key: cord-0734651-kbwdnnm3
authors: Arora, Anish K.
title: The next three epochs: Health system challenges amidst and beyond the COVID‐19 era
date: 2021-04-17
journal: Int J Health Plann Manage
DOI: 10.1002/hpm.3175
sha: f278f458dcde2652320a79466db52cb961ab071f
doc_id: 734651
cord_uid: kbwdnnm3

The COVID‐19 pandemic has brought to light tremendous gaps and issues faced by health systems globally. Commendable effort has been made to retain continuity of care for non‐COVID‐19 patients amidst the pandemic, particularly using technology‐enhanced models of care. However, these efforts are not sufficient to tackle the impending challenges that health systems around the world will face next: (1) vaccine uptake and hesitancy; (2) a mental health crisis; and (3) post‐COVID‐19 migration. In this letter to the editor, explanation of why each of these issues is concerning and how each subsequent issue grows in severity is provided. Particular focus on the issue of post‐COVID‐19 migration is made, as this challenge is quite pressing to health systems but has yet to be explored thoroughly in the literature. Possible strategies for health system planners to consider are provided in this letter. Strategies include involving stakeholders such as patients and clinicians in deliberations and deployment of interventions, focussing efforts on adapting primary health systems, and building on technology‐enhanced models of care where possible. By adhering to the recommendations made in this letter, health systems may be able to proactively deal with the identified challenges before they become crises of their own, post COVID‐19.

reconcile issues by officials and governments can be appropriate strategies to garner the trust and support of citizens and improve vaccine uptake. Patient partners can also function as critical champions in this regard.

Beyond vaccines, attention must turn to the impending mental health crisis that brews increasingly stronger day-by-day. 4 Restrictive social distancing measures have been associated with rising mental health issues, impacting populations disproportionately. 4, 5 A viable solution to addressing mental health needs for populations is embedding mental health support in primary care systems, whereby clinicians are appropriately trained to manage mental health care issues; have the support of social workers and psychologists to address the vast social and psychological needs of patients; and can coordinate care with specialists (i.e., psychiatrists) on an atneed basis without overwhelming secondary and tertiary care services. 6 Fortunately, we may have time to prepare, and the already significant advances in remote care delivery may be key to ensuring that a mental health crisis is averted.

Beyond the mental health crisis looms a final cause for concern and possibly the largest threat to global health systems; post-COVID-19 migration. It is obvious that the movement of people and populations post-COVID-19 is difficult to predict. 7 Will people be more fearful and thereby restrain their desire to travel postpandemic? Or has restricting travel for such a long period of time fueled the desire for many to visit, live, study, or work in different cities, states, countries, or continents? These and many other questions have yet to be answered. However, sentiments expressed in the media indicate that consumer desire to travel has only intensified amidst the pandemic, and that booking behaviour has shifted to favour flexibility and last-minute planning. 8 This may be quite concerning to health systems.

Migrants, particularly refugees, asylum seekers and undocumented individuals, are susceptible to numerous health-related challenges in the pre-, during, and postmigration phases depending on a variety of factors (e.g., socioeconomic status, education). 9 Their healthcare-related issues are dynamic and heterogenous, and can include infectious diseases (e.g., HIV), noncommunicable diseases (e.g., cardiovascular disease, diabetes, cancer), and mental health disorders. 9 Thus, migrants can contribute to numerous health-related burdens on host populations and health systems. For example, if infectious diseases are not appropriately identified and addressed early on in the migration process, these diseases can possibly spread and lead to endemics-an issue that systems may not be able to tackle after this prolonged battle with COVID-19.

These sentiments, however, should not be taken as reasons for preventing people from being able to travel within or across borders after the pandemic. Migrants bring tremendous economic and social value to host countries. 9 In fact, countries that rely on travel to sustain their economies may hope to upscale travel as soon as possible, despite health risks to citizens and migrants. Also, acknowledgement of the need to promote migrant health is made in the 2030 Agenda for Sustainable Development. 9 Therefore, regardless of the pandemic, we must prepare our health systems for increased migration, consisting of people that are affluent and vaccinated, and those that are not. This goes beyond the traditional measure of ensuring that migrants have access to health insurance.

Though necessary, insurance serves solely as a stop-gap measure and needs to be supported by addressing the multitude of long-standing access-related barriers that migrants, particularly those that are most vulnerable and marginalised, encounter (e.g., navigation-related challenges, language and legal status issues). 9 In addition, literature has focused tremendously on discussing the barriers to health care for migrants entering our borders. However, what also needs to be highlighted and accounted for in health system planning is the continuity of care for our citizens that travel within and across our borders. This will require us to begin re-orienting our models of care delivery and funding, with primary care and technology-enhanced models of care as the pillars for health systems. 10 To exemplify this, consider students conducting global internships post-COVID-19. If primary care is sufficiently funded, and mobile health models are appropriately integrated, clinicians can ensure that their patients (i.e., students) are consistently checked-up on, and if emergencies arise or tests are needed, they can attempt to facilitate care access for their patients while they travel and study.

In conclusion, what lies in wait are three major epochs, each more concerning than the last. To ensure that health systems are prepared to tackle these challenges in an appropriate, feasible, and sustainable way, stakeholders including patients and clinicians must be involved in deliberations and deployment of interventions. In addition, efforts should be focused on adapting primary health systems and building on technology-enhanced models of care. In doing so, we will be able to retain the health of all individuals within and across our borders.

The implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study

Increasing the capacity of primary care through enabling technology

Concerns and motivations about COVID-19 vaccination

COVID-19 and mental health deterioration by ethnicity and gender in the UK

Mental health during the COVID-19 pandemic: effects of stay-at-home policies, social distancing behavior, and social resources

Primary care mental health: a new frontier for psychology

Post-COVID-19 crisis travel behaviour: towards mitigating the effects of perceived risk

Revenge travel' is the phenomenon that could bring back tourism with a ba ng.The Washington Post

Migrants' and refugees' health: towards an agenda of solutions

Refugee health: a new model for delivering primary health care

The author thanks Dr. Kathleen Rice for her assistance in reviewing this work. Anish Arora is supported by a doctoral scholarship from the Fonds de Recherche Québec-Santé (FRQ-S) given in partnership with the Strategy for Patient-Oriented Research (SPOR) Support Unit of Quebec.

The author declares that he has no conflict of interest.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.Anish K. Arora 1,2,3 1