Health systems under a global stress test: Digital health as a pandemic mitigation enabler by Prof Ran Balicer

The Covid-19 pandemic highlights the ways in which globalisation, emerging diseases, and climate change are severely challenging health systems. This World Health Day, Commissioner Ran Balicer discusses Israel’s holistic health systems response to the pandemic – and the important role of data and digital health.

An emerging pandemic of an infectious respiratory disease is, by itself, a predictable phenomenon. For centuries, we have been witnessing one every few decades. The 1918 influenza pandemic taught humanity painful lessons about the toll such an event may have on human lives, even among the young and healthy, while the influenza pandemics of 1957, 1968, and 2009 have reminded us that not all pandemics are equally destructive. Covid-19 is considerably milder than other ‘aborted’ potential pandemics, including MERS, SARS, and Avian Influenza, but its rapid global dissemination has already taken the lives of nearly three million people, and we are months or even years away from global relief of its dire consequences.

More than any other natural disaster, mitigating infectious disease pandemics requires social cohesion and global collaborations. There is high interdependence between people as well as between countries - if my neighbor is not safe, I cannot truly be safe either.

The Covid-19 pandemic acts as an extreme stress test not only for societies, but also for health systems. Much attention is obviously drawn to hospital surge capacity, as the inability to provide emergency care to critically ill patients is the most publicly visible tip of the iceberg of a failing healthcare system. Yet it is important to keep in mind that pandemics are first and foremost an illness managed in the outpatient setting. The key to sustainable hospital care in a pandemic is a well-functioning pre-hospital community care and public health system. If this wide base of the health system falters, hospitals will inevitably fail and rapidly saturate.

Health systems geared to adequately deal with pandemics would therefore benefit from key attributes highlighted by the World Health Organization as desirable for health systems worldwide - universal health coverage with high equitable access to care and diagnostics, a strong primary care backbone that proactively cares for population health, a coordinated and integrated healthcare system, ongoing investment in emergency preparedness and surge capacity, strong public health services and capacities, and finally, high levels of digitisation and availability of telehealth options.

The global ‘exit strategy’ from this crisis invariably involves global mass-vaccination. To this avail, two key challenges must be met – securing enough vaccines for every nation, and executing an effective, equitable vaccination campaign to administer the available vaccines as quickly and safely as possible.

Israel’s Covid-19 vaccine response: A healthcare systems perspective

In the midst of a fierce third wave of severe consequences, Israel executed the world’s earliest rapid Covid-19 mass-vaccination campaign, vaccinating the majority of its population and 90% of its elderly within 12 weeks. This achievement, attributed to these same health system characteristics mentioned above, sheds light on their benefits in emergency response through the lens of one case study.

Israel’s four public health funds, mandated by law in 1995 to provide universal health coverage to all citizens, were the backbone of this vaccination campaign in which over 2.5% of the population were vaccinated per day in January 2021. These four health funds focus most of their annual expenditure and management attention on maintaining a vast network of thousands of community-embedded primary and specialty care clinics. Their teams, operating in hundreds of vaccination clinics, were trained to provide preventive services outreach to their communities in a people-centered approach, thereby increasing resilience and improving response capacity in emergency circumstances.

Coordinated, integrated design of the Israeli healthcare system allowed all of its components to take part in a collaborative effort for vaccine delivery. General hospitals and the national emergency and ambulance services were able to open additional vaccination points throughout the country and were included in the vaccine distribution chain. The integrated, centralised view of health funds on the entire country population allowed effective mechanisms of command and control, which was done in full coordination with the Israeli Ministry of Health.

The role of data and digital health

The most interesting key pillar of this successful campaign, in my view, was the use of data and digital health. Population health registries were used to allow massive outreach to the target population to be vaccinated – either through call centers or a cellular app. Electronic medical records negated the need for prolonged interviews and form-filling, allowing one-minute intake at the vaccination clinics and rapid turnaround time. Health data repositories were used to generate, in near-real-time, methodologically-sound estimates of vaccine effectiveness that were used to tackle vaccine hesitancy by allowing the matching of 600,000 vaccinated individuals with and equal number of perfectly-matched unvaccinated individuals by demographic, geographic, and health status variables. The published results suggested exceedingly high real-world vaccine effectiveness – preventing 94% of cases and 92% of severe cases.

There was a strong preexisting basis for this work. Israel has been an early adopter of digital health technologies in clinical practice for decades, with big data analytics, telemedicine, and online patient engagement widely incorporated into daily clinical care. At the core of Israel’s 20-year-long digital health transformation are four key enablers described as Israel’s 4 I’s: Information technology infrastructure and expertise, Integration of data ‘by design’, Innovation-supporting ecosystem, and Incentives aligned with prevention and care improvement.

Covid-19 as an accelerator of digital health

Indeed, these capacities cannot be built and operated overnight to mitigate an ongoing crisis or to support a national vaccination campaign, but rather require a continuous, gradual, years-long transformation. Yet, in many countries, we see that Covid-19 has been described as the most effective accelerator of the digital transformation of healthcare systems seen in decades. Individuals, organisations, and national decision makers that were hesitant to experiment with innovative technologies such as telehealth, for instance, were forced to take a leap of faith and adapt to provide such services. This took place in nearly every clinical specialty, and was adopted at a rate that was deemed unimaginable only a year ago.

Let us hope that from these immense challenges that we are currently enduring in the time of the Covid-19 global crisis, some good will arise in the form of quantum leaps in digitisation and innovation. In so doing, we can modernise and improve healthcare services for the benefit of all. This way, perhaps, we will emerge from this crisis with new hope for strengthened, more effective, efficient, and equitable healthcare services – robust and resilient enough to safeguard future generations in a changing global environment.

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Founding Director, Clalit Research Institute; Chief Innovation Officer, Clalit Health Services, Israel

Ran Balicer, MD, PhD, MPH

Ran Balicer, MD, PhD, MPH

Founding Director, Clalit Research Institute; Chief Innovation Officer, Clalit Health Services, Israel