• COVID-19

In the aftermath of the COVID-19 pandemic, discussions on strengthening global and national pandemic preparedness have reopened. In September 2023, the United Nations (UN) General Assembly hosted a meeting on Pandemic Prevention, Preparedness and Response, at which heads of government issued a political declaration for safeguarding against future pandemic risks. The prevailing sentiment on preparedness was gloomy. Indeed, a recent report highlights ‘significant weaknesses or declining capacities in several critical areas of preparedness’.1 At the heart of these deliberations lies a global consensus that forthcoming preparedness plans must prioritise equity and inclusivity: global health security will only be achieved when our most vulnerable nations are also adequately prepared.

In September the same year, another UN meeting was convened on universal health coverage (UHC), hoping to reinvigorate the process to deliver health for all, and in October a political declaration was issued expressing concerns regarding progress in reaching UHC by 2030.2 We are, as it stands, far from attaining UHC for all. But what if huge progress in health security and UHC could be realised by sustaining gains made during the COVID-19 pandemic? Specifically, what if this was realised in resource-constrained countries such as low-income countries (LICs) and low and middle-income countries (LMICs) and in fragile, conflict-affected and vulnerable countries (FCVs)?

The WHO Regional Office for the Eastern Mediterranean Region undertook a mapping exercise in 2023 to investigate capacity gains achieved during the pandemic and if there were plans in countries to sustain them. WHO’s Eastern Mediterranean Region is home to 22 countries and territories, 13 of which are classified as LICs or LMICs.3 Nine countries or territories in the Region are also considered FCV, with an estimated 19% of the Region’s population in need of humanitarian assistance.3 4

This mapping initiative included a desk review, online survey and key informant interviews, and covered core capacities as outlined in the Health Emergency Preparedness, Response and Resilience (HEPR) framework. 19 out of 22 countries and territories participated. 11 of 13 LICs/LMICs and all nine of the Region’s FCVs participated in the survey, for a total of 14 responding countries that can be classified as either FCVs, LICs or LMICs, with five classified as both FCVs/LICs. The survey analysis included responses from Afghanistan, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Pakistan, Occupied Territory of Palestine, Somalia, Sudan, Syria, Tunisia and Yemen. The mapping initiative collected and analysed information across all areas of the HEPR framework.

Driven by the need to mount an unprecedented global health response, global support for pandemic response is estimated at $9 trillion.5 Due in part to the available support, all reporting countries, regardless of income status, documented gains in multiple areas in efforts to minimise the loss of lives. These include: increased number of laboratories and surveillance sites; the establishment of infection prevention and control (IPC) or risk communication and community engagement units within ministries of health, new or enhanced databases and new outreach strategies for vaccination; and surges in capacity for clinical care and oxygen production. The gains made by LICs, LMICs and FCVs, such as improvements in new oxygen capacity and improvements in IPC, are arguably the most important because they have potentially made their respective health systems more resilient for managing future health risks.

The 14 FCV/LMIC/LIC countries that participated in the survey reported incredible gains: 93% added new or enhanced O2 sources; 86% added new intensive care unit (ICU) beds; and on average they added 26 new laboratories and 18 new sentinel sites. However, only five countries explored the cost of sustaining these new laboratories and surveillance sites. Six countries had IPC units before the pandemic, four countries added IPC units during the pandemic and four countries have no IPC units but had developed IPC guidelines for the pandemic. All respondents developed new or enhanced activities around IPC, and all new IPC units developed in the Region during the pandemic were in LIC or LMIC countries. Only two respondents had no public health emergency operation centre (PHEOC) before the pandemic (one LIC and one FCV), but both established PHEOCs to manage the response.

Most countries expressed a desire to maintain capacities developed during the pandemic, but despite important progress there are few concrete national plans to rationalise and maintain those gains. One country noted they will maintain existing gains until the ‘funding runs out at the end of 2023’, drawing attention to the fact that valuable public health capacities developed during the pandemic, particularly in FCVs/LICs, are at risk because of a lack of prioritisation, planning and funding.

The challenges presented by pandemic preparedness in resource-constrained settings have elsewhere been documented.6 Here we will highlight four priority actions for sustaining existing gains, focusing on vulnerable contexts. First, support for the integration and institutionalisation of new or enhanced capacities into routine health systems is required. New surveillance sites and laboratories can be integrated into existing systems and networks. New technical units—for example, IPC units—and PHEOCs can be institutionalised within health ministries or other bodies. This integration will foster routine resilience of health systems and better care for patients.

Second, ongoing investment is required to sustain existing gains. This can be sourced through increased financing from domestic sources, bilateral support and inputs from international instruments such as the new Pandemic Fund, which awarded $338 million in its first year.7 A focus on cementing gains already achieved in FCV, LICs and LMICs would pay huge dividends on investment while supporting health systems and future preparedness. Many of these countries need dedicated financial and planning support to integrate new capacities developed during the pandemic into their national budgets and national action plans.

Third, rational guidance on the rightsizing of new gains is needed. LICs, LMICs and FCVs added many new laboratories, surveillance sites and ICU beds, but maintaining all of them makes little sense from a public health or financial perspective. Having a rational plan for where and how to optimise these gains would prevent a reversion to prepandemic levels.

Fourth, training programmes are needed to maintain healthcare worker skills and IPC programmes. Promoting a culture of preventive upkeep to maintain new laboratory equipment, oxygen generation plants and critical care capacities is also important. Public–private partnerships were highlighted as increasingly important for responding to the pandemic, and these should be expanded to sustain and support activities for routine public health resilience.

This mapping initiative highlighted that health security is often considered separately from health systems in ‘peace time’, there is therefore a need to bring essential functions of health systems and health security together through planning for ‘routine resilience’. A year ago, Lal et al highlighted the role UHC can play in mitigating outbreaks and made the case for reconceptualising health security by scaling up UHC8: it is clear that the time for action is now.

There is a clear opportunity to ensure that essential public health functions such as IPC, surveillance and prevention are all integrated with primary care and essential health service systems to enhance health security. Cementing these gains will bolster the ‘routine resilience’ that will ultimately translate into better functioning health systems and contribute to the development of UHC. Such consolidation will also enhance the levels of preparedness and health security needed to respond effectively to future public health emergencies. However, such gains will only be sustained through ongoing financial and technical support.

A recent Global Preparedness Monitoring Board report reiterates its 2019 warning that the cycle of ‘panic and neglect’ characterised by sporadic support for public health emergencies needs to be broken.1 But here we are, poised to repeat old mistakes. Only this time there is more at stake: failing to sustain existing gains will condemn us to yet another regrettable cycle of unpreparedness and will diminish the very real possibility of genuine improvements. LICs, LMICs and FCVs stand to lose the most if support to sustain these gains dwindles. It would represent a giant step forward for both UHC and health security if capacities gained during the COVID-19 pandemic are maintained and integrated into routine public health systems.