“I remember walking through the streets of Asmara [Eritrea] with my mother as a small boy, and seeing posters about smallpox in the street in the early 1970s. That is also the first time I encountered WHO. Now, when I leave the office every evening, and when I come in, I see the smallpox memorial statue, and I remember the street in Asmara where I used to walk with my mother and have fresh memories of the smallpox eradication effort.”

“Today, with this plaque, we recognise the day – 9th December 1979 – when smallpox was confirmed to have been eradicated. Five months later, the 33rd World Health Assembly officially declared that ‘the world and its peoples have won freedom from smallpox.’ Today, smallpox is the only human disease ever eradicated, a testimony to what we can achieve when all nations work together.” 

“When it comes to epidemic disease, we have a shared responsibility and a shared destiny.  

With this plaque, we commemorate the heroes around the world who came together to fight smallpox and worked to keep future generations safe until it was wiped out.” 

Those were the words of Dr. Tedros Adhanom Ghebreyesus, World Health Organization (WHO) Director-General, during a speech of 13th December 2019 to commemorate the 40th anniversary of the eradication of smallpox13. 

Just weeks after that very speech, the Covid-19 virus would emerge on the world stage and officially become a global pandemic, with the notion of a shared responsibility, a shared destiny and frontline heroes resonating more than ever.

“Our experience with smallpox informs the strategies and tools we now use to fight polio and Ebola, such as disease surveillance, health promotion, and ring vaccination,” Dr. Ghebreyesus continued. “We use the lessons learned from smallpox when we take on emerging epidemic diseases such as Zika, MERS, and now monkeypox.” 

Many lessons have indeed been learned in healthcare and disease control, and from epidemics through the decades – and yet ‘lessons learned’ is another term, or perhaps the subject of questioning, when talking about the current Covid-19 pandemic.

Prior to the outbreak and subsequent classification of Covid-19 as a pandemic, the last epidemic to cause concern globally had been the Ebola outbreak of August 2018 (-present) in the northeast of the Democratic Republic of Congo (DRC), later reported across the border of DRC and into Uganda. That epidemic had been largely contained to Africa. By June 2019, the Ebola outbreak became the second-largest in history, and in the July the WHO declared it a Public Health Emergency of International Concern (PHEIC), urging increased international support14.

Other epidemics of international concern had been the outbreak of the Zika virus in 2015-16, the Ebola epidemic that swept West Africa from 2014-2016, the Middle East Respiratory Syndrome (MERS) outbreak in 2012 and the H1N1 influenza virus (also known as Swine flu) of 2009-10, respectively. 

All had been relatively fearsome in their transmission and effects, particularly the H1N1 virus and its disproportionate effects on children and younger people, but had also been controlled comparatively quickly.

These isolated events aside, the world had perhaps been in a collective safety net of improved wellbeing, with the comfort blanket of mass vaccination against diseases in the developed world. Indeed, as Dr. Ghebreyesus had celebrated in his smallpox speech, “The smallpox eradication programme taught us many lessons, which we still use today… Smallpox also laid the foundation for national childhood immunisation programmes worldwide, which are critical to primary healthcare and the movement for universal health coverage.”15 

The very same speech was also useful in highlighting, however, the unbalanced sense of wellbeing in healthcare systems across the globe.  

“Yet today, we are facing a lack of trust in public institutions, widespread vaccine hesitancy and disinformation… and glaring gaps in our immunisation coverage for the most vulnerable. The result has been catastrophic. Globally, measles killed 140,000 people last year, many of them infants and young children. The fact that any child is afflicted by a vaccine-preventable disease such as measles is an outrage.” 

“Yet less than 70% of children worldwide are getting the second dose of measles vaccine, when it should be 95%. Globally, there are more than 13 million children, many of them in fragile states and conflict-affected countries, who are entirely left out of vaccination services. We are not protecting the world’s most vulnerable children. This is a collective failure.” 

It continued, “The lesson from smallpox is very clear – technology is not enough. The best vaccines in the world do not help us if people are not getting them.” 

“…this achievement was done in the middle of the Cold War. So anything is possible and we cannot have any excuse with polio or other diseases. We must invest in immunisation programmes, public health communication, and strong primary care. But above all, we had global solidarity, which was really visible, and which we should celebrate, a solidarity even with our differences. That is the only way we can achieve health for all, protect people from these devastating outbreaks and make the world a safer place.”

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A complex state-of-play

This was a sentiment reinforced by the WHO’s earlier 2019 report titled Global Spending on Health: A World in Transition, which described the complex state of balance in healthcare systems globally.  

Global health spending continued to rise and the health sector continued to expand faster than the economy, it explained, yet when drilling deeper down into regional health infrastructure, these key headlines could be construed as papering over localised cracks. 

Taken at face value, there is a picture of health in domestic healthcare spending. This is underlined in the report’s preface, which explains, “Most countries have experienced economic growth and growing market demand over the past two decades. Economic growth and improvements in efficiency of public taxation have also increased public revenue, contributing to increases in both private and public spending on health, with the health sector growing faster than the economy as a whole. As a result, people’s access to needed health services continues to progress in all regions of the world and for all country income groups.”16

A look at three opening key statistics from the report’s key messages confirms this trend.  

  • Two years into the Sustainable Development Goals era, global spending on health continues to rise. It was US$ 7.8 trillion in 2017, or about 10% of GDP and $1,080 per capita – up from US$ 7.6 trillion in 2016. 
  • The health sector continues to expand faster than the economy. Between 2000 and 2017, global health spending in real terms grew by 3.9% per year while the economy grew 3% per year. 
  • Middle-income countries are rapidly converging towards higher levels of spending. In those countries, health spending rose 6.3% per year between 2000 and 2017 while the economy rose by 5.9% per year. Health spending in low-income countries rose 7.8% per year17.

In many countries, however, public spending on health was falling as a share of current health spending, even as the economy was growing. Giving priority to health appeared to remain a political choice by country. 

While public spending represented around 60% of global spending on health and grew at 4.3% per year between 2000 and 2017, this growth has been decelerating in recent years, from 4.9% per year growth in the period from 2000–2010 to 3.4% in the period from 2010–201718

This is also reflected in the report’s preface, with the commentary explaining, “…this progress continues to leave too many countries and too many people behind. Progress in access to services is slowing globally, with lower annual rates of increase between 2010 and 2015 than between 2000 and 2010. While markets adapted quickly to growing demand, public policy to address market failures in healthcare and protect the most vulnerable has adjusted more slowly.” 

“Large inequities remain between and within countries. Progress is particularly slow in improving access to skilled health workers and essential medicines.”19

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Clearly there were warning signs around healthcare preparedness even pre-Covid-19, and we might argue that this latter comment around access to skilled health workers and essential medicines was highlighted acutely during the extremes of the pandemic. 

One might also question whether medical oxygen supply should have been classified under ‘essential medicines’ previously; during the fight against Covid-19 it has clearly been an essential therapy, and there have arguably been demonstrable disparities between and within countries in terms of access to it. 

The disparity between healthcare spending across countries is evidenced in the numbers. Across low-income countries, the average health spending was only US$41 per person in 2017, compared with US$2,937 in high income countries – a difference of more than 70 times. High-income countries account for approx. 80% of global spending, but the middle-income country share increased from 13% to 19% of global spending in the period between 2000 and 201720. 

Given this imbalance in healthcare spending, might we have been able to predict that some countries and/or regions would be harder hit by the onset of Covid-19 than others? Perhaps conversely, with the aforementioned figures on health spending decelerating in the period from 2010-2017, and health spending falling relative to economic growth in many countries, could we have foreseen the at times inability of even more advanced economies/societies to deal with lethal waves of Covid-19?  This brings us to the different political philosophies at play. 

Political playbook

Different countries around the world are clearly at differing stages of economic development and healthcare prosperity at any one time.

Shouldn’t all governments seek to apportion a similar percentage of healthcare spend relative to respective GDP? Perhaps, but we have to acknowledge that various economies around the world are at starkly different points in their developmental curve.

In more established economies, there is likely a more stable or relative spend on healthcare as a percentage of GDP; the hard yards in establishing a public healthcare system have already largely been taken. In countries with fast-growing economies, however, health spending is often increasing dramatically as they move up the income ladder. 

Between 2000 and 2017, overall health spending dramatically increased in a group of 42 countries that experienced fast economic growth21, for example. Taking that analysis one step further, on average, real health spending per capita grew by 2.2 times and increased by 0.6 percentage points as a share of GDP. For most, the growth of health spending was faster than that of GDP, the WHO’s report (Global Spending on Health: A World in Transition) points out. 

The report continues to explain that most fast-growing countries embarked on the health financing transition, increasing their domestic public spending per capita, as a share of public expenditure and as a share of total health spending. In 17 of these countries, however, public spending on health fell as a share of current health spending, even as the economy was growing. “Giving priority to health – or not – is clearly a political choice,” it affirms22. 

The WHO does acknowledge later in its report that not all fast-growing economies have fully realised their potential to foster higher tax revenue.  

Both tax revenue and expenditure as a share of GDP increased in fast-growing economies overall. But several countries have not realised the potential of increasing tax revenues. While, on average, countries had a two-percentage point increase in government spending as a share of GDP. A third of the countries had public spending decline as a share of GDP, despite their growing economies. While the data do not indicate the specific reasons for this in each case, the pattern is consistent with these countries having had difficulties in adjusting to the rapid change in their economies and in strengthening institutional capacity to collect tax revenue23

Even taking this into account, and the natural disparities between mature and emerging economies, there are very clearly different political philosophies at play when it comes to healthcare spending around the world. Let’s walk through a few examples from major economies. 

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According to data from the World Bank (citation, taken on 8th June 2021), health expenditure in the US in 2018 represented just under 17% of GDP. This compares favourably versus Germany (11.43%), France (11.26%), the UK (10.0%), Spain (8.98%) and Italy (8.67%)24. These are all reasonably consistent figures across some very advanced economies. Likewise, Japan’s health expenditure was around 10.95% of GDP in 2018, while Brazil’s was 9.51% of GDP in the same year. 

Compare this to China (5.35% of GDP in 2018), Turkey (4.12% of GDP in 2018) and India (3.54% of GDP in 2018)25 for example, and we see stark differences in health expenditure around the world. 

There are many interesting observations to be drawn from such statistics, two of which are the relative health expenditure of two of the world’s fastest-emerging economies (China and India) and the disparities between two reasonably established economies in the shape of Brazil and Turkey. We can see that Brazil’s health expenditure as a percentage of GDP is more than double that of Turkey’s in the same year. 

This is also picked up in the WHO report (Global Spending on Health: A World in Transition). It notes that the distribution of global health spending remains highly unequal, explaining, “While the general pattern is that wealthier countries spend more on health, there are large variations in spending among countries of similar incomes. For example, Brazil spent more than twice as much per capita on health as Turkey did even though they have a similar GDP per capita.”26 

One could argue that health spending is down the political pecking order of both China and India too, based on the data above. One reason for this could be the allocation of increasing wealth to other areas of the economy – think infrastructure or education. The WHO affirms in its report that, “…as countries enjoy fast economic growth, the increase in government revenues that usually results does not always translate to a larger budget share for health. Indeed, in some cases the share has declined, as countries use the added government revenues for other priorities.”27 

Preparedness: Coping with Covid 

An interesting analysis is how these countries coped with the Covid-19 pandemic, respectively, compared to how their healthcare expenditures appeared to stack up prior to the outbreak of the virus. 

For this we’ll take data on confirmed cases and fatalities from coronavirus from the Covid-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at John Hopkins University (JHU)28, updated on 08/06/2021, and the aforementioned data on health expenditure from the World Bank, citing the WHO Global health Expenditure Database29

We can see that the US has far and away the highest number of confirmed cases, at more than 33 million (33,378,767). It also has a proportionate level of deaths at 597, 983. And yet, the US had earlier topped health expenditure as a percentage of GDP in 2018. Was there a political playbook here that defied the apparent preparedness of its healthcare system? 

Second to the US in confirmed cases of Covid-19 (28, 996,473) and deaths from the virus (351,309) is India, which apportioned only 3.54% of its GDP on healthcare spending in 2018. A further point to note here is that the vast majority of these figures were endured in early 2021, during a lethal second wave of the virus in the country, having managed its way through the first wave in a comparatively better manner. Had the country taken its eye off the ball with Covid-19?

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Third on the list of hard-hit countries at the hands of the pandemic, is Brazil, with almost 17 million confirmed cases (16,984,218) and 474,414 fatalities. The latter figure is clearly much higher than the death toll in India, despite far fewer confirmed cases. And yet, as described earlier, Brazil had an expenditure on healthcare of 9.51% of GDP in 2018 – almost triple that of India and more than double that of Turkey, where confirmed Covid-19 cases total 5,293,627 and fatalities total 48,255. Again, this appears to beg questions over political strategies and acknowledgement of the virus, rather than healthcare system preparedness itself. 

What countries like the US, India and to an extent Brazil all have in common are large populations. It is perhaps to be expected, then that Covid-19 case numbers and resulting deaths would be higher by comparison. 

Three of the countries in Europe – one of the early epicentres of the pandemic – that were known to have struggled in their response to Covid-19 were Italy, Spain and the UK. All had comparatively solid health expenditure percentages in 2018 as we have already explored, yet were visibly in the grasp of the virus in its deadly first wave. 

From early 2021 onwards, these countries have been able to counter the threat of Covid with the roll-out of vaccination programmes, particularly the robust programme of vaccination in the UK. As reflected upon earlier, however, clear differences in vaccination programmes and access to these treatments have long existed across the world.

Fragilities exposed 

It is evident that economics and political agendas affect healthcare budgets and policy. This is not just borne out in the reports of the WHO or the analysis of healthcare expenditure relative to GDP; it has arguably been demonstrated during the response to the Covid-19 pandemic since early 2020. 

Ultimately, a complex state of balance exists in healthcare systems globally, and it has been no guarantee that economic prosperity will translate into proportionate increases in healthcare expenditure. 

The WHO acknowledges in its 2019 report Global Spending on Health: A World in Transition, that as the world became wealthier, countries both small (Guyana and Bhutan) and large (China, India, Indonesia) had rapid economic growth, driving up government revenues that enabled greater public financing for all sectors, including health. But it also notes that many countries are either yet to realise the higher tax revenues they are capable of, or simply are not aligning healthcare spend with that of increased economic performance for other reasons. Remember that line, “Giving priority to health – or not – is clearly a political choice.” 

There have clearly been outliers in the analysis of the political-medical playbook and how that compared with the Covid-19 responses, respectively. Take Brazil, for example, where healthcare expenditure as a percentage of GDP is among the highest in the world, and yet the country still struggled to cope with Covid-19. India is another example, cited in the aforementioned WHO report as one the countries to have experienced rapid economic growth and improvements in its healthcare provision, and yet another country that has been so visibly crippled by a second wave of Covid-19 and a medical value chain found wanting.

We’ve seen the fragility of healthcare systems globally, brutally exposed by an indiscriminate and elusive virus – fragilities which pose many questions, not least, had the world settled into something of a safety net of false security with healthcare and vaccination programmes? Did political philosophies prioritise other areas of spend in the lead up to one of the biggest global public health emergencies?

In the cases of Brazil and India for example, do the answers to their respective woes at the hands of Covid-19 lie more in their political positioning towards the pandemic than healthcare readiness? Or a combination of both, and a compromised oxygen supply chain?

We’ve explored examples of relatively low levels of public spending on health by low and middle-income countries (LMICs) and further still, it’s likely reasonable to question whether oxygen even figured too greatly in that health spending at all; one would not have necessarily expected it to. Yet the spotlight has been firmly shone on the critical role of medical oxygen and, at times, a lack of access to it. Which begs the next question: is it time for all governments to list oxygen as an essential medicine and equip all health facilities with it accordingly? Is there a need for all governments to increase their health spending, to up their prioritisation on health beyond this pandemic?

In many ways, the biggest question of all is, how pandemic-prepared were we and could we be?

Part 1. Emergence of a virus…

Catch-up on Part 1 of this new series, exploring the world as we moved into 2020 and the emergence of a lethal new virus, with gasworld.

Next week, look out for Part 3 in the series, exploring Pandemic Preparedness.