Leaders and Leadership in Systemic Approaches to the Challenge Posed by COVID-19

A Reflection by Public Health Leadership Coalition’s Member – Dr. María del Rocío Sáenz Madrigal

A single-cause or opportunistic understanding of health contributes to fragmented and insufficient responses. This also results in a reduction of financial resources earmarked for the assistance of other health problems, as evidenced during the two years of the COVID-19 pandemic. This situation is especially critical in countries with fragmented, segmented and underfunded healthcare systems, which have a high degree of dissatisfaction among both healthcare staff and the population.

Unicausality as an explanatory model of the disease tends to focus attention on the agent rather than on the causes of the events. This approach conditions the analysis of the situation and the identification and implementation of measures, as it focuses on control and containment of the disease instead of effectively and comprehensively impacting the factors that determine it.

Between 2020 and 2021, the difficulty of describing and explaining the complexity of the emergence, spread and severity of a new virus both locally and globally became apparent, as well as a potentially comprehensive and integrated approach was demonstrated.

The prioritisation, excessive in my view, in the preparation for medical assistance of more severely ill people who required specialised care at hospital level, is an example of how the explanatory models of the health-disease process converge in extreme or crisis situations. This gives way to the resurgence of myths and stigmatisation, which are clearly not the product of the virus itself, but of the measures that are implemented.

It is worth mentioning that the failure to prioritise actions aimed at interrupting the transmission of the virus causes hospital collapse, including the phenomenon of burnout mainly among medical and nursing professionals. Furthermore, the fragmentation of healthcare systems and their information systems makes it difficult to collect and generate reliable, trustworthy and real-time data on mortality and morbidity, which constitute hard proof of the effectiveness of protection measures implemented at local, national and global levels.

The pandemic has also brought to light the existing tension between individual, group and global responsibility. In this sense, we can mention the importance of global collaboration around scientific information regarding morbidity and mortality, virus variants, prevention strategies, and the availability of vaccines and medical treatments. In addition, information on healthcare policies restricting movement and managing inequities is considered fundamental at the regional level. At the country level, however, essential information is information relating to the process of preparing healthcare and social security systems, taking into account the populations most at risk. All of the above, mediated by the trust that the population has placed in the governments and country leaders, as well as confidence in their ability to serve their respective communities, is crucial for the adoption of measures such as physical distancing, use of face masks and vaccination and their implementation at the individual but also collective level.

It is precisely systems thinking that allows us to comprehend organisations in the broadest sense, as a set of interrelationships, where their raison d’être and purposes are understood in this articulation. Thus, systemic thinking leads to the recognition of internal and environmental complexity as a binding part of the system, and the multiplicity of actors that make it up as a core part of the response to the health claims from the population.

In this sense, it is urgent to strengthen Health Systems based on Primary Health Care (PHC), with people, families and the community at the centre, because it is at the local level where interrelationships, collaboration and cooperation, solidarity and social justice, synergies and contradictions are settled on and developed.

It is the recognition of a systemic approach to health problems and situations that allows us to understand not only the virus, its environment and the populations it affects but also their interrelationships. At the same time, it allows us to conceive the way in which collaborative, adaptive and multidisciplinary institutional processes can be promoted, with explicit and clearly outlined and delimited future vision, values, principles and frameworks for action. For that purpose, the definition of goals framed in action plans are necessary practices; for example, the protection of everyone, having more and better healthcare, etc. These planning exercises allow, from a broader vision, to trace routes for action in areas such as trend analysis and prospective planning; use of scientific and empirical knowledge in the definition of actions in order to be implemented; coherence, consistency, monitoring and evaluation; confidence building; assessment of multilevel health information recording and analysis; education, training and continuing education to ensure healthcare; recognition and characterisation of system actors; openness to consensus building; multidimensional coordination and articulation; communication according to the various audiences; definition of information flows and decision-making chain and incorporation of technologies, as well as digitisation and artificial intelligence.

For their part, the historical inequalities within and between countries in the Americas region were revealed to the whole world throughout these two years of the pandemic. They filled the world with suffering, desolation and uncertainty about the future, not only because of the pandemic itself, but also because of the awareness of these inequalities. In most cases, inequalities have been exacerbated in the context of COVID-19, which is why it was generally observed how the population silently claimed a comprehensive approach to the crisis.

In our region and in the specific case of Costa Rica, leadership in health was characterised by harmonising a multilevel, inter-sectoral health response with an emphasis on institutional and hospital epidemiological preparedness. However, it was striking – not only in the Costa Rican scenario – that there was little emphasis on linking local governments and organised community groups from a logic of co-responsibility, self-management and co-management, but rather with restrictive and somewhat blaming messages about getting sick or making other people sick. This approach brought to the local and global imaginary the paradigm of unicausality, which leads to focused, monothematic and partial social responses to the complexity that we have experienced in recent years; with indirect effects on the suspension of care for chronic diseases and routine procedures; physical and emotional overload on hospital teams, the population’s fear of being infected in health facilities and, in the worst cases, people’s fear of dying alone or with strangers.

Taking all this into account, being a leader entails in the first instance the ability to have the social, legal and capacity legitimisation to:

1. Identify the magnitude, severity and complexity of the situation.
2. Organise the response and the projection of organisational adjustments to processes. For example, design interventions based on equity and justice (lest the measures to be implemented increase inequalities, make certain groups of the population vulnerable, victimise or even harm them.
3. Recover the scientific and empirical evidence underpinning the actions. As well as adaptation and flexibility according to the evidence.
4. Establish priorities.
5. Protect the most vulnerable people and populations.
6. Promote the empowerment of people and organised groups, developing in them not only awareness and a sense of responsibility, but also capacities for self-management and co-management.
7. Communicate assertively and have risk communication skills.
8. Build consensus with diverse actors in the public, private, national, civil society, local and global spheres.
9. Have systems for transparency, effective use of resources and strengthening democratic mechanisms for accountability to citizens.

The experience of the region in the wake of the COVID-19 pandemic taught us that leadership in health must include equity in the design and implementation of actions, otherwise the results will be partial, insufficient, and will perpetuate and exacerbate inequality gaps.