What is a resilient health system? Lessons from Ebola

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

BACKGROUND

Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response.

METHODS

This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery.

RESULTS

Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork.

CONCLUSIONS

In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

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.

Navigating the future of Alzheimer's care in Ireland - a service model for disease-modifying therapies in small and medium-sized healthcare systems

BACKGROUND

A new class of antibody-based drug therapy with the potential for disease modification is now available for Alzheimer's disease (AD). However, the complexity of drug eligibility, administration, cost, and safety of such disease modifying therapies (DMTs) necessitates adopting new treatment and care pathways. A working group was convened in Ireland to consider the implications of, and health system readiness for, DMTs for AD, and to describe a service model for the detection, diagnosis, and management of early AD in the Irish context, providing a template for similar small-medium sized healthcare systems.

METHODS

A series of facilitated workshops with a multidisciplinary working group, including Patient and Public Involvement (PPI) members, were undertaken. This informed a series of recommendations for the implementation of new DMTs using an evidence-based conceptual framework for health system readiness based on [1] material resources and structures and [2] human and institutional relationships, values, and norms.

RESULTS

We describe a hub-and-spoke model, which utilises the existing dementia care ecosystem as outlined in Ireland's Model of Care for Dementia, with Regional Specialist Memory Services (RSMS) acting as central hubs and Memory Assessment and Support Services (MASS) functioning as spokes for less central areas. We provide criteria for DMT referral, eligibility, administration, and ongoing monitoring.

CONCLUSIONS

Healthcare systems worldwide are acknowledging the need for advanced clinical pathways for AD, driven by better diagnostics and the emergence of DMTs. Despite facing significant challenges in integrating DMTs into existing care models, the potential for overcoming challenges exists through increased funding, resources, and the development of a structured national treatment network, as proposed in Ireland's Model of Care for Dementia. This approach offers a replicable blueprint for other healthcare systems with similar scale and complexity.

Local Health Service Response to COVID-19 in Mexico: Notes From an Exploratory Qualitative Study

BACKGROUND

The main goal of a health system is to maintain or improve people's health. The COVID-19 pandemic showed the fragility of health systems worldwide. In Mexico, the pandemic affected the performance of the health system, along with the presence of contextual conditions such as its segmentation and high prevalence of chronic diseases.

AIMS

To analyze from an approach to the functions of the health system, the service delivery, human resources, financing, and stewardship/governance in the local health services of five states of Mexico, from the perspective of the staff working in health centers.

METHODS

This is an exploratory qualitative study conducted from November 2020 to August 2021, involving 124 health professionals from 39 health facilities (18 rural and 21 urban). The technique used was the semi-structured interview. Interview guides were developed according to core topics. Subsequently, the thematic analysis method was used.

RESULTS

The lack of financial resources delayed prevention efforts and made it difficult for health centers to adapt to the crisis. Inequity was found in the distributive efficiency of staff between rural and urban areas and levels of care. In addition, there was evidence of capacity for coordination, capacity sharing, and joint participation between health institutions, civil authorities, and the population to face the emergency.

CONCLUSIONS

We identified relevant public health actions that showed the capacity of local health services to organize a response to the pandemic at the level of the actors responsible for these services.

Resilience of mental health services amidst Ebola disease outbreaks in Africa

Introduction

Health systems including mental health (MH) systems are resilient if they protect human life and produce better health outcomes for all during disease outbreaks or epidemics like Ebola disease and their aftermaths. We explored the resilience of MH services amidst Ebola disease outbreaks in Africa; specifically, to (i) describe the pre-, during-, and post-Ebola disease outbreak MH systems in African countries that have experienced Ebola disease outbreaks, (ii) determine the prevalence of three high burden MH disorders and how those prevalences interact with Ebola disease outbreaks, and, (iii) describe the resilience of MH systems in the context of these outbreaks.

Methods

This was a scoping review employing an adapted PRISMA statement. We conducted a five-step Boolean strategy with both free text and Medical Subject Headings (MeSH) to search 9 electronic databases and also searched WHO MINDbank and MH Atlas.

Results

The literature search yielded 1,230 publications. Twenty-five studies were included involving 13,449 participants. By 2023, 13 African nations had encountered a total of 35 Ebola outbreak events. None of these countries had a metric recorded in MH Atlas to assess the inclusion of MH in emergency plans. The three highest-burden outbreak-associated MH disorders under the MH and Psychosocial Support (MHPSS) framework were depression, post-traumatic stress disorder (PTSD), and anxiety with prevalence ranges of 1.4-7%, 2-90%, and 1.3-88%, respectively. Furthermore, our analysis revealed a concerning lack of resilience within the MH systems, as evidenced by the absence of pre-existing metrics to gauge MH preparedness in emergency plans. Additionally, none of the studies evaluated the resilience of MH services for individuals with pre-existing needs or examined potential post-outbreak degradation in core MH services.

Discussion

Our findings revealed an insufficiency of resilience, with no evaluation of services for individuals with pre-existing needs or post-outbreak degradation in core MH services. Strengthening MH resilience guided by evidence-based frameworks must be a priority to mitigate the long-term impacts of epidemics on mental well-being.

Identifying characteristics that enable resilient immunisation programmes: a scoping review

OBJECTIVES

The COVID-19 pandemic highlighted the fragility of immunisation programmes and resulted in a significant reduction in vaccination rates, with increasing vaccine-preventable disease outbreaks consequently reported. These vulnerabilities underscore the importance of resilient immunisation programmes to ensure optimal performance during crises. To date, a framework for assessing immunisation programme resilience does not exist. We conducted a scoping review of immunisation programmes during times of crisis to identify factors that characterise resilient immunisation programmes, which may inform an Immunisation Programme Resilience Tool.

DESIGN

Scoping review design followed the Arksey and O'Malley framework, and manuscript reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines.

DATA SOURCES

CINAHL, CENTRAL, Embase, Google Scholar, MEDLINE, PsycINFO and Web of Science and databases were searched between 1 January 2011 and 2 September 2023. Citation searching of identified studies was also performed.

ELIGIBILITY CRITERIA

We included primary empirical peer-reviewed studies that discussed the resilience of immunisation programme to crises, shocks or disruptions.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened records and performed data extraction. We extracted data on study location and design, crisis description, and resilience characteristics discussed, and identified evidence gaps in the literature. Findings were synthesised using tabulation and an evidence gap map.

RESULTS

Thirty-seven studies met the eligibility criteria. These studies captured research conducted across six continents, with most concentrated in Africa, Asia and Europe. One study had a randomised controlled trial design, while 36 studies had observational designs (15 analytical and 21 descriptive). We identified five characteristics of resilient immunisation programmes drawing on the Health System Resilience Index (Integration, Awareness, Resource Availability and Access, Adaptiveness and Self-regulation) and several evidence gaps in the literature.

CONCLUSIONS

To our knowledge, no immunisation programme resilience tool exists. We identified factors from the Health System Resilience Index coupled with factors identified through primary empirical evidence, which may inform development of an immunisation programme resilience tool.

Public-Private engagement and health systems resilience in times of health worker strikes: a Ghanaian case study

In low and middle-income countries like Ghana, private providers, particularly the grouping of faith-based non-profit health providers networked by the Christian Health Association of Ghana (CHAG), play a crucial role in maintaining service continuity during health worker strikes. Poor engagement with the private sector during such strikes could compromise care quality and impose financial hardships on populations, especially the impoverished. This study delves into the engagement between CHAG and the Government of Ghana (GoG) during health worker strikes from 2010 to 2016, employing a qualitative descriptive and exploratory case study approach. By analysing evidence from peer-reviewed literature, media archives, grey literature and interview transcripts from a related study using a qualitative thematic analysis approach, this study identifies health worker strikes as a persistent chronic stressor in Ghana. Findings highlight some system-level interactions between CHAG and GoG, fostering adaptive and absorptive resilience strategies, influenced by CHAG's non-striking ethos, unique secondment policy between the two actors and the presence of a National Health Insurance System. However, limited support from the government to CHAG member facilities during strikes and systemic challenges with the National Health Insurance System pose threats to CHAG's ability to provide quality, affordable care. This study underscores private providers' pivotal role in enhancing health system resilience during strikes in Ghana, advocating for proactive governmental partnerships with private providers and joint efforts to address human-resource-related challenges ahead of strikes. It also recommends further research to devise and evaluate effective strategies for nations to respond to strikes, ensuring preparedness and sustained quality healthcare delivery during such crises.

Health systems challenges, mitigation strategies and adaptations to maintain essential health services during the COVID-19 pandemic: learnings from the six geopolitical regions in Nigeria

BACKGROUND

The COVID-19 pandemic control strategies disrupted the smooth delivery of essential health services (EHS) globally. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS during the COVID-19 pandemic. This study aimed to identify the health system challenges encountered and document the mitigation strategies and adaptations made across geopolitical zones (GPZs) in Nigeria.

METHODS

The national qualitative survey of key actors across the six GPZs in Nigeria involved ten states and the Federal Capital Territory (FCT) which were selected based on resilience, COVID-19 burden and security considerations. A pre-tested key informant guide was used to collect data on service utilization, changes in service utilization, reasons for changes in primary health centres' (PHCs) service volumes, challenges experienced by health facilities in maintaining EHS, mitigation strategies implemented and adaptations to service delivery. Emerging sub-themes were categorized under the appropriate pillars of the health system.

RESULTS

A total of 22 respondents were interviewed. The challenges experienced in maintaining EHS cut across the pillars of the health systems including: Human resources shortage, shortages in the supply of personal protective equipments, fear of contracting COVID-19 among health workers misconception, ignorance, socio-cultural issues, lockdown/transportation and lack of equipment/waiting area (. The mitigation strategies included improved political will to fund health service projects, leading to improved accessibility, affordability, and supply of consumables. The health workforce was motivated by employing, redeploying, training, and incentivizing. Service delivery was reorganized by rescheduling appointments and prioritizing some EHS such as maternal and childcare. Sustainable systems adaptations included IPC and telehealth infrastructure, training and capacity building, virtual meetings and community groups set up for sensitization and engagement.

CONCLUSION

The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

Breast and cervical cancer programs' success in maintaining screening during periods of high COVID-19: A qualitative multi-case study analysis

Objective

During the first year of the COVID-19 pandemic, most of the Centers for Disease Control and Prevention (CDC)'s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) funded programs (recipients) experienced significant declines in breast and cervical cancer screening volume. However, 6 recipients maintained breast and/or cervical cancer screening volume during July-December 2020 despite their states' high COVID-19 test percent positivity. We led a qualitative multi-case study to explore these recipients' actions that may have contributed to screening volume maintenance.

Methods

We conducted 22 key informant interviews with recipients, screening provider sites, and partner organizations. Interviews explored organizational and operational changes; screening barriers; actions taken to help maintain screening volume; and support for provider sites to continue screening. We documented contextual factors that may have influenced these actions, including program structures; clinic capacity; and state COVID-19 policies.

Results

Thematic analysis revealed crosscutting themes at the recipient, provider site, and partner levels. Recipients made changes to administrative processes to reduce burden on provider sites and delivered tailored technical assistance to support safe screening. Provider sites modified clinic protocols to increase patient safety, enhanced patient reminders for upcoming appointments, and increased patient education on the importance of timely screening during the pandemic. Partners worked with provider sites to identify and reduce patients' structural barriers to screening.

Conclusion

Study findings provide lessons learned to inform emergency preparedness-focused planning and operations, as well as routine operations for NBCCEDP recipient programs, other cancer screening initiatives, primary care clinics, and chronic disease prevention programs.

Concept analysis of health system resilience

BACKGROUND

There are several definitions of resilience in health systems, many of which share some characteristics, but no agreed-upon framework is universally accepted. Here, we review the concept of resilience, identifying its definitions, attributes, antecedents and consequences, and present the findings of a concept analysis of health system resilience.

METHODS

We follow Schwarz-Barcott and Kim's hybrid model, which consists of three phases: theoretical, fieldwork and final analysis. We identified the concept definitions, attributes, antecedents and consequences of health system resilience and constructed an evidence-informed framework on the basis of the findings of this review. We searched PubMed, PsycINFO, CINAHL Complete, EBSCOhost-Academic Search and Premier databases and downloaded identified titles and abstracts on Covidence. We screened 3357 titles and removed duplicate and ineligible records; two reviewers then screened each title, and disagreements were resolved by discussion with the third reviewer. From the 130 eligible manuscripts, we identified the definitions, attributes, antecedents and consequences using a pre-defined data extraction form.

RESULTS

Resilience antecedents are decentralization, available funds, investments and resources, staff environment and motivation, integration and networking and finally, diversification of staff. The attributes are the availability of resources and funds, adaptive capacity, transformative capacity, learning and advocacy and progressive leadership. The consequences of health system resilience are improved health system performance, a balanced governance structure, improved expenditure and financial management of health and maintenance of health services that support universal health coverage (UHC) throughout crises.

CONCLUSION

A resilient health system maintains quality healthcare through times of crisis. During the coronavirus disease 2019 (COVID-19) epidemic, several seemingly robust health systems were strained under the increased demand, and services were disrupted. As such, elements of resilience should be integrated into the functions of a health system to ensure standardized and consistent service quality and delivery. We offer a systematic, evidence-informed method for identifying the attributes of health system resilience, intending to eventually be used to develop a measuring tool to evaluate a country's health system resilience performance.

Effect of the COVID-19 pandemic on HIV, malaria and tuberculosis indicators in Togo: an interrupted time series analysis

BACKGROUND

Limited data are available on the effects of the COVID-19 pandemic on health-related indicators in sub-Saharan Africa. This study aimed to estimate the effect of the COVID-19 pandemic on nine indicators of HIV, malaria and tuberculosis (TB) in Togo.

METHODS

For this interrupted time series analysis, national health information system data from January 2019 to December 2021 and TB programmatic data from the first quarter of 2018 to the fourth quarter of 2022 were analysed. Nine indicators were included. We used Poisson segmented regression to estimate the immediate impact of the pandemic and per-pandemic period trends through incidence rate ratios (IRRs) with 95% CIs.

RESULTS

Overall, there was a decrease in six of the nine indicators, ranging from 19.3% (IRR 0.807, 95% CI 0.682 to 0.955, p=0.024) for the hospitalisation of patients for malaria to 36.9% (IRR 0.631, 95% CI 0.457 to 0.871, p=0.013) for TB diagnosis by Mycobacterium tuberculosis Xpert immediately after the declaration of the COVID-19 pandemic. A comparison of the observed and predicted trends showed that the trend remained constant between the prepandemic and pandemic periods of COVID-19 for all malaria indicators. A significant downward monthly trend was observed in antiretroviral therapy initiation (IRR 0.909, 95% CI 0.892 to 0.926, p<0.001) and positive TB microscopy (IRR 0.919, 95% CI 0.880 to 0.960, p=0.002).

CONCLUSION

HIV, malaria and TB services were generally maintained over time in Togo despite the COVID-19 pandemic. However, given the decline in levels immediately after the onset of the pandemic, there is an urgent need to improve the preparedness of the healthcare system.

A scoping review of post-earthquake healthcare for vulnerable groups of the 2023 Turkey-Syria earthquakes

BACKGROUND

Identifying healthcare services and also strengthening the healthcare systems to effectively deliver them in the aftermath of large-scale disasters like the 2023 Turkey-Syria earthquakes, especially for vulnerable groups cannot be emphasized enough. This study aimed at identifying the interventions undertaken or proposed for addressing the health needs or challenges of vulnerable groups immediately after the occurrence of the 2023 Turkey-Syria earthquakes, as well as for prioritizing their healthcare service delivery in the post-Turkey-Syria earthquake.

METHODS

In this scoping review compiled with the five steps of the Arksey and O'Malley framework, five databases, including PubMed, Science Direct, Web of Science, OVID, and Google Scholar, were searched for studies published between March and April 2023 in line with the eligibility criteria. Interventions for enhancing post-earthquake healthcare services (PEHS) were grouped into seven (7) categories, adopted from previous guidelines and studies. Each one was assigned a default score of a value equal to one (1), which, in the end, was summed up.

RESULTS

Of the 115 total records initially screened, 29 articles were eligible for review. Different interventions they reported either undertaken or proposed to address the healthcare needs and challenges, especially faced by the most vulnerable groups in the aftermath of the Turkey-Syria earthquakes, were categorized into 7 PEHS. They were ranked with their scores as follows: humanitarian health relief (25); medical care (17); mental health and psychosocial support (10); health promotion, education, and awareness (9); disease surveillance and prevention (7); disability rehabilitation (7); and sexual and reproductive health (5).

CONCLUSION

Since there are no proper guidelines or recommendations about the specific or most significant PEHS to prioritize for vulnerable groups after the occurrence of large-scale earthquakes, this scoping review provides some insights that can help inform healthcare service delivery and prioritization for vulnerable groups in the post-2023 Turkey-Syria earthquakes and other similar disasters.

Guidance on sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian and fragile settings: a scoping review

INTRODUCTION

Progress related to sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) has stalled. COVID-19, conflict and climate change threaten to reverse decades of progress and to ensure the health and well-being of vulnerable populations in humanitarian and fragile settings (HFS) going forward, there is a need for tailored guidance for women, children and adolescents (WCA). This review seeks to map and appraise current resources on SRMNCAH in HFS.

METHODS

In line with the updated Joanna Briggs Institute guidance and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews framework, a manual literature review was conducted of global and regional guidance published between January 2008 and May 2023 from members of the Global Health Cluster, the Global Nutrition Cluster and the Inter-Agency Working Group on Reproductive Health in Crises. A content analysis was conducted. Scores were then calculated according to the Appraisal of Guidelines for Research and Evaluation II scoring tool and subsequently categorised as high quality or low quality.

RESULTS

A total of 730 documents were identified. Of these, 141 met the selection criteria and were analysed. Available guidance for delivering SRMNCH services exists, which can inform policy and programming for the general population and WCA. Important gaps related to beneficiaries, health services and health system strengthening strategies were identified.

CONCLUSION

The review revealed there is evidence-based guidance available to support interventions targeting WCA in HFS, including: pregnant and lactating women, women of reproductive age, adolescents, newborns, small vulnerable newborns, stillbirths, refugees and internally displaced persons and WCA with disabilities. However, gaps related to beneficiaries, health services and health system strengthening strategies must be addressed in updated guidance that is created, disseminated and monitored in a standardised way that is mindful of the need to respond rapidly in HFS.

Exploring hospital resilience protective or risk factors: lessons for future disaster response efforts

Background

Hospital resilience is essential in responding to disasters, but current research focuses mainly on frameworks and models rather than the protection of resilience and analysis of risk factors during public health emergencies. This study aims to examine the development of resilience in Chinese frontline hospitals during the initial COVID-19 outbreak in 2020, providing insights for future disaster response efforts.

Objectives

We conducted interviews with 26 hospital staff members who were involved in the initial response to the COVID-19 outbreak in China. We used a semi-structured interview approach and employed purposive sampling and snowball sampling techniques. The interview outline was guided by the 'Action Framework' proposed by the World Health Organization (WHO) for responding to infectious disease emergencies. This framework includes dimensions such as command, surveillance, risk communication, medical response, and public health response. We analyzed the collected data using Colaizzi's seven-step data analysis method and the template analysis method.

Results

WHO's 'action framework' effectively highlights the factors that contribute to hospital resilience. While medical response, including the availability of materials and facilities, the use of information technology, and the capacity for infectious disease diagnosis and treatment, remains crucial, other important aspects include awareness and beliefs about infections, treatment experience, interdisciplinary collaboration, and more. Additionally, it is essential to establish an intelligent command system, foster trusting partnerships between teams, improve monitoring capabilities for infectious disease agents, enhance risk communication through information synchronization and transparency, strengthen infection control planning, and improve environmental disinfection capabilities for effective public health emergency response. These contradictions significantly impact the enhancement of hospital resilience in dealing with major infectious disease outbreaks.

Conclusion

In responding to sudden major infectious diseases, hospitals play a vital role within the healthcare system. Enhancing hospital resilience involves more than just improving treatment capabilities. It also requires effective command coordination at the hospital level, infection control planning, and the deployment of intelligent equipment. Additionally, planning for effective communication and coordination between hospitals, communities, and the national healthcare system can further enhance hospital resilience.

Transforming health care systems towards high-performance organizations: qualitative study based on learning from COVID-19 pandemic in the Basque Country (Spain)

BACKGROUND

The COVID-19 pandemic is one of the worst health catastrophes of the last century, which caused severe economic, political, and social consequences worldwide. Despite these devastating consequences, lessons learned provide a great opportunity that can drive the reform of health systems to become high-performing, effective, equitable, accessible, and sustainable organisations. This work identifies areas in which changes must be encouraged that will enable health systems to deal effectively with current and future challenges, beyond COVID-19.

METHODS

A realist design was chosen, based on qualitative data collection techniques, content analysis and triangulation to identify key domains of organizational interventions behind the changes implemented to react to the COVID-19 pandemic in the Basque Country. Twenty key informants were used as an expert source of information. Thematic analysis was done using the Framework Method.

RESULTS

The analysis of the interviews resulted in the identification of 116 codes, which were reviewed and agreed upon by the researchers. Following the process of methodological analysis, these codes were grouped into domains: seven themes and 23 sub-themes. Specifically, the themes are: responsiveness, telehealth, integration, knowledge management, professional roles, digitisation, and organisational communication. The detailed description of each theme and subtheme is presented.

CONCLUSIONS

The findings of this work pretend to guide the transformation of health systems into organisations that can improve the health of their populations and provide high quality care. Such a multidimensional and comprehensive reform encompasses both strategic and operational actions in diverse areas and requires a broad and sustained political, technical, and financial commitment.

Practical strategies to achieve resilient health systems: results from a scoping review

BACKGROUND

This paper presents the results of a systematic review to identify practical strategies to create the institutions, skills, values, and norms that will improve health systems resilience.

METHODS

A PRISMA 2020 compliant systematic review identified peer-reviewed and gray literature on practical strategies to make health systems more resilient. Investigators screened 970 papers to identify 65 English language papers published since 2015.

RESULTS

Practical strategies focus efforts on system changes to improve a health system's resilience components of collective knowing, collective thinking, and collaborative doing. The most helpful studies identified potential lead organizations to serve as the stewards of resilience improvement, and these were commonly in national and local departments of public health. Papers on practical strategies suggested possible measurement tools to benchmark resilience components in efforts to focus on performance improvement and ways to sustain their use. Essential Public Health Function (EPHF) measurement and improvement tools are well-aligned to the resilience agenda. The field of health systems resilience lacks empirical trials linking resilience improvement interventions to outcomes.

CONCLUSIONS

The rigorous assessment of practical strategies to improve resilience based on cycles of measurement should be a high priority.

The Israeli health system's rapid responses during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic posed numerous challenges to health systems around the world. In addressing many of those challenges, Israel responded quite rapidly. While quick action is not an end in it itself, it can be important in responding to disease outbreaks. Some of Israel's rapid responses to the pandemic contributed significantly to population health and provided important learning opportunities for other countries.

MAIN BODY

Some of the most prominent Israeli rapid responses were related to vaccination. Israel led the world in the pace of its initial vaccine rollout, and it was also the first country to approve and administer booster vaccines to broad segments of the population. In addition, Israeli scholars published a series of timely reports analyzing vaccination impact, which informed policy in Israel and other countries. Israel was a rapid responder in additional areas of public health. These include the partial closure of its borders, the adoption of physical distancing measures, the use of digital surveillance technology for contact tracing, the use of wastewater surveillance to monitor viral spread, and the use of vaccine certificates ("green passes") to facilitate a return to routine in the face of the ongoing pandemic. Many factors contributed to Israel's capacity to repeatedly respond rapidly to a broad array of COVID-19 challenges. These include a national health insurance system that promotes public-private coordination, a system of universal electronic health records, a high level of emergency preparedness, a culture of focusing on goal attainment, a culture of innovation, and the presence of a strong scientific community which is highly connected internationally. In addition, some of the rapid responses (e.g., the rapid initial vaccination rollout) facilitated rapid responses in related areas (e.g., the analysis of vaccination impact, the administration of boosters, and the adoption of green passes). While rapid response can contribute to population health and economic resilience, it can also entail costs, risks, and limitations. These include making decisions and acting before all the relevant information is available; deciding without sufficient consideration of the full range of possible effects, costs, and benefits; not providing enough opportunities for the involvement of relevant groups in the decision-making process; and depleting non-renewable resources.

CONCLUSIONS

Based on our findings, we encourage leaders in the Israeli government to ensure that its emergency response system will continue to have the capacity to respond rapidly to large-scale challenges, whether of a military or civilian nature. At the same time, the emergency response systems should develop mechanisms to include more stakeholders in the fast-paced decision-making process and should improve communication with the public. In addition, they should put into place mechanisms for timely reconsideration, adjustment, and-when warranted-reversal of decisions which, while reasonable when reached, turn out to have been ill-advised in the light of subsequent developments and evidence. These mechanisms could potentially involve any or all branches of government, as well as the public, the press, and professional organizations. Our findings also have implications for health system leaders in other countries. The Israeli experience can help them identify key capacities to develop during non-emergency periods, thus positioning themselves to respond more rapidly in an emergency. Finally, health system leaders in other countries could monitor Israel's rapid responses to future global health emergencies and adopt selected actions in their own countries.

Exploring strategies for building a sustainable healthcare system in Africa: lessons from Japan and Switzerland

Strengthening healthcare infrastructure is an important strategy for building a sustainable healthcare system in Africa. This involves investing in facilities, equipment, and supplies, as well as training and retaining skilled healthcare workers. Additionally, improving healthcare infrastructure and investing in healthcare education and training can lead to significant improvements in health outcomes, such as reducing maternal and child mortality. This is critical for building a sustainable healthcare system. Through a literature review, we assessed the approaches to building a sustainable healthcare system in Africa from the perspectives of Japan's and Switzerland's healthcare systems. It was discovered that Japan currently has the highest life expectancy, which can be attributed to insurance policies, healthcare policies, and the integration of emerging technologies and clinical research into their healthcare system. Lessons that Africa must emulate from the Japanese healthcare system include ensuring universal healthcare coverage, improving the workforce, improving primary healthcare, prioritizing the aging population, and investing in technology, infrastructure, and research. Japans healthcare system is also sustainable thanks to its stable workforce and primary healthcare. Switzerland also has an exceptional healthcare system globally, with technical and socioeconomic advancements leading to increased life expectancy and population aging through a worldwide health policy approach, programs tackling professional responsibilities and interprofessional cooperation, and initiatives to support family medicine. By learning from Japan's and Switzerland's approaches, Africa will gradually achieve the Sustainable Development Goals and build a sustainable healthcare system.

Local management of the COVID-19 pandemic in Norway: a longitudinal interview study of municipality chief medical officers

OBJECTIVE

To explore the experiences and views of Norwegian Municipality Chief Medical Officers (MCMOs) on preparedness, collaboration, and organization during the COVID-19 pandemic to gain insight into local crisis management of value for future pandemic responses.

DESIGN

Longitudinal qualitative interview study. We conducted semi-structured digital interviews with nine MCMOs working in different municipalities in Norway from September to December 2020. Five MCMOs were re-interviewed from January to April 2021. We used thematic analysis to analyze the data.

RESULTS

Through the analysis, three major themes were identified in the material; 1) The view of preparedness changed from being low-priority and dormant to the desire to strengthen preparedness as a permanent measure; 2) The nature of the pandemic forced a change in internal and external communication and collaboration for the MCMOs towards direct dialogue, teamwork and digital networking; 3) The pandemic changed the role and position of the MCMO within the municipal organization. Although most MCMOs were given a leading role in the municipal pandemic response, some MCMOs experienced that they were not positioned to fully exercise their intended role. In our material, de-authorization of the MCMO role seemed to coincide with the increasing size and organizational complexity of the municipality.

CONCLUSIONS

The Norwegian pandemic response and outcome have been regarded as successful internationally. Although the MCMOs managed to implement flexible and quick responses facilitated by teamwork, dialogue, and joint sensemaking, they also identified several challenges and shortcomings of the Norwegian pandemic preparedness requiring organizational and financial changes to sustain future health system resilience.

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.

'A system that is struggling': understanding health protection resilience in England during the COVID-19 pandemic through the experiences of local health protection responders

BACKGROUND

Local health protection systems play a crucial role in infectious disease prevention and control and were critical to COVID-19 pandemic responses. Despite this vital function, few studies have explored the lived experience of health protection responders managing COVID-19. We provide new insights by examining how COVID-19 shaped infectious disease prevention and control in local health protection systems in England.

METHODS

Semi-structured interviews were conducted with twenty local health protection responders from three contrasting local authority areas, and Public Health England (PHE) health protection teams, in England between June 2021 - March 2022. Participants were from: PHE health protection teams (n=6); local authority public health teams (n=5); local authority Public Protection Services (n=7); and local authority commissioned Infection Prevention and Control Teams (n=2). Data were analysed using reflexive thematic analysis.

RESULTS

First, participants acknowledged the pandemic caused an unprecedented workload and disruption to local health protection service delivery. There was not enough capacity within existing local health protection systems to manage the increased workload. PHE health protection teams therefore transferred some COVID-19 related health protection tasks to other staff, mainly those employed by local authorities. Second, health protection responders highlighted how COVID-19 drew attention to the weaknesses in local health protection systems already stressed by reduced funding in the years leading up to the pandemic. Injecting money into the COVID-19 response did not completely overcome former losses in specialist health protection workforce. Third, health protection responders described how pandemic management raised the profile of public health, especially infectious disease prevention and control. Managing COVID-19 strengthened collaborative working, resulting in enhanced capacity of local health protection systems at the time.

CONCLUSION

The COVID-19 pandemic challenged the public health preparedness of all countries. Health protection responders in this study also expressed many challenges. There was insufficient resilience in these local health protection systems and an inability to scale up the specialist health protection workforce, as required in a pandemic situation. The UK needs to learn from the pandemic experience by acknowledging and addressing the challenges faced by local health protection responders so that it can more effectively respond to future threats.

Building a resilient health system for universal health coverage and health security: a systematic review

BACKGROUND

Resilient health system (RHS) is crucial to achieving universal health coverage (UHC) and health security. However, little is known about strategies towards RHS to improve UHC and health security. This systematic review aims to synthesise the literature to understand approaches to build RHS toward UHC and health security.

METHODS

A systematic search was conducted including studies published from 01 January 2000 to 31 December 2021. Studies were searched in three databases (PubMed, Embase, and Scopus) using search terms under four domains: resilience, health system, universal health coverage, and health security. We critically appraised articles using Rees and colleagues' quality appraisal checklist to assess the quality of papers. A systematic narrative synthesis was conducted to analyse and synthesise the data using the World Health Organization's health systems building block framework.

RESULTS

A total of 57 articles were included in the final review. Context-based redistribution of health workers, task-shifting policy, and results-based health financing policy helped to build RHS. High political commitment, community-based response planning, and multi-sectorial collaboration were critical to realising UHC and health security. On the contrary, lack of access, non-responsive, inequitable healthcare services, poor surveillance, weak leadership, and income inequalities were the constraints to achieving UHC and health security. In addition, the lack of basic healthcare infrastructures, inadequately skilled health workforces, absence of clear government policy, lack of clarity of stakeholder roles, and uneven distribution of health facilities and health workers were the challenges to achieving UHC and health security.

CONCLUSIONS

Advanced healthcare infrastructures and adequate number of healthcare workers are essential to achieving UHC and health security. However, they are not alone adequate to protect the health system from potential failure. Context-specific redistribution of health workers, task-shifting, result-based health financing policies, and integrated and multi-sectoral approaches, based on the principles of primary health care, are necessary for building RHS toward UHC and health security.

Health systems resilience in fragile and conflict-affected settings: a systematic scoping review

BACKGROUND

Health systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS.

METHODS

We used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al. RESULTS: Thirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems' resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services.

CONCLUSIONS

Our review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens.

Analysis of the availability, effectiveness and equity of deployment of resources in the health system response to COVID-19 in Nigeria

BACKGROUND

Coronavirus disease 2019 (COVID-19) exposed weaknesses in the health systems of countries such as Nigeria, which affected the effectiveness of the health system response to the pandemic. This paper provides new knowledge on the level of the availability, effectiveness and equity of resources in response to COVID-19 in Nigeria. This is valuable information for improving the delivery of countermeasures against future pandemics.

METHODS

The study was conducted at the federal level and in two states in Nigeria. The states were Lagos in the southwest and Enugu in the southeast. In-depth interviews were undertaken with 34 key informants. NVivo version 12 software was used for coding and thematic analysis.

RESULTS

There were inadequate, inequitable and suboptimal resources (human, financial, equipment and materials) for the response. In some of the countermeasures, only people that were employed in the formal sector benefitted from the distribution of welfare materials and financial packages; the informal sector, which constitutes the majority of the poor population in Nigeria, was excluded.

CONCLUSIONS

Inequity and suboptimal availability of resources to control COVID-19 led to reduced effectiveness of the health system response to the disease in Nigeria. Such negative factors must be mitigated in future responses to pandemics in the country.

Institutionalization for good governance to reach sustainable health development: a framework analysis

BACKGROUND

This article explores the concept of institutionalization, which is the process of transforming ideas into programs and automating actions, in the context of health system governance and sustainable development. Institutionalization is a key mechanism for creating accountable and transparent institutions, which are essential for achieving health system resilience and sustainability. This study identifies the components and dimensions of institutionalization in the health system and its relationship with good governance and sustainable health development.

MAIN TEXT

We applied a scoping review method in five steps. First, we formulated a question for our research. Then, we concluded a comprehensive literature search in five electronic databases for identifying relevant studies. This review has two phases: identifying the concept of institutional approach and its components in health system, and its relationship with good governance to reach Sustainable Health Development (SHD). The third step was study selection, and the 1st author performed data abstraction. The key issues which are identified in our review, related to the concepts of SDH, its goals, pillars and principles; positive peace; good governance; components of institutional approach components, and their relations. Finally, we summarized and organized our findings in a format of a proposed conceptual framework, to underpin the role of institutionalization in the health system to achieve sustainable development.

CONCLUSION

Institutionalization is a key concept for achieving positive peace and good governance, which requires meaningful involvement of leaders, politicians, civil society, and public participation. It also depends on the conditions of justice, human rights, transparency, accountability and rule of law. In the wake of COVID-19, institutionalization is more crucial than ever for advancing sustainable development, especially in the context of low and middle-income countries (LMICs).

Adaptation and Response of a Major Parisian Referral Hospital to the COVID-19 Surge: A Qualitative Study

Since the beginning of the COVID-19 pandemic, few studies have focused on crisis management of multiple services within one hospital over several waves of the pandemic. The purpose of this study was to provide an overview of the COVID-19 crisis response of a Parisian referral hospital which managed the first three COVID cases in France and to analyze its resilience capacities. Between March 2020 and June 2021, we conducted observations, semi-structured interviews, focus groups, and lessons learned workshops. Data analysis was supported by an original framework on health system resilience. Three configurations emerged from the empirical data: 1) reorganization of services and spaces; 2) management of professionals' and patients' contamination risk; and 3) mobilization of human resources and work adaptation. The hospital and its staff mitigated the effects of the pandemic by implementing multiple and varied strategies, which the staff perceived as having positive and/or negative consequences. We observed an unprecedented mobilization of the hospital and its staff to absorb the crisis. Often the mobilization fell on the shoulders of the professionals, adding to their exhaustion. Our study demonstrates the capacity of the hospital and its staff to absorb the COVID-19 shock by putting in place mechanisms for continuous adaptation. More time and insight will be needed to observe whether these strategies and adaptations will be sustainable over the coming months and years and to assess the overall transformative capacities of the hospital.

Exploring health information system resilience during COVID-19 pandemic: case studies from Norway, Sri Lanka & Rwanda

The study aims at exploring health system resilience by defining the scope on health information systems, one of the six building blocks of the health system. The empirical evidence is derived using qualitative data collection and analysis in the context of Norway, Sri Lanka and Rwanda during the COVID-19 pandemic. The case studies elicit bounce back and bounce forward properties as well as the agility as major attributes of resilience present across the countries. Existing local capacity, networking and collaborations, flexible digital platforms and enabling antecedent conditions are identified as socio-technical determinants of information system resilience based on the case studies across the countries.

"One community at a time": promoting community resilience in the face of natural hazards and public health challenges

BACKGROUND

Resilience is vital for facing natural disasters and public health challenges. Despite the significance of resilience-building activities, there is a scarcity of locally-tailored planning and response strategies, leaving communities incapable of addressing the unique challenges posed by natural disasters and public health crises. This study aims to explore how the "One Community at a Time" approach enhances community resilience in facing natural hazards and public health challenges.

METHODS

A systematic review was conducted over journal articles published from January 2001 to April 2023 through PRISMA approach. Multiple databases such as Web of Science and Scopus were thoroughly searched. We used independent screening by two researchers and painstaking data extraction using standardized forms. This approach was adopted to assure the reliability, validity, and precision of our study selection and analysis. The included studies' quality was evaluated by the Mixed Methods Appraisal Tool.

RESULTS

In the evaluation, 35 studies were deemed eligible for inclusion and underwent in-depth examination. Several major components of "One Community at a Time" have been identified, including social capital and networks, local knowledge and learning, effective governance and leadership, preparedness and response capacity, and adaptive infrastructure and resources. This framework highlights the significance of individualized approaches to resilience-building initiatives, recognizing that each community has specific strengths, needs, and challenges.

CONCLUSION

Relevant stakeholders can adapt suitable resilient strategies to help prepare and recover from natural hazards and public health challenges. By adopting a localized strategy, stakeholders can collaborate to develop a culture of readiness and resilience, ultimately leading to more sustainable and resilient communities. This framework advises community-based groups, local government, and other stakeholders on prioritizing partnerships, preparedness planning, community participation, and leadership as essential components of creating and maintaining resilience. "One Community at a Time" framework offers practical guidance for community-based organizations, local government, and other stakeholders to prioritize partnerships, preparedness planning, community participation, and leadership as essential components of creating and sustaining resilience.

Influences of community engagement and health system strengthening for cholera control in cholera reporting countries

The 2030 Global Task Force on Cholera Control Roadmap hinges on strengthening the implementation of multistranded cholera interventions, including community engagement and health system strengthening. However, a composite picture of specific facilitators and barriers for these interventions and any overlapping factors existing between the two, is lacking. Therefore, this study aims to address this shortcoming, focusing on cholera-reporting countries, which are disproportionately affected by cholera and may be cholera endemic. A scoping methodology was chosen to allow for iterative mapping, synthesis of the available research and to pinpoint research activity for global and local cholera policy-makers and shareholders. Using the Arksey and O'Malley framework for scoping reviews, we searched PubMed, Web of Science and CINAHL. Inclusion criteria included publication in English between 1990 and 2021 and cholera as the primary document focus in an epidemic or endemic setting. Data charting was completed through narrative descriptive and thematic analysis. Forty-four documents were included, with half relating to sub-Saharan African countries, 68% (30/44) to cholera endemic settings and 21% (9/44) to insecure settings. We identified four themes of facilitators and barriers to health systems strengthening: health system cooperation and agreement with external actors; maintaining functional capacity in the face of change; good governance, focused political will and sociopolitical influences on the cholera response and insecurity and targeted destruction. Community engagement had two themes: trust building in the health system and growing social cohesion. Insecurity and the community; cooperation and agreement; and sociopolitical influences on trust building were themes of factors acting at the interface between community engagement and health system. Given the decisive role of the community-health system interface for both sustained health system strengthening and community engagement, there is a need to advocate for conflict resolution, trust building and good governance for long-term cholera prevention and control in cholera reporting countries.

Systems analysis of the effects of the 2014-16 Ebola crisis on WHO-reporting nations' policy adaptations and 2020-21 COVID-19 response: a systematized review

BACKGROUND

Recent case studies indicate that the 2014-2016 Ebola outbreak, one of the worst pre-2020 global biological catastrophes in modern history, helped some nations to better prepared their responses for the COVID-19 pandemic. While such national case studies explore how specific nations applied EVD-related policies in their domestic battle against the COVID-19 pandemic, there is no known study that assesses how many WHO nations learned from the West African crisis and to what scale.

OBJECTIVE

Applying the policy legacies analytical framework and a systematized literature review, this research examines how prior policy experiences with the 2014-16 EVD crisis as a large-scale emergent outbreak helped to inform and to condition WHO nations to proactively prepare their national policies and health systems for future threats, including ultimately COVID-19.

METHODS

A systematized literature review of 803 evaluated sources assesses to what extent Ebola-affected and non-affected nations directly modified governmental health systems in relation to this warning. The study further evaluates how nations with documented Ebola-related changes fared during COVID-19 compared to nations that did not. We present a categorical theoretical framework that allows for classifying different types of national response activities (termed conditioned learning).

RESULTS

Ten (90.9%) of 11 nations that were affected by 2014-16 Ebola crisis have documented evidence of repurposing their EVD-related policies to fight COVID-19. 164 (70.0%) of 234 non-EVD-affected nations had documented evidence of specifically adapting national systems to incorporate policy recommendations developed from the 2014-16 crisis, which informed their COVID-19 responses in 2020.

CONCLUSIONS

The shock of 2014-16 EVD outbreak affected most nations around the world, whether they experienced Ebola cases. We further develop a categorical framework that helps characterised nations previous experiences with this biological catastrophe, providing a means to analyse to what extent that individual nations learned and how these EVD-related changes helped inform their COVID-19 response. Nations that demonstrated EVD-related conditioned learning nations tended to have more stringent COVID-19 responses before April 2020 and utilized documented response mechanisms developed out of the West African crisis.

Conditions for health system resilience in the response to the COVID-19 pandemic in Mauritania

INTRODUCTION

A country's ability to manage a crisis depends on its level of resilience. Efforts are made to clarify the concept of health system resilience, but its operationalisation remains little studied. In the present research, we described the capacity of the local healthcare system in the Islamic Republic of Mauritania, in West Africa, to cope with the COVID-19 pandemic.

METHODS

We used a single case study with two health districts as units of analysis. A context analysis, a literature review and 33 semi-structured interviews were conducted. The data were analysed using a resilience conceptual framework.

RESULTS

The analysis indicates a certain capacity to manage the crisis, but significant gaps and challenges remain. The management of many uncertainties is largely dependent on the quality of the alignment of decision-makers at district level with the national level. Local management of COVID-19 in the context of Mauritania's fragile healthcare system has been skewed to awareness-raising and a surveillance system. Three other elements appear to be particularly important in building a resilient healthcare system: leadership capacity, community dynamics and the existence of a learning culture.

CONCLUSION

The COVID-19 pandemic has put a great deal of pressure on healthcare systems. Our study has shown the relevance of an in-depth contextual analysis to better identify the enabling environment and the capacities required to develop a certain level of resilience. The translation into practice of the skills required to build a resilient healthcare system remains to be further developed.

Is the Self-Evaluation of Resilience a Valid Assessment to Measure Resilience in Healthcare? A Confirmatory validation Study in Italian Healthcare Settings

Although the Self-Evaluation of Resilience (SEOR) scale is a promising tool for assessing resilience in healthcare, its psychometric structure has not yet been confirmed. This study aimed to assess and validate the four-factor psychometric structure of the SEOR. Between September 2020 and January 2021, cross-sectional data were collected from randomly selected healthcare workers, managers, and administrators from a predefined network of 70 healthcare facilities in 12 Italian regions. The sample size was based on a Monte Carlo simulation using estimates from the SEOR developmental study. Two confirmatory factor models (first-order and second-order) were predefined. The responders (n = 199, response rate, 81%) were healthcare workers (n = 99; 49.7%), managers (n = 86; 43.2%), and administrators (n = 14; 7%). The two confirmatory factor models each showed a good fit in explaining sample statistics, corroborating the capacity of the scale to provide a total score of resilience and sub-scores for organizational resilience, network-based resilience, skill-based resilience, and individual-based resilience. The Molenaar-Sijtsma coefficients (internal consistency) ranged between 0.889 and 0.927. The SEOR enables managers and policy-makers to comprehensively screen resilience in healthcare from an epidemiological perspective.

Disruption Of Non-COVID-19 Health Care In Latin America During The Pandemic: Effects On Health, Lessons For Policy

COVID-19 had severe direct and indirect effects on health and well-being in Latin America. To understand the extent to which disruptions among non-COVID-19-related health services affected population health, we used administrative data from the period 2015-21 to examine public hospital discharges and mortality for conditions amenable to health care in four Latin American countries: Brazil, Ecuador, Mexico, and Peru. Between March 2020 and December 2021, hospitalization rates for these conditions declined by 28 percent and mortality rates increased by 15 percent relative to prepandemic years. Noncommunicable diseases accounted for 89 percent of this rise in mortality. The poorest states in each country experienced relatively larger increases in mortality. Our results, which focus on the health effects of service disruption, suggest that maintaining health care services in this region during the pandemic could have avoided at least 96,000 deaths. Policies should focus on maintaining essential health care services during emergencies, particularly for patients with noncommunicable diseases, and on minimizing negative consequences by ensuring coordinated and continuous care; leveraging alternative modalities of care, such as telemedicine; broadening the role of nonphysician health care workers; and expanding options for medication delivery.

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.

The COVID-19 pandemic and disruptions to maternal and child health services in public primary care Malaysia: a retrospective time-series analysis

INTRODUCTION

The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide. Maintaining essential health services, including maternal and child health (MCH), while addressing the pandemic is an enormous task. This study aimed to assess the impact of the COVID-19 pandemic on the utilisation of MCH services in Malaysian public primary care.

METHODS

A retrospective analysis was conducted using national administrative data from 1124 public primary care clinics. Eight indicators were selected to measure service utilisation covering antenatal, postnatal, women's health, child health, and immunisation services. Interrupted time-series analysis was used to evaluate changes in levels and trends of indicators during four different periods: pre-pandemic (January 2019-February 2020), during pandemic and first lockdown (March-May 2020), after the first lockdown was lifted (June-December 2020) and after the second lockdown was implemented (January-June 2021).

RESULTS

Most indicators showed no significant trend in monthly utilisation prior to the pandemic. The onset of the pandemic and first lockdown implementation were associated with significant decreasing trends in child health (-19.23%), women's health (-10.12%), antenatal care (-8.10%), contraception (-6.50%), postnatal care (-4.85%) and postnatal care 1-week (-3.52%) indicators. These indicators showed varying degrees of recovery after the first lockdown was lifted. The implementation of the second lockdown caused transient reduction ranging from -11.29% to -25.92% in women's health, contraception, child and two postnatal indicators, but no sustained reducing trend was seen afterwards. Two immunisation indicators appeared unaffected throughout the study period.

CONCLUSION

The COVID-19 pandemic significantly impacted MCH services utilisation in Malaysia. While most MCH services were negatively affected by the lockdown implementation with varying degrees of recovery, infant immunisation showed resilience throughout. This highlights the need for a targeted preparedness plan to ensure the resilience of MCH services in future crises.

How Central Ugandan HIV Clinics Adapted During COVID-19 Lockdown Restrictions to Promote Continuous Access to Care: A Qualitative Analysis

We used qualitative data from the Partners PrEP Program (PPP) to address the question: How did Central Ugandan HIV clinics adapt to COVID-19 lockdown restrictions to promote continuous access to HIV care? PPP was a stepped-wedge cluster randomized trial of integrated PrEP and ART delivery for HIV serodifferent couples at Central Ugandan HIV clinics (NCT03586128). Individual interviews with purposefully selected PPP couples (N = 42) and clinicians, coordinators, and counselors providing HIV care (N = 36) were carried out. Sixty-four interviews were completed after lockdown and included questions about accessing and providing ART/PrEP refills during lockdown restrictions. We used an inductive, content-focused approach to analyze these interview data. Barriers to continuous access identified by interviewees included loss of income with increased cost of transport, reduced staff at clinics, and physical distancing at clinics. Interviewees pointed to multi-month refills, visits to clinics "close to home," transport to clinics for providers, and delivery of refills in neighborhoods as factors promoting continuous access to antiretroviral medications. Access barriers appeared somewhat different for ART and PrEP. Fewer resources for community delivery and pre-refill HIV testing requirements were identified as PrEP-specific access challenges. Participants emphasized their success in continuing ART/PrEP adherence during the lockdown, while providers emphasized missed refill visits. These results highlight the contributions of providers and ART/PrEP users to adaptation of HIV services during COVID-19 lockdown restrictions in Uganda. The roles of direct care providers and service users as drivers of adaptation should be recognized in future efforts to conceptualize and investigate health system resiliency.

A resilient workforce: patient safety and the workforce response to a cyber-attack on the ICT systems of the national health service in Ireland

BACKGROUND

In May 2021, the Irish public health service was the target of a cyber-attack. The response by the health service resulted in the widespread removal of access to ICT systems. While services including radiology, diagnostics, maternity, and oncology were prioritised for reinstatement, recovery efforts continued for over four months. This study describes the response of health service staff to the loss of ICT systems, and the risk mitigation measures introduced to safely continue health services. The resilience displayed by frontline staff whose rapid and innovative response ensured continuity of safe patient care is explored.

METHODS

To gain an in-depth understanding of staff experiences of the cyber-attack, eight focus groups (n = 36) were conducted. Participants from a diverse range of health services were recruited, including staff from radiology, pathology/laboratories, radiotherapy, maternity, primary care dental services, health and wellbeing, COVID testing, older person's care, and disability services. Thematic Analysis was applied to the data to identify key themes.

RESULTS

The impact of the cyber-attack varied across services depending on the type of care being offered, the reliance on IT systems, and the extent of local IT support. Staff stepped-up to the challenges and quickly developed and implemented innovative solutions, exhibiting great resilience, teamwork and adaptability, with a sharp focus on ensuring patient safety. The cyber-attack resulted in a flattening of the healthcare hierarchy, with shared decision-making at local levels leading to an empowered frontline workforce. However, participants in this study felt the stress placed on staff by the attack was more severe than the cumulative effect of the COVID-19 pandemic.

CONCLUSIONS

Limited contingencies within the health system IT infrastructure - what we call a lack of system resilience - was compensated for by a resilient workforce. Within the context of the prevailing COVID-19 pandemic, this was an enormous burden on a dedicated workforce. The adverse impact of this attack may have long-term and far-reaching consequences for staff wellbeing. Design and investment in a resilient health system must be prioritised.

Post-epidemic health system recovery: A comparative case study analysis of routine immunization programs in the Republics of Haiti and Liberia

Large-scale epidemics in resource-constrained settings disrupt delivery of core health services, such as routine immunization. Rebuilding and strengthening routine immunization programs following epidemics is an essential step toward improving vaccine equity and averting future outbreaks. We performed a comparative case study analysis of routine immunization program recovery in Liberia and Haiti following the 2014-16 West Africa Ebola epidemic and 2010s cholera epidemic, respectively. First, we triangulated data between the peer-reviewed and grey literature; in-depth key informant interviews with subject matter experts; and quantitative metrics of population health and health system functioning. We used these data to construct thick descriptive narratives for each case. Finally, we performed a cross-case comparison by applying a thematic matrix based on the Essential Public Health Services framework to each case narrative. In Liberia, post-Ebola routine immunization coverage surpassed pre-epidemic levels, a feat attributable to investments in surveillance, comprehensive risk communication, robust political support for and leadership around immunization, and strong public-sector recovery planning. Recovery efforts in Haiti were fragmented across a broad range of non-governmental agencies. Limitations in funding, workforce development, and community engagement further impeded vaccine uptake. Consequently, Haiti reported significant disparities in subnational immunization coverage following the epidemic. This study suggests that embedding in-country expertise within outbreak response structures, respecting governmental autonomy, aligning post-epidemic recovery plans and policies, and integrating outbreak response assets into robust systems of primary care contribute to higher, more equitable levels of routine immunization coverage in resource-constrained settings recovering from epidemics.

Impact of COVID-19 on TB diagnostic services at primary healthcare clinics in eThekwini district, South Africa

We assessed the impact of the pandemic on TB diagnostics at primary healthcare clinics (PHCs) during the different stages of COVID-19 in eThekwini district, South Africa. Data from the District Health Information System (DHIS) were used to conduct an interrupted time series analysis that assessed the changes in TB investigations and confirmed TB cases during four pandemic periods: lockdown and the subsequent three peaks of infection compared to the two years prior (2018-2022). The initial lockdown resulted in - 45% (95% CI - 55 to - 31) and - 40% (95% CI - 59 to - 28) immediate declines in TB investigations and confirmed cases, respectively. Both indicators showed substantial recovery in the months after the first wave (p < 0.05). However, while TB investigations sustained smaller declines throughout the pandemic, they rebounded and surpassed pre-COVID-19 levels by the end of the investigation period. On the other hand, confirmed cases experienced reductions that persisted until the end of the investigation period. TB diagnostic services at PHCs were considerably disrupted by COVID-19, with the confirmation of cases being the most adversely affected throughout the pandemic. The reasons for these persistent declines in TB detection must be determined to inform the development of sustainable diagnostic systems that are capable of withstanding future pandemics.

Preparing for the next outbreak: A review of indices measuring outbreak preparedness, vulnerability, and resilience

The COVID-19 pandemic has highlighted the need for relevant metrics describing the resources and community attributes that affect the impact of communicable disease outbreaks. Such tools can help inform policy, assess change, and identify gaps to potentially reduce the negative outcomes of future outbreaks. The present review was designed to identify available indices to assess communicable disease outbreak preparedness, vulnerability, or resilience, including articles describing an index or scale developed to address disasters or emergencies which could be applied to addressing a future outbreak. This review assesses the landscape of indices available, with a particular focus on tools assessing local-level attributes. This systematic review yielded 59 unique indices applicable to assessing communicable disease outbreaks through the lens of preparedness, vulnerability, or resilience. However, despite the large number of tools identified, only 3 of these indices assessed factors at the local level and were generalizable to different types of outbreaks. Given the influence of local resources and community attributes on a wide range of communicable disease outcomes, there is a need for local-level tools that can be applied broadly to various types of outbreaks. Such tools should assess both current and long-term changes in outbreak preparedness with the intent to identify gaps, inform local-level decision makers, public policy, and future response to current and novel outbreaks.

Gearing health systems for universal health coverage

Universal health coverage requires adequate and sustainable resourcing, which includes human capital, finance and infrastructure for its realization and sustainability. Well-functioning health systems enable health service delivery and therefore need to be either adequately or optimally geared-prepared and equipped-for service delivery to advance universal health coverage. Adequately geared health systems have sufficient capacity and capability per resourcing levels whereas optimally geared health systems achieve the best possible capacity and capability per resourcing levels. Adequately or optimally geared health systems help to mitigate health system constraints, challenges and inefficiencies. Effective, efficient, equitable, robust, resilient and responsive health systems are elements for implementing and realizing universal health coverage and are embedded and aligned to a global people-centric health strategy. These elements build, enhance and sustain health systems to advance universal health coverage. Effective and efficient health systems encompass continuous improvement and high performance for providing quality healthcare. Robust and resilient health systems provide a supportive and enabling environment for health service delivery. Responsive and equitable health systems prioritize people and access to healthcare. Efforts should be made to design, construct, re-define, refine and optimize health systems that are effective, efficient, equitable, robust, resilient and responsive to deliver decent quality healthcare for all.

Resilience of primary healthcare system across low- and middle-income countries during COVID-19 pandemic: a scoping review

INTRODUCTION

Globally, the coronavirus disease 2019 (COVID-19) pandemic tested the resilience of the health system and its shock-absorbing capacity to continue offering healthcare services. The available evidences does not provide comprehensive insight into primary health care (PHC) system functioning across low- and middle- income countries (LMICs) during the pandemic. Therefore, the objective of this scoping review was to generate evidence on the resilience of PHC systems in LMICs during the COVID-19 pandemic.

METHODS

A scoping review was carried out utilizing an iterative search strategy using the National Library of Medicine (NLM) and the WHO COVID-19 electronic databases. Data from the identified studies in LMICs were charted in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist in the first step. The analysis framework was adapted and modified using COVID-19 and health systems resilience framework developed by Sagan et al., Blanchet et al., and the WHO position paper on 'Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond'. A total of 26 documents were included on the basis of predefined eligibility criteria for our analysis.

RESULTS

Our review explored data from 44 LMICs that implemented strategies at the PHC level during the COVID-19 pandemic. Most of the LMICs developed national guidelines on sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH). Most of the countries also transformed and reoriented PHC service delivery by introducing digital healthcare services to continue essential services. Task shifting, task sharing, and redeployment of retired staff were some frequently adopted health workforce strategies adopted by most of the countries. Only a few of the countries demonstrated the availability of necessary monetary resources to respond to the pandemic.

CONCLUSIONS

The functionality of the PHC system during the COVID-19 pandemic was demonstrated by a variety of resilience strategies across the six building blocks of the health system. To strengthen PHC resilience, we recommend strengthening community-based PHC, cross-sectoral collaboration, establishing surveillance systems, capacity building in financial risk planning, and investing in strengthening the digital healthcare system.

Strategies for Strengthening the Resilience of Public Health Systems for Pandemics, Disasters, and Other Emergencies

OBJECTIVE

The aim of this study was to identify and prioritize strategies for strengthening public health system resilience for pandemics, disasters, and other emergencies using a scorecard approach.

METHODS

The United Nations Public Health System Resilience Scorecard (Scorecard) was applied across 5 workshops in Slovenia, Turkey, and the United States of America. The workshops focused on participants reviewing and discussing 23 questions/indicators. A Likert type scale was used for scoring with zero being the lowest and 5 the highest. The workshop scores were analyzed and discussed by participants to prioritize areas of need and develop resilience strategies. Data from all workshops were aggregated, analyzed, and interpreted to develop priorities representative of participating locations.

RESULTS

Eight themes emerged representing the need for better integration of public health and disaster management systems. These include: assessing community disease burden; embedding long-term recovery groups in emergency systems; exploring mental health care needs; examining ecosystem risks; evaluating reserve funds; identifying what crisis communication strategies worked well; providing non-medical services; and reviewing resilience of existing facilities, alternate care sites, and institutions.

CONCLUSIONS

The Scorecard is an effective tool for establishing baseline resilience and prioritizing actions. The strategies identified reflect areas in most need for investment to improve public health system resilience.

Health system resilience: a critical review and reconceptualisation

This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neglect of equity and of who is bearing the costs of resilience strategies. Resilience depends crucially on relationships between system actors and components, and-as amply shown during the COVID-19 pandemic-relationships with wider systems (eg, economic, political, and global governance structures). Resilience is therefore connected to power imbalances, which need to be addressed to enact the transformative strategies that are important in dealing with more persistent shocks and stressors, such as climate change. We discourage the framing of resilience as an outcome that can be measured; instead, we see it emerge from systemic resources and interactions, which have effects that can be measured. We propose a more complex categorisation of shocks than the common binary one of acute versus chronic, and outline some of the implications of this for resilience strategies. We encourage a shift in thinking from capacities towards capabilities-what actors could do in future with the necessary transformative strategies, which will need to encompass global, national, and local change. Finally, we highlight lessons emerging in relation to preparing for the next crisis, particularly in clarifying roles and avoiding fragmented governance.

Health System Performance and Resilience in Times of Crisis: An Adapted Conceptual Framework

With the COVID-19 pandemic, the notion of health system (HS) performance has been discussed, and the notion of resilience has become increasingly important. Lacking a recognised framework that measures the performance of HSs throughout a crisis, i.e., one that explicitly includes time as a key aspect, we examined the literature about conceptual frameworks for measuring the performance and the resilience of HSs. This review highlighted a significant diversity among 18 distinct HS performance frameworks and 13 distinct HS resilience frameworks. On this basis, we developed a model that integrates the WHO's widely recognised six building block framework in a novel approach derived from the European Observatory on HSs and Policies. The resulting framework adapts the building blocks to the different stages of a crisis, thereby allowing for a comprehensive assessment of an entire health system's performance throughout the crisis's duration, while also considering the key aspect of resilience. For a more pragmatic use of this framework in the future, indicators will be developed as a next step.

"Africans, we know how to adapt indeed": Adaptations to family planning and reproductive health services in humanitarian settings in Nigeria during the COVID-19 pandemic

On March 30, 2020, the Government of Nigeria implemented its first COVID-19 related lockdown. We worked with two humanitarian projects in Nigeria, the Integrated Humanitarian Assistance to Northeast Nigeria (IHANN II) in Borno State and the United Nations High Commissioner for Refugees South-South Health and Nutrition Intervention (UNHCR-SS-HNIR) for Cameroon Refugees and vulnerable populations in Cross River State, to document the programmatic adaptations to Family Planning/Reproductive Health (FP/RH) services in response to COVID-19 and identify successes and challenges of those adaptations. A mixed methods approach including quantitative analysis of data from routine programmatic activities, qualitative data from in-depth interviews (IDIs) with project staff and process documentation of programmatic activities and modifications was used to 1) identify modifications in FP/RH services due to COVID-19, 2) understand staff perception of their utility and impact, and 3) gauge trends in key FP/RH in-service delivery indicators to assess changes prior to and after the March 2020 lockdown. Monitoring data shows notable declines in service utilization after lockdowns in antenatal care, postnatal care, and outreach campaigns, followed by a return to pre-lockdown levels by July 2020. Results show projects introduced numerous COVID-19 precaution strategies including: community sensitization; triage stations and modification of service flow in facilities; and appointment scheduling for essential services. Findings from IDIs speak to a well-coordinated and implemented COVID-19 response with project staff noting improvements in their time management and interpersonal communication skills. Lessons learned included the need to better sensitize and educate communities, maintain FP commodities and increase support provided to health workers. Deliberate adaptations in IHANN II and UNHCR-SS-HNIR projects turned challenges to opportunities, ensuring continuity of services to the most vulnerable populations.

The role of universal health coverage and global health security nexus and interplay on SARS-CoV-2 infection and case-fatality rates in Africa : a structural equation modeling approach

BACKGROUND

The Coronavirus Disease (COVID-19) caused by SARS-CoV-2 infections remains a significant health challenge worldwide. There is paucity of evidence on the influence of the universal health coverage (UHC) and global health security (GHS) nexus on SARS-CoV-2 infection risk and outcomes. This study aimed to investigate the effects of UHC and GHS nexus and interplay on SARS-CoV-2 infection rate and case-fatality rates (CFR) in Africa.

METHODS

The study employed descriptive methods to analyze the data drawn from multiple sources as well used structural equation modeling (SEM) with maximum likelihood estimation to model and assess the relationships between independent and dependent variables by performing path analysis.

RESULTS

In Africa, 100% and 18% of the effects of GHS on SARS-CoV-2 infection and RT-PCR CFR, respectively were direct. Increased SARS-CoV-2 CFR was associated with median age of the national population (β = -0.1244, [95% CI: -0.24, -0.01], P = 0.031 ); COVID-19 infection rate (β = -0.370, [95% CI: -0.66, -0.08], P = 0.012 ); and prevalence of obesity among adults aged 18 + years (β = 0.128, [95% CI: 0.06,0.20], P = 0.0001) were statistically significant. SARS-CoV-2 infection rates were strongly linked to median age of the national population (β = 0.118, [95% CI: 0.02,0.22 ], P = 0.024); population density per square kilometer, (β = -0.003, [95% CI: -0.0058, -0.00059], P = 0.016 ) and UHC for service coverage index (β = 0.089, [95% CI: 0.04,0.14, P = 0.001 ) in which their relationship was statistically significant.

CONCLUSIONS

The study shade a light that UHC for service coverage, and median age of the national population, population density have significant effect on COVID-19 infection rate while COVID-19 infection rate, median age of the national population and prevalence of obesity among adults aged 18 + years were associated with COVID-19 case-fatality rate. Both, UHC and GHS do not emerge to protect against COVID-19-related case fatality rate.

Pumpkin and Pumpkin Byproducts: Phytochemical Constitutes, Food Application and Health Benefits

Nowadays, agricultural waste byproducts are exploited in the food industry rather than discarded. Pumpkin is one of the most significant vegetable crops that is widely consumed in farmland and certain urban regions. The current study was designed to measure the phytochemical constituents, food application, health benefits, and toxicity of pumpkin and pumpkin byproducts. Pumpkins and pumpkin byproducts (seeds, leaf, and skin/peel) can be utilized as functional ingredients. Different parts of the pumpkin contain bioactive compounds including carotenoids, lutein, zeaxanthin, vitamin E, ascorbic acid, phytosterols, selenium, and linoleic acid. Pumpkin is used in various food sectors as a functional food, including baking, beverages, meat, and dairy industries. Furthermore, the leaves and pulp of the pumpkin are used to produce soups, purees, jams, and pies. Different parts of pumpkins have several health benefits such as antidiabetic, antioxidant, anticancer, and anti-inflammatory effects. Therefore, this review paper elaborates on the pumpkins and pumpkin byproducts that can be used to develop food products and may be valuable against various diseases.