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FCDO Position Paper, December 2021 9Part 1. Why do strong health systems matter?1.1 Making the case for the strong,resilient health systems that areneeded to achieve UHCStrong, resilient, and inclusive healthsystems are a critical foundation uponwhich solutions to the world’s mostchallenging health issues depend,including reaching the SDG target ofUHC. In 2015, the UK joined with 190 othercountries to commit to the SDGs. Theyinclude SDG 3, ‘to ensure healthy lives andpromote wellbeing for all at all ages’, withthe commitment to achieve UHC in everycountry.10 Investing in UHC and healthsystems makes sense. It improves the healthof nations, in turn building human capitaland future prosperity. For example, aroundone quarter of economic growth between2000 and 2011 in low- and middle-incomecountries (LMICs) is estimated to haveresulted from improved health outcomes overtime.11UHC is fundamentally about equity, whereall people—irrespective of individualcharacteristics (e.g. wealth, gender, age,geography, ethnicity, disability status etc.)—are able to access safe and quality healthservices in a timely manner and free fromfinancial burden, as defined in Box 1.12Achieving UHC requires governments tomake complex political and policy choicesabout how to use limited resources. Tomake it easier to see and understandhow to achieve UHC, we talk about threedimensions—often referred to as the UHCcube (see Figure A)—all of which requiretargeted action by governments and healthpartners. These dimensions include:1) whois covered by UHC (population); 2) whichservices are covered and what is theirquality (services), and 3) what proportionof people’s health costs are covered(costs) without impacting household financialvulnerability.Figure A—Three dimensions to consider whenmoving towards UHC (Source: World HealthOrganization)Progress on UHC depends on countrieshaving strong, resilient, inclusive andequitable health systems.13 Strong healthsystems are essential if we are to successfullyovercome some of the common barriers toachieving the three core dimensions of UHCto improve health outcomes, including: Improving coverage of health servicesto reach those that currently don’thave access. Only one-third to half of theworld’s population is covered by essentialhealth services, and the pace of progresshas slowed since 2010.14 The poorestcommunities and people affected byconflict generally face more challenges,with the most marginalised and mostvulnerable, including women, adolescents,and people with disabilities, often facingdisproportionate barriers to accessingrespectful care.15,16,17 Increasing the quality and packageof health services delivered in a moreintegrated way. More than 8 million

10 Health Systems Strengthening for Global Health Security and Universal Health CoverageBox 1: What is Universal Health Coverage?The aim of UHC is for all people and communities to receive the health, nutrition, and water,sanitation and hygiene (WaSH) services they need without experiencing financial hardship.UHC means that all people can access the full spectrum of quality and inclusive essentialservices: from health promotion to prevention, treatment, rehabilitation and palliative care(such as end-of-life care). UHC also involves highly cost-effective public health measuresthat prevent ill health, protect the whole population from health threats and provide healthsecurity. These include disease surveillance—including linkages to surveillance in the animalhealth and environment sectors—preventing drug resistant infections, safely managedwater and sanitation, addressing unhealthy diets, responding to the health challenges ofclimate change, and improving air quality.people per year in low- and middle-incomecountries (LMICs) die from conditionsthat should be addressed by their healthsystem. Poor quality care is now at leastas significant (and in many cases moresignificant) as a barrier to reducing mortalityas lack of access to services.18 Packagesof services need to cover a wide range ofservices that both promote good healththrough prevention and health promotionand provide treatment (for both physicaland mental health), rehabilitation andpalliative care. A strong primary healthcare system is critical to deliver these. Yetservices are not always well prioritised, wellorganised, or sufficiently coordinated oradaptable to reflect the constantly changingburdens of disease and wider causes ofill-health, undermining their effectiveness,and creating inefficiencies and offering lessvalue for money. Making sure people are not pushed intopoverty because of the costs of healthservices. Many poor and vulnerable peopledo not seek care due to an inability to payand/or fall (back) into poverty as the resultof the costs of health services. About 930million people spend more than 10% oftheir household budget on health care eachyear, causing financial hardship for many—and the figure is rising.19 To help reducethe burden on households and achieveUHC and the associated health targets,governments need to increase spendingon, for example, primary health care byat least 1% of gross domestic product.The latest evidence suggests low-incomecountries (LICs) are still unable to affordan essential package of health services(based on 112 per capita) and on averageallocate between 7-9 per capita instead.20As a result, out-of-pocket spending onhealth can represent more than 40% ofsome country’s total health expenditures,leaving households vulnerable andcountries heavily dependent on externalassistance.21Efforts to build strong health systemsfor UHC are more important than ever.The impacts of the COVID-19 pandemichave stretched health services across theglobe, overwhelming even some of thestrongest health systems. In the poorestcountries with the weakest systems, healthprofessionals have struggled to respond tothe twin burden of COVID-19 response andmaintaining essential health service delivery,with coverage of critical health services (e.g.immunisation, prevention and treatment ofdiarrhoea and malaria, family planning, andsafe delivery) falling in many geographies andhealth inequalities growing the world over.22This is at a time when too many countriesare already tackling persistently high rates of

FCDO Position Paper, December 2021 11maternal, newborn and child mortality andmalnutrition, while experiencing substantialrising rates of non-communicable diseases(NCDs) such as diabetes, heart diseaseand cancer, and health impacts of climatechange.231.2 Strong, resilient health systemsare critical for global healthsecurityStrong, resilient health systems arefundamental to achieving national,regional, and global health security. Globalhealth security (GHS) is centred on preparing,preventing, detecting, and responding toexisting and new, emerging public healththreats.24 WHO defines GHS as “the activitiesrequired, both proactive and reactive, tominimize vulnerability to acute public healthevents that endanger the collective healthof populations living across geographicalregions and international boundaries”.25Sustained progress on GHS cannot bemade without functioning and resilienthealth systems capable of protecting allpeople, including the poorest and mostmarginalised, from health threats such asinfectious diseases, AMR, and the impacts ofclimate change. Strong health systems, suchas routine surveillance, health information,laboratory and immunisation systems,procurement and supply chain managementand quality of care, are essential to helpprevent, mitigate and respond to thesehealth threats within a country and acrossborders, strengthening in turn regionaland global health security. Having effectivesystems in place supports and enhancesmore targeted health security interventionssuch as implementation of the InternationalHealth Regulations (IHR) that are explainedbelow. Taking a One Health approach alsocontributes to health security (see Box 2) aswell as improving multi-sectoral coordinationand action.To improve health security, we needstronger, integrated public healthfunctions that protect people from healththreats. Public health functions include afocus on integrated surveillance; responseto emergencies; health protection; healthpromotion and disease prevention.26 Publichealth functions need to be interconnectedBox 2: What a One Health approach can doThe UK sees One Health as referring to two related ideas: first, it is the concept that thehealth of humans, animals, plants and the environment we live in are inextricably linkedand interdependent. Second, it refers to the collaborative and sustained effort of multipledisciplines working locally, nationally, regionally, and globally to attain optimal health for allliving things and the ecosystems in which they co-exist.The COVID-19 pandemic has highlighted poor coordination and collaboration at globaland country levels across the human, animal, plant and environment interface. Theseissues can limit our ability to prevent, detect and respond to new and emerging diseasesof epidemic and pandemic potential as well as endemic zoonoses and other challengesincluding antimicrobial resistance (AMR).Applying an intersectoral One Health approach will ensure that the interlinkages betweenthe health of humans, animals, plants and the environment are accounted for, and canstrengthen our approach to global health security as well as contribute more broadly toimproved health for people, animals and ecosystems.

12 Health Systems Strengthening for Global Health Security and Universal Health Coverageto animal and environmental services sothat health threats are tackled from allangles. A strong public health system alsorelies on resilient community systems andresponses. The COVID-19 response hasshown that we know we can strengthenthese public health functions, for example,by using genomic sequencing as part ofour surveillance systems and by buildinginternational cooperation to pool knowledgeand the monitoring of likely health threats,using this information ahead of time torapidly develop new technologies such asvaccines, therapeutics, and diagnostics.27We can also improve contact tracing andtesting by involving communities right fromthe start, adapting our primary health caresystems, strengthening laboratory capacityand developing more interconnected datasystems. This will enable policy makers,health professionals and communities tohave the latest up-to-date information toinform their decisions about what needs tohappen to respond.To date, 196 countries, including all 194WHO member states, have committed toimproving health security by signing up tothe International Health Regulations (2005)(IHR). The IHR provide an overarching legalframework that defines countries’ rights andobligations around the handling of publichealth events and emergencies that have thepotential to cross borders. Implementationof, and compliance with, the IHR relies oncountries having strong health systems withintegrated public health functions.28Strong health systems are needed now forthe rapid rollout of COVID-19 vaccines,therapeutics, and diagnostics acrossthe globe. New and ambitious COVID-19coverage targets for vaccinating all adultsequitably are necessary, but risk puttingfragile health systems under more pressure,adding to the challenge of further outbreaks,and displacing essential health services thathave already been affected by the indirectimpacts of COVID-19, including routineimmunisation. As well as vaccine rollout,health systems need integrated testing andsurveillance to manage outbreaks, assessvaccine effectiveness and ensure accessto new early treatments to prevent severedisease. We also need to think ahead and bebetter prepared for the next pandemic. Thatis why at the UK-hosted G7 Summit in CarbisBay, the UK—along with the G7 Leaders—supported the ambition to ensure that theworld can respond to future pandemics in100 Days with safe and effective vaccines,therapeutics, and diagnostics.29 This goeshand in hand with the need for countries tohave strong health systems that are ableto rapidly deploy such new technologies toprotect their populations.1.3 Health systems: a critical linkbetween UHC and global healthsecurityStrong health systems form thefoundation that underpins both UHC andGHS.30 UHC and GHS both need stronggovernance and leadership, motivatedhealth workers, adequate financing, the rightmedicines, and diagnostics—delivered tothe right people in the right places—strongcommunity systems and good data and datasystems for decision making. Often it is thesame health worker who manages a diseaseoutbreak as it is who immunises a child orprovides antenatal care. We often refer tothese basic parts of the health system as thebuilding blocks, which are explained in moredetail in Section 1.5. These inter-connectionsbetween UHC and GHS are illustrated inthe diagram in Figure B. We will not improveoverall health outcomes without addressingboth UHC and GHS at the same time—it

FCDO Position Paper, December 2021 13is not a case of ‘either/or’. Investments ina health systems approach represents a“double-win”.existing and rising health threats includingAMR, animal to human spread of diseases(zoonoses), climate change, demographicshifts, and chronic diseases.1.4 Health systems need tocontinually adapt to addresscurrent and emerging challenges Climate change. WHO describes climatechange as the biggest public health threatof the century.31 The impact of climatechange on health will be increasingly feltthrough a range of factors including, butnot limited to: pollution; extreme weatherevents; increasing frequency and intensityNational efforts to strengthen health systemsneed to be combined with internationalefforts to continually adapt to tackleFigure B—How Universal Health Coverage, Global Health Security and Health Systems Strengtheningefforts are interconnected Source: adapted from Wenham C, Katz R, Birungi C, et al. Global health securityand universal health coverage: from a marriage of convenience to a strategic, effective partnership. BMJ GlobalHealth, 2019.

14 Health Systems Strengthening for Global Health Security and Universal Health Coverageof heatwaves; water and food insecurity;spikes in acute malnutrition; populationdisplacement; and changing patterns ofinfectious disease. The resilience of healthsystems must be built so that they remaineffective, efficient, and responsive to theneeds of the population in an increasinglyunstable and changing climate (see Box 3). One Health. Human health is inextricablylinked to the health of animals and ourshared living ecosystem. We need tofind a way to take account of theseinterlinkages making sure that there isstrong collaboration between ministriesof health, agriculture and environmentalongside partners from those sectors.This “One Health” approach can supportgreater health system resilience as well assupporting benefits in other sectors (suchas animal health). Antimicrobial resistance (AMR). Weakhealth systems increase the risk of AMRand are less able to withstand its effects.Weak supply chains, insufficient regulations,poor infrastructure including inadequatehygiene, water and sanitation services,and lack of healthcare worker training andsupport can undermine infection preventionand control. Stronger health systems areneeded to address the half a million newcases of drug-resistant tuberculosis (TB),growing antimicrobial resistance, as well asresistance to insecticides and antimalarialmedicines.32,33,34Box 3: Building sustainable climate resilient health systemsClimate change impacts the ability of the health system to serve the health needs of thepopulation. These impacts can directly affect the service delivery infrastructure (human andphysical) of the health sector, or its ability to cope with increasing climate related demandfor services. It is therefore critically important that health systems are strengthened sothat they remain effective, efficient, and responsive to the needs of the population in anincreasingly unstable and changing climate.The impact of the health sector on local air pollution and carbon emissions is alsosubstantial, with up to 5% of the world’s carbon emissions related to health sectoractivities.56 To protect the health of the population, health systems must address bothresilience to climate change and its impact on carbon emission.A global shift toward sustainable climate resilient health systems requires action at bothnational and global levels. If we are to see tangible change, national governments need todevelop plans which address their health system’s current and projected vulnerability toclimate change, and which limit the carbon emissions of their health systems. In the UK,the National Health Service in England has shown global leadership on building a healthsystem which strives to be sustainable and low carbon by making a commitment to benet zero by 2045.57 Such targets in LMICs must be supported through the internationaldevelopment architecture ensuring that climate and health system strengthening fundingand strategic direction are inclusive of sustainable and climate resilient health systems. Thiscannot be a passive process; global funding mechanisms must be revised to ensure theycan deliver on global and local visions. Country commitments through the COP26 HealthProgramme are a key step to garnering widespread political support.

FCDO Position Paper, December 2021 15 Demographic changes and increasingurbanisation. Many countries around theworld are undergoing rapid demographicchange.35 In LMICs, where populationgrowth is increasing significantly, there is anincreasing shift in people moving to urbanareas searching for greater opportunities.These trends are projected to continue withgrowing speed. The world’s urban areasare highly varied but rapid and unplannedgrowth of cities can result in different healthrisks and poorer health outcomes due toa multitude of factors such as, but notlimited to, inadequate housing, air pollution,changing diets (often unhealthier), as wellas changes to community structures andsocial support networks. Health systemsneed to consider and plan for widerdemographic changes, addressing theneeds of both an ageing population and agrowing youth generation (for example insub-Saharan Africa) and remain adaptable,allowing the right resources to be in theright places, at the right times. Rising rates of chronic diseasesand conditions. Many countries areexperiencing a

interdependencies between HSS, UHC and global health security (GHS) and why strong and inclusive health systems are critical to realising the international community's collective global health goals and the SDGs. Part 2 goes on to set out our approach to HSS. It outlines the FCDO's principles by which we will deliver all our HSS work