Health system preparedness for emerging infectious diseases: A synthesis of the literature

The critical elements of the health system that could make for resilience in the World Health Organization African Region: a scoping review

Background

Unpredictable events, such as the outbreak of infectious diseases and humanitarian crises, are putting a strain on health care systems. As a result, African countries will need to prepare themselves with appropriate strategies to withstand such occurrences. Therefore, the purpose of this scoping review was to map available evidence about what type and what components of health systems are needed to help countries cope with health emergencies and to foster health system resilience in the WHO African Region.

Methods

A systematic search was performed independently in Scopus and PubMed electronic databases as well as grey literature. Studies were selected based on set eligibility criteria based on the Joanna Brigg's Institute (JBI) methodology for scoping reviews. The key findings were focused on health system resilience and were mapped based on the WHO's core health system components. Our data were tabulated, and a narrative synthesis was conducted.

Results

A total of 28 studies were included in this scoping review, mostly conducted in the WHO African Region and region of the Americas. Studies focused on a variety of strategies, such as the continuous delivery of essential services, the strengthening of the health workforce, including community health care workers, community engagement, the provision of protective mechanisms for the health workforce, and flexible leadership and governance measures.

Conclusion

Our findings suggest that strategies to improve health system resilience must include all areas of the healthcare delivery process, including primary care. A resilient health system should be ready for a crisis and have adaptable policies in place to offer adequate response at all levels, as well as post-recovery planning. Such health systems should also seek for continuous improvement. More research is needed to assess the efficacy of initiatives for improving health system resilience, particularly in vulnerable African health systems.

Harnessing technology for infectious disease response in conflict zones: Challenges, innovations, and policy implications

Epidemic outbreaks of infectious diseases in conflict zones are complex threats to public health and humanitarian activities that require creativity approaches of reducing their damage. This narrative review focuses on the technology intersection with infectious disease response in conflict zones, and complexity of healthcare infrastructure, population displacement, and security risks. This narrative review explores how conflict-related destruction is harmful towards healthcare systems and the impediments to disease surveillance and response activities. In this regards, the review also considered the contributions of technological innovations, such as the improvement of epidemiological surveillance, mobile health (mHealth) technologies, genomic sequencing, and surveillance technologies, in strengthening infectious disease management in conflict settings. Ethical issues related to data privacy, security and fairness are also covered. By advisement on policy that focuses on investment in surveillance systems, diagnostic capacity, capacity building, collaboration, and even ethical governance, stakeholders can leverage technology to enhance the response to infectious disease in conflict settings and, thus, protect the global health security. This review is full of information for researchers, policymakers, and practitioners who are dealing with the issues of infectious disease outbreaks in conflicts worn areas.

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.

The Role of Trust as a Driver of Private-Provider Participation in Disease Surveillance: Cross-Sectional Survey From Nigeria

BACKGROUND

Recognition of the importance of valid, real-time knowledge of infectious disease risk has renewed scrutiny into private providers' intentions, motives, and obstacles to comply with an Integrated Disease Surveillance Response (IDSR) framework. Appreciation of how private providers' attitudes shape their tuberculosis (TB) notification behaviors can yield lessons for the surveillance of emerging pathogens, antibiotic stewardship, and other crucial public health functions. Reciprocal trust among actors and institutions is an understudied part of the "software" of surveillance.

OBJECTIVE

We aimed to assess the self-reported knowledge, motivation, barriers, and TB case notification behavior of private health care providers to public health authorities in Lagos, Nigeria. We measured the concordance between self-reported notification, TB cases found in facility records, and actual notifications received.

METHODS

A representative, stratified sample of 278 private health care workers was surveyed on TB notification attitudes, behavior, and perceptions of public health authorities using validated scales. Record reviews were conducted to identify the TB treatment provided and facility case counts were abstracted from the records. Self-reports were triangulated against actual notification behavior for 2016. The complex health system framework was used to identify potential predictors of notification behavior.

RESULTS

Noncompliance with the legal obligations to notify infectious diseases was not attributable to a lack of knowledge. Private providers who were uncomfortable notifying TB cases via the IDSR system scored lower on the perceived benevolence subscale of trust. Health care workers who affirmed "always" notifying via IDSR monthly reported higher median trust in the state's public disease control capacity. Although self-reported notification behavior was predicted by age, gender, and positive interaction with public health bodies, the self-report numbers did not tally with actual TB notifications.

CONCLUSIONS

Providers perceived both risks and benefits to recording and reporting TB cases. To improve private providers' public health behaviors, policy makers need to transcend instrumental and transactional approaches to surveillance to include building trust in public health, simplifying the task, and enhancing the link to improved health. Renewed attention to the "software" of health systems (eg, norms, values, and relationships) is vital to address pandemic threats. Surveys with private providers may overestimate their actual participation in public health surveillance.

Twenty-first-century demographic and social inequalities of heat-related deaths in Brazilian urban areas

Population exposure to heat waves (HWs) is increasing worldwide due to climate change, significantly affecting society, including public health. Despite its significant vulnerabilities and limited adaptation resources to rising temperatures, South America, particularly Brazil, lacks research on the health impacts of temperature extremes, especially on the role played by socioeconomic factors in the risk of heat-related illness. Here, we present a comprehensive analysis of the effects of HWs on mortality rates in the 14 most populous urban areas, comprising approximately 35% of the country's population. Excess mortality during HWs was estimated through the observed-to-expected ratio (O/E) for total deaths during the events identified. Moreover, the interplay of intersectionality and vulnerability to heat considering demographics and socioeconomic heterogeneities, using gender, age, race, and educational level as proxies, as well as the leading causes of heat-related excess death, were assessed. A significant increase in the frequency was observed from the 1970s (0-3 HWs year-1) to the 2010s (3-11 HWs year-1), with higher tendencies in the northern, northeastern, and central-western regions. Over the 2000-2018 period, 48,075 (40,448-55,279) excessive deaths were attributed to the growing number of HWs (>20 times the number of landslides-related deaths for the same period). Nevertheless, our event-based surveillance analysis did not detect the HW-mortality nexus, reinforcing that extreme heat events are a neglected disaster in Brazil. Among the leading causes of death, diseases of the circulatory and respiratory systems and neoplasms were the most frequent. Critical regional differences were observed, which can be linked to the sharp North-South inequalities in terms of socioeconomic and health indicators, such as life expectancy. Higher heat-related excess mortality was observed for low-educational level people, blacks and browns, older adults, and females. Such findings highlight that the strengthening of primary health care combined with reducing socioeconomic, racial, and gender inequalities represents a crucial step to reducing heat-related deaths.

Assessing healthcare capacity crisis preparedness: development of an evaluation tool by a Canadian health authority

Introduction

The COVID-19 pandemic presented health systems across the globe with unparalleled socio-political, ethical, scientific, and economic challenges. Despite the necessity for a unified, innovative, and effective response, many jurisdictions were unprepared to such a profound health crisis. This study aims to outline the creation of an evaluative tool designed to measure and evaluate the Vitalité Health Network's (New Brunswick, Canada) ability to manage health crises.

Methods

The methodology of this work was carried out in four stages: (1) construction of an evaluative framework; (2) validation of the framework; (3) construction of the evaluative tool for the Health Authority; and (4) evaluation of the capacity to manage a health crisis.

Results

The resulting evaluative tool incorporated 8 dimensions, 74 strategies, and 109 observable elements. The dimensions included: (1) clinical care management; (2) infection prevention and control; (3) governance and leadership; (4) human and logistic resources; (5) communication and technologies; (6) health research; (7) ethics and values; and (8) training. A Canadian Health Authority implemented the tool to support its future preparedness.

Conclusion

This study introduces a methodological strategy adopted by a Canadian health authority to evaluate its capacity in managing health crises. Notably, this study marks the first instance where a Canadian health authority has created a tool for emergency healthcare management, informed by literature in the field and their direct experience from handling the SARS-CoV-2 pandemic.

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.

Health system to response to economic sanctions: global evidence and lesson learned from Iran

BACKGROUND

Sanctions have direct and indirect impacts on people's lives. Therefore, the health systems of countries targeted by sanctions must respond effectively. This study proposes a set of mitigating measures and response strategies to improve the health systems of countries under sanctions.

METHODS

This three-stage study was conducted in Iran within the 2020-2021 period, in which a rapid review of evidence was carried out to identify the measures implemented or proposed to make the health system resilient in confronting sanctions. A qualitative approach was then adopted to determine how the health system could be improved to response to sanctions from the perspectives of 10 key experts. Semi-structured interviews and document analysis were conducted for data collection. Finally, a two-round Delphi technique was employed to help eleven experts reach a consensus on a set of mitigating measures, which were then prioritized.

RESULTS

In this research, 62 proposed or implemented mitigating measures were extracted from 13 eligible studies to improve the health system performance in confronting sanctions. Moreover, 18 measures were identified in interviews for a better health system response to sanctions. They were then classified as five categories: sustained financing, good governance, integrated and updated health information systems, qualified workforce, and efficient and equitable service delivery. In the first Delphi round, 28 mitigating measures were discovered. Nine measures were identified as more effective and feasible in both short and long runs. They were introduced as below: conducting proactive inventory control, developing the nationally essential list of medicines, providing additional clarification that oil revenues can be freely used for medicines procurement, defining tailored health service packages for vulnerable populations, establishing and enhancing an efficient surveillance system, reducing prices of imported medicines, developing dual policies of equity and priority for vulnerable groups, institutionalizing fair and effective resource allocations, and providing clinical guidelines.

CONCLUSIONS

According to the findings, the most critical areas for the resilience of a health system in confronting sanctions include strengthening particular components of governance, improving efficiency, and caring for vulnerable populations. The experts collectively emphasized investment in domestic capacities, public participation, and health diplomacy. Despite the proposed measures, it is unclear how effective these are and, especially whether they can significantly affect the harsh impacts of sanctions on health. Moreover, intensive and long-term sanctions have significant irreversible outcomes that cannot be reversed easily or quickly.

Lessons from the frontline: Leadership and governance experiences in the COVID-19 pandemic response across the Pacific region

Background

Universal access to safe, effective emergency care (EC) during the COVID-19 pandemic has illustrated its centrality to healthcare systems. The 'Leadership and Governance' building block provides policy, accountability and stewardship to health systems, and is essential to determining effectiveness of pandemic response. This study aimed to explore the experience of leadership and governance during the COVID-19 pandemic from frontline clinicians and stakeholders across the Pacific region.

Methods

Australian and Pacific researchers collaborated to conduct this large, qualitative research project in three phases between March 2020 and July 2021. Data was gathered from 116 Pacific regional participants through online support forums, in-depth interviews and focus groups. A phenomenological approach shaped inductive and deductive data analysis, within a previously identified Pacific EC systems building block framework.

Findings

Politics profoundly influenced pandemic response effectiveness, even at the clinical coalface. Experienced clinicians spoke authoritatively to decision-makers; focusing on safety, quality and service duty. Rapid adaptability, past surge event experience, team-focus and systems-thinking enabled EC leadership. Transparent communication, collaboration, mutual respect and trust created unity between frontline clinicians and 'top-level' administrators. Pacific cultural assets of relationship-building and community cohesion strengthened responses.

Interpretation

Effective governance occurs when political, administrative and clinical actors work collaboratively in relationships characterised by trust, transparency, altruism and evidence. Trained, supported EC leadership will enhance frontline service provision, health security preparedness and future Universal Health Coverage goals.

Funding

Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Lessons from the frontline: The value of emergency care processes and data to pandemic responses across the Pacific region

Background

Emergency care (EC) addresses the needs of patients with acute illness and injury, and has fulfilled a critical function during the COVID-19 pandemic. 'Processes' (e.g. triage) and 'data' (e.g. surveillance) have been nominated as essential building blocks for EC systems. This qualitative research sought to explore the impact of the pandemic on EC clinicians across the Pacific region, including the contribution of EC building blocks to effective responses.

Methods

The study was conducted in three phases, with data obtained from online support forums, key informant interviews and focus group discussions. There were 116 participants from more than 14 Pacific Island Countries and Territories. A phenomenological approach was adopted, incorporating inductive and deductive methods. The deductive thematic analysis utilised previously identified building blocks for Pacific EC. This paper summarises findings for the building blocks of 'processes' and 'data'.

Findings

Establishing triage and screening capacity, aimed at assessing urgency and transmission risk respectively, were priorities for EC clinicians. Enablers included support from senior hospital leaders, previous disaster experience and consistent guidelines. The introduction of efficient patient flow processes, such as streaming, proved valuable to emergency departments, and checklists and simulation were useful implementation strategies. Some response measures impacted negatively on non-COVID patients, and proactive approaches were required to maintain 'business as usual'. The pandemic also highlighted the value of surveillance and performance data.

Interpretation

Developing effective processes for triage, screening and streaming, among other areas, was critical to an effective EC response. Beyond the pandemic, strengthening processes and data management capacity will build resilience in EC systems.

Funding

Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Mapping the Swiss Vaccine Supply Chain

Objectives

The design of the supply chain determines how effectively any vaccination campaign can be operated. This case study of Switzerland's vaccine supply chain compares its design with public health objectives. It maps the vaccine supply chain in Switzerland as it was set up to handle the first shipments of Covid-19 vaccine in 2021 to enable a more holistic view of supply and demand flows. Recommendations are made to improve emergency logistics of vaccines in the future.

Methods

Twenty-six semi-structured interviews with international and Swiss stake-holders were coded and analyzed to arrive at a description of planning and distribution processes. The vaccine supply chain network structure was mapped, linking upstream and downstream flows of material and information. The visualization of nodes and flows was combined with spatial information, including population data. The results are summarized in narrative form to support decision-makers across disciplines.

Results

Despite adequate vaccine supply, abundant local endowments and high investment in infrastructure, the 2021 design of Switzerland's vaccine supply chain reduced the potential reach of target populations. The segmentation of catchment populations, collaboration between administrative units and better use of information on geolocation and material flows could have improved the speed and reach of vaccinations during the emergency response phase. Three recommendations are made for supply chain structures to support higher vaccination rates in the future.

Conclusions

The visualization identifies design alternatives which could have improved vaccination rates under the prevailing conditions. A supply chain map provides public health officials with a shared view of the vaccine supply chain in order to better match supply with demand. The case study contributes to developed country studies. In order to improve public health outcomes in Switzerland, investments to secure supply, strong national endowments, and excellent infrastructure must be combined with optimized supply chain design.

Evaluating the governance and preparedness of the Lebanese health system for the COVID-19 pandemic: a qualitative study

OBJECTIVES

This study aimed to assess the capacities and governance of Lebanon's health system throughout the response to the COVID-19 pandemic until August 2020.

DESIGN

A qualitative study based on semi-structured interviews.

SETTING

Lebanon, February-August 2020.

PARTICIPANTS

Selected participants were directly or indirectly involved in the national or organisational response to the COVID-19 pandemic in Lebanon.

RESULTS

A total of 41 participants were included in the study. 'Hardware' capacities of the system were found to be responsive yet deeply influenced by the challenging national context. The health workforce showed high levels of resilience, despite the shortage of medical staff and gaps in training at the early stages of the pandemic. The system infrastructure, medical supplies and testing capacities were sufficient, but the reluctance of the private sector in care provision and gaps in reimbursement of COVID-19 care by many health funding schemes were the main concerns. Moreover, the public health surveillance system was overwhelmed a few months after the start of the pandemic. As for the system 'software', there were attempts for a participatory governance mechanism, but the actual decision-making process was challenging with limited cooperation and strategic vision, resulting in decreased trust and increased confusion among communities. Moreover, the power imbalance between health actors and other stakeholders affected decision-making dynamics and the uptake of scientific evidence in policy-making.

CONCLUSIONS

Interventions adopting a centralised and reactive approach were prominent in Lebanon's response to the COVID-19 pandemic. Better public governance and different reforms are needed to strengthen the health system preparedness and capacities to face future health security threats.

Taking Systems Thinking to the Global Level: Using the WHO Building Blocks to Describe and Appraise the Global Health System in Relation to COVID-19

Adequately preparing for and containing global shocks, such as COVID-19, is a key challenge facing health systems globally. COVID-19 highlights that health systems are multilevel systems, a continuum from local to global. Goals and monitoring indicators have been key to strengthening national health systems but are missing at the supranational level. A framework to strengthen the global system-the global health actors and the governance, finance, and delivery arrangements within which they operate-is urgently needed. In this article, we illustrate how the World Health Organization Building Blocks framework, which has been used to monitor the performance of national health systems, can be applied to describe and appraise the global health system and its response to COVID-19, and identify potential reforms. Key weaknesses in the global response included: fragmented and voluntary financing; non-transparent pricing of medicines and supplies, poor quality standards, and inequities in procurement and distribution; and weak leadership and governance. We also identify positive achievements and identify potential reforms of the global health system for greater resilience to future shocks. We discuss the limitations of the Building Blocks framework and future research directions and reflect on political economy challenges to reform.

COVID-19 frontline primary health care professionals' perspectives on health system preparedness and response to the pandemic in the Mahalapye Health District, Botswana

Background

The World Health Organization issued interim guidelines on essential health system preparedness and response measures for the coronavirus disease 2019 (COVID-19) pandemic. The control of the pandemic requires healthcare system preparedness and response.

Aim

This study aimed to evaluate frontline COVID-19 primary health care professionals’ (PHC-Ps) views on health system preparedness and response to the pandemic in the Mahalapye Health District (MHD).

Setting

In March 2020, the Botswana Ministry of Health directed health districts to educate their health professionals about COVID-19. One hundred and seventy frontline PHC-Ps were trained in MHD; they evaluated the health system’s preparedness and response.

Methods

This was a cross-sectional study that involved a self-administered questionnaire using the Integrated Disease Surveillance and Health System response guidelines.

Results

The majority (72.5%) of participants felt unprepared to deal with the COVID-19 pandemic at their level. Most of the participants (70.7%) acknowledged that the health system response plan has been followed. About half of the participants attributed a low score regarding the health system’s preparedness (44.4%), its response (50.0%), and its overall performance (55.6%) to the COVID-19 pandemic. There was an association between participants’ age and work experience and their overall perceptions of preparedness and response (p = 0.009 and p = 0.005, respectively).

Conclusion

More than half of the participants gave a low score to the MHD regarding the health system’s preparedness and response to the COVID-19 pandemic. Further studies are required to determine the causes of such attitudes and to be better prepared to respond effectively.

Fragility and challenges of health systems in pandemic: lessons from India's second wave of coronavirus disease 2019 (COVID-19)

The unprecedented healthcare demand due to sudden outbreak of coronavirus disease 2019 (COVID-19) pandemic has almost collapsed the health care systems especially in the developing world. Given the disastrous outbreak of COVID-19 second wave in India, the health system of country was virtually at the brink of collapse. Therefore, to identify the factors that resulted into breakdown and the challenges, Indian healthcare system faced during the second wave of COVID-19 pandemic, this paper analysed the health system challenges in India and the way forward in accordance with the six building blocks of world health organization (WHO). Applying integrated review approach, we found that the factors such as poor infrastructure, inadequate financing, lack of transparency and poor healthcare management resulted into the overstretching of healthcare system in India. Although health system in India faced these challenges from the very beginning, but early lessons from first wave should have been capitalized to avert the much deeper crisis in the second wave of the pandemic. To sum-up given the likely future challenges of pandemic, while healthcare should be prioritized with adequate financing, strong capacity-building measures and integration of public and private sectors in India. Likewise fiscal stimulus, risk assessment, data availability and building of human resources chain are other key factors to be strengthened for mitigating the future healthcare crisis in country.

Health and immigration systems as an ethnographic field: Methodological lessons from examining immigration enforcement and health in the US

The complexity of health systems and their social, political, and economic contexts has resulted in a call for multidisciplinary research that can appropriately examine the relationships and interactions surrounding health systems. Anthropologists, who have a disciplinary training that emphasizes social structures and human relationships, are well-suited to conduct health systems research. However, there remains a gap in anthropologically-ground methodological approaches for conducting in-depth, qualitative research that simultaneously conceptualizes and maps out a health system and examines connections between health systems and other social structures, such as immigration enforcement systems. Without such methodological approaches, limitations in examining a health system and its constituent elements will persist, and health and social scientists will miss opportunities to identify links between different factors in a health system and outside the system itself. In this article, I use ethnographic research examining the health-related consequences of immigration enforcement laws and police practices in the United States to show how to examine relationships between multiple social systems. In doing so, I provide an example for how to conduct in-depth, qualitative health systems research by merging theoretical frameworks in health sciences and anthropology to demonstrate how medical anthropologists can conceptualize a health system as a social field for ethnographic inquiry. Overall, I argue that such an approach permits anthropologists a way to conduct rigorous health systems research that emphasizes relationships and reveals potentially hidden interactions.

The COVID-19 pandemic in francophone West Africa: from the first cases to responses in seven countries

Background

In early March 2020, the COVID-19 pandemic hit West Africa. In response, countries in the region quickly set up crisis management committees and implemented drastic measures to stem the spread of the SARS-CoV-2 virus. The objective of this article is to analyse the epidemiological evolution of COVID-19 in seven Francophone West African countries (Benin, Burkina Faso, Côte d’Ivoire, Guinea, Mali, Niger, Senegal) as well as the public health measures decided upon during the first 7 months of the pandemic.

Methods

Our method is based on quantitative and qualitative data from the pooling of information from a COVID-19 data platform and collected by a network of interdisciplinary collaborators present in the seven countries. Descriptive and spatial analyses of quantitative epidemiological data, as well as content analyses of qualitative data on public measures and management committees were performed.

Results

Attack rates (October 2020) for COVID-19 have ranged from 20 per 100,000 inhabitants (Benin) to more than 94 per 100,000 inhabitants (Senegal). All these countries reacted quickly to the crisis, in some cases before the first reported infection, and implemented public measures in a relatively homogeneous manner. None of the countries implemented country-wide lockdowns, but some implemented partial or local containment measures. At the end of June 2020, countries began to lift certain restrictive measures, sometimes under pressure from the general population or from certain economic sectors.

Conclusion

Much research on COVID-19 remains to be conducted in West Africa to better understand the dynamics of the pandemic, and to further examine the state responses to ensure their appropriateness and adaptation to the national contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11529-7.

Policy innovation and emergence of innovative health technology: The system dynamics modelling of early COVID-19 handling in Indonesia

This article examines policy innovation, emergence of innovative health technology and its implication for a health system. The complexity of policy innovation implementation resulting from mixing public health resolution and economic interest will trigger the emergence of innovative health technology, which implies a health system improvement. The findings revealed that: First, policy innovation based on a science-mix category created the complexity of policy enforcement, affected the scale and speed of COVID-19 transmissions, and triggered the emergence of health innovative technology. Second, despite policy innovation in early COVID-19, handling was relatively less successful due to restricting factors in policy implementation but provided a new market for the emergence of innovative health technology. Third, the emergence of innovative health technology has strengthened health system preparedness during the pandemic, and provide an opportunity to re-examine the strengths and deficiencies of an entire health system for better health care.

Responsibility, repair and care in Sierra Leone's health system

Central to the workings of a hospital are the technical and bureaucratic systems that ensure the effective coordination of information and biological materials of patients across time and space. In this paper, which is based on ethnographic research in a public referral hospital in Freetown, Sierra Leone, conducted between October 2018 and September 2019, we adopt a patient pathway approach to examine moments of breakdown and repair in the coordination of patient care. Through the in-depth analysis of a single patient pathway through the hospital, we show how coordination work depends on frequent small acts of intervention and improvisation by multiple people across the pathway, including doctors, managers, nurses, patients and their relatives. We argue that such interventions depend on the individualisation of responsibility for 'making the system work' and are best conceptualised as acts of temporary repair and care for the health system itself. Examining how responsibility for the repair of the system is distributed and valued, both within the hospital and in terms of broader structures of health funding and policy, we argue, is essential to developing more sustainable systems for repair.

First recourse for care-seeking and associated factors among rural populations in the eastern Democratic Republic of the Congo

BACKGROUND

Access to quality healthcare is a global fundamental human right. However, in the Democratic Republic of the Congo, several parameters affect the choices of health service users in fragile, rural contexts (zones). The overarching aim of this study was to identify the first recourse of healthcare-seeking and the determinants of utilization of health centers (primary health care structures) in the rural health zones of Katana and Walungu.

METHODS

A cross-sectional survey was conducted from June to September 2017. Consenting respondents comprised 1751 adults. Continuous data were summarized using means (standard deviation) and medians (interquartile range). We used Pearson's chi-square test and Fisher exact test to compare proportions. Logistic regression was run to assess socio-determinants of health center utilization.

RESULTS

The morbidity rate of the sample population for the previous month was 86.4% (n = 1501) of which 60% used health centers for their last morbid episode and 20% did not. 5.3% of the respondents patronized prayer rooms and 7.9% resorted to self-medication principally because the cost was low, or the services were fast. Being female (OR: 1.51; p = 0.005) and a higher level of education (OR: 1.79; p = 0.032) were determinants of the use of health centers in Walungu. Only the level of education was associated with the use of health centers in Katana (OR: 2.78; p = 0.045).

CONCLUSION

Our findings suggest that health centers are the first recourse for the majority of the population during an illness. However, a significant percentage of patients are still using traditional healers or prayer rooms because the cost is low. Our results suggest that future interventions to encourage integrated health service use should target those with lower levels of education.

Media and Digital Technologies for Mixed Methods Research in Public Health Emergencies Such as COVID-19: Lessons Learned From Using Interactive Radio-SMS for Social Research in Somalia

Radio shows which invite audience participation via short message service (SMS)-interactive radio-SMS-can be designed as a mixed methods approach for applied social research during COVID-19 and other crises in low and middle income countries. In the aftermath of a cholera outbreak in Somalia, we illustrate how this method provides social insights that would have been missed if a purely qualitative or quantitative approach were used. We then examine the strengths and limitations associated with interactive radio-SMS through an evaluation using a multimethod comparison. Our research contributes an application of a mixed methods approach which addresses a specific challenge raised by COVID-19, namely utilizing media and digital technologies for social research in low and middle income countries.

Barriers to maternal health services during the Ebola outbreak in three West African countries: a literature review

Introduction

The Ebola virus disease (EVD) outbreak in West Africa, affecting Guinea, Liberia and Sierra Leone from 2014 to 2016, was a substantial public health crisis with health impacts extending past EVD itself. Access to maternal health services (MHS) was disrupted during the epidemic, with reductions in antenatal care, facility-based deliveries and postnatal care. We aimed to identify and describe barriers related to the uptake and provision of MHS during the 2014–2016 EVD outbreak in West Africa.

Methods

In June 2020, we conducted a scoping review of peer-reviewed publications and grey literature from relevant stakeholder organisations. Search terms were generated to identify literature that explained underlying access barriers to MHS. Published literature in scientific journals was first searched and extracted from PubMed and Web of Science databases for the period between 1 January 2014 and 27 June 2020. We hand-searched relevant stakeholder websites. A ‘snowball’ approach was used to identify relevant sources uncaptured in the systematic search. The identified literature was examined to synthesise themes using an existing framework.

Results

Nineteen papers were included, with 26 barriers to MHS uptake and provision identified. Three themes emerged: (1) fear and mistrust, (2) health system and service constraints, and (3) poor communication. Our analysis of the literature indicates that fear, experienced by both service users and providers, was the most recurring barrier to MHS. Constrained health systems negatively impacted MHS on the supply side. Poor communication and inadequately coordinated training efforts disallowed competent provision of MHS.

Conclusions

Barriers to accessing MHS during the EVD outbreak in West Africa were influenced by complex but inter-related factors at the individual, interpersonal, health system and international level. Future responses to EVD outbreaks need to address underlying reasons for fear and mistrust between patients and providers, and ensure MHS are adequately equipped both routinely and during crises.

How Can Health Systems Better Prepare for the Next Pandemic? Lessons Learned From the Management of COVID-19 in Quebec (Canada)

The magnitude of the COVID-19 pandemic challenged societies around our globalized world. To contain the spread of the virus, unprecedented and drastic measures and policies were put in place by governments to manage an exceptional health care situation while maintaining other essential services. The responses of many governments showed a lack of preparedness to face this systemic and global health crisis. Drawing on field observations and available data on the first wave of the pandemic (mid-March to mid-May 2020) in Quebec (Canada), this article reviewed and discussed the successes and failures that characterized the management of COVID-19 in this province. Using the framework of Palagyi et al. on system preparedness toward emerging infectious diseases, we described and analyzed in a chronologically and narratively way: (1) how surveillance was structured; (2) how workforce issues were managed; (3) what infrastructures and medical supplies were made available; (4) what communication mechanisms were put in place; (5) what form of governance emerged; and (6) whether trust was established and maintained throughout the crisis. Our findings and observations stress that resilience and ability to adequately respond to a systemic and global crisis depend upon preexisting system-level characteristics and capacities at both the provincial and federal governance levels. By providing recommendations for policy and practice from a learning health system perspective, this paper contributes to the groundwork required for interdisciplinary research and genuine policy discussions to help health systems better prepare for future pandemics.

A qualitative study of governance predicament on dengue prevention and control in Malaysia: the elite experience

Background

The challenges faced by healthcare personnel in relation to dengue prevention and control are perennial but noticeably unexplored. It is often difficult to translate policies and decision making by the elite into astute management in consonance with the needs of rank-and-file personnel. In this study, we assess the impact of governance on dengue prevention and control activities in Malaysia as narrated by the elite.

Methods

A qualitative study using a case-study approach was conducted between January 2019 and November 2019 in the districts of Gombak and Klang, where the relevant key informants were located. Nineteen interviews were conducted among elite healthcare personnel from different divisions: management, vector, laboratory, inspectorate, health promotion and entomology. Semi-structured interviews were conducted. The sample size was determined through saturation point criteria. Purposive sampling techniques were used to recruit the participants. The interviews were audio recorded, and the transcribed text was analysed with deductive thematic analysis.

Results

Data analysis led to the development of 5 themes and 13 categories. The major principles of governance were embodied in a milieu of predicament, linked to constraints but also opportunities. The constraints resulted from inherent determinants of dengue outbreaks, the serviceability of governing policies and the macro-economics of budget allocation. The opportunities to sustain governance at the local operating level stem from a prevalent supportive internal management system, collaborative efforts among corresponding external government agencies and willingness to innovate and embrace novel technology.

Conclusion

Elites are influential, often well-informed personnel tasked with making decisions that can reverberate across an organisation, impacting future plans and strategic policies. Political arrangements at higher levels will reflect in advance the tone of how governance in dengue prevention and control is operationalised by entities and individuals at lower levels of the health system. The prevailing centralised structure in the Malaysian health system will continue to entrench the position of the elite and intertwine it with governance and its predicaments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10917-3.

Human security as biosecurity Reconceptualizing national security threats in the time of COVID-19

Research within security studies has struggled to determine whether infectious disease (ID) represents an existential threat to national and international security. With the emergence of SARS-CoV-2 (COVID-19), it is imperative to reexamine the relationship between ID and global security. This article addresses the specific threat to security from COVID-19, asking, "Is COVID-19 a threat to national and international security?" To investigate this question, this article uses two theoretical approaches: human security and biosecurity. It argues that COVID-19 is a threat to global security by the ontological crisis posed to individuals through human security theory and through high politics, as evidenced by biosecurity. By viewing security threats through the lens of the individual and the state, it becomes clear that ID should be considered an international security threat. This article examines the relevant literature and applies the theoretical framework to a case study analysis focused on the United States.

Nurses at the frontline of public health emergency preparedness and response: lessons learned from the HIV/AIDS pandemic and emerging infectious disease outbreaks

The years 2020–21, designated by WHO as the International Year of the Nurse and Midwife, are characterised by unprecedented global efforts to contain and mitigate the COVID-19 pandemic. Lessons learned from successful pandemic response efforts in the past and present have implications for future efforts to leverage the global health-care workforce in response to outbreaks of emerging infectious diseases such as COVID-19. Given its scale, reach, and effectiveness, the response to the HIV/AIDS pandemic provides one such valuable example, particularly with respect to the pivotal, although largely overlooked, contributions of nurses and midwives. This Personal View argues that impressive achievements in the global fight against HIV/AIDS would not have been attained without the contributions of nurses. We discuss how these contributions uniquely position nurses to improve the scale, reach, and effectiveness of response efforts to emerging infectious diseases with pandemic potential; provide examples from the responses to COVID-19, Zika virus disease, and Ebola virus disease; and discuss implications for current and future efforts to strengthen pandemic preparedness and response.

What Is the Preparedness and Capacity of Palliative Care Services in Middle-Eastern and North African Countries to Respond to COVID-19? A Rapid Survey

CONTEXT

Evidence from prior public health emergencies demonstrates palliative care's importance to manage symptoms, make advance care plans, and improve end-of-life outcomes.

OBJECTIVE

To evaluate the preparedness and capacity of palliative care services in the Middle-East and North Africa region to respond to the COVID-19 pandemic.

METHODS

A cross-sectional online survey was undertaken, with items addressing the WHO International Health Regulations. Nonprobabilistic sampling was used, and descriptive analyses were conducted.

RESULTS

Responses from 43 services in 12 countries were analyzed. Half of respondents were doctors (53%), and services were predominantly hospital based (84%). All but one services had modified at least one procedure to respond to COVID-19. Do Not Resuscitate policies were modified by a third (30%) and unavailable for a fifth (23%). While handwashing facilities at points of entry were available (98%), a third had concerns over accessing disinfectant products (37%), soap (35%), or running water (33%). The majority had capacity to use technology to provide remote care (86%) and contact lists of patients and staff (93%), though only two-fifths had relatives' details (37%). Respondents reported high staff anxiety about becoming infected themselves (median score 8 on 1-10 scale), but only half of services had a stress management procedure (53%). Three-fifths had plans to support triaging COVID-19 patients (60%) and protocols to share (58%).

CONCLUSION

Participating services have prepared to respond to COVID-19, but their capacity to respond may be limited by lack of staff support and resources. We propose recommendations to improve service preparedness and relieve unnecessary suffering.

Preparedness of African Palliative Care Services to Respond to the COVID-19 Pandemic: A Rapid Assessment

CONTEXT

Palliative care is an essential component of the coronavirus disease 2019 (COVID-19) pandemic response but is overlooked in national and international preparedness plans. The preparedness and capacity of African palliative care services to respond to COVID-19 is unknown.

OBJECTIVES

To evaluate the preparedness and capacity of African palliative care services to respond to the COVID-19 pandemic.

METHODS

We developed, piloted, and conducted a cross-sectional online survey guided by the 2005 International Health Regulations. It was electronically mailed to the 166 African Palliative Care Association's members and partners. Descriptive analyses were conducted.

RESULTS

About 83 participants from 21 countries completed the survey. Most services had at least one procedure for the case management of COVID-19 or another infectious disease (63%). Respondents reported concerns over accessing running water, soap, and disinfectant products (43%, 42%, and 59%, respectively) and security concerns for themselves or their staff (52%). Two in five services (41%) did not have any or make available additional personal protective equipment. Most services (80%) reported having the capacity to use technology instead of face-to-face appointment, and half (52%) reported having palliative care protocols for symptom management and psychological support that could be shared with nonspecialist staff in other health care settings.

CONCLUSION

Our survey suggests that African palliative care services could support the wider health system's response to the COVID-19 pandemic with greater resources such as basic infection control materials. It identified specific and systemic weaknesses impeding their preparedness to respond to outbreaks. The findings call for urgent measures to ensure staff and patient safety.

Factors influencing the performance of community health workers: A qualitative study of Anganwadi Workers from Bihar, India

Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.

A Systematic Narrative Review of Comprehensive Preparedness Strategies of Healthcare Resources for a Large Resurgence of COVID-19 Nationally, with Local or Regional Epidemics: Present Era and Beyond

Coronavirus disease 2019 (COVID-19) has penetrated our daily lives, leading us to a new normal era. The unexpected impact of COVID-19 has posed a unique challenge for the health care system, bringing innovation around the world. Considering the current pandemic pattern, comprehensive preparedness strategies of healthcare resources need to be implemented to prepare for a large resurgence of COVID-19 within a short time. With the unprecedented spread of the new pandemic and the impending influenza season, scientific evidence-based schemes need to be developed through cooperation, coordination, and solidarity. Based on the early experience with the current pandemic, this narrative interpretive review of qualitative studies suggests a 6-domain plan to establish a better health care system that is prepared to deal with the current and future public health crises. The 6 domains are medical institutions, medical workforce, medical equipment, COVID-19 surveillance, data and information application, and governance structure.

Gauging Cameroon’s resilience to the COVID-19 pandemic: implications for enduring a novel health crisis

Purpose

This paper aims to examine Cameroon’s health service resilience in the first five months (March–July 2020) of the coronavirus (COVID-19) outbreak. The motive is to diagnose sub-optimal performance in sustaining health-care services during the pandemic to identify areas for improvement and draw lessons for the future.

Design/methodology/approach

This is principally qualitative, exploratory, analytical and descriptive research that involves the collation of empirical, primary and secondary data. A conceptual framework [health systems resilience for emerging infectious diseases (HSREID)] provides structure to the study and an anchor for interpreting the findings. The research validity has been established by analysing the aims/objectives from multiple perspectives in the research tradition of triangulation.

Findings

Cameroon has exerted much effort to combat the COVID-19 pandemic. Yet, several constraints and gaps exist. The findings reveal limitations in Cameroon’s response to the COVID-19 pandemic in the provision of fundamental health-care services under contextual themes of health infrastructure/medical supplies, human capital, communication/sensitisation/health education, governance and trust/confidence. Analysis of the identified impediments demonstrates that Cameroon’s health-care system is not resilient enough to cope with the COVID-19 pandemic and provides several insights for an enhanced response as the pandemic accelerates in the country.

Originality/value

This is one of the first scholarly articles to examine how Cameroon’s health-care system is faring in COVID-19 combat. Underscored by the novel HSREID model, this study provides initial insights into Cameroon’s resilience to COVID-19 with a view to enhancing the health system’s response as the pandemic unfolds and strengthens readiness for subsequent health crises.

Country-level factors associated with the early spread of COVID-19 cases at 5, 10 and 15 days since the onset

The COVID-19 pandemic is causing a significant global health crisis. As the disease continues to spread worldwide, little is known about the country-level factors affecting the transmission in the early weeks. The present study objective was to explore the country-level factors, including government actions that explain the variation in the cumulative cases of COVID-19 within the first 15 days since the first case reported. Using publicly available sources, country socioeconomic, demographic and health-related risk factors, together with government measures to contain COVID-19 spread, were analysed as predictors of the cumulative number of COVID-19 cases at three time points (t = 5, 10 and 15) since the first case reported (n = 134 countries). Drawing on negative binomial multivariate regression models, HDI, healthcare expenditure and resources, and the variation in the measures taken by the governments, significantly predicted the incidence risk ratios of COVID-19 cases at the three time points. The estimates were robust to different modelling techniques and specifications. Although wealthier countries have elevated human development and healthcare capacity in respect to their counterparts (low- and middle-income countries) the early implementation of effective and incremental measures taken by the governments are crucial to controlling the spread of COVID-19 in the early weeks.

Protocol: Leveraging a demographic and health surveillance system for Covid-19 Surveillance in rural KwaZulu-Natal

A coordinated system of disease surveillance will be critical to effectively control the coronavirus disease 2019 (Covid-19) pandemic. Such systems enable rapid detection and mapping of epidemics and inform allocation of scarce prevention and intervention resources. Although many lower- and middle-income settings lack infrastructure for optimal disease surveillance, health and demographic surveillance systems (HDSS) provide a unique opportunity for epidemic monitoring. This protocol describes a surveillance program at the Africa Health Research Institute's Population Intervention Platform site in northern KwaZulu-Natal. The program leverages a longstanding HDSS in a rural, resource-limited setting with very high prevalence of HIV and tuberculosis to perform Covid-19 surveillance. Our primary aims include: describing the epidemiology of the Covid-19 epidemic in rural KwaZulu-Natal; determining the impact of the Covid-19 outbreak and non-pharmaceutical control interventions (NPI) on behaviour and wellbeing; determining the impact of HIV and tuberculosis on Covid-19 susceptibility; and using collected data to support the local public-sector health response. The program involves telephone-based interviews with over 20,000 households every four months, plus a sub-study calling 750 households every two weeks. Each call asks a household representative how the epidemic and NPI are affecting the household and conducts a Covid-19 risk screen for all resident members. Any individuals screening positive are invited to a clinical screen, potential test and referral to necessary care - conducted in-person near their home following careful risk minimization procedures. In this protocol we report the details of our cohort design, questionnaires, data and reporting structures, and standard operating procedures in hopes that our project can inform similar efforts elsewhere.

COVID-19: Can this crisis be transformative for global health?

The UN has described the health, social and economic consequences of Covid-19 as a global crisis unlike any other encountered in its history. Although a pandemic of this nature was not unforeseeable, its arrival seems to have caught the world off guard, hurling us into a state of partly haphazard disaster mitigation. It has shed sharper light on the failure of global health in its current form to tackle acute and systemic challenges in a rapidly changing world, and the unequal patterns in society that leave us vulnerable. This commentary argues that, despite its devastating effects, the Covid-19 pandemic can be a longer-term positively transformative event for global health. However, this will require going beyond the development of more effective plans for health emergency preparedness, to confront the crisis in global health governance and leadership, and rethink the roles of key actors involved in world health. It ultimately calls us back to the very concept of 'global health': the values it should encompass, what we should expect from it and how we might envisage reshaping or 'co-creating' it for the future.

Handwashing in averting infectious diseases: Relevance to COVID-19

After officially declared as a pandemic by the World Health Organization (WHO), drastic measures to restrict human movements to contain the COVID-19 infection are employed by most of the countries. Maintaining high personal hygiene by frequent handwashing and be vigilant of clinical signs are widely recommended to reduce the disease burden. The national and international health agencies, including the Centers for Disease Control and Prevention (CDC) and the WHO, have provided guidelines for prevention and treatment suggestions. Here, in this brief article, based on available clinical information, the author discusses why handwashing could be protective of COVID-19 infections. Although a detailed and in-depth discussion of various preventive and protective measures is beyond the scope of this article, this review will focus on the utility of frequent handwashing in minimizing the risk of spreading COVID-19 infection.

Protocol: Leveraging a demographic and health surveillance system for Covid-19 Surveillance in rural KwaZulu-Natal

A coordinated system of disease surveillance will be critical to effectively control the coronavirus disease 2019 (Covid-19) pandemic. Such systems enable rapid detection and mapping of epidemics and inform allocation of scarce prevention and intervention resources. Although many lower- and middle-income settings lack infrastructure for optimal disease surveillance, health and demographic surveillance systems (HDSS) provide a unique opportunity for epidemic monitoring. This protocol describes a surveillance program at the Africa Health Research Institute's Population Intervention Platform site in northern KwaZulu-Natal. The program leverages a longstanding HDSS in a rural, resource-limited setting with very high prevalence of HIV and tuberculosis to perform Covid-19 surveillance. Our primary aims include: describing the epidemiology of the Covid-19 epidemic in rural KwaZulu-Natal; determining the impact of the Covid-19 outbreak and non-pharmaceutical control interventions (NPI) on behaviour and wellbeing; determining the impact of HIV and tuberculosis on Covid-19 susceptibility; and using collected data to support the local public-sector health response. The program involves telephone-based interviews with over 20,000 households every four months, plus a sub-study calling 750 households every two weeks. Each call asks a household representative how the epidemic and NPI are affecting the household and conducts a Covid-19 risk screen for all resident members. Any individuals screening positive are invited to a clinical screen, potential test and referral to necessary care - conducted in-person near their home following careful risk minimization procedures. In this protocol we report the details of our cohort design, questionnaires, data and reporting structures, and standard operating procedures in hopes that our project can inform similar efforts elsewhere.

Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis

BACKGROUND

This review is one of a series of rapid reviews that Cochrane contributors have prepared to inform the 2020 COVID-19 pandemic. When new respiratory infectious diseases become widespread, such as during the COVID-19 pandemic, healthcare workers' adherence to infection prevention and control (IPC) guidelines becomes even more important. Strategies in these guidelines include the use of personal protective equipment (PPE) such as masks, face shields, gloves and gowns; the separation of patients with respiratory infections from others; and stricter cleaning routines. These strategies can be difficult and time-consuming to adhere to in practice. Authorities and healthcare facilities therefore need to consider how best to support healthcare workers to implement them.

OBJECTIVES

To identify barriers and facilitators to healthcare workers' adherence to IPC guidelines for respiratory infectious diseases.

SEARCH METHODS

We searched OVID MEDLINE on 26 March 2020. As we searched only one database due to time constraints, we also undertook a rigorous and comprehensive scoping exercise and search of the reference lists of key papers. We did not apply any date limit or language limits.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with a distinct qualitative component) that focused on the experiences and perceptions of healthcare workers towards factors that impact on their ability to adhere to IPC guidelines for respiratory infectious diseases. We included studies of any type of healthcare worker with responsibility for patient care. We included studies that focused on IPC guidelines (local, national or international) for respiratory infectious diseases in any healthcare setting. These selection criteria were framed by an understanding of the needs of health workers during the COVID-19 pandemic.

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed the titles, abstracts and full texts identified by our search. We used a prespecified sampling frame to sample from the eligible studies, aiming to capture a range of respiratory infectious disease types, geographical spread and data-rich studies. We extracted data using a data extraction form designed for this synthesis. We assessed methodological limitations using an adapted version of the Critical Skills Appraisal Programme (CASP) tool. We used a 'best fit framework approach' to analyse and synthesise the evidence. This provided upfront analytical categories, with scope for further thematic analysis. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence intervention implementation and developed implications for practice.

MAIN RESULTS

We found 36 relevant studies and sampled 20 of these studies for our analysis. Ten of these studies were from Asia, four from Africa, four from Central and North America and two from Australia. The studies explored the views and experiences of nurses, doctors and other healthcare workers when dealing with severe acute respiratory syndrome (SARS), H1N1, MERS (Middle East respiratory syndrome), tuberculosis (TB), or seasonal influenza. Most of these healthcare workers worked in hospitals; others worked in primary and community care settings. Our review points to several barriers and facilitators that influenced healthcare workers' ability to adhere to IPC guidelines. The following factors are based on findings assessed as of moderate to high confidence. Healthcare workers felt unsure as to how to adhere to local guidelines when they were long and ambiguous or did not reflect national or international guidelines. They could feel overwhelmed because local guidelines were constantly changing. They also described how IPC strategies led to increased workloads and fatigue, for instance because they had to use PPE and take on additional cleaning. Healthcare workers described how their responses to IPC guidelines were influenced by the level of support they felt that they received from their management team. Clear communication about IPC guidelines was seen as vital. But healthcare workers pointed to a lack of training about the infection itself and about how to use PPE. They also thought it was a problem when training was not mandatory. Sufficient space to isolate patients was also seen as vital. A lack of isolation rooms, anterooms and shower facilities was a problem. Other important practical measures described by healthcare workers included minimising overcrowding, fast-tracking infected patients, restricting visitors, and providing easy access to handwashing facilities. A lack of PPE, and equipment that was of poor quality, was a serious concern for healthcare workers and managers. They also pointed to the need to adjust the volume of supplies as infection outbreaks continued. Healthcare workers believed that they followed IPC guidance more closely when they saw the value of it. Some healthcare workers felt motivated to follow the guidance because of fear of infecting themselves or their families, or because they felt responsible for their patients. Some healthcare workers found it difficult to use masks and other equipment when it made patients feel isolated, frightened or stigmatised. Healthcare workers also found masks and other equipment uncomfortable to use. The workplace culture could also influence whether healthcare workers followed IPC guidelines or not. Across many of the findings, healthcare workers pointed to the importance of including all staff, including cleaning staff, porters, kitchen staff and other support staff when implementing IPC guidelines.

AUTHORS' CONCLUSIONS

Healthcare workers point to several factors that influence their ability and willingness to follow IPC guidelines when managing respiratory infectious diseases. These include factors tied to the guideline itself and how it is communicated, support from managers, workplace culture, training, physical space, access to and trust in personal protective equipment, and a desire to deliver good patient care. The review also highlights the importance of including all facility staff, including support staff, when implementing IPC guidelines.

What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review

Background

The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency.

Methods

We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the World Health Organization’s Joint External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public health organizations.

Results

We identified 16 themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. Most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings.

Conclusions

An implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. However, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.