Pandemic resilience and health systems preparedness: lessons from COVID-19 for the twenty-first century

Kerala's progress towards universal health coverage: the road travelled and beyond

BACKGROUND

Kerala has initiated many Universal Health Coverage (UHC) reforms in the last decade. The Aardram Mission launched in 2017 stands out owing to its scope, objectives, and commitments for strengthening Primary Health Care (PHC) in the State. The current study proposes to explore access and financial protection through the lens of equity in Kerala especially in the context of major UHC reforms carried out during the last decade. This paper will also highlight the key lessons from Kerala's approach towards UHC and health systems strengthening through a political economy approach.

METHODS

Data from the Kerala state sample of 75th Round (2017-18) National Sample Survey is used for this study. Comparison is also drawn from the 71st Round Sample Survey, 2014, to measure the state's progress in terms of access and financial protection. Logistic regression was used for the calculation. The findings were further explored through a political economy approach.

RESULTS

The share of public facilities for outpatient care is 47.5%, which is a significant increase from 34.0% (in 2014) in the state. The share of public sector for out-patient care has increased for the lower socio-economic population in the state. The share of public sector for in-patient care has also increased to 37.3% in 2017-18 from 33.9% in 2014, but not to the extent as the increase shown in outpatient care. The average out-of-pocket-expenditure during hospitalization has increased more in private facilities as compared to public for both outpatient care and hospitalization.

CONCLUSIONS

Overall increase in the share of public facilities for both outpatient care and hospitalization is indicative of the enhanced trust among the people at large of the public healthcare delivery system in Kerala, post the launch of UHC reforms in the State. The insurance linked UHC reforms would be insufficient for the State to progress further towards UHC. Kerala with a long and successful history in 'public provisioning' should focus more on strengthening PHC through Aardram Mission in its journey towards pursuit of UHC.

Pandemic preparedness and health system resilience in 14 European countries

Objective

To assess national pandemic preparedness and response plans from a health system perspective to determine the extent to which implementation strategies that support health system performance have been included.

Methods

We systematically mapped pandemic preparedness and response implementation strategies that improve resilience to pandemics onto the Health System Performance Assessment Framework for Universal Health Coverage. Using this framework, we conducted a document analysis of 14 publicly available national influenza pandemic preparedness plans, submitted to the European Centre for Disease Prevention and Control, to assess how well health system functions are accounted for in each plan.

Findings

Implementation strategies found in national influenza pandemic preparedness plans do not systematically consider all health system functions. Instead, they mostly focus on specific aspects of governance. In contrast, little to no mention is made of implementation strategies that aim to strengthen health financing. There was also a lack of implementation strategies to strengthen the health workforce, ensure availability of medical equipment and infrastructure, govern the generation of resources and ensure delivery of public health services.

Conclusion

While national influenza pandemic preparedness plans often include provisions to support health system governance, implementation strategies that support other health system functions, namely, resource generation, service delivery, and in particular, financing, are given less attention. These oversights in key planning documents may undermine health system resilience when public health emergencies occur.

Primary healthcare in the aftermath of the COVID-19 pandemic: a qualitative interview study in Sweden

OBJECTIVE

To explore how primary healthcare workers in Sweden experienced and perceived the long-term impact of the pandemic on their work.

DESIGN

This is a descriptive qualitative study with individual semistructured interviews conducted 2 years after the onset of COVID-19. Data were analysed using an inductive thematic approach.

SETTING

Swedish primary healthcare units in rural and urban locations.

PARTICIPANTS

29 healthcare providers (6 registered nurses, 7 assistant nurses, 8 physicians and 8 managers) in Swedish primary healthcare.

RESULTS

Data analysis yielded three overarching themes: (1) primary healthcare still affected by the pandemic; (2) primary healthcare changes made permanent; and (3) lessons learnt for handling future crises affecting primary healthcare. The participants experienced a high workload, even after the pandemic, and concluded that it would take years to catch up both mentally and workwise. Four lessons were learnt for future handling of crises that might affect primary healthcare: the importance of creating a cohesive primary healthcare management system to provide clarity regarding recommendations for how primary healthcare personnel should work, the need for management support at all levels, restricting and adapting the flow of information for primary healthcare and ascertaining the necessary resources if primary healthcare is to take on additional tasks.

CONCLUSION

Two years after the onset of the COVID-19 pandemic, primary healthcare workers in Sweden experienced that their work was still affected by the pandemic. Our findings highlight the importance of ensuring sufficient recovery time and providing opportunities for reflection on the experiences of primary healthcare personnel. This also includes preparedness for managing the heavy workload and strained energy levels of healthcare workers in the aftermath of a crisis.

Strategies to strengthen the resilience of primary health care in the COVID-19 pandemic: a scoping review

BACKGROUND

Primary Health Care (PHC) systems are pivotal in delivering essential health services during crises, as demonstrated during the COVID-19 pandemic. With varied global strategies to reinforce PHC systems, this scoping review consolidates these efforts, identifying and categorizing key resilience-building strategies.

METHODS

Adopting Arksey and O'Malley's scoping review framework, this study synthesized literature across five databases and Google Scholar, encompassing studies up to December 31st, 2022. We focused on English and Persian studies that addressed interventions to strengthen PHC amidst COVID-19. Data were analyzed through thematic framework analysis employing MAXQDA 10 software.

RESULTS

Our review encapsulated 167 studies from 48 countries, revealing 194 interventions to strengthen PHC resilience, categorized into governance and leadership, financing, workforce, infrastructures, information systems, and service delivery. Notable strategies included telemedicine, workforce training, psychological support, and enhanced health information systems. The diversity of the interventions reflects a robust global response, emphasizing the adaptability of strategies across different health systems.

CONCLUSIONS

The study underscored the need for well-resourced, managed, and adaptable PHC systems, capable of maintaining continuity in health services during emergencies. The identified interventions suggested a roadmap for integrating resilience into PHC, essential for global health security. This collective knowledge offered a strategic framework to enhance PHC systems' readiness for future health challenges, contributing to the overall sustainability and effectiveness of global health systems.

COVID-19 healthcare success or failure? Crisis management explained by dynamic capabilities

INTRODUCTION

This paper presents a structured review of the use of crisis management, specifically examining the frameworks of surge capacity, resilience, and dynamic capabilities in healthcare organizations. Thereafter, a novel deductive method based on the framework of dynamic capabilities is developed and applied to investigate crisis management in two hospital cases during the COVID-19 pandemic.

BACKGROUND

The COVID-19 pandemic distinguishes itself from many other disasters due to its global spread, uncertainty, and prolonged duration. While crisis management in healthcare has often been explained using the surge capacity framework, the need for adaptability in an unfamiliar setting and different information flow makes the dynamic capabilities framework more useful.

METHODS

The dynamic capabilities framework's microfoundations as categories is utilized in this paper for a deductive analysis of crisis management during the COVID-19 pandemic in a multiple case study involving two Swedish public hospitals. A novel method, incorporating both dynamic and static capabilities across multiple organizational levels, is developed and explored.

RESULTS

The case study results reveal the utilization of all dynamic capabilities with an increased emphasis at lower organizational levels and a higher prevalence of static capabilities at the regional level. In Case A, lower-level managers perceived the hospital manager as brave, supporting sensing, seizing, and transformation at the department level. However, due to information gaps, sensing did not reach regional crisis management, reducing their power. In Case B, with contingency plans not initiated, the hospital faced a lack of management and formed a department manager group for patient care. Seizing was robust at the department level, but regional levels struggled with decisions on crisis versus normal management. The novel method effectively visualizes differences between organizational levels and cases, shedding light on the extent of cooperation or lack thereof within the organization.

CONCLUSION

The researchers conclude that crisis management in a pandemic, benefits from distributed management, attributed to higher dynamic capabilities at lower organizational levels. A pandemic contingency plan should differ from a plan for accidents, supporting the development of routines for the new situation and continuous improvement. The Dynamic Capabilities framework proved successful for exploration in this context.

Common laboratory organic solvents are better medium for molecular detection of RNA viruses using PCR

PURPOSE

The unavailability of recommended viral transport medium during epidemics of respiratory viral infections is a substantial healthcare concern. It may prompt the use of alternatives, which may give rise to results with questionable validity. The present study was carried out to assess and validate the utility of commonly available solvents in the hospital/healthcare set-ups which may be used as ready and economical alternatives to commercial VTMs.

METHODS

To evaluate the readily available solvents as an alternative to VTM, cell culture supernatant of pH1N1 2009 isolate with HA titres of 1:4 and extracted viral RNA of SARS-CoV-2 were spiked in a 1:10 ratio in ethanol, acetone, methanol and were compared to commercially available VTM for detection of influenza virus by real time RT-PCR (qRT-PCR). The tubes were kept at room temperature 24 h, 48 h and 72 h. Ct values of the various solvents at different time points were compared and statistical analysis was performed using Python.

RESULTS

The Ct values of the Influenza and SARS-CoV2 viral genes in each solvent were maintained for 3 days at room temperatures, suggesting viral samples were stably preserved in the solvent for 3 days.

CONCLUSION

Methanol was found to be the most promising solvent for increasing the stability of viral RNA thereby enhancing the molecular diagnosis of the concerned pathogen.

Lessons From the COVID-19 Pandemic Response Implementation: A Case Study of South Sudan and Sierra Leone

INTRODUCTION

The COVID-19 pandemic caused havoc to health systems worldwide and in countries that already had weak health systems. There are lessons to be learned that could contribute to improved response preparedness to future public health emergencies, but there is little documentation on best practices in fragile countries. We describe lessons from South Sudan and Sierra Leone during the COVID-19 response implementation.

METHODS

We conducted a retrospective descriptive analysis of COVID-19 vaccination implementation at national and subnational levels between 2020 and 2022 in South Sudan and Sierra Leone to identify those practices that had a positive impact on public health.

RESULTS

Several interventions were identified that not only improved the COVID-19 situation but also had a positive effect on routine immunizations. The development of a near-real-time vaccination dashboard gave stakeholders a quick look at vaccine implementation, allowing them to make decisions based on current data. The experience acquired from deploying the COVID-19 dashboard has since been applied to the development of a routine immunization dashboard in South Sudan. Surge vaccination was an effective approach to improving COVID-19 vaccination uptake. A measles reactive campaign was conducted during the initial stages of the pandemic when movement was restricted; experience gained from that effort was subsequently applied to COVID-19 mass vaccination initiatives and outbreak reactive campaigns. Additional vaccinators recruited for COVID-19 response also received comprehensive Immunization in Practice training, allowing them to provide routine childhood vaccinations alongside COVID-19 vaccination, contributing to the maintenance of routine vaccination services in both countries.

CONCLUSION

Lessons were learned during the COVID-19 response implementation that have had a positive impact on routine health services. However, it is essential that these effects are maintained and further refined to strengthen the country's preparedness for future public health emergencies and better support the broader immunization service delivery.

Physical Impact of Traditional and Virtual Physical Exercise Programs on Health Outcomes among Corporate Employees

Background: Technology-based exercise programs have the potential to reduce chronic disease prevalence and obesity-related risks. This research focuses on the impact of both traditional and virtual exercise programs on the health metrics of corporate employees. Methods: The study involved 30 corporate employees (16 females, average age ± SD = 37.8 ± 8.8 years) from Nigeria, who were divided into two experimental groups (one experiencing traditional exercises with an on-site trainer, and the other participating in live, virtual classes via Zoom) and a control group continuing usual practices. The 6-week intervention measured several health outcomes, including resting heart rate, blood pressure (both diastolic and systolic), body mass index (BMI), waist circumference, and waist-hip ratio, both before and after the intervention. Results: One-way analysis of covariance yielded significantly greater decreases in the diastolic blood pressure, F(2,27) = 3.7, p < 0.04; systolic blood pressure F(2,27) = 3.5, p < 0.04, body mass index, F(2,26) = 7.8, p < 0.01, and waist circumference, F(2,27) = 39.1, p < 0.01. Conclusions: The study concludes that virtual-based exercise programs are as effective as traditional ones. Offering a virtual exercise option provides flexibility, potentially increasing adherence to exercise routines among corporate workers.

Influenza immunization of healthcare personnel in the post-COVID-19 pandemic era: Still a lot to do!

Healthcare-associated influenza is frequently encountered in healthcare settings with significant morbidity and mortality among vulnerable patients, absenteeism among healthcare personnel (HCP), and interruption of healthcare services. Numerous investigations indicate that nosocomial outbreaks are often traced to HCP. Despite the international and national endorsements, seasonal influenza vaccine acceptance among HCP continues suboptimal worldwide. Infection control is the major objective for healthcare risk management in order to guarantee patient safety, limit the cost of hospitalization and assurance health management in controlling influenza seasons. Vigilance and anticipation are required as globally we are moving from a reactive COVID-19 pandemic response phase to one of planning for the co-circulation of viral respiratory infections. Declining to understand HCP perception of influenza risk and acceptance of vaccination might have impact patient safety as well as healthcare services.

The perceived impact of the COVID-19 pandemic on interprofessional education and collaborative practice: preliminary results from phase I of a global survey

The COVID-19 pandemic has had a sizable effect on interprofessional education and collaborative practice (IPECP) globally, yet much of the available literature on the topic remains anecdotal and locally bounded. This body of literature reflects celebratory and aspirational reports, with many case studies of successful response and perseverance under conditions of extreme pressure. There is, however, a more worrisome narrative emerging that pointed to differences in pandemic response with concerns raised about the sustainability of IPECP during and after the pandemic. The COVID-19 task force of InterprofessionalResearch.Global (IPRGlobal) set out to capture the successes and challenges of the interprofessional community over the pandemic through a longitudinal survey, with a view to inform global attempts at recovery and resilience. In this article, we report preliminary findings from Phase 1 of the survey. Phase 1 of the survey was sent to institutions/organizations in IPRGlobal (representing over 50 countries from Europe, North and South America, Australia, and Africa). The country-level response rate was over 50%. Key opportunities and challenges include the abrupt digitalization of collaborative learning and practice; de-prioritization of interprofessional education (IPE); and rise in interprofessional collaborative spirit. Implications for IPECP pedagogy, research, and policy post-pandemic are considered.

What made primary health care resilient against COVID-19? A mixed-methods positive deviance study in Nigeria

INTRODUCTION

The SARS-CoV-2 (COVID-19) pandemic overwhelmed some primary health care (PHC) systems, while others adapted and recovered. In Nigeria, large, within-state variations existed in the ability to maintain PHC service volumes. Identifying characteristics of high-performing local government areas (LGAs) can improve understanding of subnational health systems resilience.

METHODS

Employing a sequential explanatory mixed-methods design, we quantitatively identified 'positive deviant' LGAs based on their speed of recovery of outpatient and antenatal care services to prepandemic levels using service volume data from Nigeria's health management information system and matched them to comparators with similar baseline characteristics and slower recoveries. 70 semistructured interviews were conducted with LGA officials, facility officers and community leaders in sampled LGAs to analyse comparisons based on Kruk's resilience framework.

RESULTS

A total of 57 LGAs were identified as positive deviants out of 490 eligible LGAs that experienced a temporary decrease in PHC-level outpatient and antenatal care service volumes. Positive deviants had an average of 8.6% higher outpatient service volume than expected, and comparators had 27.1% lower outpatient volume than expected after the initial disruption to services. Informants in 12 positive deviants described health systems that were more integrated, aware and self-regulating than comparator LGAs. Positive deviants were more likely to employ demand-side adaptations, whereas comparators primarily focused on supply-side adaptations. Barriers included long-standing financing and PHC workforce gaps.

CONCLUSION

Sufficient flexible financing, adequate PHC staffing and local leadership enabled health systems to recover service volumes during COVID-19. Resilient PHC requires simultaneous attention to bottom-up and top-down capabilities connected by strong leadership.

"Like One Long Battle:" Employee Perspectives of the Simultaneous Impact of COVID-19 and an Electronic Health Record Transition

BACKGROUND

Healthcare organizations regularly manage external stressors that threaten patient care, but experiences handling concurrent stressors are not well characterized.

OBJECTIVE

To evaluate the experience of Veterans Affairs (VA) clinicians and staff navigating simultaneous organizational stressors-an electronic health record (EHR) transition and the COVID-19 pandemic-and identify potential strategies to optimize management of co-occurring stressors.

DESIGN

Qualitative case study describing employee experiences at VA's initial EHR transition site.

PARTICIPANTS

Clinicians, nurses, allied health professionals, and local leaders at VA's initial EHR transition site.

APPROACH

We collected longitudinal qualitative interview data between July 2020 and November 2021 once before and 2-4 times after the date on which the health system transitioned; this timing corresponded with local surges of COVID-19 cases. Interviewers conducted coding and analysis of interview transcripts. For this study, we focused on quotes related to COVID-19 and performed content analysis to describe recurring themes describing the simultaneous impact of COVID-19 and an EHR transition.

KEY RESULTS

We identified five themes related to participants' experiences: (1) efforts to mitigate COVID-19 transmission led to insufficient access to EHR training and support, (2) clinical practice changes in response to the pandemic impacted EHR workflows in unexpected ways, (3) lack of clear communication and inconsistent enforcement of COVID-19 policies intensified pre-existing frustrations with the EHR, (4) managing concurrent organizational stressors increased work dissatisfaction and feelings of burnout, and (5) participants had limited bandwidth to manage competing demands that arose from concurrent organizational stressors.

CONCLUSION

The expected challenges of an EHR transition were compounded by co-occurrence of the COVID-19 pandemic, which had negative impacts on clinician experience and patient care. During simultaneous organizational stressors, health care facilities should be prepared to address the complex interplay of two stressors on employee experience.

Resilience perspective on healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic: a meta-synthesis

OBJECTIVE

To identify, review and synthesise qualitative literature on healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic.

DESIGN

Systematic review with meta-synthesis.

DATA SOURCES

Academic Search Elite, CINAHL, MEDLINE, PubMed, Science Direct and Scopus.

ELIGIBILITY CRITERIA

Qualitative or mixed-methods studies published between 2019 and 2021 investigating healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a predesigned data extraction form that included details about publication (eg, authors, setting, participants, adaptations and outcomes). Data were analysed using thematic analysis.

RESULTS

Forty-seven studies were included. A range of adaptations crucial to maintaining healthcare delivery during the COVID-19 pandemic were found, including taking on new roles, conducting self and peer education and reorganising workspaces. Triggers for adaptations included unclear workflows, lack of guidelines, increased workload and transition to digital solutions. As challenges arose, many health professionals reported increased collaboration across wards, healthcare teams, hierarchies and healthcare services.

CONCLUSION

Healthcare professionals demonstrated significant adaptive capacity when faced with challenges imposed by the COVID-19 pandemic. Several adaptations were identified as beneficial for future organisational healthcare service changes, while others exposed weaknesses in healthcare system designs and capacity, leading to dysfunctional adaptations. Healthcare professionals' experiences working during the COVID-19 pandemic present a unique opportunity to learn how healthcare systems rapidly respond to changes, and how resilient healthcare services can be built globally.

Performance patterns of primary health care in the face of COVID-19 in Brazil: characteristics and contrasts

The adequate fight against pandemics requires effective coordination between primary health care (PHC) and health surveillance, guaranteed attention to acute and chronic demands, and a bond with the community dimension in the scope of basic health units (UBS, acronym in Portuguese). This study aims to contrast two extreme standards of PHC performance in the fight against COVID-19 in Brazil, comparing them with the profiles of the corresponding municipalities and characteristics of the organization of services. Based on the results of a cross-sectional national survey with a representative sample of UBSs, we created a synthetic index to evaluate how PHC performs against COVID-19 called CPI, composed of axes of health surveillance and social support (collective dimension) and of COVID-19 care and continuity of care (individual dimension). Of the 907 surveyed UBSs, 120 were selected, half of which had the highest indexes (complete standard) and the other half, the lowest ones (restricted standard). The municipalities of the UBSs with a complete standard are predominantly rural, have low Municipal Health Development Index (MHDI), high Family Health Strategy (FHS) coverage, and stand out in the collective dimension, whereas the UBSs in urban municipalities with this same standard have high MHDI, low FHS coverage, and an emphasis on the individual dimension. In the restricted standard, we highlight community health workers' reduced work in the territory. In the Brazilian Northeast, UBSs with complete standard predominate, whereas, in its Southeast, UBSs with restricted standard predominate. The study poses questions that refer to the role and organization of PHC in the health care network under situations that require prompt response to health issues and indicates the greater potential capacity of the FHS program in such situations.

Exploring senior managers' experiences preparedness to respond to COVID-19: a qualitative study in Iran

BACKGROUND

Epidemics caused by emerging respiratory viruses are challenging for the health system of most societies, and preparedness of the health system in responding to such epidemics is important. Therefore, the aim of this study was identifying different fields and key issues of the senior managers' experiences preparedness to respond to the COVID-19 epidemic from the Iranian senior managers' point of view.

METHODS

This is a qualitative descriptive study. Eighteen in-depth and semi-structured individual interviews were conducted for data collection. For this purpose, 18 senior managers with work experience in managing the COVID-19 crisis were enrolled in the study using purposive sampling. The collected data were analyzed according to Graneheim and Lundman's approach.

RESULTS

Analysis of the data resulted in the emergence of five themes and twelve sub-themes. The main themes and sub-themes included: (1) capacity improvement consisting of performance improvement and logistic improvement; (2) resource and infrastructure management including supply and support of human resources, infrastructure improvement, and supply of equipment; (3) an increase in epidemiology capacity including epidemiology improvement and emerging disease surveillance; (4) application of the principles of disaster and emergency management including intra- and extra-organizational interaction management, disaster risk management, and data management; and (5) society resilience increase including improving adaptation skill and maintaining health and social participation.

CONCLUSION

The results of this study present the key issues for the management of future emergency situations. Health system managers and policymakers in Iran and other countries should be aware of these key issues and apply them in practice to prepare the health systems to respond to next outbreaks. Indeed, the study results can help policymakers and health system managers to plan to achieve acceptable preparedness for the management of such outbreaks.

On the forms, contributions and impacts of community mobilisation involved with Kerala's COVID-19 response: Perspectives of health staff, Local Self Government institution and community leaders

BACKGROUND

Kerala, a south Indian state, has a long and strong history of mobilisation of people's participation with institutionalised mechanisms as part of decentralisation reforms introduced three decades ago. This history formed the backdrop of the state's COVID-19 response from 2020 onwards. As part of a larger health equity study, we carried out an analysis to understand the contributions of people's participation to the state's COVID-19 response, and what implications this may have for health reform as well as governance more broadly.

METHODS

We employed in-depth interviews with participants from four districts of Kerala between July and October, 2021. Following written informed consent procedures, we carried out interviews of health staff from eight primary health care centres, elected Local Self Government (LSG, or Panchayat) representatives, and community leaders. Questions explored primary health care reforms, COVID responses, and populations left behind. Transliterated English transcripts were analysed by four research team members using a thematic analysis approach and ATLAS.ti 9 software. For this paper, we specifically analysed codes and themes related to experiences of community actors and processes for COVID mitigation activities.

RESULTS

A key feature of the COVID-19 response was the formation of Rapid Response Teams (RRTs), groups of lay community volunteers, who were identified and convened by LSG leaders. In some cases, pre-pandemic 'Arogya sena' (health army) community volunteer groups were merged with RRTs. RRT members were trained and supported by the health departments at the local level to distribute medicine and essential items, provided support for transportation to health facilities, and assisted with funerary rites during lockdown and containment period. RRTs often comprised youth cadres of ruling and opposition political parties. Existing community networks like Kudumbashree (Self Help Groups) and field workers from other departments have supported and been supported by RRTs. As pandemic restrictions eased, however, there was concern about the sustainability of this arrangement as well.

CONCLUSION

Participatory local governance in Kerala allowed for the creation of invited spaces for community participation in a variety of roles as part of the COVID 19 response, with manifest impact. However, the terms of engagement were not decided by communities, nor were they involved more deeply in planning and organising health policy or services. The sustainability and governance features of such involvement warrant further study.

Evaluation of the Global Health Security Index as a predictor of COVID-19 excess mortality standardised for under-reporting and age structure

BACKGROUND

Previous studies have observed that countries with the strongest levels of pandemic preparedness capacities experience the greatest levels of COVID-19 burden. However, these analyses have been limited by cross-country differentials in surveillance system quality and demographics. Here, we address limitations of previous comparisons by exploring country-level relationships between pandemic preparedness measures and comparative mortality ratios (CMRs), a form of indirect age standardisation, of excess COVID-19 mortality.

METHODS

We indirectly age standardised excess COVID-19 mortality, from the Institute for Health Metrics and Evaluation modelling database, by comparing observed total excess mortality to an expected age-specific COVID-19 mortality rate from a reference country to derive CMRs. We then linked CMRs with data on country-level measures of pandemic preparedness from the Global Health Security (GHS) Index. These data were used as input into multivariable linear regression analyses that included income as a covariate and adjusted for multiple comparisons. We conducted a sensitivity analysis using excess mortality estimates from WHO and The Economist.

RESULTS

The GHS Index was negatively associated with excess COVID-19 CMRs (table 2; β= -0.21, 95% CI= -0.35 to -0.08). Greater capacities related to prevention (β= -0.11, 95% CI= -0.22 to -0.00), detection (β= -0.09, 95% CI= -0.19 to -0.00), response (β = -0.19, 95% CI= -0.36 to -0.01), international commitments (β= -0.17, 95% CI= -0.33 to -0.01) and risk environments (β= -0.30, 95% CI= -0.46 to -0.15) were each associated with lower CMRs. Results were not replicated using excess mortality models that rely more heavily on reported COVID-19 deaths (eg, WHO and The Economist).

CONCLUSION

The first direct comparison of COVID-19 excess mortality rates across countries accounting for under-reporting and age structure confirms that greater levels of preparedness were associated with lower excess COVID-19 mortality. Additional research is needed to confirm these relationships as more robust national-level data on COVID-19 impact become available.

Measurement of unmet healthcare needs to assess progress on universal health coverage - exploring a novel approach based on household surveys

BACKGROUND

Universal Health Coverage (UHC) aims to ensure universal access to quality healthcare according to health needs. The extent to which population health needs are met should be a key measure for progress on UHC. The indicators in use for measuring access mostly relate to physical accessibility or insurance coverage. Or, utilization of services is taken as indirect measure for access but it is assessed against only the perceived healthcare needs. The unperceived needs do not get taken into account. The present study was aimed at demonstrating an approach for measuring the unmet healthcare needs using household survey data as an additional measure of UHC.

METHODS

A household survey was conducted in Chhattisgarh state of India, covering a multi-stage sample of 3153 individuals. Healthcare need was measured in terms of perceived needs which would be self-reported and unperceived needs where clinical measurement supplemented the interview response. Estimation of unperceived healthcare needs was limited to three tracer conditions- hypertension, diabetes and depression. Multivariate analysis was conducted to find the determinants of the various measures of the perceived and unperceived needs.

RESULTS

Of the surveyed individuals, 10.47% reported perceived healthcare needs for acute ailments in the last 15 days. 10.62% individuals self-reported suffering from chronic conditions. 12.75% of those with acute ailment and 18.40% with chronic ailments received no treatment, while 27.83% and 9.07% respectively received treatment from unqualified providers. On an average, patients with chronic ailments received only half the medication doses required annually. The latent need was very high for chronic ailments. 47.42% of individuals above 30 years age never had blood pressure measured. 95% of those identified with likelihood of depression had not sought any healthcare and they did not know they could be suffering from depression.

CONCLUSION

To assess progress on UHC more meaningfully, better methods are needed to measure unmet healthcare needs, taking into account both the perceived and unperceived needs, as well as incomplete care and inappropriate care. Appropriately designed household surveys offer a significant potential to allow its periodic measurement. Their limitations in measuring the 'inappropriate care' may necessitate supplementation with qualitative methods.

Organization of primary health care and surveillance in response to COVID-19 in municipalities in the Northeast of Brazil

The aim of this study was to analyze the organization and development of primary health care and surveillance, including normative frameworks and the implementation of local health actions. Qualitative descriptive multiple-case study involving three municipalities in the state of Bahia. We conducted 75 interviews and a document analysis. The results were categorized into the following two dimensions: approach to the organization of the pandemic response; and development of care and surveillance actions at local level. Municipality 1 was found to have a well-defined concept of the integration of health and surveillance with a view to organizing team work processes. However, the municipality did not strengthen the technical capacity of health districts to support surveillance actions. In M2 and M3, delays in defining PHC as the entry point for the health system and the prioritization of a central telemonitoring service run by the municipal health surveillance department compounded the fragmentation of actions and meant that PHC services played only a limited role in the pandemic response. Clear policy and technical guidelines and adequate structural conditions are vital to ensure the effective reorganization of work processes and foster the development of permanent arrangements that strengthen intersectoral collaboration.

The level of countries' preparedness to health risks during Covid-19 and pre-pandemic: the differential response to health systems building blocks and socioeconomic indicators

The global health security (GHS) Index assesses countries' level of preparedness to health risks. However, there is no evidence on how and whether the effects of health systems building blocks and socioeconomic indicators on the level of preparedness differ for low and high prepared countries. The aim of this study was to examine the contributions of health systems building blocks and socioeconomic indicators to show differences in the level of preparedness to health risks. The study also aimed to examine trends in the level of preparedness and the World Health Organization (WHO) regional differences before and during the Covid-19 pandemic. We used the 2021 GHS index report data and employed quantile regression, log-linear, double-logarithmic, and time-fixed effects models. As robustness checks, these functional form specifications corroborated with one another, and interval validity tests confirmed. The results show that increases in effective governance, supply chain capacity in terms of medicines and technologies, and health financing had positive effects on countries' level of preparedness to health risks. These effects were considerably larger for countries with higher levels of preparedness to health risks. The positive gradient trends signaled a sense of capacity on the part of countries with higher global health security. However, the health workforce including doctors, and health services including hospital beds, were not statistically significant in explaining variations in countries' level of preparedness. While economic factors had positive effects on the level of preparedness to health risks, their impacts across the distribution of countries' level of preparedness to health risks were mixed. The effects of Social Development Goals (SDGs) were greater for countries with higher levels of preparedness to health risks. The effect of the Human Development Index (HDI) was greatest for countries whose overall GHS index lies at the midpoint of the distribution of countries' level of preparedness. High-income levels were associated with a negative effect on the level of preparedness, especially if countries were in the lower quantiles across the distributions of preparedness. Relative to poor countries, middle- and high-income groups had lower levels of preparedness to health risks, an indication of a sense of complacency. We find the pandemic period (year 2021) was associated with a decrease in the level of preparedness to health risks in comparison to the pre-pandemic period. There were significant WHO regional differences. Apart from the Eastern Mediterranean, the rest of the regions were more prepared to health risks compared to Africa. There was a negative trend in the level of preparedness to health risks from 2019 to 2021 although regional differences in changes over time were not statistically significant. In conclusion, attempts to strengthen countries' level of preparedness to health shocks should be more focused on enhancing essentials such as supply chain capacity in terms of medicines and technologies; health financing, and communication infrastructure. Countries should also strengthen their already existing health workforce and health services. Together, strengthening these health systems essentials will be beneficial to less prepared countries where their impact we find to be weaker. Similarly, boosting SDGs, particularly health-related sub-scales, will be helpful to less prepared countries. Moreover, there is a need to curb complacency in preparedness to health risks during pandemics by high-income countries. The negative trend in the level of preparedness to health risks would suggest that there is a need for better preparedness during pandemics by conflating national health with global health risks. This will ensure the imperative of having a synergistic response to global health risks, which is understood by and communicated to all countries and regions.

Health systems resilience: is it time to revisit resilience after COVID-19?

The concept of health system resilience has been challenged by the COVID-19 pandemic. Even well-established health systems, considered resilient, collapsed during the pandemic. To revisit the concept of resilience two years and a half after the initial impact of COVID-19, we conducted a qualitative study with 26 international experts in health systems to explore their views on concepts, stages, analytical frameworks, and implementation from a comparative perspective of high- and low-and-middle-income countries (HICs and LMICs). The interview guide was informed by a comprehensive literature review, and all interviewees had practice and academic expertise in some of the largest health systems in the world. Results show that the pandemic did modify experts' views on various aspects of health system resilience, which we summarize and propose as refinements to the current understanding of health systems resilience.

Resilience in keeping the balance between demand and capacity in the COVID-19 pandemic, a case study at a Swedish middle-sized hospital

BACKGROUND

In pandemics, it is critical to find a balance between healthcare demand, and capacity, taking into consideration the demands of the patients affected by the pandemic, as well as other patients (in elective or emergency care). The purpose of this paper is to suggest conceptual models for the capacity requirements at the emergency department, the inpatient care, and intensive care unit as well as a model for building staff capacity in pandemics.

METHODS

This paper is based on a qualitative single case study at a middle-sized hospital in Sweden. The primary data are collected from 27 interviewees and inductively analyzed.

RESULTS

The interviewees described a large difference between the immediate catastrophe scenario described in the emergency plan (which they had trained for), and the reality during the COVID-19 pandemic. The pandemic had a much slower onset and lasted longer compared to, for example, an accident, and the healthcare demand fluctuated with the societal infection. The emergency department and inpatient care could create surge capacity by reducing elective care. Lower inflow of other emergency patients also helped to create surge capacity. The number of intensive care beds increased by 350% at the case hospital. At the same time, the capacity of the employees decreased due to infection, exhaustion, and fear. The study contributes to knowledge of conceptional models and key factors affecting the balance between demand and capacity.

CONCLUSION

The framework suggests conceptual models for balancing surge capacity during a pandemic Health care practitioners need to provide assumptions of the key factors to find the balance between the demand and capacity corresponding to the reality and maintain the delivery of high-quality healthcare services.

Community health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies

Community health workers (CHWs) are a key part of the health workforce, with particular importance for reaching the most marginalised. CHWs' contributions during pandemics have received growing attention, including for COVID-19. This paper contributes to learning about CHWs' experiences during COVID-19, based on evidence from India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia. The paper synthesises evidence from a set of research projects undertaken over 2020-2021. A thematic framework based on the research focus and related literature was used to code material from the reports. Following further analysis, interpretations were verified with the original research teams. CHWs made important contributions to the COVID-19 response, including in surveillance, community education, and support for people with COVID-19. There was some support for CHWs' work, including training, personal protective equipment and financial incentives. However, support varied between countries, cadres and individual CHWs, and there were significant gaps, leaving CHWs vulnerable to infection and stress. CHWs also faced a range of other challenges, including health system issues such as disrupted medical supply chains, insufficient staff and high workloads, a particular difficulty for female CHWs who were balancing domestic responsibilities. Their work was also affected by COVID-19 public health measures, such as restrictions on gatherings and travel; and by supply-side constraints related to community access and attitudes, including distrust and stigmatization of CHWs as infectious or informers. CHWs demonstrated commitment in adapting their work, for example ensuring patients had adequate drugs in advance of lockdowns, and using their own money and time to address increased transport costs and higher workloads. Effectiveness of these adaptations varied, and some involved coping in a context of inadequate support. CHW are critical for effective response to disease outbreaks, including pandemics like COVID-19. To support CHWs' contribution and protect their wellbeing, CHWs need adequate resources, managerial support, and motivation.

Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic

BACKGROUND

Health challenges like coronavirus disease 2019 (COVID-19) are becoming increasingly complex, transnational, and unpredictable. Studying health system responses to the COVID-19 pandemic is an opportunity to enhance our understanding of health system resilience and establish a clearer link between theoretical concepts and practical ideas on how to build resilience.

METHODS

This narrative literature review aims to address four questions using a health system resilience framework: (i) What do we understand about the dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? A scientific literature database search was conducted in December 2020 and in April 2022 to identify publications that discussed health system resilience in relation to COVID-19, excluding articles on psychological and other types of resilience. A total of 63 publications were included.

RESULTS

There is good understanding around information sharing, flexibility and good leadership, learning, maintaining essential services, and the need for legitimate, interdependent systems. Decision-making, localized trust, influences on interdependence, and transformation remain uncertain. Vertical interdependence, monitoring risks beyond the health system, and consequences of changes on the system were not discussed. Teamwork, actor legitimacy, values, inclusivity, trans-sectoral resilience, and the role of the private sector are identified as lessons from COVID-19 that should be further explored for health system resilience.

CONCLUSION

Knowledge of health system resilience has continued to cohere following the pandemic. The eventual consequences of system changes and the resilience of subsystems are underexplored. Through governance, the concept of health system resilience can be linked to wider issues raised by the pandemic, like inclusivity. Our findings show the utility of resilience theory for strengthening health systems for crises and the benefit of continuing to refine existing resilience theory.

A Study on the Evaluation of the Public Health Governance in Countries along the Belt and Road Initiative (BRI)

Social resilience for public health is a new theoretical framework for understanding public health risk governance capacity. This study identifies 18 indicators from the publicly available database and adopts the method of multivariable analysis to evaluate the level of social resilience for public health in 73 countries along the Belt and Road Initiative (BRI). The study finds that the main influencing factors of social resilience for public health are institutional resilience, physical resilience, and participation resilience. The capacity of public health risk governance in countries along the BRI is classified into three levels: high, medium, and low. A high level of public health risk governance capacity is mainly shown in developed European countries such as Italy, rich Southwestern Asian countries such as the United Arab Emirates, and East Asian countries represented by Japan, South Korea, and Singapore. The middle-level countries are mainly distributed at the junction of Eurasia, which Russia represents. The low-level countries are primarily distributed in South Asia, Africa, and the war zones. In general, countries along the BRI have polarized the capacity of public health risk governance and structural inequalities, mainly manifested in large differences in the organizational capacity and mobilization capacity between countries in response to public health risk events, and the gap between the rich and the poor within a country. Under such circumstances, the building of a Community of Common Health is required to be accelerated.

Interrupted Access to and Use of Family Planning Among Youth in a Community-Based Service in Zimbabwe During the First Year of the COVID-19 Pandemic

The COVID-19 pandemic has had serious impacts on economic, social, and health systems, and fragile public health systems have become overburdened in many countries, exacerbating existing service delivery challenges. This study describes the impact of the COVID-19 pandemic on family planning services within a community-based integrated HIV and sexual and reproductive health intervention for youth aged 16-24 years being trialled in Zimbabwe (CHIEDZA). It examines the experiences of health providers and clients in relation to how the first year of the pandemic affected access to and use of contraceptives.

Healthcare worker resilience during the COVID-19 pandemic: A qualitative study of primary care providers in India

Since 2020, the world saw a myriad of creative health-care policy responses to the COVID-19 pandemic. This article studied the experience of rural primary care providers (PCPs) in India deputized for COVID-19 care in urban areas. In-depth interviews were conducted with PCPs (n = 19), who served at COVID-19 facilities. Lack of epidemic management and intensive tertiary care experience, limited and inadequate training, and fear of infection emerged as the primary sources of distress, in addition to absent systemic mental health support and formalized recognition. Even so, resilience among the respondents emerged as a result of encouragement from their families, peers, and mentors through various means including social media, and from individual recognition from communities and local governments. Rural PCPs expressed an eagerness to serve at the frontlines of COVID-19 and demonstrated indomitable spirit in the face of an acutely understaffed health system, growing uncertainty, and concerns about personal and family health. It is imperative to reconfigure health-care education and continuing professional development, and equip all health-care professionals with mental health support and the ability to deal with public health emergencies and build a more resilient health workforce.

Innovations, contestations and fragilities of the health system response to COVID-19 in the Gauteng Province of South Africa

Background

Gauteng province, with 26.3% of South Africa’s population, is the commercial and industrial powerhouse of the country. During the first epidemic wave in 2020, Gauteng accounted for 32.0% of South Africa’s reported COVID-19 cases.

Aim

The aim of this study was to describe the health system response to the COVID-19 pandemic during the first epidemic wave in Gauteng province and to explore the perspectives of key informants on the provincial response.

Material and methods

Using an adapted Pandemic Emergency Response Conceptual Framework, this was a qualitative case study design consisting of 36 key informant interviews and a document analysis. We used thematic analysis to identify themes and sub-themes from the qualitative data.

Results

Our case study found that Gauteng developed an innovative, multi-sectoral and comprehensive provincial COVID-19 response that aimed to address the dual challenge of saving lives and the economy. However, the interviews revealed multiple perspectives, experiences, contestations and contradictions in the pandemic response. The COVID-19 pandemic exposed and amplified the fragilities of existing systems, reflected in the corruption on personal protective equipment, poor data quality and inappropriate decisions on self-standing field hospitals. Rooted in a chronic under-investment and insufficient focus on the health workforce, the response failed to take into account or deal with their fears, and to incorporate strategies for psychosocial support, and safe working environments. The single-minded focus on COVID-19 exacerbated these fragilities, resulting in a de facto health system lockdown and reported collateral damage. The key informants identified missed opportunities to invest in primary health care, partner with communities and to include the private health sector in the pandemic response.

Conclusion

Gauteng province should build on the innovations of the multi-sectoral response to the COVID-19 pandemic, while addressing the contested areas and health system fragilities.

SARS-CoV-2 Infection among School Population of One Developing Country. Do School Closures Protect Students and Teachers against SARS-CoV-2 Infection?

Evidence about the effectiveness of school closures as a measure to control the spread of COVID-19 is controversial. We posit that schools are not an important source of transmission; thus, we analyzed two surveillance methods: a web-based questionnaire and a telephone survey that monitored the impact of the pandemic due to COVID-19 cases in Bogotá, Colombia. We estimated the cumulative incidences for Acute Respiratory Infection (ARI) and COVID-19 for each population group. Then, we assessed the differences using the cumulative incidence ratio (CIR) and 95% confidence intervals (CI95%). The ARI incidence among students was 20.1 times higher when estimated from the telephone survey than from the online questionnaire (CIR: 20.1; CI95% 17.11-23.53). Likewise, the ARI incidence among schoolteachers was 10 times higher in the telephone survey (CIR: 9.8; CI95% 8.3-11.5). the incidence of COVID-19 among schoolteachers was 4.3 times higher than among students in the online questionnarie (CIR: 4.3, CI95%: 3.8-5.0) and 2.1 times higher in the telephone survey (CIR = 2.1, CI95%: 1.8-2.6), and this behavior was also observed in the general population data. Both methods showed a capacity to detect COVID-19 transmission among students and schoolteachers, but the telephone survey estimates were probably closer to the real incidence rate.

Healthworker preparedness for COVID-19 management and implementation experiences: a mixed methods study in Uganda's refugee-hosting districts

Background

The negative impact of COVID-19 on population health outcomes raises critical questions on health system preparedness and resilience, especially in resource-limited settings. This study examined healthworker preparedness for COVID-19 management and implementation experiences in Uganda’s refugee-hosting districts.

Methods

A cross sectional, mixed-method descriptive study in 17 health facilities in 7 districts from 4 major regions. Total sample size was 485 including > 370 health care workers (HCWs). HCW knowledge, attitude and practices (KAP) was assessed by using a pre-validated questionnaire. The quantitative data was processed and analysed using SPSS 26, and statistical significance assumed at p < 0.05 for all statistical tests. Bloom's cutoff of 80% was used to determine threshold for sufficient knowledge level and practices with scores classified as high (80.0–100.0%), average (60.0–79.0%) and low (≤ 59.0%). HCW implementation experiences and key stakeholder opinions were further explored qualitatively using interviews which were audio-recorded, coded and thematically analysed.

Results

On average 71% of HCWs were knowledgeable on the various aspects of COVID-19, although there is a wide variation in knowledge. Awareness of symptoms ranked highest among 95% (p value < 0.0001) of HCWs while awareness of the criteria for intubation for COVID-19 patients ranked lowest with only 35% (p value < 0.0001). Variations were noted on falsehoods about COVID-19 causes, prevention and treatment across Central (p value < 0.0356) and West Nile (p value < 0.0161) regions. Protective practices include adequate ventilation, virtual meetings and HCW training. Deficient practices were around psychosocial and lifestyle support, remote working and contingency plans for HCW safety. The work environment has immensely changed with increased demands on the amount of work, skills and variation in nature of work. HCWs reported moderate control over their work environment but with a high level of support from supervisors (88%) and colleagues (93%).

Conclusions

HCWs preparedness is inadequate in some aspects. Implementation of healthcare interventions is constrained by the complexity of Uganda’s health system design, top-down approach of the national response to COVID-19 and longstanding health system bottlenecks. We recommend continuous information sharing on COVID-19, a design review with capacity strengthening at all health facility levels and investing in community-facing strategies.

COVID-19 vaccine-taking hesitancy among Bangladeshi people: knowledge, perceptions and attitude perspective

Several novel efforts have been put forth to make a readily available vaccine against the global pandemic of COVID-19. However, there seems to appear vaccine-taking hesitancy among the general people. Against this backdrop, this current study sets to assess the vaccine-taking intention, ways to overcome the vaccine-taking reluctance among Bangladeshi people and explore their knowledge, perceptions, and attitude toward the COVID-19 vaccine. To this end, this study leveraged on a cross-sectional survey, which was consisted of 1377 respondents covering the eight divisions of Bangladesh. The descriptive statistical method and ordinal logistics regression were employed to explore and rationalize our study outlined objectives. Empirical findings revealed that approximately 71% of the respondents had adequate knowledge about the COVID-19 vaccine, whereas 46% of the respondents were willing to be vaccinated against COVID-19 while the rest of the respondents were hesitant to take the vaccine. However, concern about the potential side effects was one of the core reasons for vaccine-taking hesitancy. Assuring the common people about vaccine safety and efficacy, along with easing the registration procedure, can ameliorate people's confidence to get vaccinated. Meanwhile, about 60% of the respondents believed that a vaccine could help Bangladesh win the battle against COVID-19 and will allow back to normal life. Although the government has taken some pragmatic action steps to promote the vaccination rate, it is recommended that the mass vaccination program should be extended to the grassroots level with proper extension community support and easing the registration process.

A systematic review of health sector responses to the coincidence of disasters and COVID-19

BACKGROUND

In December 2019, the Chinese city of Wuhan reported a novel pneumonia caused by COVID-19. While the COVID-19 pandemic has been increasingly affecting the world, the occurrence of disasters resulted in complex emergencies. The present review is aimed to identify the literature focused on health system response to coincidence of COVID-19 and disasters as well as describing their finding, implications and lessons-learned.

METHODS

This study was conducted and reported based on PRISMA guideline. The databases of Web of Sciences, PubMed, Scopus, Google Scholar and World Health Organization Library were searched. The inclusion criteria were all forms of published articles which investigated the coincidence of disasters and COVID-19 pandemic. Using the title and abstract screening, the selections of studies were performed by two researchers. Once, the relevant papers were finalized, the analysis was done in two parts of descriptive analysis and implications for health systems.

RESULTS

Out of 1245 studies generated by initial search, a number of 13 articles was selected for final analysis. Earthquake was the most frequent disaster which its coincidence with COVID-19 was studied by researchers (31%). The implications of researchers for healthcare system were explained in three sections of climatic events, earthquakes and all hazard approach in relation to COVID-19.

CONCLUSION

Extracting the lessons learned from the regions affected by disasters at the time of COVID-19 pandemic can be helpful for healthcare professionals and policy-makers to improve their preparedness and response during disasters and a serious pandemic such as COVID-19. Further research is needed to identify the factors which strengthen the preparedness of health system for the dual risk of natural hazards and pandemics.