How can bilateral and multilateral actors facilitate public health system strengthening?
Different countries are at different stages in developing their public health systems and NPHIs, and many are restructuring as a result of lessons learnt from COVID-19. This presents challenges and opportunities for WHO in its global public health system leadership role and for IANPHI, in support of its global network of member institutions. The balance of responsibilities between different actors in the public health system face significant change as each nation reflects on its COVID-19 response.
Countries such as Finland and the USA, which established their NPHIs decades ago, operate from a position of strength which comes from an established track record, making them a significant resource for knowledge and experience exchange globally. Countries with NPHIs that have recently undergone or are undergoing restructuring, such as Canada, China and the UK, can share lessons of their reorganisations, increasing understanding of the rationale, benefits and potential pitfalls of change.21 Resource-rich NPHIs, such as the Robert Koch Institute in Germany, Fiocruz in Brazil and Public Health England, have expertise in delivering the EPHFs as well as in international collaboration for capacity building, which enhances their ability to offer peer to peer engagement in support of others.22 However, important learning between NPHIs will also come from exchanges between NPHIs that are newly formed or working in low-resource settings, where the ability to travel and exchange experience with neighbours and peers is severely limited by work demands, limited funds and flexibility to invest time collaborating with others.23
At the regional level, the European CDC’s (Centre for Disease Prevention and Control) work is closely linked with that of NPHIs, Ministries of Health and public health research institutions within the European Union. This includes daily interaction with stakeholders through information exchange and sharing of analysis, guidance and technical assistance. The European CDC’s role as a regional, apolitical, scientific and technical agency includes providing the European Commission, European Parliament and national health policy-makers with the evidence needed for health policy, and can serve to inform models of regional public health capacity building. The African Union’s Africa CDC has made a commitment to promoting and strengthening functional NPHIs24 seeing them as critical for the implementation of the International Health Regulations (2005) which underpin global health security.25 Africa CDC also sees its role extending beyond health security and infectious disease control, with recent discussions on how the African Union can respond to the growing burden of non-communicable diseases. Building public health capacity to deliver the full range of EPHF is important, recognising that public health systems need to address both communicable and non-communicable disease as well as acting to reduce the impact of the broader determinants of health. In a similar vein, the WHO European regional office has been working with IANPHI and the Association of Schools of Public Health in the European Region to develop competency-based public health training, intended to equip future public health leaders with a full range of competencies needed to address varied public health challenges. Competency-based training has been at the heart of the UK’s public health system, recognising that leadership in public health requires more than just academic qualifications. The training encompasses a wider range of competencies which build leadership, management and diplomacy skills as well as skills in health promotion, disease prevention and health protection.26 Extending this approach globally has the potential to develop a global cadre of public health practitioners, trained to meet the needs of the organisations that will employ them and to be system leaders who can work across the business of government in order to address barriers to equity and act to address the broader determinants of health. Through such networks of networks, with Schools of Public Health working with National Institutes, with professional bodies and international agencies, lessons can also be transmitted from region to region. For example, the Association of Schools of Public Health in the Africa is beginning to adapt the European competency framework to their context.27
Collaborative multilateral international networks are also being used to strengthen EPHFs, however, there is scope for better utilisation of these and IANPHI and WHO are working together to ensure synergy between the bilateral and multilateral system strengthening they support.1 20 22 All six WHO regional offices have undertaken consultations with their WCCs to better align technical work to WHO’s global health objectives including public health system strengthening for universal health coverage and health security.20 The WHO and IANPHI, along with other key partners, are evolving their collaboration in support of developing NPHI and WCC public health capacity in under-resourced settings, including initial discussions on the use of IANPHI’s peer-to-peer support approach.28 29 WHO, IANPHI and partners can also advocate for strengthening of NPHIs and greater equity in global health including distribution of vaccines at high-level fora such as the World Health Assembly, G7 and G20. For example, in May 2021, IANPHI represented the interests of NPHI leaders at a G7 roundtable discussion on opportunities for greater collaboration on public health in the African region and emphasised the importance of G7 nations investing in NPHIs and the EPHFs. There has also been discussion between WHO’s Deputy Director-General and the President of IANPHI, and other senior leadership to position the public health agenda in joint support to countries during ongoing and post-COVID-19 recovery efforts.
Challenges and a new way forward
The most significant challenge faced by NPHIs and WCCs is limited resources which hinder their capacity to rapidly generate and disseminate the evidence needed to inform policy.20 This is particularly prevalent in the low-income and middle-income country contexts, however, public health infrastructure in high-income countries also face resource challenges, particularly during health emergencies.30 Health spending and attention is overwhelmingly directed towards strengthening healthcare, often in a reactive manner on emergency response interventions, with limited investment in public health promotion, improvement and protection, and disease prevention capacities.
WCCs in high-income countries need to be able to internally justify delivering work in support of global health objectives to demonstrate that this is not diverting resource from domestic priorities. WCCs, therefore, tend to be concentrated in better resourced institutions, perpetuating inequity within high-income countries with WCC status often given to ‘elite’ status public health schools, from the Russel Group of universities in the UK and Ivy League schools in the US for example, who receive greater research funding and are therefore better placed to engage in national and global policy dialogue.31–33 Opportunities need to be explored to determine how these institutions can extend their support to less well-resourced institutions, particularly those in low-income countries, which would make a commitment to addressing inequity a key part of gaining WCC status.
An important challenge is overcoming the current focus of individual NPHIs and WCCs on specific technical areas with limited coordination, gaps and overall coverage of the EPHFs nationally. Siloed attention and funding on health security, disease- and age-specific areas, although beneficial in terms of providing focus, requires careful planning and coordination to benefit health systems strengthening, in alignment with national priorities and national health research agendas. This requires strong stewardship capacity for public health within Ministries of Health and allied Ministries to avoid the development of fragmented health systems and can result in duplication and lack of sustainability.34
A new way of working will be required to overcome the challenges of tackling local, national and global public health threats with limited resources. Harnessing of the opportunities that widespread political and multisectoral attention COVID-19 has brought to public health will be needed if we are to take a more integrated approach to health system strengthening by bringing together actors within and outside the health sector and overcome nationalistic and isolationist policies.
Ministries of Health and NPHIs should have the operational capacity to build and deliver the EPHFs during both times of emergency, such as COVID-19, and periods of normalcy. Championing public health should not just be limited to periods of emergency response, building health system capacities for effective delivery of EPHFs requires sustainable long-term investment. Networks such as IANPHI and WCCs should be expanded in countries with low coverage and be better utilised by systematically collating and disseminating good practices and harvesting their use in evidence-based policymaking, irrespective of location and country income status. Current transfer of experiences and expertise in existing networks from North-to-South is beneficial but there is a need to bolster the direction of exchange from South-to-South, South-to-North and North-to-North.