹⁸

A sustainable approach to health systems is needed now and in the post-COVID-19 era to ensure that health care delivery will remain safe and of high quality, but also will be accessible to all segments of the population, especially the most disadvantaged who, as mentioned above, are dying (and will continue to die) at disproportionate rates during the ongoing pandemic. Importantly, a socially sustainable approach to health care systems will be more attentive to social responsibility as well as to the ethical and moral aspects of health and wellbeing. For instance, with such an approach, the health care system will not be the sole key driver of health and wellbeing outcomes (as is currently the case in the US). This would mean a health system that recognizes that other systemic factors and processes (social, economic, environmental, cultural) need to be addressed simultaneously in order to achieve health equity. These systemic factors are known as the “social determinants of health” (the conditions in which people are born, and grow, live, work and age), which strongly influence accessibility to health care in every country regardless of its current stage of development.^19,20

Health systems post COVID-19

Health care systems in developed nations, need to rethink their role, especially with regard to the achievement of SDG 3 and contributing to Agenda 2030.This will be even more important in the post-COVID-19 era because of the likelihood of a potential increase in demand for health services due to i) forgone health care (due to individuals’ lack of income to pay for treatment and medications, consultations and other services); and ii) the increased burden of chronic diseases as spill-over effects related to COVID-19 mitigation interventions aimed to the outbreak (e.g., social isolation, strain on social networks, and job and income losses). Here, social sustainability of health systems will help as health care organizations will need to be redeployed as a consequence of shortterm reductions in the availability of human resources for health, due to disease risk and job stress associated with fighting the infection (e.g., medical and nursing personnel stress, anxiety, depression and post-traumatic stress disorder).^21-23 Furthermore, based on WHO recommendations, several measures need to be implemented by health systems worldwide in order to strengthen their responses to pandemic events (e.g., the capacity of communication networks, increasing intensive care unit capacity, protecting the physical and mental health of health care workers, assessing and mitigating financial barriers related to access to care, etc.).²¹

In many countries, as the pandemic still unfolds, with a resurgence of cases (due to the massive natural experiment of reopening economies), government expenditure on health care is likely to be strained.²⁴ Ozili argues that the measures to mitigate the spread of the COVID-19 pandemic (social distancing and shelter in place) affected economies with an impact on financial markets, business and events, as well as corporate offices. In addition, he suggested that the exponential rate of the COVID-19 spread and uncertainty led to flight to safety in consumption and investment among consumers, investors and international trade partners.²⁵ Several countries, even industrialized ones might experience reduction in tax revenues linked to economic disruptions, and economic debt from unprecedented economic measures to remedy the pandemic effects (e.g., liquidity support for business organizations, salary supplementation schemes), which may require large-scale sovereign debt financing.^25-27

Conclusion

The current pandemic has challenged health systems in developed countries with a variety of outcomes due to differences in the systems of care. We expect that experiences and lessons from the COVID-19 pandemic will serve as catalyst for developed countries to rethink their systems where social equity is a priority. To have equity as basis for action in health care accessibility, availability and treatment will be a catalyst for socially sustainable health systems for today and future generations. This would mean that countries would have health systems where everyone has coverage for and access to the care they need, at affordable costs. Socially sustainable health systems will in turn contribute to sustainable societies as well as the achievement of SDG 3 and Agenda 2030.