Two Key WHA Resolutions Must Learn from COVID, and Focus on Universal Scale Up of Oxygen and Essential Care

Next week, the World Health Assembly (WHA) is considering two key resolutions, one on oxygen supply and another on emergency and critical care. Together, these resolutions represent an acknowledgement of a major lesson from the COVID pandemic: delivery of rapid care for the critically ill, including oxygen, is a vital cross-cutting building block of both universal health coverage (UHC) and pandemic preparedness. The need to strengthen this component of health systems was brought to public attention in all countries during the pandemic but was perhaps most dramatic in India during its overwhelming Delta outbreak.

The two WHA resolutions are an excellent step forward and have the potential to lead to positive, long-lasting health system change. We support these resolutions—but they fall short of what is needed. We urge Member States to submit an amendment that explicitly articulates the order of priorities in this field. Without consideration of the priorities, there is a risk of repeating the early errors of the COVID response, when attention focused on ventilators and intensive care units but efforts to strengthen the basics were neglected. We believe the resolutions should call countries to first scale up universal access to the essential care of critical illness before expanding more advanced services, and to prioritise the fundamentals when implementing the resolutions, in line with the WHO Fair Priorities framework.

The two resolutions deserve WHA support

The first resolution is on increasing access to medical oxygen. This resolution argues that oxygen improves outcomes across the health system, for almost all diseases including respiratory pandemics. It calls for the development of national costed plans to scale up safe supply and use, supported by the WHO, by domestic and international finance, to be monitored by future WHAs. This resolution is welcome as oxygen systems have historically been neglected and can result in highly cost-effective improvements in patient care. Because access to medical oxygen is a core health system function that does not rely on international commodities, the resolution rightly places the emphasis on national plans and the regulation of domestic markets. It is also right in calling for investment in the ecosystem around oxygen production that is required for clinical impact, including infrastructure, reliable supply chains, trained health workers to use oxygen safely and appropriately, and skilled engineers to maintain the equipment.

Oxygen is necessary but is never sufficient for saving the life of a sick patient. It is, therefore, welcome news that the WHA is considering a second resolution on integrated emergency, critical and operative care (ECO). This resolution raises the profile of emergency and critical care—the key parts of the health system that are required to function at speed—to provide rapid identification and immediate treatment of the severely ill, regardless of underlying diagnosis. It calls for national policies, governance, and implementation plans, supported by WHO technical guidance, and monitored biannually by the WHA. A strength of the resolution is its acknowledgement that the care for critical illness happens across the system—from prevention via road safety, to community, pre-hospital care and triage, to care within hospitals. Care for critical illness is the systemwide identification and treatment of the critically ill and is far more than just care in intensive care units. The resolution also rightly stresses the importance of developing national quality improvement systems, such as audits, national guidelines, and training. Finally, out-of-pocket payment for emergency care has substantial practical, equity, and access concerns, and the resolution is right to call for Member States to include these services in universal health benefits packages, and develop alternative (presumably pooled) financing modalities.

The missing piece of the puzzle – what should countries do first, given limited budgets?

Whilst ECO services are vital for the impact of oxygen scale up, and scale up of ECO are vital for UHC, no country can afford every ECO service, for every person who needs it. The resolutions do not, however, give guidance on what should be prioritised for scale up first. We believe that an approach of “everything, everywhere, all at once,” is a persistent, common, and problematic approach in global health planning. It doesn’t recognise the resource limitations that are present in all health systems, leaving decision-makers without guidance for the tough and necessary decisions on what to scale up first, and what to say “not yet” to. The risk is planners, doctors, and funders prioritise expensive and highly visible interventions such as ventilators in intensive care units and neglect the most cost-effective, sustainable, systemwide and equitable interventions. The result would be the world misses out on the full benefit of realising the population health impact of the resolutions. For example, in our research during COVID, we identified a core package of cheap interventions known as Essential Emergency and Critical Care (EECC). We found, in line with other research, that scaling up this care first could save many more lives than scaling up advanced care, for a much lower cost.

Recommendations

These two resolutions have a great potential for impact on global population heath, and we support them. The resolutions will have maximal impact if they promote investment in the fundamentals of care for all before progression to advanced care. With this in mind, we recommend Member States add the following amendments to the EOC resolution:

• A preamble paragraph, such as: “Noting that timely, safe and high-quality ECO care services that are designed to ensure the most cost-effective, impactful care is the priority to implement to all, followed by additional care built on that foundation, can effectively contribute to better population health and the reduction of disparities in health outcomes.”
• An operative paragraph calling for, “Member States to consider the resources they have available, and develop affordable, prioritised, costed ECO action plans, including first scaling up universal access to fundamental care before expanding more advanced services, in line with the WHO Fair Priorities framework.”
• An operative paragraph calling for the WHO director-general to “develop tiered context-sensitive guidance on ECO that lays out the priorities for an initial scale up of fundamental care before adding later tiers when more resources become available” (for example building on the approach taken in this recent WHO malaria bed-nets guidance).

Finally, the WHA resolutions should be seen as an important milestone, but not as the end goal. Following the approval of the WHA, Member States, the WHO, technical assistance partners, and donors will need to commit to, and make choices along, the long road of implementation. Essential Emergency and Critical Care provides an approach for this to ensure the most cost-effective, sustainable, and equitable interventions are implemented first. Even if the resolutions are not amended as we propose, we argue that Member States’ ECO and oxygen implementation plans consider initial scaling up of fundamental care for acutely unwell patients to ensure that such care is provided to all those who need it.