From resilient to transilient health systems: the deep transformation of health systems in response to the COVID-19 pandemic

[Should I Stay or Should I go? Resilience, Intention to Quit and Job Satisfaction among Nurses in Intensive Care Units]

AIM

Addressing the global nursing shortage is crucial to both national and international public health efforts. This paper aims to highlight the importance of resilience and its impact on primary care nurses' job satisfaction and intentions to quit, especially in the face of current challenges.

METHODS

The study utilized a mixed methods design involving nurses in intensive care units of a university hospital in Austria. In the first phase of data collection, qualitative focus group interviews were conducted to gather insights on the current challenges and stressors faced by nursing professionals. Building on relevant literature, a quantitative survey was then administered to all nurses, using scales measuring resilience, intention to quit, and job satisfaction in order to examine the relationships between these variables. In addition, a data structuring of the resilience scale by factors was achieved with the help of confirmatory factor analysis. Subsequently, the correlations of the resilience factors with the other variables were examined by means of an additional correlation, regression and mediation analysis.

RESULTS

The results showed negative correlations with regard to resilience and intention to quit as well as with regard to job satisfaction and intention to quit. In contrast, job satisfaction and resilience correlated significantly positively with each other. The negative correlation between resilience and the intention to quit was confirmed, but only for the factors "goal focus" and "pride and commitment". A closer examination of the two factors and their associated items revealed a connection to both professional identity and organizational identity.

CONCLUSION

This study provides valuable insights for health care leaders and health care decision makers to effectively lead, develop, and thereby retain primary care nurses. The authors argue that improving resilience and strengthening organizational identity are important influencing factors in increasing job satisfaction and reducing nurses' intention to quit.

Lessons for Strengthening a Resilient Health System from the View of Health Facilities During the COVID-19 Pandemic: A Qualitative Study

Background

Coronavirus disease 2019 caused significant negative damage to the health status of populations and health systems globally. In Uganda, our previous study revealed that the strict Public Health and Social measures (PHSMs) and the closure of Entebbe Regional Referral Hospital (ERRH) led to missed healthcare access among the citizens in the Entebbe municipality. Limited studies, however, exist on the impact of the response measures on the local health systems. This study aims to explore the impacts of these measures on the local health service provision from the views of health facilities in Entebbe.

Methods

We used a thematic framework method, grounded by the health systems resilience framework consisting of five components: (1) health service delivery; (2) medical products and technology; (3) health workforce; (4) public health functions; and (5) governance and financing. Key informant interviews with eight representatives from four private hospitals and four health centers were conducted from September to October 2022.

Results

Fifteen themes and 25 subthemes were identified. With the closure of the ERRH and the strict PHSMs, the citizens faced various difficulties in accessing the needed health services. The facilities received an overwhelming number of patients and faced various challenges, such as a lack of medicine, healthcare workers, facility capacity, and no means to transfer patients. Nevertheless, the facilities made efforts to maintain the required services. Moreover, mobilizing vertical and horizontal actors through a flexible network, from the district health office to community health volunteers, helped to coordinate the medicines, transportation for both patients and healthcare workers, conduct patient tracking, etc.

Conclusion

Our study suggested the importance of an integrated system of public health and health service delivery systems, the formalization of a vertical cooperative mechanism, and the introduction of public health insurance for strengthening resilient health systems. These insights may benefit other sub-Saharan cities.

State capacity impact on COVID-19 mortality in Brazil

This study addresses the State's capacity to combat the COVID-19 pandemic and contributes to the literature on crisis management in health care. We analyzed whether the capacity level impacted the State response to COVID-19 in Brazilian healthcare regions in 2020 using a set of statistical analysis techniques and public health impact analysis, including propensity score matching (PSM). Results revealed that a low COVID-19 mortality was associated with participation in municipal health consortia, schooling level of municipal health managers and the resources allocated by the Brazilian National Program for Improvement of Access and Quality of Basic Care (PMAQ). Conversely, the number of intensive care units (ICU) and life-sustaining equipment available were associated with higher mortality, as locations with a larger population concentrated operational capacity to treat the most severe cases. In conclusion, the different levels of State capacity in health regions led to different outcomes in combating the pandemic. This reinforces the importance of discussing State capacity and crisis management, since the COVID-19 confrontation in Brazil related to the level of existing resources concerning health system capacity, bureaucratic capacity and participation in consortia for sharing inputs and ensuring the provision of health services to the population.

The resilience of the Brazilian Unified Health System is not (only) in responding to disasters

Coping with the recent COVID-19 pandemic has shown that the Brazilian Unified Health System (SUS) needs to improve its resilience to handle the rapid spread of communicable diseases while ensuring the necessary care for an aging population with comorbidities and in a vulnerable situation. This article identifies, analyzes, and discusses critical aspects of the resilience of the SUS, calling into question the prevailing focus on the robustness and volume of resources mobilized during the outbreak of major disasters. Recent studies demonstrate that the skills that favor adaptation to unexpected situations emerge from the daily functioning of organizations. Restricting the discussion to the mobilization of structures to respond to adverse events has the effect of limiting their potential, inhibiting the emergence of the transformative, adaptive, anticipatory, and learning skills necessary for the sustainable development of resilience.

Healthcare team resilience during COVID-19: a qualitative study

BACKGROUND

Resilience, in the field of Resilience Engineering, has been identified as the ability to maintain the safety and the performance of healthcare systems and is aligned with the resilience potentials of anticipation, monitoring, adaptation, and learning. In early 2020, the COVID-19 pandemic challenged the resilience of US healthcare systems due to the lack of equipment, supply interruptions, and a shortage of personnel. The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a cognizant, singular source of knowledge and defined by its collective identity, purpose, competence, and actions, versus the resilience of an individual or an organization.

METHODS

We developed a descriptive model which considered the healthcare team as a unified cognizant entity within a system designed for safe patient care. This model combined elements from the Patient Systems Engineering Initiative for Patient Safety (SEIPS) and the Advanced Team Decision Making (ADTM) models. Using a qualitative descriptive design and guided by our adapted model, we conducted individual interviews with healthcare team members across the United States. Data were analyzed using thematic analysis and extracted codes were organized within the adapted model framework.

RESULTS

Five themes were identified from the interviews with acute care professionals across the US (N = 22): teamwork in a pressure cooker, consistent with working in a high stress environment; healthcare team cohesion, applying past lessons to present challenges, congruent with transferring past skills to current situations; knowledge gaps, and altruistic behaviors, aligned with sense of duty and personal responsibility to the team. Participants' described how their ability to adapt to their environment was negatively impacted by uncertainty, inconsistent communication of information, and emotions of anxiety, fear, frustration, and stress. Cohesion with co-workers, transferability of skills, and altruistic behavior enhanced healthcare team performance.

CONCLUSION

Working within the extreme unprecedented circumstances of COVID-19 affected the ability of the healthcare team to anticipate and adapt to the rapidly changing environment. Both team cohesion and altruistic behavior promoted resilience. Our research contributes to a growing understanding of the importance of resilience in the healthcare team. And provides a bridge between individual and organizational resilience.

Patterns and determinants of healthcare utilization and medication use before and during the COVID-19 crisis in Afghanistan, Bangladesh, and India

BACKGROUND

COVID-19 rapidly spread through South Asian countries and overwhelmed the health systems that were unprepared for such an outbreak. Evidence from high-income countries showed that COVID-19 impacted healthcare utilization, including medication use, but empirical evidence is lacking in South Asia. This study aimed to investigate the effect of COVID-19 on healthcare utilization and medication use in South Asia.

METHOD

The current study used longitudinal data from the 'Premise Health Service Disruption Survey' 2020 and 2021. The countries of interest were limited to Afghanistan, Bangladesh, and India. In these surveys, data related to healthcare utilization and medication use were collected for three-time points; 'Pre-COVID phase', 'Initial phase of COVID-19 outbreak', and 'One year of COVID-19 outbreak'. Generalized estimating equation (GEE) along with McNemar's test, Kruskal-Wallis test and χ2 test were applied in this study following the conceptualization of Andersen's healthcare utilization model.

RESULT

The use of healthcare and medication was unevenly impacted by the COVID-19 epidemic in Afghanistan, Bangladesh, and India. Immediately after the COVID-19 outbreak, respondents in Bangladesh reported around four times higher incomplete healthcare utilization compared to pre-COVID phase. In contrast, respondents in Afghanistan reported lower incomplete utilization of healthcare in a similar context. In the post COVID-19 outbreak, non-adherence to medication use was significantly higher in Afghanistan (OR:1.7; 95%CI:1.6,1.9) and India (OR:1.3; 95%CI:1.1,1.7) compared to pre-COVID phase. Respondents of all three countries who sought assistance to manage non-communicable diseases (NCDs) had higher odds (Afghanistan: OR:1.5; 95%CI:1.3,1.8; Bangladesh: OR: 3.7; 95%CI:1.9,7.3; India: OR: 2.3; 95% CI: 1.4,3.6) of non-adherence to medication use after the COVID-19 outbreak compared to pre-COVID phase.

CONCLUSION

The present study documented important evidence of the influence of COVID-19 epidemic on healthcare utilization and medication use in three countries of South Asia. Lessons learned from this study can feed into policy responses to the crisis and preparedness for future pandemics.

"I feel broken": Chronicling burnout, mental health, and the limits of individual resilience in nursing

Healthcare systems and health professionals are facing a litany of stressors that have been compounded by the pandemic, and consequently, this has further perpetuated suboptimal mental health and burnout in nursing. The purpose of this paper is to report select findings from a larger, national study exploring gendered experiences of mental health, leave of absence (LOA), and return to work from the perspectives of nurses and key stakeholders. Given the breadth of the data, this paper will focus exclusively on the qualitative results from 53 frontline Canadian nurses who were purposively recruited for their workplace insight. This paper focuses on the substantive theme of "Breaking Point," in which nurses articulated a multiplicity of stress points at the individual, organizational, and societal levels that amplified burnout and accelerated mental health LOA from the workplace. These findings exemplify the complexities that underlie nurses' mental health and burnout and highlight the urgent need for multipronged individual, organizational, and structural interventions. Robust and timely interventions are needed to restore the health of the nursing profession and sustain its future.

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 Clinical Resource Hub Telehealth Program and Use of Primary Care, Emergency, and Inpatient Care During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic disrupted delivery of health care services worldwide. We examined the impact of the pandemic on clinics participating in the Veterans Affairs (VA) Clinical Resource Hub (CRH) program, rolled out nationally in October 2019, to improve access to care at under-resourced VA clinics or "spoke" sites through telehealth services delivered by regional "hub" sites.

OBJECTIVE

To assess whether the CRH program was associated with increased access to primary care, we compared use of primary, emergency, and inpatient care at sites that adopted CRH for primary care (CRH-PC) with sites that did not adopt CRH-PC, pre-post pandemic onset.

DESIGN

Difference-in-difference and event study analyses, adjusting for site characteristics.

STUDY COHORT

A total of 1050 sites (254 CRH-PC sites; 796 comparison sites), fiscal years (FY) 2019-2021.

INTERVENTION

CRH Program for Primary Care.

MAIN MEASURES

Quarterly number of VA visits per site for primary care (across all and by modality, in-person, video, and phone), emergency care, and inpatient care.

RESULTS

In adjusted analyses, CRH-PC sites, compared with non-CRH-PC sites, had on average 221 additional primary care visits (a volume increase of 3.4% compared to pre-pandemic). By modality, CRH-PC sites had 643 fewer in-person visits post-pandemic (- 14.4%) but 723 and 128 more phone and video visits (+ 39.9% and + 159.5%), respectively. CRH-PC sites, compared with non-CRH-PC sites, had fewer VA ED visits (- 4.2%) and hospital stays (- 5.1%) in VA medical centers. Examining visits per patient, we found that CRH-PC sites had 48 additional telephone primary care visits per 1000 primary care patients (an increase of 9.8%), compared to non-program sites.

CONCLUSIONS

VA's pre-pandemic rollout of a new primary care telehealth program intended to improve access facilitated primary care visits during the pandemic, a period fraught with care disruptions, and limited in-person health care delivery, indicating the potential for the program to offer health system resilience.

COVID-19, SDGs and public health systems: Linkages in Brazil

Background

The global 2030 Agenda covers a range of interconnected issues which need interdisciplinary and holistic approaches to improve human well-being and protect the natural environment. The COVID-19 pandemic has brought to light critical inequities in society and policy gaps in health services. As highlighted through analyses of the interlinkages among the Sustainable Development Goals (SDGs), connections between human health and well-being and the environment, can help support new policy needs in addressing systemic health crises, including widespread pandemics.

Method

We identify links between the COVID-19 crisis and multiple SDGs in the context of Brazil based on a review of the current literature in the health sector.Findings: We identify synergistic connections between 88 out of 169 SDG targets and COVID-19, notably around themes such as City Environment, Contextual Policies and the value created by improved Information and Technology. Using the context of the Brazilian National Health Service (SUS) highlights recurrent interconnections from the focal point of target 3.8. This includes topics such as challenges for universal healthcare coverage, budget allocation, and universalisation.

Conclusions

The framework developed for supporting policy-making decisions and the design of toolkits for dealing with future health-related emergency scenarios offers a practical solution in the health sector. It is worth noting that progress and action on public health systems and policies must go hand in hand with addressing existing socio-economic vulnerabilities in society. This is vital for tackling future pandemics and simultaneously addressing the SDGs.

A management perspective on resilience in healthcare: a framework and avenues for future research

Recent major health shocks, such as the 2014-16 Ebola, the Zika outbreak, and, last but not least, the COVID-19 pandemic, have strongly contributed to drawing attention to the issue of resilience in the healthcare domain. Nevertheless, the scientific literature appears fragmented, creating difficulties in developing incremental research in this relevant managerial field.To fill this gap, this systematic literature review aims to provide a clear state of the art of the literature dealing with resilience in healthcare. Specifically, from the analysis of the theoretical articles and reviews, the key dimensions of resilience are identified, and a novel classification framework is proposed. The classification framework is then used to systematize extant empirical contributions. Two main dimensions of resilience are identified: the approach to resilience (reactive vs. proactive) and the type of crisis to deal with (acute shocks vs. chronic stressors). Four main streams of research are thus identified: (i) proactive approaches to acute shocks; (ii) proactive approaches to chronic stressors; (iii) reactive approaches to acute shocks; and (iv) reactive approaches to chronic stressors. These are scrutinised considering three additional dimensions: the level of analysis, the resources to nurture resilience, and the country context. The classification framework and the associated mapping contribute to systematising the fragmented literature on resilience in healthcare, providing a clear picture of the state of the art in this field and drawing a research agenda that opens interesting paths for future research.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary healthcare providers challenged during the COVID-19 pandemic: a qualitative study

BACKGROUND

Primary healthcare (PHC) providers are widely acknowledged for putting the most efficient and long-lasting efforts for addressing community health issues and promoting health equity. This study aimed to explore PHC providers' experiences with coronavirus pandemic preparedness and response in Armenia.

METHODS

We applied a qualitative study design using semi-structured in-depth interviews and structured observation checklists. Study participants were recruited using theoretical and convenience sampling techniques throughout Armenia. Inductive conventional content analysis was utilized to analyze the in-depth interviews. Nineteen in-depth interviews were conducted with 21 participants. Observations took place in 35 PHC facilities. The data collected during the observations was analyzed using the "SPSS22.0.0.0" software.

RESULTS

Five main themes of primary healthcare providers' experiences were drawn out based on the study findings: 1) the gap in providers' risk communication skills; 2) uneven supply distributions; 3) difficulties in specimen collection and testing processes; 4) providers challenged by home visits; 5) poor patient-provider relationships. The results revealed that primary care providers were affected by uneven supply distribution throughout the country. The lack of proper laboratory settings and issues with specimen collection were challenges shaping the providers' experiences during the pandemic. The study highlighted the health systems' unpreparedness to engage providers in home visits for COVID-19 patients. The findings suggested that it was more challenging for healthcare providers to gain the trust of their patients during the pandemic. The study results also underlined the need for trainings to help primary care providers enhance their risk communication expertise or assign other responsible bodies to carry out risk communication on PHC providers' behalf.

CONCLUSION

The study discovered that PHC providers have a very important role in healthcare system's preparedness and response to handle public health emergencies such as the COVID-19 pandemic. Based on the findings the study team recommends prioritizing rural PHC development, ensuring appropriate supply distributions, developing comprehensive protocols on safe home visits and specimen collection and testing processes, and trainings PHC providers on risk communication, patient-centeredness, as well as proper use of personal protective equipment.

Extending health systems resilience into communities: a qualitative study with community-based actors providing health services during the COVID-19 pandemic in the Philippines

BACKGROUND

Amidst ongoing calls for increased health systems resilience, gaps remain in our understanding of how health systems can reach further into communities to ensure resilient service delivery. Indeed, public health emergencies caused by infectious hazards reveal both the value and vulnerability of the workforce delivering health services in communities. This study explores ways in which a non-governmental organization (NGO) in the Philippines protected their frontline workforce during the first year of the COVID-19 pandemic.

METHODS

Guided by a qualitative descriptive approach, 34 in-depth interviews were conducted with community-based health actors employed by the NGO between June 2020 and February 2021. Data analysis was guided by an iterative deductive and inductive approach.

RESULTS

We identified four key activities that enabled the NGO and their staff to provide health and social services in communities in a safe and consistent manner as part of the organization's pandemic response. These include (1) ensuring adequate personal protective equipment (PPE) and hygiene supplies; (2) providing contextualized and role-specific infection prevention and control (IPC) training; (3) ensuring access to testing for all staff; and (4) providing support during quarantine or isolation.

CONCLUSION

Learning from the implementation of these activities offers a way forward toward health emergency preparedness and response that is crucially needed for NGOs to safely leverage their workforce during pandemics. Further, we describe how community-based health actors employed by NGOs can contribute to broader health systems resilience in the context of health emergency preparedness and response.

Health Security, Quality of Life and Democracy during the COVID-19 Pandemic: Comparative Approach in the EU-27 Countries

The aim of this paper is to emphasize the role played by the social, economic and political variables in shaping models of sustainable healthcare systems and strategies able to support and improve the quality of life during and after the COVID-19 pandemic. The context of our research is represented by the medical and socioeconomic crises generated by the COVID-19 pandemic. The current pandemic negatively affects healthcare systems, quality of life and the global economy. In this respect, this paper aims to thoroughly scrutinize the effects of the COVID-19 pandemic on the social and healthcare systems of EU countries, to analyze the impact of human development in the field of the Global Health Security Index and to estimate the relation between resilience and quality of life during the COVID-19 pandemic. The research design is quantitative, resorting to the use of both descriptive and inferential statistics, against the background of a long-term comparative approach to the respective situations in the EU-27 countries. Empirical findings are relevant for emphasizing the fact that human development and social progress are predictors for the dynamics of health security measures. Moreover, the quality of the political regime, particularly in the case of full and flawed democracies, is strongly related to a high level of resilience and could influence the perception of quality of life. All of these empirical results could prove valuable for scholars interested in understanding the relationships between democracy, healthcare systems and quality of life, and for political decision makers involved in the effort of reducing the negative effects of COVID-19 in EU-27 countries.

The contribution of community health systems to resilience: Case study of the response to the drought in Ethiopia

Background

Ethiopia’s exposure to the El Niño drought (2015-2016) resulted in high malnutrition, internally displaced people, and epidemics of communicable diseases, all of which strained the health system. The drought was especially challenging for mothers and children. We aimed to identify salient factors that can improve health system resilience by exploring the successes and challenges experienced by a community-based health system during the drought response.

Methods

We collected data via key informant interviews and focus group discussions to capture diverse perspectives across the health system (eg, international, national, district, facility, and community perspectives). Data were collected from communities in drought-affected regions of: 1) Somali, Sitti Zone, 2) Hawassa, Southern Nations, Nationalities, and Peoples’ Region (SNNPR), and 3) Tigray, Eastern Zone. Data were analysed using a deductive-inductive approach using thematic content analysis applied to a conceptual framework.

Results

A total of 94 participants were included (71 from the communities and 23 from other levels). Key themes included the importance of: 1) organized community groups linked to the health system, 2) an effective community health workforce within strong health systems, 3) adaptable human resource structures and service delivery models, 4) training and preparedness, and 5) strong government leadership with decentralized decision making.

Conclusions

The results of this study provide insights from across the health system into the successes and challenges of building resilience in community-based health systems in Ethiopia during the drought. As climate change exacerbates extreme weather events, further research is needed to understand the determinants of building resilience from a variety of shocks in multiple contexts, especially focusing on harnessing the power of communities as reservoirs of resilience.

Big data analytics and the effects of government restrictions and prohibitions in the COVID-19 pandemic on emergency department sustainable operations

Grounded in dynamic capabilities, this study mainly aims to model emergency departments' (EDs) sustainable operations in the current situation caused by the COVID-19 pandemic by using emerging big data analytics (BDA) technologies. Since government may impose some restrictions and prohibitions in coping with emergencies to protect the functioning of EDs, it also aims to investigate how such policies affect ED operations. The proposed model is designed by collecting big data from multiple sources and implementing BDA to transform it into action for providing efficient responses to emergencies. The model is validated in modeling the daily number of patients, the average daily length of stay (LOS), and daily numbers of laboratory tests and radiologic imaging tests ordered. It is applied in a case study representing a large-scale ED. The data set covers a seven-month period which collectively means the periods before COVID-19 and during COVID-19, and includes data from 238,152 patients. Comparing statistics on daily patient volumes, average LOS, and resource usage, both before and during the COVID-19 pandemic, we found that patient characteristics and demographics changed in COVID-19. While 18.92% and 27.22% of the patients required laboratory and radiologic imaging tests before-COVID-19 study period, these percentages were increased to 31.52% and 39.46% during-COVID-19 study period. By analyzing the effects of policy-based variables in the model, we concluded that policies might cause sharp decreases in patient volumes. While the total number of patients arriving before-COVID-19 was 158,347, it decreased to 79,805 during-COVID-19. On the other hand, while the average daily LOS was 117.53 min before-COVID-19, this value was calculated to be 165,03 min during-COVID-19 study period. We finally showed that the model had a prediction accuracy of between 80 to 95%. While proposing an efficient model for sustainable operations management in EDs for dynamically changing environments caused by emergencies, it empirically investigates the impact of different policies on ED operations.

Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view

Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives - all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.

Big data analytics and COVID-19: investigating the relationship between government policies and cases in Poland, Turkey and South Korea

We used big data analytics for exploring the relationship between government response policies, human mobility trends and numbers of coronavirus disease 2019 (COVID-19) cases comparatively in Poland, Turkey and South Korea. We collected daily mobility data of retail and recreation, grocery and pharmacy, parks, transit stations, workplaces, and residential areas. For quantifying the actions taken by governments and making a fairness comparison between these countries, we used stringency index values measured with the 'Oxford COVID-19 government response tracker'. For the Turkey case, we also developed a model by implementing the multilayer perceptron algorithm for predicting numbers of cases based on the mobility data. We finally created scenarios based on the descriptive statistics of the mobility data of these countries and generated predictions on the numbers of cases by using the developed model. Based on the descriptive analysis, we pointed out that while Poland and Turkey had relatively closer values and distributions on the study variables, South Korea had more stable data compared to Poland and Turkey. We mainly showed that while the stringency index of the current day was associated with mobility data of the same day, the current day's mobility was associated with the numbers of cases 1 month later. By obtaining 89.3% prediction accuracy, we also concluded that the use of mobility data and implementation of big data analytics technique may enable decision-making in managing uncertain environments created by outbreak situations. We finally proposed implications for policymakers for deciding on the targeted levels of mobility to maintain numbers of cases in a manageable range based on the results of created scenarios.

Managing Brazil’s Health System at municipal level against Covid-19: a preliminary analysis

ABSTRACT This qualitative, observational, and exploratory study was supported by quantitative data to analyze the Brazilian Unified Health System (SUS) response to Covid-19 in three Brazilian municipalities. We used semi-structured interviews to listen to and dialogue with managers of the cities analyzed, guided by a roadmap to explore the managers’ perception during the response to the pandemic, understand the motivations that guided their strategic choices, and visualize the weaknesses and potentials of the municipal system in a public health emergency. We conducted a qualitative analysis considering the critical points of the SUS response to the pandemic, including coordination and governance, surveillance and prevention, and the health services network. In the results, we present and discuss the main characteristics of the municipalities, the 2020 pandemic course, the response actions adopted, and submit an analysis of the response pattern of municipal SUS managers in the pandemic.

Gerenciando o SUS no nível municipal ante a Covid-19: uma análise preliminar

RESUMO Este é um estudo observacional, exploratório, que utilizou metodologia qualitativa, com apoio de dados quantitativos, para analisar a resposta do Sistema Único de Saúde (SUS) à Covid-19 em três municípios brasileiros. Utilizaram-se entrevistas semiestruturadas para escuta e diálogo com gestores das cidades analisadas, que foram orientadas por roteiro para explorar a percepção dos gestores durante o processo de resposta à pandemia, compreender as motivações que orientaram suas escolhas estraté- gicas e visualizar as fragilidades e potencialidades do sistema municipal em uma emergência de saúde pública. Realizou-se análise qualitativa considerando pontos-chave da resposta do SUS à pandemia, entre eles, coordenação e governança, vigilância e prevenção, e rede de serviços de saúde. Nos resultados, apresentam-se e discutem-se as principais características dos municípios, o curso da pandemia em 2020, ações de resposta adotadas; e exibe-se uma análise do padrão de resposta dos gestores do SUS municipal na pandemia.

Why Resilience in Health Care Systems is More than Coping with Disasters: Implications for Health Care Policy

Health care systems need to be resilient to deal with disasters like the global spread of the Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) on top of serving the changing needs of a multi-morbid, ageing and often dispersed population. This paper identifies, discusses and augments critical dimensions of resilience retrieved from the academic literature. It pulls together an integrated concept of resilience characterised by organisational capabilities. Our concept does not focus on the micro-level like most resilience literature in health care but addresses the system level with many stakeholders involved. Distinguishing exogenous shocks to the health care system into adverse events and planned innovations provides the basis for our conclusions and insights. It becomes apparent only when dealing with planned interventions that transformative capabilities are indispensable to cope with sudden increases in health care pressures. Due to the current focus on absorptive and adaptive resilience, organisations over-rely on management capabilities that cannot generate a lasting increase in functionality. Therefore, reducing the resilience discussion to bouncing back from adverse events could deceive organisations into cultivating a suboptimal mix of organisational capabilities lacking transformative capabilities, which pave the way for a structural change that aims at a sustainably higher functionality.

The Influence of China's COVID-19 Treatment Policy on the Sustainability of Its Social Health Insurance System

Background

While past experiences show that a health system financing mechanism can support resilience to shocks, the impact on the sustainability of the financing system is exceptionally important considering the magnitude of the COVID-19 pandemic. The role of Social Health Insurance (SHI) in responding to the pandemic brings about an influence on insurance system sustainability. This study investigates the impact of China’s COVID-19 treatment policy on the sustainability of its SHI system, explores influences of the policy on Wuhan’s system, and discusses the effects of an assumed equivalent emergency on SHI funds for five other provincial capital cities in China.

Methods

The study was conducted using pay-as-you-go actuarial models of Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Residents Basic Medical Insurance (URRBMI) funds, which constitute China’s basic health insurance system. Current and accumulated balances of the funds in 2020 are predicted and utilized to measure the sustainability of health insurance funds during emergencies.

Results

The findings suggest a disparity in the capacities of insurance schemes and localities. If the surplus before 2018 is not considered, it is likely that the URRBMI fund of Wuhan would suffer a deficit, whereas the UEBMI would retain a considerable surplus. To maintain the current actuarial balance of the URRBMI fund, coverage for ordinary inpatient and outpatient expenses would have to be significantly reduced in Wuhan, potentially affecting enrollees’ wellbeing. A similar situation may occur in three other cities, some with underdeveloped economies and lower per capita income are likely to be encountered with worse situation than Wuhan.

Conclusion

Concerning fragmentation of China’s SHI system, to strengthen longer-term preparedness to manage future emergencies, this study suggests the integration of insurance schemes and provincial pooling, fund balance adjusting and an emergency safety net are also advised. All options call for more public health investments.

Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries

Health systems resilience is key to learning lessons from country responses to crises such as coronavirus disease 2019 (COVID-19). In this perspective, we review COVID-19 responses in 28 countries using a new health systems resilience framework. Through a combination of literature review, national government submissions and interviews with experts, we conducted a comparative analysis of national responses. We report on domains addressing governance and financing, health workforce, medical products and technologies, public health functions, health service delivery and community engagement to prevent and mitigate the spread of COVID-19. We then synthesize four salient elements that underlie highly effective national responses and offer recommendations toward strengthening health systems resilience globally.

Learning from public health and hospital resilience to the SARS-CoV-2 pandemic: protocol for a multiple case study (Brazil, Canada, China, France, Japan, and Mali)

BACKGROUND

All prevention efforts currently being implemented for COVID-19 are aimed at reducing the burden on strained health systems and human resources. There has been little research conducted to understand how SARS-CoV-2 has affected health care systems and professionals in terms of their work. Finding effective ways to share the knowledge and insight between countries, including lessons learned, is paramount to the international containment and management of the COVID-19 pandemic. The aim of this project is to compare the pandemic response to COVID-19 in Brazil, Canada, China, France, Japan, and Mali. This comparison will be used to identify strengths and weaknesses in the response, including challenges for health professionals and health systems.

METHODS

We will use a multiple case study approach with multiple levels of nested analysis. We have chosen these countries as they represent different continents and different stages of the pandemic. We will focus on several major hospitals and two public health interventions (contact tracing and testing). It will employ a multidisciplinary research approach that will use qualitative data through observations, document analysis, and interviews, as well as quantitative data based on disease surveillance data and other publicly available data. Given that the methodological approaches of the project will be largely qualitative, the ethical risks are minimal. For the quantitative component, the data being used will be made publicly available.

DISCUSSION

We will deliver lessons learned based on a rigorous process and on strong evidence to enable operational-level insight for national and international stakeholders.