Agnes Binagwaho: Rwanda’s resilient health system was designed to serve all citizens equitably, with a particular focus on the most vulnerable. To break geographical barriers to access, the system is decentralized: 60,000 community health workers have been selected by their village-peers and trained by the Ministry of Health to carry out essential tasks. These include providing preventive care, treating uncomplicated cases of common illnesses (upper respiratory infections, gastroenteritis, and malaria), and referring patients for higher levels of care when necessary.

Crucially, community health workers also communicate to those they serve how, when, and why to take advantage of health services. By bridging the gap between the health system and communities, this decentralized approach improves health outcomes, contributes to social-capital enrichment, and facilitates the rapid detection of – and response to – new health threats.

The key to such a system is trust. Community health workers are entrusted by their village-peers to deliver health care. More broadly, the Rwandan government has demonstrated a commitment to protecting the most vulnerable members of society by pursuing equity-focused policies, strategies, and programs. During the COVID-19 pandemic, for example, those most in need received social support. This reinforces people’s trust in their country’s public-health system and increases adherence to outbreak guidelines and protocols – essential to prevent new health threats from turning into epidemics.

But this level of public trust cannot be established overnight, much less in the midst of a crisis. It demands many years of participatory, people-centered governance. Any strategy for preventing the next pandemic must make this a high priority.

AB: The coronavirus crisis has made clear that solidarity is the only way to end a pandemic. And numerous solidarity-based initiatives – such as the COVID-19 Vaccine Global Access (COVAX) facility – have been created or strengthened over the last year, albeit with varying degrees of success.

Policymakers should capitalize on this awareness to push forward a global solidarity agenda, backed by comprehensive strategies, long-term commitments, and supportive organizations and policies. Governments should also send a clear message to their citizens that, during a pandemic, nationalism kills and prolongs the global crisis for all. And they should take advantage of international meetings, such as G7 and G20 summits and the United Nations General Assembly, to advocate for the uptake of the recommendations made by the Independent Panel on Pandemic Preparedness and Response.

To succeed, policymakers must synchronize their arguments and secure multisectoral support for solidarity-based initiatives. They must make clear that solidarity is not synonymous with charity. Rather, it is a means of ensuring international health security by supporting health systems that bear a legacy of centuries of exploitation, as well as the brain drain that occurs when health professionals, educated at high cost in low- and middle-income countries, move to high-income countries to work.

To put this in perspective, as of 2011, nine Sub-Saharan countries were losing a total of $2.17 billion in returns on their investments in training doctors who had moved to Australia, Canada, the United Kingdom, and the United States to work. Meanwhile, the UK alone gained $2.7 billion in benefits from recruiting trained doctors from these nine countries.

Angus Deaton: I think that health-care reform is enormously important to America’s long-term economic and social prospects. We are spending $1 trillion more on health care per year than we ought to be. This burden is reducing wages and eliminating good jobs for less-educated Americans. It is also limiting the prospects for future federal spending, though the pandemic has temporarily redirected attention to the costs of tackling COVID-19. And it is hurting state governments: the mounting costs of Medicaid are limiting US states’ ability to provide other services, particularly education. For example, states used to provide much more ample funding to public universities, ensuring that a high-quality education could be had at relatively low cost.

The US cannot tackle its health-care problem without cost-control measures. The problem is that those who benefit from keeping health-care costs exorbitant have undue influence over certain political forces. This makes real progress highly unlikely, even impossible.

The introduction of a British-style National Institute for Health and Care Excellence would help. For example, it would prevent a repeat of the Food and Drug Administration’s recent decision to provide accelerated approval to an Alzheimer’s drug of doubtful efficacy, which will be a financial boon for its makers: it costs around $100,000 per year per patient, several million of whom are likely to demand it.

A public option would also go a long way toward addressing America’s health-care problem, but it faces strong political opposition. It is disappointing that President Joe Biden’s administration has not committed to tackling this problem. I suspect they have decided that success is not possible.

AD: I believe that everyone in the world, wherever they live, should have access to quality and affordable health care. Yet, given that there is essentially zero chance of achieving universal health coverage in the US in the foreseeable future, we Americans are uniquely ill-equipped to give advice on how to deliver it.

Providing health care is difficult everywhere. Markets have fundamental problems delivering in this area, including in the provision of health insurance. Governments have different but equally fundamental problems doing so. The ideal mix of state and market will be different in different places. Foreign aid has often been successful in helping with vertical health measures – vaccinations, vector control, clean water – but not in providing routine health care.

It is up to governments to make intelligent decisions about health-care provision that reflect the needs, traditions, and desires of their citizens. To this end, they must measure the amount their citizens spend on health care, and in what kinds of facilities. They also need to keep tabs on the performance of public and private health providers, particularly on whether staff turn up for work, and on the quality of care that they provide. Governments need to decide which state-provided services will do the most good based on real information on performance, and not be bound by external mantras that demand the provision of one kind of service over another. Finally, they need to avoid any health-care or health-insurance system that is designed to benefit providers at the expense of everyone else.

Tom Frieden: Epidemics don’t have to spread uncontrollably and cause devastating loss of life. Our report highlights the great work of public-health professionals around the world and shows that if we work together, and follow the science, we can make the world a much safer and healthier place.

The eight case studies in the report show that devastating human and economic losses can be avoided with a few simple ingredients: modest but sustained investment; strengthened public-health systems; better coordination among – and communication by – determined leaders; and structures that detect, respond to, and contain infectious-disease outbreaks before they grow into epidemics.

Infectious diseases and other health threats will not stop with COVID-19. That’s why we need to ensure that our public-health systems are prepared to handle the next pandemic threat. The last year has highlighted the critical importance of global, regional, and local-level coordination aimed at building the resilience needed to weather – and mitigate – future health emergencies. Acting now to implement preparedness and response systems will save millions of lives and trillions of dollars.

TF: Countries should seek not only to strengthen primary health care, but to make it the center of their health-care system, thereby establishing preservation of health and prevention of disability as the system’s organizing principle. This would revolutionize health care, which today tends to be disorganized, ineffective, and ultimately wasteful. By improving population and community resilience, countries would reduce the risk and harm of future health crises.

To this end, countries must build political consensus on key priorities, including ensuring long-term funding, making the most of community health workers and full health-care teams, and integrating public health (and public-health teams) into the health-care system.

In the United States, Congress can establish sustainable mechanisms that ensure we invest in our core public-health infrastructure and health-security programs to break the deadly cycle of panic and neglect. This is best achieved through a permanent exemption from budget caps for our health defense – that is, public-health functions that are critical to prevent, detect, and respond to infectious diseases. The creation of a Health Defense Operations budget designation would exempt critical health funding from spending caps, enabling our public-health agencies to protect us as effectively as possible.

Carl Manlan: As the pandemic has made clear, health is a powerful determinant of socioeconomic development. Countries’ ability to push through headwinds – or recover lost ground – depends on their ability to draw a line connecting the health of their people to the health of their economies . This means that better health must be regarded not as a positive potential upshot of structural transformation, but as a pillar of economic-recovery plans.

In Africa’s case, this should come in the form of efforts to enable market-creating innovations in health care. Such efforts must include investment in physical infrastructure and human capital. They must also include measures to improve the business environment for micro, small, and medium-size enterprises (MSMEs), thereby enabling them to expand their market access and boost employment along value chains, especially in the agricultural sector.

CM: Most fundamentally, governments must build resilience with the majority in mind. They must recognize that the strength of a country’s socioeconomic fabric depends significantly on the ability of MSMEs not only to survive, but to thrive – and not to have to risk their survival when they invest in growth.

To this end, one crucial step is for countries to leverage technology to shift cash-based transactions to digital financial-services platforms. This implies the provision of supplemental resources that enable the expansion of market access.

If MSMEs are prospering, their owners and employees are more likely to have the means to plan and prepare for their future, including by ensuring their own financial and physical health. They would not have to sacrifice their longer-term welfare to survive economically from day to day.