No global health security without strong and resilient health systems in the Mediterranean

12 December 2022 | Focus | English


slideshow image Nurse Chaimaa helps Doctor Meryem Bouchbika to adjust her protective gear as the spread of the coronavirus disease (COVID-19) continues in Sale, Morocco April 22, 2020. REUTERS/Youssef Boudlal

Health as a security and development approach

Health security (or global health security (GHS)) is defined as “the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of population living across geographical regions and international boundaries” (WHO, nd). Health becomes a major security concern when it threatens a nation’s ability to function and safeguard its citizens’ welfare, including provision of basic services (McInnes, 2018). The rapid spread of COVID-19 pandemic globally demonstrates this new critical concern. It also necessitates the adoption of a holistic approach to health, reflecting both a security approach (fighting symptomatic issues) and a health development approach (tackling upstream causes and determinants) (Paul, Brown & Ridde 2020).

COVID-19 Pandemic: Exemplifying the tie between global health security & health system

When it comes to public health crises, health security efforts are crucial. Investments in early warning systems and advanced laboratories are unquestionably needed; however global health security alone is not sufficient. A hyper-focus on infectious disease control often overlooks the broader reality: health systems worldwide are chronically underfunded, fragmented, and inequitable (Lal, 2021).

The COVID-19 pandemic sheds light on the crucial relationship between health system capacities and effective health security response (Brown et al 2022). In most countries, health system deficiencies hindered effective response. These include (Brown et al 2022; Kandel et al 2020) a lack of emergency planning and leadership, shortages of equipment, disruptions to medical supply chains, limited scale-up capacity to respond to increases in caseload frequency, poor information on health systems capacities, as well as a weak engagement of private sector providers with governments in national pandemic responses.

Figure 1. Overview of COVID-19 pandemic response in selected Mediterranean countries

In the Eastern Mediterranean Region (EMR), the pandemic exacerbated inequities at different levels. For instance, at the socioeconomic level, the pandemic fostered socioeconomic inequities in rates of infection and mortality from COVID-19, as well as health care services access was unequal to different groups of individuals, and specially for people living in disadvantaged geographical areas, who were served by under-resourced health services. At the same time, the total number of people living on less than 1.90$ per day rose to 2.8-3.4 million people due to pandemic-related unemployment, reduced working hours, and inadequate social support, and the levels of food insecurity and undernutrition substantially increased during 2020.

The rapid spread of the COVID-19 pandemic revealed long-existing gaps and bottlenecks in the global health security architecture which hindered public health systems from preventing, detecting and responding to international infectious disease threats. As such, global health security efforts will fall short unless concretely tied to broader health systems strengthening initiatives (Lal 2022). In other word, there can be no genuine and resilient global health security without strong health systems characterized by essential capacities and adequate resources at all levels.

Strengthening health system for global health security and Universal health Coverage (UHC)

Although most countries faced challenges in sustaining an effective response over the course of the pandemic, health systems that could effectively leverage both robust global health security core capacities -for instance risk communication, surveillance and laboratories- and fundamental universal health coverage (UHC) interventions such as primary health care, accessible health facilities, community health workers and affordable medicines and supplies, were in a better position to protect their citizens against the social and economic impacts of the pandemic (Lal et al 2022; Malik et al 2021; Assefa et al 2021). For instance, between May and September 2020, 74% of countries in the EMR reported disruptions to communicable disease treatment, 73% reported disruptions to immunization, and 38% reported disruptions to non-communicable disease treatment (World Bank, 2021). These disruptions could largely be attributed to inadequate progress on UHC and poor consideration of the role of primary health care in preparedness and response. Thus, overall health outcomes are unlikely to improve without simultaneously addressing both UHC and global health security. Hus, mobilizing investments in a health system approach therefore represents a “double-win” (FCDO 2021).

Way Forward

The COVID-19 pandemic highlighted the role of health systems in promoting and strengthening health security. This has triggered a global re-think on how initiatives to promote health security are approached, with a renewal of focus on strengthening health systems and considering health security in the context of resilient health systems.

Rethinking global health security architecture

There is a tendency in the literature to consider health security as an exceptional form of response or that it relates primarily to acute health emergencies as opposed to a concept embedded within the wider public health continuum and/or health system strengthening approach (Brown et al 2022). This means that recommendations for improving security capacities are often isolated to a single building block, a sub-set of a building block, or disregarded health systems approaches altogether, opting to focus on the use of emergency powers (Brown et al 2022). This may explain the insufficient COVID-19 readiness and response, particularly in high-income countries (HICs) where health security was depicted as a ‘once in a century’ exceptionalism, with the assumption that threats would largely impact the Global South and that HICs capacities were sufficiently prepared, creating a condition of complacency (Brown et al 2022). Such traditional health security paradigms “continue to speak in the terms of costly ‘countermeasures’ versus prevention and health system strengthening” (Paul, Brown and Ridde, 2020).

Aligning Health Systems, Global Health Security and UHC Capacities

Strong health systems constitute the foundation that underpins both UHC and global health security. UHC and global health security both require strong governance and leadership, motivated health workers, robust financing, sufficient supplies and medications, strong community systems and good data for decision making (FCDO, 2021). Future pandemic preparedness and response mechanisms should prioritize health systems strengthening that simultaneously leverages global health security and UHC to ensure long-term resilience and equity (FCDO, 2021). Investing in primary health care and essential public health functions while addressing gaps in health systems foundations can be a key approach for creating cohesion between global health security and UHC (WHO, 2021).

Reinforcing Health Security through Health System Resilience

Sustained progress on health security cannot be made without functioning and resilient health systems capable of protecting all people, including the poorest and most marginalized, from health threats such as infectious diseases, AMR, and the impacts of climate change (FCDO, 2021). Improving the resilience of health systems is a key policy challenge for all governments emerging from the pandemic and looking to prepare for the future. Acknowledging the importance of developing stronger and more resilient health systems for health emergency preparedness, the World Bank, in collaboration with technical experts from the Knowledge to Policy (K2P) Center and other international institutions, has developed a Health Systems Resilience Tool focusing on Eastern Mediterranean Region (to be published). The tool is currently being pilot tested in selected EMR countries.

Positioning Health System Reform as Part of Overall Health Sector Reform

Health system reform should be part of a broader health sector reform, encompassing an increase of investments in health sector and re-orientation of curative-oriented health systems towards prevention, primary care and public health. Moreover, another key measure would be to develop whole-of-government and whole-of-society engagement to position health as central to socioeconomic growth and resilience. Enhanced stewardship and leadership capacity to steer a whole of government whole of society response for addressing national health challenges would help advance this goal, as well as involving stakeholders, communities and civil society organizations via a bottom-up approach would allow policymakers to take more transparent and social-grounded health policy decisions. Finally, shifting from passive to strategic purchasing and partnering with the private health sector would also strengthen the health system and would help move towards its reform.

Promoting Regional Dialogues & Collaborative Capacities in the Mediterranean

Promoting dialogue across countries of the Mediterranean is critical to agree on key measures as a basis for strengthening forms of cross-border cooperation, including the coordination of cross-border health responses (among all but not limited to leveraging digital technology and artificial intelligence for efficient exchanges) and the strengthening of public health cooperation measures to contain pandemics & protect people in the Mediterranean. Moreover, fostering collaborative research efforts and scientific experiments addressing the different dimensions of emergency responses would certainly pave the way towar ds this end, as well as improving the share of information, knowledge and experiences towards a more open, real-time and transparent manner. Last but not least, the preservation of supply chain connectivity and the collective mitigation of the socioeconomic impacts of the pandemic while protecting public well-being as a basis for (political) stability are key to advance in cross-border health cooperation in the region.


ASSEFA, Y., GILKS, C. F., VAN DE PAS, R., REID, S., GETE, D. G., & VAN DAMME, W. (2021). Reimagining global health systems for the 21st century: lessons from the COVID-19 pandemic. BMJ global health, 6(4), e004882.
BROWN, G. W., BRIDGE, G., MARTINI, J., UM, J., WILLIAMS, O. D., CHOUPE, L. B. T., … & KANDEL, N. (2022). The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages. Globalization and Health, 18(1), 1-17.
FOREIGN, COMMON WEALTH AND DEVELOPMENT PAPER (FCDO) (2021). Health Systems Strengthening for Global Health Security and Universal Health Coverage.
government/uploads/system/uploads/attachment_data/file/1039209/Health-Systems- Strengthening-Position-Paper.pdf
KANDEL N, CHUNGONG S, OMAAR A, ET AL (2020). Health security capacities in the context of COVID- 19 outbreak: an analysis of International Health Regulations annual report data from 182 countries. Lancet. 395:1047–53.
LAL, A. Opinion: global health security must be tied to health systems. Devex, June 17, 2021.
LAL, A., ABDALLA, S. M., CHATTU, V. K., ERONDU, N. A., LEE, T. L., SINGH, S., … & PHELAN, A. (2022). Pandemic preparedness and response: exploring the role of universal health coverage within the global health security architecture. The Lancet Global Health.
MALIK, S. M., BARLOW, A., & JOHNSON, B. (2021). Reconceptualising health security in post-COVID-19 world. BMJ Global Health, 6(7), e006520.
MCINNES, “Health.” In Security Studies, 543, Routledge, 2018. 2
PAUL, E., BROWN, G. W., & RIDDE, V. (2020). COVID-19: time for paradigm shift in the nexus between local, national and global health. BMJ global health, 5(4), e002622.
WHO (nd). Health security.
WHO (2021). Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond: WHO position paper. Geneva: World Health Organization
WORLD BANK BLOG (2021). A year after patient zero: Essential health services and systems in MENA.