key: cord-0926946-14un9f9z authors: Forman, Rebecca; Azzopardi-Muscat, Natasha; Kirkby, Victoria; Lessof, Suszy; Nathan, Naomi Limaro; Pastorino, Gabriele; Permanand, Govin; van Schalkwyk, May CI; Torbica, Aleksandra; Busse, Reinhard; Figueras, Josep; McKee, Martin; Mossialos, Elias title: Drawing light from the pandemic: Rethinking strategies for health policy and beyond date: 2021-12-05 journal: Health Policy DOI: 10.1016/j.healthpol.2021.12.001 sha: 39799e156530758185db23ff28c4978938d5bb5a doc_id: 926946 cord_uid: 14un9f9z The COVID-19 pandemic is a catastrophe. It was also preventable. The potential impacts of a novel pathogen were foreseen and for decades scientists and commentators around the world warned of the threat. Most governments and global institutions failed to heed the warnings or to pay enough attention to risks emerging at the interface of human, animal, and environmental health. We were not ready for COVID-19, and people, economies, and governments around the world have suffered as a result. We must learn from these experiences now and implement transformational changes so that we can prevent future crises, and if and when emergencies do emerge, we can respond in more timely, robust and equitable ways, and minimize immediate and longer-term impacts. In 2020-21 the Pan-European Commission on Health and Sustainable Development assessed the challenges posed by COVID-19 in the WHO European region and the lessons from the response. The Commissioners have addressed health in its entirety, analyzing the interactions between health and sustainable development and considering how other policy priorities can contribute to achieving both. The Commission's final report makes a series of policy recommendations that are evidence-informed and above all actionable. Adopting them would achieve seven key objectives and help build truly sustainable health systems and fairer societies.  The catastrophic impacts of COVID-19 were preventable, but we were underprepared.  The Commission's final report provides actionable recommendations to achieve seven objectives.  One Health approaches, health system investment, better governance structures are all needed.  Efforts to minimize systemic inequalities and improve innovation incentives must be increased.  Health governance in Europe must be reinforced and the role of and funding for WHO strengthened both. The Commission's final report makes a series of policy recommendations that are evidenceinformed and above all actionable. Adopting them would achieve seven key objectives and help build truly sustainable health systems and fairer societies. A catastrophe on the scale of the COVID-19 pandemic was preventable. For decades scientists and commentators around the world have urged governments and global institutions to prepare for the emergence of new diseases at the interface of human, animal, and environmental health(1) -but such warnings went unheeded. The potential impact of a novel airborne pathogen was known, yet we were still not ready. Global and national policy responses were inadequate; many countries have paid a heavy health, societal and economic price. We must learn the lessons from this pandemic, (2) acting now to minimize its consequences, and to prevent another. Development (3), an independent multidisciplinary group of experts, have reviewed lessons from the pandemic, identifying ways that society might change and address future threats to health, with a particular focus on the European Region of the World Health Organization (WHO). The Commission took a broad approach to health that went beyond pandemics to analyze the interactions between health and sustainable development and the position of health in relation to other policy priorities. Adopting a 'One Health' approach, the commissioners reviewed evidence that embraces humans, animals, micro-organisms and the natural environment to consider the many proximal and distal determinants of health and the policies that impact on them.(4) The Commission's final report(5) recommends a series of evidence-informed policy recommendations designed to achieve the seven objectives it identified as key to building sustainable health systems and resilient societies (Table 1) . Below, we briefly summarize each of these objectives and its associated recommendations in turn. COVID-19 is a tragedy we must lament, but we can also seize it as an opportunity to rethink our existing global health architecture.(6) Many threats to health arise at the intersection of human, animal and environmental health -not least, the increase in antimicrobial resistance (AMR) that may yet reverse the achievements of modern medicine. (7) The inordinate effects on the planet of human (in)action are recognized in the naming of a new era, the Anthropocene (8) . The danger that the planet has reached an irrevocable tipping point is real: human activities have caused global warming and loss of habitat and biodiversity, and we know that exacerbating feedback between these phenomena is increasing the risks of food insecurity, conflict, mass migration, and more. Despite the intrinsic links between their areas of work, those engaged with the different aspects of One Health frequently work in silos ( Figure 1 ). From now on, we must instead operationalize an integrated, holistic One Health approach(9,10), which acknowledges the complex interconnections between its various elements, and convenes and aligns stakeholders wherever relevant. Challenges to operationalizing One Health have been described in the past, (11, 12) including a lack of surveillance capacity, siloed thinking and actors, unequal representation of disciplines and stakeholders, difficulties in engaging actors from a diverse set of backgrounds, lack of evidence on the benefits of One Health, including problems generating and obtaining access to relevant and accurate One Health data and other information. (13) We need to address these challenges with solutions that promote equitable engagement and collaboration between diverse stakeholders and enhanced monitoring and evaluation of One Health initiatives so that continued improvements can be made based on lessons learned through an increasingly comprehensive evidence-base. The COVID-19 pandemic has revealed the importance of effective joint working by national and regional governments, supported by timely access to high quality comparable data. Structures, incentives and a supportive policy environment are needed to establish whole-of-government One Health strategies. Mechanisms for strengthening coordination and collaboration (14) has also highlighted the importance of tackling the divisions encouraged by disinformation spread through social media -including anti-vax messaging. (20, 21) As lives move increasingly into the digital space it will be necessary to develop novel methods of addressing the growing number of online threats, working across sectors to design and implement policies that make the online world safe. As the role of technology and social media continues to increase in our daily lives, and governments must work together with tech leaders and companies and civil society, and effectively regulate social media platforms to ensure users are exposed to information backed by evidence and science, and to guarantee disinformation is promptly addressed. Recognizing the particular consequences that the pandemic has had for women and the vital role they have played in the COVID-19 response, (22) it is essential that their input into decision-making is equal to that of men and that their involvement goes beyond the tokenistic. This same call was made more than 20 years ago in the Beijing Declaration, endorsed by the international community at the Fourth World Conference of Women in 1995(23,24) -it must be acted on now. what rapid mobilization of financial resources, collaboration, partnership between public, private and third sector organizations, and accelerated procedures for evaluating and approving innovative products can do to support One Health. Building on this momentum, governments must develop and support innovation strategies that proactively identify and address needs that are not otherwise being met. We must also learn the negative lessons from the experience of innovation during the pandemic. In particular, we must ask why so much risk is borne by the public sector (through research funding), while most of the returns flow to the private sector. (25) Governance and accountability mechanisms must be employed to ensure that incentives for discovery, development and implementation align with interventions that improve One Health, based on true public-private partnerships where risks and rewards are shared. (26) It is vital, too, to plan and prepare for the potential unintended or negative consequences of Investments in health may have short-term costs but, if planned well, they often bring higher longterm financial benefits. Past failures to invest in health have been fuelled by short-termism, and failure to recognize the wider benefits that health systems bring to society. We cannot afford to Echoing many others who have already expressed support (35) for an international legal framework for pandemics, the Commission supports the establishment of a pandemic treaty which is truly global. It must include as many countries as possible; be flexible yet also enforceable; and be feasible in terms of its scope. It needs to incentivize governments and foster willingness to pool sovereign decision-making in the case of pandemics. We also need ways to hold countries to account for contributions towards the global public goods discussed above. Drawing on insights from experiences following the global financial crisis, a Global Health Board under the auspices of the G20 could be established to promote a better assessment of COVID-19 has highlighted the world's interconnectedness and both the benefits and the risks that this brings. Europe is vulnerable to any health threat that emerges anywhere in the world and, equally, the world is vulnerable to any health threat that emerges in Europe. ( A Pan-European Health Threats Council convened by the WHO Regional Office for Europe could support an early warning system and mechanisms to track and respond to changes in pathogens and disease symptoms across the region. The body should be regionally representative and serve to enhance political commitment to pandemic and health threat preparedness using a One Health approach, and to ensure that complementarity and cooperation across the pan-European region is maximized at all levels. The pandemic has also shed light on the need for an interoperable health data network based on common standards developed by the WHO Regional Office for Europe to enable better coordination of crisis response efforts across the region. Multilateral development banks and development finance institutions can also play a role and prioritize investments in these fields. Of course, to support all these measures above, and to better manage and coordinate health security and preparedness across the WHO European Region and globally, the WHO needs more sustainable and flexible financing at all levels of the organization -headquarters, regional offices, and country offices. Increased financing for WHO alone is not enough though. We need to address existing challenges in the operationalization of One Health, with realization of commitments to improve population health and enhancement of health systems resilience. We also need stronger governance at national and international levels with effective leadership, transparent communication, coordinated activities across stakeholder groups, stronger surveillance systems and improved organizational learning. (40, 41) We, as a global community, have our work cut out for us -but, with a shift in attitude and policy priorities, our goals are within reach. It is imperative that we implement the concept of One Health in all settings and proactively adopt prevention and resilience measures in the settings where threats to sustainable health are most likely to occur. (42) We cannot allow the conditions that created the catastrophe that is the COVID-19 pandemic to continue. We owe it to all those who have suffered in its wake to strengthen governance, transparency and accountability, and to make smarter investments now to achieve more resilient and equitable societies and health systems, and so prevent similar crises occurring in the future. The recommendations of the Pan-European Commission have drawn light from the catastrophe to illuminate the way forward. Now, we must take the steps to get there -together: only by collaborating in a powerful joint effort can we succeed in implementing the changes required. for Animal Health (OIE) and the United Nations Environment Programme (UNEP) are strengthened, in order to support efforts towards a shared understanding, common terminologies, and an appropriate international architecture for establishing priorities, agreeing areas of responsibility and identifying the scope for joint work to promote the health of humans, animals and the natural environment. c) Coordinated action is taken at all levels to reduce environmental risks to health, including biodiversity-and climate-related risks, and to enhance One Health reporting systems. Take action at all levels of societies to heal the fractures exacerbated by the pandemic a) Information systems capture the many inequalities in health and access to care within populations, in order to inform policies and interventions that address the deep-seated causes of these inequalities. b) Those in society who lead impoverished or precarious lives are identified, and policies are developed and implemented to give them the security that underpins good health. c) Explicit quotas are adopted for the representation of women on public bodies that are involved in the formulation and implementation of health policy. a) A strategic review is made of areas of unmet need for the innovations required to improve One Health in Europe. b) Mechanisms are established to align research, development and implementation of policies and interventions to improve One Health, based on a true partnership between the public and private sectors in which both risks and returns are shared. c) With the support of the WHO Regional Office for Europe, continue efforts to develop a mechanism for constant generation of knowledge, learning and improvement, based on innovation in the pan-European region. a) All investments in health systems are increased, particularly in those parts of systems that have traditionally attracted fewer resources, such as primary and mental health care, while ensuring that this investment is directed in ways that maximise the ability of health systems to deliver the best possible health for those who use them. b) The health workforce is invested in and strengthened in the light of experiences during the pandemic, with a focus on ways of attracting, retaining and supporting health and care workers throughout their careers, coupled with reviews of how the roles of health workers can evolve, given the rapidly changing nature of medicine and technology. c) The links between health and social care are reassessed and strengthened in the light of experiences during the pandemic, with the goal of increasing integration between them. d) Communicable and noncommunicable disease prevention is prioritized and investment in public health capacities is scaled up. a) The way in which health expenditure data are captured changes, so that there is a clearer distinction between consumed health expenditure, on the one hand, and so-called frontier-shifting investments in disease prevention and improvements in the efficiency of care delivery, on the other. b) Investment in measures to reduce threats, provide early warning systems and improve responses to crises is scaled up. c) WHO's health system surveillance powers are strengthened and include periodic assessments of preparedness, which feed into monitoring by the International Monetary Fund, development banks and other technical institutions. d) The share of development finance spent on global public goods, long-standing cross-border externalities and, more generally, health is increased. e) Health-related considerations are incorporated into economic forecasts, business strategies and risk management frameworks at all levels. a) A Global Health Board is established under the auspices of the G20, in order to promote a better assessment of the social, economic and financial consequences of health-related risks, drawing on insights from experience with the Network for Greening the Financial System, the Financial Stability Board and other climate and biodiversity initiatives, and to scale up private finance for health. b) A Pandemic Treaty is agreed that is truly global, enables compliance, has sufficient flexibility and entails inventive mechanisms that encourage governments to pool some sovereign decisionmaking for policy-making areas. c) A global pandemic vaccine policy is developed that sets out the rights and responsibilities of all concerned to ensure the availability and distribution of vaccines. a) A Pan-European Network for Disease Control is established, led by the WHO Regional Office for Europe, to provide rapid, effective responses to emerging threats by strengthening early warning systems, including epidemiological and laboratory capacity, and supporting the development of an interoperable health data network based on common standards developed by WHO, recognising that governments will move at different speeds. b) A Pan-European Health Threats Council is convened by the WHO Regional Office for Europe to enhance and maintain political commitment, complementarity and cooperation across the multilateral system, accountability, and promotion of collaboration and coordination between legislatures and executive agencies in the pan-European region. c) Multilateral development banks and development finance institutions prioritise investments in data-sharing and data interoperability platforms. d) The necessary funding is secured for WHO to fulfil its mandate within the WHO European Region. Source: Pan-European Commission on Health and Sustainable Development. Drawing light from the pandemic: A new strategy for health and sustainable development. Copenhagen; 2021 . The Coming Plague 12 Lessons learned from the management of the coronavirus pandemic. Health Policy World Health Organization Regional Office for Europe. Pan-European Commission on Health and Sustainable Development. World Health Organization Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies Drawing light from the pandemic: A new strategy for health and sustainable development Our Postpandemic World: What Will It Take to Build a Better Future for People and Planet? Milbank Quarterly Tackling Drug-Resistant Infections Globally: Final Report and Recommendations. Review on Antimicrobial Resistance Anthropocene now: influential panel votes to recognize Earth's new epoch World Health Organization. One Health. World Health Organization Targeting innovation in antibiotic drug discovery and development: The need for a One Health -One Europe -One World Framework. European Observatory Health Policy Series The challenges of implementing an integrated One Health surveillance system in Australia The One Health Concept: 10 Years Old and a Long Road Ahead. Front Vet Sci Overcoming challenges for designing and implementing the One Health approach: A systematic review of the literature. One Health The Tripartite's Commitment: Providing multi-sectoral, collaborative leadership in addressing health challenges Covid-19 pandemic and the social determinants of health Why inequality could spread COVID-19. The Lancet Public Health Health information technology and digital innovation for national learning health and care systems. The Lancet Digital health Racism as a Determinant of Health: A Systematic Review and Meta-Analysis Living on the edge: precariousness and why it matters for health The Relationship Between the COVID-19 Pandemic and Vaccine Hesitancy: A Scoping Review of Literature Until Vaccine misinformation and social media. The Lancet Digital Health Women are most affected by pandemics -lessons from past outbreaks Fourth World Conference on Women: Beijing Declaration. UN Women Stimulating pharmaceutical research and development for neglected diseases. Health Policy The Entrepreneurial State: Debunking Public vs. Private Sector Myths Systematic Literature Review on the Spread of Healthrelated Misinformation on Social Media The contribution of health to the economy in the European Union. Public Health Health systems, health, wealth and societal well-being. Assessing the case for investing in health systems The best person (or machine) for the job: Rethinking task shifting in healthcare. Health Policy Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study The Wanless report and decision-making in public health The Incentive to Supply Global Public Goods What are the economic barriers of antibiotic R&D and how can we overcome them? An international treaty on pandemic prevention and preparedness COVID-19 vaccine challenges: What have we learned so far and what remains to be done? Health Policy Ensuring access and affordability through COVID-19 vaccine research and development investments: A proposal for the options market for vaccines DHL Global Connectedness Index 2020 -The State of Globalization in a Distancing World. NYU Stern School of Business Big Data and Health Care: Challenges and Opportunities for Coordinated Policy Development in the EU. Health Systems & Reform Strengthening health systems resilience: key concepts and strategies Brussels: European Observatory on Health Systems and Policies A new strategy for health and sustainable development in the light of the COVID-19 pandemic