Widespread social distancing has heightened our sense of connectedness. Across the globe we witness uplifting displays of solidarity for our key workers. We smile or shed a tear at the kindness of strangers and are humbled by the generosity of volunteers. History tells us this crisis will pass, sometime, but we know the consequences will stay with us for many years. COVID-19 has stark implications for our economy, for health and wellbeing, and for health inequalities. The decisions made now by governments, health and care professionals, and civil society, will shape our future health and care systems.
How can we plan for a post pandemic future that better supports the poor and the underserved? Hard questions for any society, even tougher for low and middle income economies with high levels of social inequality and where the policy discourse is rarely followed by change at pace.
Dr David Nabarro, a WHO Special Envoy has published a series of COVID-19 narratives. Their messages on a humanitarian and solidarity response are simple yet powerful: Engage people, Unleash local capacity; Activate networks; Coordinate efforts; Put vulnerable people first; Leave nobody behind. These actions offer a useful compass to improve health equity and adopt the WHO global framework on integrated people – centred health services. The pursuit of health equity and integrated care has never been more important nor more urgent for global health.
A beacon of hope is emerging from Health in Action, an ambitious programme to increase public healthcare capacity and coverage and improve performance and cost-effectiveness in the state of São Paulo in Brazil. The International Centre for Integrated Care partnered with São Paulo State Secretary of Health and Regional Department of Health on a Transforming Together pathfinder project in the relatively underserved and inaccessible coastal and island communities of Litoral Norte. The project has delivered rapid change in just 12 months despite a challenging and changing political landscape. Four municipalities took forward actions that have touched the lives of many thousands of vulnerable families with low income and complex needs in communities with high social and health inequalities.
A network of champions have adopted and spread new ways of integrated working across the region: health, education and social development professionals working together to identify those with social vulnerability and provide joint outreach from primary care centres; NGOs and community partners working with schools and community health agents to support self-management and wellbeing for those who rarely engage; joint needs assessment and population health initiatives in low income housing contributing to a significant reduction in rates of dengue and gestational syphilis; health promotion, mental health and suicide prevention initiatives in schools; community intermediate care alternatives to hospital care; and revised protocols to increase efficiency of ambulatory care. All achieved by the existing workforce with some upgraded community facilities, additional IT equipment, but time and space to build relationships and trust between sectors, to understand how to draw on the assets and kindness of local communities, and to learn how to grow stronger together.
The learning from this project will be of interest to other countries with fragmented municipal, state and federal systems and a mix of private and public healthcare. There are lessons too for high income economies as we reflect on the report of the Marmot review ten years on. Austerity has taken a heavy toll. We must look to the promise of population health and integrated systems to reduce the health inequalities experienced by our most vulnerable citizens.
Right now, in the eye of the Coronavirus storm, our immediate focus is saving lives and managing demand rather than transformation. But we must act swiftly to harness the disruptive innovation this pandemic has unleashed. Community action and social leadership, scaling up of teleconsultation and remote monitoring, and a more pragmatic approach to information governance represent a step change in public and professional behaviours achieved in a matter of weeks. We can’t afford to drift back to the old ways.
This global pandemic could well create the conditions for radical transformation towards greater health equity and integrated care. But only if we make the right choices and invest in social justice, collaboration, and show courageous and compassionate leadership. Standing at our doors and balconies to thank public service workers is not enough. They need to be liberated and resourced to create integrated care and support with local people designed around what really matters to them.
Transforming together is surely within our grasp if we are brave enough to design a better future with solidarity, health equity and integrated care as our compass.