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Last weekend, the G7 leaders met in Cornwall to discuss, amongst other priorities, how to ‘build back better’ from the COVID-19 pandemic. A landmark global health agreement was reached between the member states that takes steps to ensure the devastation caused by the pandemic is never repeated. The Carbis Bay Declaration will also establish a new vaccine development centre specialising in the prevention of zoonotic diseases and there is a commitment to greater international collaboration to speed up pandemic response, dubbed the 100 Days Mission. In addition, the G7 have pledged to donate one billion COVID-19 vaccine doses to Low and Middle Income Countries (LMICs) by the end of 2022.

These are all progressive, important commitments that rightly seek to draw on the power of international collaboration to globally recover from the pandemic and enable resilience to grow in health systems. To be truly effective, we believe that these commitments also need to recognise, acknowledge and help plan to solve the huge disparities in the equitability of provision of quality healthcare around the world, most particularly in LMICs.

As a definition of health system resilience, we find “the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it,” helpful.1 In reality, this pandemic, and epidemics before, have demonstrated the limitation of capacity, fragility of core functions and inflexibility to reorganise even in some of the better funded systems – even those of the G7 countries. It has also further reinforced inequities in access in those systems that are less well-funded, and still suffering chronically from other, as yet unbeaten, infectious diseases.

The allocation of resources is of particular concern to LMICs. When the pandemic hit Nigeria, the government and private sector acted quickly to pool diagnostic and logistical resources to fight COVID-19, yet this meant that stretched disease programmes saw already-limited resources reallocated. The National Coordinator of the National Malaria Elimination Programme (NMEP) in Nigeria, Dr Perpetua Uhomoibhi told us, “There was global disruption in production, procurement and supply chain systems, affecting production of many health products including malaria commodities. This resulted in long stock outs of essential medicines at the health facility level and also affected implementation, particularly resulting in delays in key malaria interventions such as seasonal malaria chemoprevention (SMC) and the mass long lasting insecticidal net (LLIN) campaign. Although the country was able to respond – some of these campaigns didn’t start when they were supposed to last year. There was also a diversion of resources for healthcare services by government and the private sector, including what could have been for malaria programme implementation, diverted to the COVID-19 response.”

Disruptions like these have huge knock-on effects. In Nigeria – which has the largest malaria burden in the world – delays in, or curtailment of, malaria services will see hard won progress stall or even reverse. In light of examples such as this, the G7 approach to future pandemic preparedness and ‘building back better’ must respond to the reality and heterogeneity of challenges inherent in LMIC health systems and facilitate prioritisation and planning accordingly. In addition to increased funding and support at every stage of the COVID-19 vaccine supply chain, there needs to be a commitment to supporting other disease programmes, such as malaria, so that the vital gains made over recent years are not lost. Should this happen, the WHO estimate malaria deaths in sub-Saharan Africa will far exceed those killed by COVID-19.2

The international collaboration needed to solve the COVID-19 pandemic and the momentum do so, is encouraging. While resources are constrained and the complexities of prioritising in a health system remain, this momentum should be harnessed to find ways to solve other inequalities, not create more.

1Kruk ME Ling EJ Bitton A et al. Building resilient health systems: a proposal for a resilience index. BMJ. 2017; 357j2323