Intended for healthcare professionals


Global health system resilience is in everyone’s interest

BMJ 2021; 375 doi: (Published 08 December 2021) Cite this as: BMJ 2021;375:n3043
  1. Laura E Downey1 2,
  2. Matthew Harris3,
  3. Stephen Jan2,
  4. Marisa Miraldo4,
  5. David Peiris2,
  6. Kent Buse1 2
  1. 1The George Institute for Global Health, School of Public Health, Imperial College London, UK
  2. 2The George Institute for Global Health, University of New South Wales, Australia
  3. 3Department of Primary Care and Public Health, Imperial College London, UK
  4. 4Department of Economics and Public Policy & Centre for Health Economics and Policy Innovation, Business School, Imperial College London, UK

With an official death toll that has just surpassed five million, the covid-19 global crisis is on a scale unobserved by most people in living memory, disproportionately affecting the most socially and economically vulnerable. Like so many humanitarian crises, those who are, and will continue to be, impacted most are people in low-income and middle-income countries (LMICs), reliant on fragile systems to meet their health needs. These systems are letting people down; that needs to change. What can the UK do to strengthen fragile health systems?

We can start by redressing where we have recently gone wrong. For example, with the dramatic reduction of Official Development Assistance (ODA) to global “partners” in their fight against the pandemic and its socio-economic impacts. Reducing ODA to the world’s poorest countries creates a false economy, and thousands of global health researchers oppose these cuts.1 This act, particularly at this time, was not only morally questionable, but self-defeating given the economic and health spillover effects across countries globally and how connected we have all shown to be during the crisis.

As the UK Foreign, Commonwealth, and Development Office (FCDO) prepares to publish its first position paper for health systems strengthening, we highlight five recommendations we hope will be prioritised in its future path towards supporting stronger, fairer, and more resilient health systems:

Become a beacon of global solidarity: returning to the 0.7% of Gross National Income (GNI) commitment should be at the core of the FCDOs mission. The FCDO position on health system strengthening should promote recommendations made by the independent panel for pandemic preparedness and response, including stepping up financing for mitigating climate change, to set an example for world leaders to follow and protect human health through the strengthening of health systems.2 This is everyone’s responsibility and in everyone’s interest.

Support policies, programmes, and the research which underpins them, with the community for which they are designed to benefit: Community members with lived experience are uniquely placed to articulate their own needs and provide valuable ideas for pathways to policy impact; for example, new mothers know better than most where gaps in antenatal care service provision lie; people who use drugs can inform the development of proactive drug policies with more insight than any academic or policymaker, patients are increasingly valuable sources of healthcare innovation.34 Slowly but surely donors, commissioners, and researchers are moving towards community involvement and programme co-creation with lived experience experts, but now is the time to make it the norm in FCDO-supported programmes.

Put equity at the centre of health reform support: access to high quality healthcare and prevention must not be driven by disparities in geography, socioeconomic status, gender, class, caste, or ethnicity, and no one accessing healthcare should suffer financial hardship in doing so. And yet, policy makers fail to acknowledge the complex determinants of health and wellbeing and how these disproportionately affect the most vulnerable. This manifests as individual vulnerability to ill-health, driven primarily by unequal distribution of the social, economic, and environmental determinants of health. The FCDO must adopt and promote a “health for all” approach that puts equity at the centre of reform, collaborating with all sectors of the economy towards multisectoral action to address health inequalities while tackling wider issues such as socio-economic inequalities, unemployment, or unequal access to education.

Invest in strategies to address the structural and social determinants of health: One silver lining to the pandemic in some countries has been that barriers that once may have prevented governments from bold actions, such as to invest in healthier societies and incentivise inter-sectoral action on the upstream drivers of health, have been overcome in the face of this urgent crisis. Pandemic response has necessitated and accelerated collaborative action across health, social care, social protection, education, employment, environment and immigration sectors in many countries—with massive state-led investments. While this is not true for all countries, the pandemic has provided fertile ground for initiating rights-based, inter-sectoral action.5 The FCDO must adopt and promote a “health in all” sectors approach, explicitly direct funding towards efforts that address the social determinants of health as a crucial mechanism in supporting countries to move towards healthier societies as a whole.

Prioritise gender based rights in health system reforms: the pandemic has derailed gender equality efforts across the globe and aggravated socio-economic inequalities for women. Women make up over 70% of the global healthcare workforce, and on average do three times more unpaid care work than men. And yet over 70% of the global health senior leadership positions are held by men.6 We know that societies with higher levels of gender equality are more peaceful, prosperous, and resilient.7 Improving women’s representation in positions of leadership and the funding that is available for conditions that specifically affect women is essential to building more robust and resilient health systems and can also be a crucial tool to economic recovery. The FCDO must support country partners to look at all programmes through a gender lens, and support countries to make gender-forward policies for improving women’s social and economic empowerment.

As the world prepares to “build back better,” the UK must play a prominent role in supporting fairer, more sustainable systems that work for everyone, everywhere. If implemented well, the FCDO position on health systems strengthening has a real opportunity to support meaningful change. Health system strengthening in the era of covid-19, and beyond, is everyone’s responsibility and in everyone’s interests. We’re in this together.


  • Competing interests: none declared

  • Provenance and peer review: not commissioned, not peer reviewed