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COVID-19: transformative actions for more equitable, resilient, sustainable societies and health systems in the Americas
  1. Carissa F Etienne1,
  2. James Fitzgerald2,
  3. Gisele Almeida2,
  4. Maureen E Birmingham3,
  5. Monica Brana1,
  6. Ernesto Bascolo2,
  7. Camilo Cid2,
  8. Claudia Pescetto2
  1. 1Office of the Director, Pan American Health Organization, Washington, District of Columbia, USA
  2. 2Department of Health Systems and Services, Pan American Health Organization, Washington, District of Columbia, USA
  3. 3Office of the Representative, Pan American Health Organization Representation, Argentina, Buenos Aires, Argentina
  1. Correspondence to Dr James Fitzgerald; fitzgerj{at}

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Summary box

  • COVID-19 has exposed structural deficiencies in health, social and economic policies and sectors in the Americas impacting the resilience of health systems and societies.

  • Due to the pandemic, the region of the Americas is facing unprecedented challenges in the health, economic and social sectors, intensifying inequalities already present in the region.

  • Strategic areas for priority action moving forward include (1) realignment of core values in favour of health and social development with economic development; (2) prioritisation of and investment in health, social cohesiveness, social development and protection, and (3) transformation of health systems based on primary health care.

  • Key actions that promote needed change comprise (1) elevating health as a priority, essential for human security, as a driver for economic and social development; (2) prioritising integrated policy development and planning; (3) transforming health systems to achieve universal health and human security; (4) investing in science, technology and innovation to ensure equitable access to medicines and other health technologies; (5) strengthening the essential public health functions and risk reduction and mitigation.


The COVID-19 pandemic has resulted in terrible loss of life, disproportionately impacting the poor and those with underlying health conditions, devastating lives and livelihoods as a consequence of its effect on economic activity. Weak health system responses, chronic and longstanding underinvestment, and inadequate policies to tackle the root causes of inequity that most affect those living in conditions of vulnerability to access needed health and social services have exacerbated the problem. In addition, this pandemic has confirmed the precarious relationship and interdependence of health and the economy in the context of a disease outbreak.1 2 The impact on economies and sustainable development is evident, with COVID-19 uncovering the structural deficiencies and inequities in access to health services and social protection. The region of the Americas, similar to the rest of the world, is already experiencing a deepening economic crisis caused by the COVID-19 pandemic and the necessary measures for its mitigation. The most recent forecast3 suggests a global contraction of 4.9% and a Gross Domestic Product decline in the order of 9.4% for Latin America and the Caribbean, with the greatest losses registered by Mexico at 10.5% and Brazil at 9.1%. Although a gradual recovery is projected in 2021, this recession constitutes the worst economic crisis in the past 80 years. The region will face unprecedented challenges in fiscal, monetary and social protection policy, intensifying the inequalities already present in the region.

As the Americas persistently remains one of the most impacted regions globally by COVID-19 and one of the most inequitable in terms of income distribution and access to health, this pandemic has laid bare the core values on which societies have been built and exposed the inextricable interdependency between health, well-being and the economy. A healthy economy cannot exist without healthy people, and the health and well-being of people depend on an inclusive, sustainable economy and social development policies that benefit all within society. As we begin to realise that this health crisis may remain over time, there is a growing consensus on the need to critically look at the future in terms of health, social and economic policy.4–6 Fundamental changes are required in how we approach health and development objectives from the perspective of health and economic security, and on the basic principle of the guarantee of rights, protections and access to health, so that people and societies can be protected and survive in the face of multifaceted threats and risks—biological, natural or economic in nature.

Resilient health systems and societies

The capacity to respond globally to a pandemic depends on health governance and the ability of health systems to respond at the national and local levels in a coordinated manner. Fragmented, segmented and poorly organised and financed health systems that do not meet the needs of its people under normal circumstances, will not have the capacity to respond to their needs in the face of major public health emergencies.7 8

COVID-19, HIV/AIDS, H1N1, Middle East respiratory syndrome, severe acute respiratory syndrome, Zika, Ebola and measles, among others, remind us that disease outbreaks will continue to occur, and countries should always be prepared for them. The impact of these outbreaks has largely depended on how health systems are organised and financed, and their capacity to prepare and rapidly adapt and respond to the threat at hand. These are the attributes of a resilient health system. The broader impact of a pandemic or similar threat on a society and the economy depends on the confidence of the people in the actions taken by their government, on the balance in values and policies promoting health, well-being and wealth, and the willingness of society for collective action, to pool resources and risk while protecting its population, especially the most vulnerable. These are the attributes of a resilient and cohesive society.7 9

Many countries in the Americas have made progress in the development of resilient health systems and societies in the last 50 years, recognising health as a right and as a prerequisite for social and economic development and stability. The Sustainable Development Goals (SDGs) 2030 (, adopted by countries in 2016, is an expression of political commitment to build resilient, sustainable and inclusive societies that focus on the elimination of poverty while adopting hand-in-hand strategies to promote health, education, economic development and well-being. The region has actively engaged the private sector as a partner in achieving the SDGs in key areas of implementation and innovation, seeking large-scale solutions to the large-scale complex challenges.

While recognising progress, however, actions in many countries have largely been timid, with glaring gaps in policy and action being exposed by COVID-19. Policies favouring economic growth are predominantly prioritised region-wide, with social development and health policies being relegated as second-tier. The imbalance between economic, health and social policy contributes to the persisted poverty and inequities in the region.

Fiscal priority for health and public expenditures in health have been persistently low, with investments in health systems, public health and the social determinants of health being insufficient to address the needs of the population.2 While social protection mechanisms have had some success in alleviating poverty and improving health, action has not been sustained, producing mixed results. Progress has been slow in addressing the informal economy in many countries in the region, impacting the implementation of economic, social development and health policies.10

Strategic areas and key actions for transformation post COVID-19

As efforts continue to mitigate against COVID-19, countries in the Americas will soon be required to envision a post-COVID-19 development era to prioritise, build and embed resilience within societies and health systems, within the context of the SDGs. The resilience of health systems and societies in the mid to long term will depend, in part, on countries’ capacity to address three strategic areas: (1) realignment of core values—rebalancing societal core values in favour of health, social cohesiveness and development with inclusive and sustainable economic development; (2) prioritisation and investment in health, social development and protection, and (3) transformation and investment in health systems to ensure preparedness in the face of external threats while at the same time ensuring universal access to health and universal health coverage (universal health).

The foundations for action in each of the above strategic areas already exist. Side-tracking from evidence-informed strategies will divert the time, money and effort needed to address the pandemic and strengthen our systems. COVID-19 has shown to us the intrinsic inter-dependency between health, social protection and the economy within a society and the urgent need for structural transformation to achieve joint prosperity. Structural and transformative actions will, however, require strong political leadership and significant investment to affect change. Given the current scenario and the evidence available, the implementation of the following key actions is needed to achieve joint prosperity: (1) elevating health as a human security, economic and social development issue; (2) prioritising integrated policy development and planning; (3) transforming health systems to achieve universal health and human security; (4) investing in science, technology and innovation to ensure equitable access to medicines, vaccines and other health technologies; and (5) strengthening the essential public health functions and the national capacity in risk reduction and mitigation. These actions, further described in table 1, provide a way forward to address the crises at hand, and strengthen our health systems and societies.

Table 1

Key actions for transformation


The post COVID-19 era cannot be characterised by a return to ‘business-as-usual’. The fissures exposed in the capacity of countries to respond to this pandemic and deal with future disease outbreaks and emergencies, and their catastrophic impact on health, social protection and the economy require leaders to renew their thinking and establish a new social contract at the national level and across multiple sectors. In addition to the immediate response, countries will need to undertake a more profound, structural and sustained transformation to address the underlying causes that impact the capacity to weather the direct and indirect effects of different disasters and emergencies.

The proposals presented here are based on those adopted in different international agreements, frameworks and mandates of international agencies crossing multiple sectors. What is different here however is the full realisation that our interests in health, social, human and economic development do not have to compete against one another, nor destroy the environment or exacerbate climate change, but can coalesce around one another to move the region forward in the development of resilient, sustainable and inclusive societies and health systems in the Americas. If COVID-19 has shown us anything, it is that the protection and well-being of human life and meeting the critical needs of those living in condition of vulnerability are prerequisites to a future of sustainable development in the Americas.



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  • Contributors CFE, JF and MB conceived the paper. JF wrote the first draft. GA revised the paper extensively. GA, MEB, CC, EB and CP contributed to the initial draft and critically reviewed different versions of the manuscript. All authors contributed to the revision and final manuscript in its present form.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article.