Global lessons learnt are not as valuable as we might think!

Having lived and worked in low-, middle- and high-income countries, I do not like sweeping ‘global lessons learnt’. The situational, cultural, and operational contexts based on countries’ income levels vary hugely. Moreover, the reports and recommendations from global apex bodies are often drafted by people from primarily high-income country experiences. Many of them may have never actually worked at the country level. Often their lexica are so watered down in assessments of low-income countries that severe reprimand ends up sounding like applause by publication. Without a scorecard system where each country would know where they need to improve to achieve standards, it is difficult to get a reality check. We, the low-income countries, have a choice to make. We can believe that we are high performers or quench our vanity, critically examine our performance, and take corrective measures.

The glaring gaps in public health that COVID-19 exposed

COVID-19 has exposed critical societal gaps across the globe. In the case of high-income-developed democracies, this means adjustments and fine-tuning. In the case of low-income countries, this has meant seeing a horrid picture in the mirror and the need for transformational change. So a natural enquiry would be-what has been happening in the business of Health Systems Strengthening over the years and billions of donated dollars later? We would have thought that SARS, Ebola, MERS, and ZIKA emergencies would have better prepared our health systems, but here we are.

This pandemic has opened some chronic societal wounds, especially in low-income countries. The top issue that warrants an urgent societal debate is what services are essential and must remain in the public domain and how we regulate the private sector. Many proponents for the rapid privatisation of public services in low-income countries are foreign experts. Their countries have achieved an equilibrium between top-notch public services and effective private-sector regulation.

Public Health, Corruption & Transparency

Corruption, lack of transparency, power asymmetry, and invisibility of women in decision-making all contribute to the complexity of public versus private debate in low-income countries. When lawmakers overtly or by proxy own significant numbers of private hospitals, mainstream media, and educational institutions, it becomes difficult to have an objective national debate. The COVID-19 pandemic has allowed us to rethink and reboot societal contracts. The pandemic struck when public trust in institutions- governmental, civil society, private sector, media, academia, and the judiciary was at the lowest after years of steady decline globally.

Public sector- the saviour during COVID-19

Suppose we reflect on the past two years of the pandemic in low-income countries. In that case, we will note that we turned to either the public sector organisation or the defence forces whenever we needed a timely nationwide response. For example, when students needed to be brought back from abroad in India, the then-national carrier Air India stepped up. When stranded migrant workers needed to return home, it was the Indian Railways that rose to the occasion. When liquid oxygen had to be mobilised, the public sector was at work again. Working around the clock to secure scarce supplies from other countries and securing evacuation permissions were diplomats who are public servants. On the borders, facilitating the movement of people, supporting testing, quarantine etc., were members of the border police, armed forces, and the police. Similar was the case with many countries in South and Southeast Asia.

Other rich countries, such as Germany and South Korea, responded robustly. Attribution to the ability of their governments to manage private-sector activity and essentially public ownership of critical health system elements. Their impressive testing capacity was thanks to public laboratories and the presence of industries that could supply the required safety equipment and chemicals.

The South and Southeast Asia neighbourhood

Some governments in Southeast Asia have managed to build public health systems that learn. So, lessons from SARS and Tsunami have fed into their preparedness systems, allowing them to respond efficiently and effectively. The city-state of Singapore has traditionally shown a proactive approach based on solid scenario planning and proactive public health communication. Within India, the response of the southern state of Kerala has stood out. Over the decades, Kerala has invested in health, education, and women’s empowerment. It has consistently adopted an evidence-based approach to decision-making on health matters. Theirs is a learning system that drew heavily on lessons from the NIPAH virus emergency not too long ago. Kerala has also avoided the black-and-white notion of Public or Private and established a successful public-private partnership model. The government of Vietnam efficiently diagnosed the regional situation and closed its borders. Similarly, they were swift in developing low-cost test kits.

Public Health and the private vs public discourse- an axis of national security too

The considerations that need to be at the centre of this post-COVID-19 public-private discourse are:

• Re-evaluate and reign in the privatisation spree of health-related assets and services. Nurture back to health underperforming units through quick and transparent reform.
• Two, Reboot and relaunch sensible and practical national health policies that serve the objective of achieving universal health coverage. These should not be a copy-paste of what middle- or high-income countries are doing but should be rooted in the realities of poverty, patriarchy, and emerging democracy.
• Three, While the issue may appear to be of health, the scope of solution searching is well beyond the expertise or experience of health actors. The complexity of this matter warrants the leadership of the Ministries of Finance, Law, Commerce and Home. For example, supply chains, the rule of law during the lockdown, transportation of people, and labour issues related to health workers have solutions outside of health agencies’ remit.
• Four, Governments must take the lead and regulate the private sector more effectively and transparently. While governing the somewhat more streamlined public sector may be more satisfying, the rapidly and wildly growing private sector needs aggressive regulation. In many low-income countries, this means enforcing the existing fantastic on-paper rules and not drafting new ones. Moreover, the hopelessness of data collection from private sector health providers, whether on testing, bed occupancy, oxygen availability, or mortality during COVID-19, has hampered many low-income countries’ effective and timely response.

Refocusing on the Health for All agenda

This public discourse requires us to open our eyes to what we witnessed in the last two years and set aside our ambition and vanity. Let us acknowledge the actual situation in our countries and not artificially push ourselves into a higher boxing category for mere prestige. Organic, home-grown solutions are needed now, not a collage of random international best practices. Instead of drawing lessons from countries in the region, we need to study states and provinces with similar challenges and partner with them. Cross-border areas should be of interest in standard solution searching.

Many glorious careers are built worldwide in the name of Health Systems Strengthening. However, COVID-19 has shown that not much strengthening may have happened. WHO’s “Health for All” agenda ought to remain our focus. However, the tools, processes and commitment need to be indigenous. Countries must bring their sharpest, most independent, and most fearless minds to this debate.

Let us not forget that health, education, and security are nation-building tools. Taxpayers will have little incentive to contribute their fair share if all these continue being disproportionately privatised. One can only imagine the threat to democracy this will pose.

About the Author

Dr Sunoor Verma is a global health practitioner. He has advised WHO, UNICEF, UNHCR, HUG-Geneva and Cambridge University on Strategy, Leadership Communication, Advocacy and Resource Mobilization. He is credited with setting up WHO’s communication portfolio from scratch in Nepal in the midst of COVID-19. He has set up and led the country and regional operations for the European Centre for Minority Issues in the Balkans. He has supported track two peace processes in Macedonia, Kosovo and Sri Lanka and emergency response to the Tsunami, Avian Influenza and COVID-19. He has taught Global Health at Boston University. He has curated partnership initiatives with Macedonia, Kosovo, Germany, Switzerland, Australia, and Nepal parliamentarians. He divides his time between the foothills of the Jura Mountains in France and Buddhanilkantha in Nepal.

Published in Nepal’s national daily Kantipur on 30 June 2022 in Nepali language. This is a translation with some additional text.