Global Health and the Challenges of Prevention – From EU to UN Emergency Preparedness Mechanisms

As we are already aware – or, we may definitively assess on our daily bases experience – that the Covid-19 Pandemic has changed our perception around that we already thought about the topic “emergency”, “health”, “global” and “virus”; and from both sides, personally and collectively. The Covid-19  pandemic has created the “impetus” for a European strategy to better prepare for, and respond to, different health emergencies. To quote the European Commission President von der Leyen, when Covid-19 hit Europe in March 2020, “too many [EU Member states] initially looked out for themselves […], too many initially gave an ‘only for me’ response”. To be better prepared in the future, the European Commission has put forward ambitious plans for a European Health Union, to protect the health of EU citizens and respond to cross-border health threats.

Now that we can clearly acknowledge and agree that Covid-19 will not be the last world’s last public health emergency we will have to face Based on this assessment, Europe needs to be better prepared to anticipate and address jointly, the ongoing and increasing risks, not only of pandemics but also of man-made threats such as bioterrorism or chemical macro-incident. For sure, every community, from any level or dimension, may need to prepare new response- mechanism to be able to face unthinkable or un- imaginable threats and hazard that may crack or even weaken the EU way of life.

The best hope to manage future health crises is to anticipate and prepare before that any sort of hazard can materialise.

The new Health Emergency preparedness and Response Authority (HERA ¹) is a new panel that is being set up to strengthen Europe’s ability to prevent, detect, and rapidly respond to cross-border health emergencies, by ensuring the development, manufacturing, procurement, and equitable distribution of key medical countermeasures ².

The core mission of HERA will be:

– to strengthen health security coordination within the Union during preparedness and crisis response times, and bringing together the Member States, the industry and the relevant stakeholders in a common effort;
– to identify and address potential vulnerabilities and strategic dependencies within the Union related to the development, production, procurement, stockpiling and distribution of medical countermeasures;
– to contribute to reinforcing the global health emergency preparedness and response architecture.

HERA will be established within the Commission as a shared resource for Member States and EU alike. Establishing HERA within the Commission will allow for a swift operationalisation by early 2022, flexibility in its organisation and the mobilisation of the Commission’s existing powers, tools and programmes. HERA has been defined as a “key pillar of the European Health Union” ³ as announced by President von der Leyen in her 2021 State of the Union address “and will fill a gap in the EU’s health emergency response and preparedness”. The Health Union ⁴ will be funded with a sizable EUR 5.1 billion over a seven-year period (2021- 2027), a total that is ten times larger than the previous health budget. The proposals include extending the mandates of the European Medicines Agency (EMA ⁵) and the European Centre for Disease Prevention and Control (ECDC ⁶) and revising the Regulation on serious cross-border health threats. The EU Health Emergency Preparedness and Response Authority (HERA) was also announced as part of this package – framed by President Ursula von der Leyen as an Authority to be modelled on the US Biomedical Advanced Research and Development Authority, BARDA⁷.

Based on an interesting evaluation study on the EHRA’s effective ability to realistically meet the needs of affected communities during an emergency health crisis by the Federation of European Academies of Medicine, (FEAM ⁸), we may try to summarise the following main points that could define the role, and task of HERA:

• HERA needs to be focused, yet at the same time, flexible enough to deliver results, build credibility, efficacy, and consider the long-term implications and risks In the short-term, HERA should seek to understand in detail and remedy the gaps at a European level on medical countermeasures for pandemic preparedness and response. HERA must ensure these are accessible to low and middle-income countries. At the same time, it should be realistic about what it can achieve with the limited funding available.
• HERA’s structure, remit and funding must be ambitious and flexible enough to react in scenarios different from the Covid-19 context.
• In the mid to long term, the Commission should analyse all cross-border health threats facing European citizens and propose a larger ambition role for HERA. Activities, that HERA pursues in the future should be defined after an in-depth gap analysis.
• The creation of HERA is an opportunity to harmonise the European research and development biomedical landscape for pandemic preparedness and rapid response capacity.
• HERA should formalise and coordinate end-to-end oversight for R&D efforts across the EU during health emergencies.
• HERA must maintain expertise and resources be- tween crises. HERA should embed a One Health approach.
• HERA must be collaborative to build on strengths in the EU health and research system.
• HERA must work closely with other EU institutions (including European health-related agencies), initiatives and programmes to enable and amplify, rather than detract from, existing activities.
• HERA must work closely with Member States to build legitimacy and trust, incorporating and sharing national expertise.
• HERA must build and maintain relationships between crises so that in emergencies it can respond quickly in collaboration with trusted partners.
• HERA must prioritise building strong relationships with industry.
• HERA must build a broad base of support to be effective and to gain trust.
• HERA must be global in its approach to health threats to reflect European values, by embedding collaboration and access in its work.
• HERA must take a global approach to emergency preparedness and rapid response capacity.
• HERA should prioritise equitable access in its funding and operations.

International Context

1.1 Universal Health Cover- age (UHC)

– Universal Health Coverage (UHC) ⁹ means that all individuals and communities receive the health services they need without suffer- ing financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the full life course.

– The delivery of these services requires sufficient staffing of skilled and competent Health and Care workers with an optimal skills mix at facility, outreach and community level, and who are equitably distributed, adequately supported and enjoy de- cent work conditions. The UHC strategies will need to enable everyone to access the services that address the most significant causes of disease and death and ensures that the quality of those services are good enough to improve the health of the people who receive them.

– These challenges are as relevant in low and middle income countries, so that expanding coverage also translates into better health outcomes for all.

– Protecting people from the financial consequences of paying for health services out of their own pockets reduces the risk that people will be pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow – destroying their futures and often those of their children¹⁰.

1.2 How can countries make progress towards UHC?

– Many countries are already making significant progress towards UHC, although everywhere the Covid-19 pandemic impacted the availability the ability of health systems to provide undisrupted health services.

All countries can take actions to move more rapidly towards UHC despite the setbacks of the Covid-19 pandemic, or to maintain the gains they have already made. In countries where health services have traditionally been accessible and affordable, governments are finding it increasingly difficult to respond to the health needs of the populations and the increasing costs of health services.

– The Covid-19 pandemic dramatically demonstrated the invaluable role of the health and care workforce and the importance of expanding investments in this area.

– To meet the health workforce requirements of the SDGs and UHC targets, over 18 million additional health workers are needed by 2030. Gaps in the supply of and demand for health workers are concentrated in low and lower-middle-income countries. The growing demand for health workers is projected to add an estimated 40 million health sector jobs to the global economy by 2030.

– Investments are needed from both public and private sectors in health worker education, as well as in the creation and filling of funded positions in the health sector and the health economy. The Covid-19 pandemic, which has initially affected the health workforce disproportionately, has highlighted the need to protect health and care workers, to prioritize investment in their education and employment, and to leverage partnerships to provide them with decent working conditions.

– UHC focuses not only on what services are covered, but also how they are funded, managed, and delivered.

A fundamental shift in service delivery is needed such that services are integrated and focused on the needs of people and communities.

This includes reorienting health services to ensure that care is provided in the most appropriate setting, with the right balance be- tween out and in-patient care and strengthening the coordination of care.

– Therefore, to achieve SDG target 3.8 of Universal Health Coverage for all by 2030, at least 1 billion more people will need to have access to essential health services in each five-year period between 2015 and 2030.

– The efforts of UHC is to create an universal access to a strong and resilient people-centred health system with primary care as its foundation. Community-based services, health pro- motion and disease prevention are key components as well as immunization, which represents a strong platform for primary care upon which UHC needs to be built.

1.3 Can UHC be measured?

The answer is YES the monitoring progress towards UHC should focus on 2 things:

– The proportion of a population that can access essential quality health services (SDG 3.8.1).

– The proportion of the population that spends a large amount of household income on health (SDG 3.8.2).

Measuring equity is also critical to understand who is being left behind, where and why. Together with the World Bank, WHO has developed
a framework to measure and track the progress of UHC by monitoring both categories, taking into account both the overall level and the extent to which UHC is equitable, offering service coverage and financial protection to all people within a population, such as the poor or those living in remote rural areas.

OECD Perspective About Global Health And Its Impact At National Level

According to OECD last report “Healthy for everyone?”¹¹ good health is a key component for the well-being of a population. Well-being doesn’t necessarily mean only to be not be medically ill but to consider the individual in a holistic approach: “the influence on social, education and labour market outcomes – being in good or bad health has also wider implications on people’s chances of leading a fulfilling and productive life output”.

Inequalities in health system access create a massive impact in living and working conditions and in behavioural fac- tors¹² at all levels and in a great part of the world, especially in the South-south cooperation.

A general overview on that can be picked up looking at the OECD Health Database which offers the most comprehensive source of comparable statistics on health and health systems across OECD countries.

It is an essential tool to carry out comparative analyses and draw lessons from international comparisons of diverse health systems ¹³.