Executive summary

The COVID-19 pandemic is a tragedy. Over 6.8 million deaths due to COVID-19 were reported worldwide in January 2023. Analysis of excess mortality suggests that as many as 18 million people may have died worldwide because of the pandemic by the end of 2021. Life expectancy decreased in many OECD countries in 2020 and 2021. There was widespread disruption to society and education. GDP dropped by 4.7% in 2020 across OECD economies.

New crises beyond a further pandemic could severely test the global community: antimicrobial resistance; armed conflict; climate change; financial crisis; biological, chemical, cyber, and nuclear threats; environmental disasters; and social unrest. Chronic stressors such as ageing and demographic change challenge health systems and compound the impact of crises.

Building the resilience of our health systems has never been more urgent. Resilience entails much more than planning for a crisis. Resilience helps to absorb shocks and accelerates recovery. Importantly, health systems can enhance resilience by learning lessons which lead to better adaptation in a crisis. Doing so now is vital to facing tomorrow’s threats.

The pandemic provided lessons on what worked. OECD countries implemented whole-of-society responses, including through containment and mitigation measures. Surge capacity for critical care was raised – an 8% increase in critical care beds occurred in 2020 – while other care, such as elective surgery, was deferred. Health data availability and timeliness improved. Flexibility and agility in the health care workforce facilitated new care models and increases in crucial activities such as critical care and vaccination. Telehealth was a positive transformation, with a dramatic increase in the proportion of adults who had a medical consultation online or by phone. By early 2021, almost one in two adults had consulted their physician remotely in 22 reporting OECD countries.

However, populations and health systems in many countries are struggling to recover fully as 2023 begins. Disruptions in care, COVID-19 infections and the challenge of post-COVID-19 syndrome or “long COVID” continue to burden health systems. The legacy of the pandemic could endure for decades.

Three major vulnerabilities weakened health system resilience.

Health systems were underprepared. Spending on prevention accounted for only 2.7% of total health spending across OECD countries in 2019. As well as age, obesity and chronic diseases such as diabetes were risk factors for serious health impacts and death from COVID-19. More than a third (35%) of the population aged over 16 years across OECD countries had longstanding illnesses or health problems prior to the pandemic. Prevalence was even higher (43%) among people on lower incomes. Multimorbid patients were also vulnerable to care disruptions, which led to severe consequences and long-term complications. Poverty, unemployment and socio-economic disadvantage were highly associated with poor health outcomes. In the first year of the pandemic, the relative risk of dying from COVID-19 doubled for those living in the most socially deprived areas and for ethnic minority populations. Symptoms of depression doubled amongst young people in several OECD countries in 2020-2021, compared to 2019.

Health systems were understaffed. The pandemic left front-line health care and long-term care workers overstretched and exhausted, raising concerns that this could lead to an exodus. This would compound the strain on those remaining in the sector and stretch the resources needed for high-quality care delivery, including to address the substantial increase in mental health needs. Before the pandemic there was a wide variation across the OECD in the density of doctors and nurses, ranging from less than 5 per 1 000 people to over 20 per 1 000 people with an average of 12.4 per 1 000 across the OECD in 2019. Over 11 million fewer investigations and operations were conducted in 2020 than 2019, leading to a backlog of cases. The availability of the health workforce will be a constraint in increasing activity. The impact of long COVID is a large and uncertain burden for health systems and society: estimates are that 10% or more of those infected with SARS-CoV-2 have persistent symptoms.

Health systems suffered from underinvestment. Smart spending will be essential to strengthen public health and prevention, boost staffing, stockpile emergency supplies, increase availability of critical care beds and use data for better decision making, surveillance and research. Many countries increased their investments in workforce, digital infrastructure and equipment in response to the pandemic, but this effort will need to be maintained. Boosting the resilience of health systems requires an annual targeted investment of 1.4% of GDP across OECD countries relative to expenditure in 2019. The major investment, approximately half, should be in the health workforce.

Below are six policy recommendations to improve health system resilience. These recommendations aim to reduce the impact of future shocks on societies and economies, not only health systems. Reforms need to be cohesive and forward looking. They should not only address current issues but also anticipate future challenges by ensuring physical resources, data, governance and financing arrangements are in place.

Maximising people’s health before a crisis minimises the damage to the population, reducing the risk of death and long-term health problems. It can also reduce demand for acute health services during a shock, benefiting all. Promoting healthier lifestyles and addressing wider determinants of poor health – including poverty and unemployment – are critical to mitigating the impact of future shocks on health systems. A strong primary care system offering universal health coverage helps to improve health prior to a crisis. Including mental health considerations in crisis preparedness and response planning should be routine. Improving population health is cost-effective, and these investments will improve both the welfare of society and resilience.

Workforce shortages pose one of the biggest threats to resilient health systems. In the context of the pandemic, workforce limitations proved to be a more binding constraint than the availability of hospital beds. A proportionally larger number of health and social care workers in an OECD country was associated with relatively better outcomes. The pandemic also highlighted the importance of valuing front-line workers – particularly nurses and care workers – to revitalise health systems. Despite record high numbers of health care workers across OECD countries, over 3 million additional health care and long-term care workers may be required to improve resilience. Increased investment in retention and recruitment will make the recovery less onerous and improve workforce flexibility to meet future shocks.

Although it is not known what form the next crisis will take, data will be vital to tackle it. Better use of data and the tools to convert it into actionable information is critical to surveillance of new threats and to providing a better picture of health. Prior to the pandemic, digital infrastructure was fragmented. Only 14 OECD countries were able to link data across multiple settings within health care. Key information for health system management was not available in real-time. Only two countries reported availability of weekly mortality data prior to the pandemic. Linked data and timeliness of health data improved greatly in response to the pandemic. All OECD countries reported improved data reporting, and almost all enhanced the timeliness of data to inform policy choices and to foster more efficient resource use. These gains must be consolidated and built upon to improve the response to future crises.

Investing in digital infrastructure will also improve health system performance between crises. For future crises, data will need to be collected and linked beyond the health system, taking into account the interdependencies that arise during a crisis. For example, few national statistical offices or education ministries undertook special data collections related to the COVID-19 pandemic and its effects on education (including school closures).

Global mobility and connection have significant benefits but can magnify shocks. International decision making was challenged at the beginning of the pandemic and the speed of response was compromised. A stronger international surveillance system with continuous information gathering, risk assessment and rapid co-ordination of responses would have facilitated a quicker response.

The unparalleled success and speed of COVID-19 vaccine development saved millions of lives. Massive public sector funding was provided for research, development and manufacturing capacity, but vaccine distribution has been inequitable. The failure to complete development of vaccines against earlier coronavirus outbreaks (severe acute respiratory syndrome in 2003 and Middle East respiratory syndrome in 2015) was a missed opportunity.

Prioritising innovation through public support of research and development and exploring new incentives would help prepare the global community for a range of threats, such as antimicrobial resistance, climate change and pandemics. Internationally co-ordinated approaches are required for technology transfer and management of intellectual property for currently under-produced essential health technologies. Credible governance frameworks, enforceable commitment mechanisms, and stable long-term funding would facilitate the equitable distribution and use of essential products, such as personal protective equipment and vaccines, and global public goods such as surveillance. Global instruments are being developed for pandemics – the goals of the World Health Organization and Pandemic Fund initiatives to foster this co-operation should be supported. However, initiatives will need to go beyond pandemics to address a wider array of risks. Without progress, global challenges will result in greater disruption and inequity.

The supply of medical products hampered the initial response to the pandemic. Almost all OECD countries reported difficulties in obtaining personal protective equipment (92%), as well as testing materials (83%) and ventilators (68%). The lack of personal protective equipment was devastating. International trade underpinned a large increase in availability of vaccines and essential medical devices later in the pandemic, but barriers to trade hampered distribution. Difficulty in identifying supplies and countries involved in supply chains undermined the assessment of risk.

More detailed information on supplies, suppliers and countries of origin of finished products and key inputs are needed to better assess risks and prepare for crises. Having a limited number of suppliers for essential products is a key vulnerability. While countries are diversifying their supply chains for such products, risks remain. International co-operation around stockpiling and distribution of scarce products would promote more equitable and effective responses. For those technologies that are useful in a crisis, ensuring that sufficient manufacturing capacity exists should be combined with supplier commitments to ensure access where the need is greatest. Investing in more resilient supply chains will not only improve outcomes during crises but also encourage predictability and reliability between times of disruption.

Governance structures need to reflect the reality that the whole-of-society is involved in addressing large shocks. Interdependencies exist between the health sector and the rest of society. An example in the context of the pandemic was the long-term care sector, which was hit hard. One-third (34%) of all cumulative COVID-19 deaths in 25 OECD countries were among residents in long-term care facilities by April 2022. About 20% of older people who received personal care from professionals or relatives (living outside their household) regularly reported forgone or postponed care in 2021 across 23 OECD countries. Increased integration of long-term care with health and explicit inclusion in crisis planning would improve outcomes for the next shock.

Trust in institutions is necessary for whole-of-society responses. Misinformation and disinformation have the potential to undermine societal responses. It is critical to actively counter this and also promote legitimate and transparent decision making: 19 out of 23 OECD countries reported engaging with the media to combat misinformation and disinformation at the end of 2021. Involving stakeholders early and communicating the evidence for decisions is important to legitimacy. This is especially true when crisis responses involve liberty-restricting measures and altering of usual standards of health care. In these circumstances, leadership at the highest level is required for rapid decision making in the face of uncertainty.

With the outlook darkening for 2023 and multiple crises such as Russia’s war against Ukraine, inflationary pressures and energy insecurity, governments face tough policy choices. However, smart targeted investments in health system resilience will benefit societies by ensuring that the building blocks are there and ready for the next crisis. Without such investments, the costs will be larger and the impact on people greater.


This work is published under the responsibility of the Secretary-General of the OECD. The opinions expressed and arguments employed herein do not necessarily reflect the official views of the Member countries of the OECD.

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