First: Relationships between public health, primary, secondary and tertiary health services

During the COVID-19 pandemic, health systems needed to monitor outbreaks and provide new services, in rapid time, on a large scale. The ability of health systems to surge in capacity and deploy technologies and workforce proved critical. The organisation of health services throughout health systems determined this capacity, in particular the extent to which access to COVID-19 related services was eased (single point of contact and free of upfront costs), trained workforce (clinical and administrative) was able to be redeployed, and diagnostic and treatment services were able to be coordinated.

Vital factors included where in the system key functions of public health were located (who undertook contact tracing, who held responsibility for communicating public health messaging); how pathology was integrated into disease surveillance and reporting systems (including data transfer); and the how the place of primary care physicians—as system entry points—was managed. Most countries struggled to organise contact-tracing efforts and fully integrate primary health services into COVID-19 responses due to a mismatch between the workforce, resources and skills required, and the administrative and financing models that located these functions and services in effectively separate systems.9

Second: Relationships between central and local administrative levels

Key case studies in the responses of centralised and devolved government systems to the pandemic have consistently found that political and public discourse favoured strong centralised action and decision making in the first half of 2020, and this often led to new and innovative ways of working.10 However, as the pandemic progressed the difficulties of compromise in devolved systems re-emerged as they struggled to implement cohesive national action once the pandemic moved into a management phase with differential effects across regions. Rivalries ensued between administrative units, particularly those governed by rival political parties, and much needed cooperation during critical times slowed. Centralised systems on the other hand also faced difficulties establishing and implementing easily accessible test regimes and contact-tracing which function best with localised coordination across health service provider types.11 The Organisation for Economic Co-operation and Development (OECD) found that a comparison of federalised and non-federalised health systems in the pandemic did not advantage one or the other on the whole, but did highlight the importance of clear roles, responsibilities, capabilities and, importantly, rules of deliberation, compromise and decision-making between levels of government and health administration.12

Third: Relationships between evidence production, expertise, technical advisory and decision makers

Decision makers relied on evidence synthesis and expert advice to underpin policy decisions, ranging from interventions such as wearing face masks, curfews, border closures to economic stimulus and vaccine allocations. The extent to which such evidence can be successfully gathered and used has relied on two key factors during the COVID-19 pandemic. The first is an institutional infrastructure for gathering evidence, synthesising it and interpreting it into technical advice. Systems of public health surveillance needed to be time efficient and accurate with efficient data transfer from local to central reporting units and ultimately to established institutions for the analysis and communication of the meaning of these data. This function was dispersed in various combinations in different countries between established or ad hoc centres for disease surveillance and standing technical advisory committees.

The second key factor required to maintain an effective evidence-based response is sound relationships between these institutions, technical experts and decision makers, in particular leadership in government. These relationships require a particularly high level of maturity to steer the course during high-stakes decisions, especially as there was frequently fierce debate where evidence was still emerging or equivocal. Many countries struggled with the need to be able to accept the nature of such debate, respect the independence of health research institutions, and be willing to fully deliberate and take decisions based on technical advice.13

Fourth: Relationships between public and private sectors in health systems

Most health systems are comprised of a mix of public and private actors; from the providers of health services to health insurance; from the information technology platforms that underpin medical records to the research, development and application of diagnostics, therapeutics and vaccines. The pandemic has demonstrated the need to optimise the relationships between the public and private actors that now underpin the fundamental functioning of health systems14 that must be organised to enable health systems that progress towards health equity and improvement. COVID-19 has demonstrated the extent to which poor governance of these relationships can have severe consequences during times of crisis. For example, regions that experienced acute COVID-19 outbreaks required surge capacity in often unprofitable preventative, critical and intensive care services. Health systems became overwhelmed where drivers of health system funding had depleted these services and isolated both public and private sectors from a whole-of-system crisis response.15

The pursuit of suitable vaccines to fight the COVID-19 pandemic also exemplified the opportunities and challenges of optimising relationships between public and private actors for health. The complex patterns of revenue raising, licensing and purchasing have highlighted the truly incremental and global nature of medical research, while the ongoing challenges of manufacturing, procurement and distribution demonstrate the co-dependence of public and private sectors.