Global health security and universal health coverage: from a marriage of convenience to a strategic, effective partnership

Integrating COVID-19 Vaccination in Primary Care Service Delivery: Insights From Implementation Research in the Philippines

BACKGROUND

In 2019, the Philippines enacted a universal health coverage law that aimed to establish an integrated health system centered around robust primary care as a core strategy of its health system reform agenda. Although the COVID-19 pandemic disrupted initial progress in the reform process, it also presented an opportunity to pilot interventions to demonstrate integration in various ways.

METHODS

We conducted a participatory implementation research study to integrate selected public health interventions into the implementation of the primary care benefit package funded by public health insurance. The study was conducted from October 2022 to April 2023 in the Province of Iloilo, Philippines. Entry points within the primary care service delivery process were identified, and interventions related to COVID-19 vaccination and family planning were implemented and monitored. We used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to organize the results and present the analysis.

RESULTS

The intervention showed substantial improvement across the 5 dimensions of the RE-AIM framework, including enhanced access to health care services, as indicated by improvements in primary care patient registration, family planning services, and COVID-19 vaccination processes, as well as an increase in registrations and first patient encounters. These improvements corresponded to sustained primary care facility participation throughout the study period. Additionally, emergent factors that either impeded or facilitated the integration process were identified, providing insights for effectively integrating COVID-19 vaccination within the primary care health system.

CONCLUSION

Our study provides evidence of the feasibility of integrating public health interventions into primary care settings. It highlights the potential of using existing primary care service delivery and financing mechanisms as entry points for integration. However, further iteration of the model is required to identify specific conditions for success that can be applied in other contexts and settings.

Strategies for improving the financing of family medicine program: Evidence from Iran

Background and Aims

The impact of health financing on the performance of the entire health system, including access, quality, and efficiency of healthcare, has been emphasized in the Astana Declaration, and the need to strengthen primary healthcare (PHC) and policy integration has been emphasized. After about two decades, the family medicine (FM) program in Iran is still facing great challenges. The aim of this study is to explore strategies for strengthening financing of the FM program in Iran, a vital component of PHC.

Methods

A qualitative study was conducted in 2021. Purposeful sampling was used to select 34 policymakers, managers, and experts from various levels of the Ministry of Health, Iran universities of medical sciences, plan and budget organization of Iran, and health insurance organization in Iran. Thirty-four semistructured interviews were conducted to collect data, which were analyzed by content analysis.

Results

Through the analysis of interviews, our study has identified five strategies (identification and management of sustainable resources, pooling of sustainable resources, modeling of service provision, payment system model and its implementation process, and FM management structure), and 13 actions for strengthening financing of the FM program in Iran.

Conclusion

Our study has identified five strategies and 13 actions for strengthening the financing of the FM program in Iran. These strategies and actions should be considered by policymakers during the review of the FM program in Iran. Without implementation of the suggested strategies and action, allocated resources may be wasted.

Exploring the global health and defence engagement interface

Militaries have an important and inevitable role in global health and will interface with existing health systems on deployments. While the primary concern of militaries is not global health, there are clear, and increasingly frequent, circumstances when global health activities align with the interests of defence. Recognising this link between global health and security warrants thoughtful consideration and action where concerns affecting both intersect. In addition to providing medical support to military personnel on operations, advantageous effects can be achieved directly from military medical activities as part of Defence Engagement. While there are limitations and ethical boundaries to the role of militaries in global health, further training, research and conceptual development are warranted to optimise military medical activity at the intersection of security and global health to deliver advantageous effects. This paper forms part of a special issue of BMJ Military Health dedicated to Defence Engagement.

Exploring the interest of medical students in global health in South Korea: Does taking a global health course matter?

BACKGROUND

Prioritizing global health is important for positive health outcomes. Doctors play a pivotal role in addressing health issues that they need to recognize the importance of global health practice. However, medical education in global health is still in its early stages in many countries, including South Korea.

METHODS

This study is a quantitative cross-sectional study. Medical students were recruited from all 40 Korean medical schools and data collection was conducted in 2021. Stratified proportional quota sampling was employed as the sampling method. The study examined medical students' interest in global health as the dependent variable. Independent variables included whether individuals had taken global health courses as part of their medical curriculum, while covariates included student background and institutional factors. Logistic regression was used to determine if taking a global health class was associated with global health interests.

RESULTS

The study included 2450 participants and almost 32% of medical students (n = 781) were interested in global health. Taking global health classes in school was associated with a higher likelihood of developing an interest in global health (OR: 1.29, 95% CI: 1.00-1.67). The likelihood of being interested in global health decreased across the academic year (OR: 0.70, 95% CI: 0.53-0.94). Individuals in graduate entry programs were associated with an interest in global health (OR: 1.32, 95% CI: 1.01-1.72).

CONCLUSION

This study provides the first comprehensive nationwide assessment of medical students' perspectives on global health education in South Korea. The findings underscore the importance of early and sustained exposure to global health topics in medical education in fostering interest in global health. These results can serve as valuable evidence for medical educators seeking to integrate global health education into their curricula.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Global Health Security Index not a proven surrogate for health systems capacity to respond to pandemics: The case of COVID-19

INTRODUCTION

Global Health Security borders on prevention, detection and response to public health threats like the novel coronavirus disease 2019 (COVID-19). Global Health Security Index (GHSI) of 2019 and 2021 revealed the world remains ill-prepared to deal with future pandemics, evident in the historic impact of COVID-19 on countries. As at 7th December 2022, COVID-19 has infected over 600 million people and claimed over six million lives, mostly in countries with higher GHSI scores.

OBJECTIVE

Determine whether the GHSI scores of countries have a correlation with COVID-19 cases, deaths and vaccination coverage, while adjusting for country level dynamics.

METHODS

This paper utilizes GHSI database of 195 countries. Data consists of 171 questions grouped into 37 indicators across six overarching categories on health security and COVID-19. Multivariate multiple regression analysis with robust standard errors was conducted to test the hypothesis that high GHSI ratings do not guarantee better COVID-19 outcomes like cases, deaths and vaccination coverage. Also, avplots STATA command was used to check outliers with potential negative effect on outcome and predictor variables.

RESULTS

Global average GHSI score for all 195 countries was 38.9. United States of America recorded the highest GHSI score of 75.9 but also recorded one of the highest COVID-19 cases and deaths; Somalia recorded the worst GHSI score of 16.0 and one of the lowest COVID-19 cases and deaths. High GHSI scores did not associate positively with reduction in COVID-19 cases (Coef=157133.4, p-value=0.009, [95%CI 39728.64 274538.15]) and deaths (Coef=1405.804, p-value=0.047, [95%CI 18.1 2793.508]). However, high GHSI ratings associated with increases in persons fully vaccinated per 100 population (Coef=0.572, p-value=0.000, [95%CI.272.873]).

CONCLUSION

It appears the world might still not be adequately prepared for the next major pandemic, if the narrative remains unchanged. Countries that recorded higher GHSI scores, counter-intuitively, recorded higher COVID-19 cases and deaths. Countries need to invest more in interventions towards attaining Universal Health Coverage (UHC) including integrated health systems and formidable primary health care to enhance preparedness and response to pandemics.

The role of the university in recovering from COVID-19 and preparing for future crises-perspectives and experiences from Sunway University, Malaysia

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Universities, as engines of knowledge creation and dissemination and as incubators of disciplined yet original thinking, have a key role to play in tackling the most complex challenges that societies and our planet face, from infectious diseases to the climate emergency. This commentary presents the perspectives from Sunway University, a young private university in Malaysia that made a strong commitment to the sustainable development goals (SDGs) prior to the pandemic, and its experiences in promoting research, innovation, and learning as part of COVID-19 recovery and in preparation for future crises such as the climate emergency. Some of the university's initiatives include embracing the planetary health approach, reviving essential public health functions, exploring pandemic resilience, addressing 'infodemics' and promoting science diplomacy. The example of Sunway University provides some insights on the opportunities and challenges that academic institutions face as they seek to reorient the paradigm of education, research, and service away from disciplinary siloes and towards a more integrated, preventive, accessible and translational approach.

A critical look at synergies and fragmentations of universal health coverage, global health security, and health promotion in delivery of frontline health care services: A case study of Bangladesh

Universal Health Coverage (UHC) and Global Health Security (GHS) activities encompass mitigation of risks to health and well-being rights posed by infectious disease outbreaks and facilitated by health promotion (HP) activities. This case study investigated Bangladesh's readiness and capacity to 'prevent, detect and respond' to such outbreaks of an epidemic/pandemic nature. A rapid review of relevant documents, key informant interviews with policymakers/practitioners, and a deliberative dialogue with a crisscross of stakeholders were used to identify challenges and opportunities for 'synergy' among these streams of activities. Findings reveal conceptual ambiguity among respondents about the scope of the three `agendas and their inter-linkages. They perceived the synergy between UHC and GHS superfluous and were obsessed with losing their respective constituencies and resources. Poor coordination among the focal agencies in field activities, lack of supporting infrastructure, and shortage of human and financial resources posed additional challenges for better pandemic/epidemic preparation in future.

Funding

This study, "Researching the UHC-GHS-HP Triangle in Bangladesh," was funded by the Wellcome Trust, UK.

Optimising health system capacity: A case study of community care staff's role transition in response to the coronavirus pandemic

The coronavirus disease (COVID-19) increased the demand for critical care spaces and the task for individual countries was to optimise the capacity of their health systems. Correlating governance and health system capacity to respond to global crises has subsequently garnered the pace in reviewing normalised forms of identifying health priorities. Aligning global health security and universal health security enhances the capacity and resilience of a health system. However, weak methods of governance hinder the alignment necessary for controlling infection spread and coping with the increase in demand for hospital critical care. A range of qualitative studies has explored staff experiences of providing care in hospitals amidst the COVID-19 pandemic. Nonetheless, limited understanding of the influence of governance on health and social care staff experiences in response to the COVID-19 pandemic exists. This case study aimed to explore the influence of health system governance on community care staff experiences of role transition in response to the COVID-19 pandemic in England. We used criterion sampling to include community care staff initially recruited to deliver a community integrated model of dementia care at two facilities repurposed in March 2020 to optimise hospital critical care space. Six community care staff participated in the narrative correspondence inquiry. A lack of control over resources, limitations in collective action in decision making and lack of a voice underpinned staff experiences of role transition in contexts of current crisis preparedness, transition shock and moral dilemmas. Health system governance influenced the disposition of community care staff's role transition in response to the COVID-19 pandemic. Staff's mere coping clouds the glass of wider issues in health system governance and capacity. The normative dominance that the control over resources and centrally determined health system priorities ordain require reviewing to enable optimal health and social care cross systems' capacity and resilience.

Universal healthcare coverage and health service delivery before and during the COVID-19 pandemic: A difference-in-difference study of childhood immunization coverage from 195 countries

BACKGROUND

Several studies have indicated that universal health coverage (UHC) improves health service utilization and outcomes in countries. These studies, however, have primarily assessed UHC's peacetime impact, limiting our understanding of UHC's potential protective effects during public health crises such as the Coronavirus Disease 2019 (COVID-19) pandemic. We empirically explored whether countries' progress toward UHC is associated with differential COVID-19 impacts on childhood immunization coverage.

METHODS AND FINDINGS

Using a quasi-experimental difference-in-difference (DiD) methodology, we quantified the relationship between UHC and childhood immunization coverage before and during the COVID-19 pandemic. The analysis considered 195 World Health Organization (WHO) member states and their ability to provision 12 out of 14 childhood vaccines between 2010 and 2020 as an outcome. We used the 2019 UHC Service Coverage Index (UHC SCI) to divide countries into a "high UHC index" group (UHC SCI ≥80) and the rest. All analyses included potential confounders including the calendar year, countries' income group per the World Bank classification, countries' geographical region as defined by WHO, and countries' preparedness for an epidemic/pandemic as represented by the Global Health Security Index 2019. For robustness, we replicated the analysis using a lower cutoff value of 50 for the UHC index. A total of 20,230 country-year observations were included in the study. The DiD estimators indicated that countries with a high UHC index (UHC SCI ≥80, n = 35) had a 2.70% smaller reduction in childhood immunization coverage during the pandemic year of 2020 as compared to the countries with UHC index less than 80 (DiD coefficient 2.70; 95% CI: 0.75, 4.65; p-value = 0.007). This relationship, however, became statistically nonsignificant at the lower cutoff value of UHC SCI <50 (n = 60). The study's primary limitation was scarce data availability, which restricted our ability to account for confounders and to test our hypothesis for other relevant outcomes.

CONCLUSIONS

We observed that countries with greater progress toward UHC were associated with significantly smaller declines in childhood immunization coverage during the pandemic. This identified association may potentially provide support for the importance of UHC in building health system resilience. Our findings strongly suggest that policymakers should continue to advocate for achieving UHC in coming years.

Hospitals early challenges and interventions combatting COVID-19 in the Eastern Mediterranean Region

Background

During rapidly evolving outbreaks, health services and essential medical care are interrupted as facilities have become overwhelmed responding to COVID-19. In the Eastern Mediterranean Region (EMR), more than half of countries are affected by emergencies, hospitals face complex challenges as they respond to humanitarian crises, maintain essential services, and fight the pandemic. While hospitals in the EMR have adapted to combat COVID-19, evidence-based and context-specific recommendations are needed to guide policymakers and hospital managers on best practices to strengthen hospitals’ readiness, limit the impact of the pandemic, and create lasting hospital sector improvements towards recovery and resilience.

Aim

Guided by the WHO/EMR’s “Hospital readiness checklist for COVID-19”, this study presents the experiences of EMR hospitals in combatting COVID-19 across the 22 EMR countries, including their challenges and interventions across the checklist domains, to inform improvements to pandemic preparedness, response, policy, and practice.

Methods

To collect in-depth and comprehensive information on hospital experiences, qualitative and descriptive quantitative data was collected between May-October 2020. To increase breadth of responses, this comprehensive qualitative study triangulated findings from a regional literature review with the findings of an open-ended online survey (n = 139), and virtual in-depth key informant interviews with 46 policymakers and hospital managers from 18 out of 22 EMR countries. Purposeful sampling supported by snowballing was used and continued until reaching data saturation, measures were taken to increase the trustworthiness of the results. Led by the checklist domains, qualitative data was thematically analyzed using MAXQDA.

Findings

Hospitals faced continuously changing challenges and needed to adapt to maintain operations and provide essential services. This thematic analysis revealed major themes for the challenges and interventions utilized by hospitals for each of hospital readiness domains: Preparedness, Leadership, Operational support, logistics, supply management, Communications and Information, Human Resources, Continuity of Essential Services and Surge Capacity, Rapid Identification and Diagnosis, Isolation and Case Management, and Infection, Prevention and Control.

Conclusion

Hospitals are the backbone of COVID-19 response, and their resilience is essential for achieving universal health coverage. Multi-pronged (across each of the hospitals readiness domains) and multi-level policies are required to strengthen hospitals resilience and prepare health systems for future outbreaks and shocks.

Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Human resources for health (HRH) include a range of occupations that aim to promote or improve human health. The UN Sustainable Development Goals (SDGs) and the WHO Health Workforce 2030 strategy have drawn attention to the importance of HRH for achieving policy priorities such as universal health coverage (UHC). Although previous research has found substantial global disparities in HRH, the absence of comparable cross-national estimates of existing workforces has hindered efforts to quantify workforce requirements to meet health system goals. We aimed to use comparable and standardised data sources to estimate HRH densities globally, and to examine the relationship between a subset of HRH cadres and UHC effective coverage performance.

METHODS

Through the International Labour Organization and Global Health Data Exchange databases, we identified 1404 country-years of data from labour force surveys and 69 country-years of census data, with detailed microdata on health-related employment. From the WHO National Health Workforce Accounts, we identified 2950 country-years of data. We mapped data from all occupational coding systems to the International Standard Classification of Occupations 1988 (ISCO-88), allowing for standardised estimation of densities for 16 categories of health workers across the full time series. Using data from 1990 to 2019 for 196 of 204 countries and territories, covering seven Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) super-regions and 21 regions, we applied spatiotemporal Gaussian process regression (ST-GPR) to model HRH densities from 1990 to 2019 for all countries and territories. We used stochastic frontier meta-regression to model the relationship between the UHC effective coverage index and densities for the four categories of health workers enumerated in SDG indicator 3.c.1 pertaining to HRH: physicians, nurses and midwives, dentistry personnel, and pharmaceutical personnel. We identified minimum workforce density thresholds required to meet a specified target of 80 out of 100 on the UHC effective coverage index, and quantified national shortages with respect to those minimum thresholds.

FINDINGS

We estimated that, in 2019, the world had 104·0 million (95% uncertainty interval 83·5-128·0) health workers, including 12·8 million (9·7-16·6) physicians, 29·8 million (23·3-37·7) nurses and midwives, 4·6 million (3·6-6·0) dentistry personnel, and 5·2 million (4·0-6·7) pharmaceutical personnel. We calculated a global physician density of 16·7 (12·6-21·6) per 10 000 population, and a nurse and midwife density of 38·6 (30·1-48·8) per 10 000 population. We found the GBD super-regions of sub-Saharan Africa, south Asia, and north Africa and the Middle East had the lowest HRH densities. To reach 80 out of 100 on the UHC effective coverage index, we estimated that, per 10 000 population, at least 20·7 physicians, 70·6 nurses and midwives, 8·2 dentistry personnel, and 9·4 pharmaceutical personnel would be needed. In total, the 2019 national health workforces fell short of these minimum thresholds by 6·4 million physicians, 30·6 million nurses and midwives, 3·3 million dentistry personnel, and 2·9 million pharmaceutical personnel.

INTERPRETATION

Considerable expansion of the world's health workforce is needed to achieve high levels of UHC effective coverage. The largest shortages are in low-income settings, highlighting the need for increased financing and coordination to train, employ, and retain human resources in the health sector. Actual HRH shortages might be larger than estimated because minimum thresholds for each cadre of health workers are benchmarked on health systems that most efficiently translate human resources into UHC attainment.

FUNDING

Bill & Melinda Gates Foundation.

Building resilient hospitals in the Eastern Mediterranean Region: lessons from the COVID-19 pandemic

Since the COVID-19 pandemic began, hospitals in the Eastern Mediterranean Region (EMR) have faced significant challenges in providing essential services, while simultaneously combatting this pandemic and responding to new and ongoing shocks and emergencies. Despite these challenges, policy-makers and hospital managers adapted their hospital responses to maintain operations and continue providing essential health services in resource-restraint and fragile and conflict affected, offering valuable insights to others in similar contexts. The aim of this paper is to share the lessons learnt from hospital responses to COVID-19 from the EMR. To do this, we triangulated findings from literature review, open-ended online surveys and 46 in-depth key informant interviews from 18 EMR countries. Qualitative findings from semistructured key informant interviews along with the open-ended survey responses resulted in nine major themes for lessons learnt in the EMR. These themes include Preparedness, Leadership and Coordination, Communication, Human Resources, Supplies and Logistics, Surge Capacity and Essential Services, Clinical Management (including Rapid Identification, Diagnosis and Isolation), Infection Prevention and Control, and Information and Research. Each of the nine themes (domains) included 4-6 major subthemes offering key insights into the regional hospital response to health emergencies. Resilient hospitals are those that can provide holistic, adaptable, primary-care-based health systems to deliver high-quality, effective and people-centred health services and respond to future outbreaks. Both bottom-up and top-down approaches are needed to strengthen collaboration between policy-makers, hospitals, front-line workers and communities to mitigate the continued spread of SARS CoV2, build resilient hospital systems and improve public health preparedness and emergency response.

Successes and challenges of health systems governance towards universal health coverage and global health security: a narrative review and synthesis of the literature

Background

The shift in the global burden of disease from communicable to noncommunicable was a factor in mobilizing support for a broader post-Millennium Development Goals (MDGs) health agenda. To curb these and other global health problems, 193 Member States of the United Nations (UN) became signatories of the Sustainable Development Goals (SDGs) and committed to achieving universal health coverage (UHC) by 2030. In the context of the coronavirus disease 2019 (COVID-19) pandemic, the importance of health systems governance (HSG) is felt now more than ever for addressing the pandemic and continuing to provide essential health services. However, little is known about the successes and challenges of HSG with respect to UHC and health security. This study, therefore, aims to synthesize the evidence and identify successes and challenges of HSG towards UHC and health security.

Methods

We conducted a structured narrative review of studies published through 28 July 2021. We searched the existing literature using three databases: PubMed, Scopus and Web of Science. Search terms included three themes: HSG, UHC and health security. We synthesized the findings using the five core functions of HSG: policy formulation and strategic plans; intelligence; regulation; collaboration and coalition; and accountability.

Results

A total of 58 articles were included in the final review. We identified that context-specific health policy and health financing modalities helped to speed up the progress towards UHC and health security. Robust health intelligence, intersectoral collaboration and coalition were also essential to combat the pandemic and ensure the delivery of essential health services. On the contrary, execution of a one-size-fits-all HSG approach, lack of healthcare funding, corruption, inadequate health workforce, and weak regulatory and health government policies were major challenges to achieving UHC and health security.

Conclusions

Countries, individually and collectively, need strong HSG to speed up the progress towards UHC and health security. Decentralization of health services to grass root levels, support of stakeholders, fair contribution and distribution of resources are essential to support the implementation of programmes towards UHC and health security. It is also vital to ensure independent regulatory accreditation of organizations in the health system and to integrate quality- and equity-related health service indicators into the national social protection monitoring and evaluation system; these will speed up the progress towards UHC and health security.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00858-7.

On the resilience of health systems: A methodological exploration across countries in the WHO African Region

The need for resilient health systems is recognized as important for the attainment of health outcomes, given the current shocks to health services. Resilience has been defined as the capacity to “prepare and effectively respond to crises; maintain core functions; and, informed by lessons learnt, reorganize if conditions require it”. There is however a recognized dichotomy between its conceptualization in literature, and its application in practice. We propose two mutually reinforcing categories of resilience, representing resilience targeted at potentially known shocks, and the inherent health system resilience, needed to respond to unpredictable shock events. We determined capacities for each of these categories, and explored this methodological proposition by computing country-specific scores against each capacity, for the 47 Member States of the WHO African Region. We assessed face validity of the computed index, to ensure derived values were representative of the different elements of resilience, and were predictive of health outcomes, and computed bias-corrected non-parametric confidence intervals of the emergency preparedness and response (EPR) and inherent system resilience (ISR) sub-indices, as well as the overall resilience index, using 1000 bootstrap replicates. We also explored the internal consistency and scale reliability of the index, by calculating Cronbach alphas for the various proposed capacities and their corresponding attributes. We computed overall resilience to be 48.4 out of a possible 100 in the 47 assessed countries, with generally lower levels of ISR. For ISR, the capacities were weakest for transformation capacity, followed by mobilization of resources, awareness of own capacities, self-regulation and finally diversity of services respectively. This paper aims to contribute to the growing body of empirical evidence on health systems and service resilience, which is of great importance to the functionality and performance of health systems, particularly in the context of COVID-19. It provides a methodological reflection for monitoring health system resilience, revealing areas of improvement in the provision of essential health services during shock events, and builds a case for the need for mechanisms, at country level, that address both specific and non-specific shocks to the health system, ultimately for the attainment of improved health outcomes.

From dichotomisation towards intersectionality in addressing covid-19

Anne-Sophie Jung and colleagues argue that understanding mechanisms of response to the covid-19 pandemic as trade-offs reinforces false dichotomies and hamstrings attempts to create stronger and more equitable health systems

COVID-19 calls for health systems strengthening in Africa: A case of Nigeria

The COVID‐19 pandemic has proven the need for countries worldwide to implement strategies that promote health systems strengthening and ensure epidemic preparedness. Many African countries are burdened by fragile healthcare systems, hence, this paper emphasises the need for African policymakers to improve healthcare quality in their countries. Through a brief review of various online literatures concerning health systems strengthening in Africa, this paper focuses on the nature of healthcare in Nigeria amidst the COVID‐19 pandemic. The major stress areas include COVID‐19 testing capacity, health workforce, infection prevention and control, health information and surveillance systems, health insurance, public‐private partnerships, and governance. The COVID‐19 pandemic has amplified several challenges ravaging Africa's already fragile healthcare systems, leaving the health sectors of most African countries ill‐prepared to deal with the pandemic. If Nigeria and many other African countries had invested sufficiently in strengthening their healthcare systems prior to COVID‐19, their pandemic response efforts would have been more effective. Health systems strengthening is necessary to ensure steady progress toward universal health coverage and global health security. Through health systems strengthening, Nigeria and other African countries can greatly improve their infection prevention and control measures.

Evidence of integrated health service delivery during COVID-19 in low and lower-middle-income countries: protocol for a scoping review

INTRODUCTION

The importance of integrated, people-centred health systems has been recognised as a central component of Universal Health Coverage. Integration has also been highlighted as a critical element for building resilient health systems that can withstand the shock of health emergencies. However, there is a dearth of research and systematic synthesis of evidence on the synergistic relationship between integrated health services and pandemic preparedness, response, and recovery in low-income and lower-middle-income countries (LMICs). Thus, the authors are organising a scoping review aiming to explore the application of integrated health service delivery approaches during the emerging COVID-19 pandemic in LMICs.

METHODS AND ANALYSIS

This scoping review adheres to the six steps for scoping reviews from Arksey and O'Malley. Peer-reviewed scientific literature will be systematically assembled using a standardised and replicable search strategy from seven electronic databases, including PubMed, Embase, Scopus, Web of Science, CINAHL Plus, the WHO's Global Research Database on COVID-19 and LitCovid. Initially, the title and abstract of the collected literature, published in English from December 2019 to June 2020, will be screened for inclusion which will be followed by a full-text review by two independent reviewers. Data will be charted using a data extraction form and reported in narrative format with accompanying data matrix.

ETHICS AND DISSEMINATION

No ethical approval is required for the review. The study will be conducted from June 2020 to May 2021. Results from this scoping review will provide a snapshot of the evidence currently being generated related to integrated health service delivery in response to the COVID-19 pandemic in LMICs. The findings will be developed into reports and a peer-reviewed article and will assist policy-makers in making pragmatic and evidence-based decisions for current and future pandemic responses.

Global Fund contributions to health security in ten countries, 2014-20: mapping synergies between vertical disease programmes and capacities for preventing, detecting, and responding to public health emergencies

BACKGROUND

The Global Fund to Fight AIDS, Tuberculosis and Malaria is a robust vertical global health programme. The extent to which vertical programmes financially support health security has not been investigated. We, therefore, endeavoured to quantify the extent to which the budgets of this vertical programme support health security. We believe this is a crucial area of work as the global community works to combine resources for COVID-19 response and future pandemic preparedness.

METHODS

We examined budgets for work in Kenya, Uganda, Vietnam, Democratic Republic of the Congo, Guatemala, Guinea, India, Indonesia, Nigeria, and Sierra Leone from January, 2014 to December, 2020. These ten countries were selected because of the robustness of investments and the availability of data. Using the International Health Regulations Joint External Evaluation (JEE) tool as a framework, we mapped budget line items to health security capacities. Two researchers independently reviewed each budget and mapped items to the JEE. Budgets were then jointly reviewed until a consensus was reached regarding if an item supported health security directly, indirectly, or not at all. The budgets for the study countries were inputted into a single Microsoft Excel spreadsheet and line items that mapped to JEE indicators were scaled up to their respective JEE capacity. Descriptive analyses were then done to determine the total amount of money budgeted for activities that support health security, how much was budgeted for each JEE capacity, and how much of the support was direct or indirect.

FINDINGS

The research team reviewed 37 budgets. Budgets totalled US$6 927 284 966, and $2 562 063 054 (37·0%) of this mapped to JEE capacities. $1 330 942 712 (19·2%) mapped directly to JEE capacities and $1 231 120 342 (17·8%) mapped indirectly to JEE capacities. Laboratory systems, antimicrobial resistance, and the deployment of medical countermeasures and personnel received the most overall budgetary support; laboratory systems, antimicrobial resistance, and workforce development received the greatest amount of direct budgetary support.

INTERPRETATION

Over one-third of the Global Fund's work also supports health security and the organisation has budgeted more than $2 500 000 000 for activities that support health security in ten countries since 2014. Although these funds were not budgeted specifically for health security purposes, recognising how vertical programmes can synergistically support other global health efforts has important implications for policy related to health systems strengthening.

FUNDING

Resolve to Save Lives: An Initiative of Vital Strategies.

Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage

The COVID-19 pandemic has placed enormous strain on countries around the world, exposing long-standing gaps in public health and exacerbating chronic inequities. Although research and analyses have attempted to draw important lessons on how to strengthen pandemic preparedness and response, few have examined the effect that fragmented governance for health has had on effectively mitigating the crisis. By assessing the ability of health systems to manage COVID-19 from the perspective of two key approaches to global health policy-global health security and universal health coverage-important lessons can be drawn for how to align varied priorities and objectives in strengthening health systems. This Health Policy paper compares three types of health systems (ie, with stronger investments in global health security, stronger investments in universal health coverage, and integrated investments in global health security and universal health coverage) in their response to the ongoing COVID-19 pandemic and synthesises four essential recommendations (ie, integration, financing, resilience, and equity) to reimagine governance, policies, and investments for better health towards a more sustainable future.

Global health security and universal health coverage: Understanding convergences and divergences for a synergistic response

BACKGROUND

Global health security (GHS) and universal health coverage (UHC) are key global health agendas which aspire for a healthier and safer world. However, there are tensions between GHS and UHC strategy and implementation. The objective of this study was to assess the relationship between GHS and UHC using two recent quantitative indices.

METHODS

We conducted a macro-analysis to determine the presence of relationship between GHS index (GHSI) and UHC index (UHCI). We calculated Pearson's correlation coefficient and the coefficient of determination. Analyses were performed using IBM SPSS Statistics Version 25 with a 95% level of confidence.

FINDINGS

There is a moderate and significant relationship between GHSI and UHCI (r = 0.662, p<0.001) and individual indices of UHCI (maternal and child health and infectious diseases: r = 0.623 (p<0.001) and 0.594 (p<0.001), respectively). However, there is no relationship between GHSI and the non-communicable diseases (NCDs) index (r = 0.063, p>0.05). The risk of GHS threats a significant and negative correlation with the capacity for GHS (r = -0.604, p<0.001) and the capacity for UHC (r = -0.792, p<0.001).

CONCLUSION

The aspiration for GHS will not be realized without UHC; hence, the tension between these two global health agendas should be transformed into a synergistic solution. We argue that strengthening the health systems, in tandem with the principles of primary health care, and implementing a "One Health" approach will progressively enable countries to achieve both UHC and GHS towards a healthier and safer world that everyone aspires to live in.

Building health system resilience in the context of primary health care revitalization for attainment of UHC: proceedings from the Fifth Health Sector Directors' Policy and Planning Meeting for the WHO African Region

Background

The recent 2018 Declaration of Astana recognized primary health care (PHC) as a means to achieve universal health coverage (UHC) and the health-related Sustainable Development Goals (SDGs). Following this declaration, country progress on operationalization of the PHC agenda and attainment of UHC has been stalled by the new challenges posed by the COVID-19 pandemic. The pandemic has also disrupted the continuity of essential health service provision and tested the resilience of the region’s health systems.

Methods

In accordance with this, the WHO Regional Office for Africa convened the Fifth Health Sector Directors’ Planning and Policy Meeting across the 47 Member States of the Region. The two-day forum focused on building health system resilience to facilitate service continuity during health threats, PHC revitalization, and health systems strengthening towards UHC.

Results

The Regional Forum provided evidence on building resilient health systems in the WHO African Region and engaged participants in meaningful and critical discussion. It is from these discussions that four key themes emerged: (1) working multisectorally/intersectorally, (2) moving from fragmentation to integration, (3) ensuring implementation and knowledge exchange, and (4) rethinking resilience and embracing antifragility. These discussions and associated groupings by thematic areas lend themselves to recommendations for the WHO.

Conclusions

This paper details the proceedings and key findings on building resilient health systems, the four themes that emerged from participant deliberation, and the recommendations that have emerged from the meeting. Deliberations from the Regional Forum are critical, as they have the potential to directly inform policy and program design, given that the meeting convenes health sector technocrats, who are at the helm of policy design, action, and implementation.

From the Frontline: Strengthening Surveillance and Response Capacities of the Rural Workforce in the Asia-Pacific Region. How Can Grass-Roots Implementation Research Help?

Health systems in the Asia-Pacific region are poorly prepared for pandemic threats, particularly in rural/provincial areas. Yet future emerging infectious diseases are highly likely to emerge in these rural/provincial areas, due to high levels of contact between animals and humans (domestically and through agricultural activities), over-stretched and under-resourced health systems, notably within the health workforce, and a diverse array of socio-cultural determinants of health. In order to optimally implement health security measures at the frontline of health services where the people are served, it is vital to build capacity at the local district and facility level to adapt national and global guidelines to local contexts, including health systems, and community and socio-cultural realities. During 2017/18 James Cook University (JCU) facilitated an implementation research training program (funded by Australian Department of Foreign Affairs and Trade) for rural/provincial and regional health and biosecurity workers and managers from Fiji, Indonesia, Papua New Guinea (PNG), Solomon Islands and Timor-Leste. This training was designed so frontline health workers could learn research in their workplace, with no funding other than workplace resources, on topics relevant to health security in their local setting. The program, based upon the WHO-TDR Structured Operational Research and Training IniTiative (SORT-IT) consists of three blocks of teaching and a small, workplace-based research project. Over 50 projects by health workers including surveillance staff, laboratory managers, disease control officers, and border security staff included: analysis and mapping of surveillance data, infection control, IHR readiness, prevention/response and outbreak investigation. Policy briefs written by participants have informed local, provincial and national health managers, policy makers and development partners and provided on-the-ground recommendations for improved practice and training. These policy briefs reflected the socio-cultural, health system and disease-specific realities of each context. The information in the policy briefs can be used collectively to assess and strengthen health workforce capacity in rural/provincial areas. The capacity to use robust but simple research tools for formative and evaluative purposes provides sustainable capacity in the health system, particularly the rural health workforce. This capacity improves responses to infectious diseases threats and builds resilience into fragile health systems.

'Never let a crisis go to waste': post-Ebola agenda-setting for health system strengthening in Guinea

Introduction

Guinea is a country with a critical deficit and maldistribution of healthcare workers along with a high risk of epidemics' occurrence. However, actors in the health sector have missed opportunities for more than a decade to attract political attention. This article aims to explain why this situation exists and what were the roles of actors in the agenda-setting process of the post-Ebola health system strengthening programme. It also assesses threats and opportunities for this programme's sustainability.

Methods

We used Kingdon’s agenda-setting methodological framework to explain why actors promptly focused on the health sector reform after the Ebola outbreak. We conducted a qualitative explanatory study using a literature review and key informant interviews.

Results

We found that, in the problem stream, the Ebola epidemic caused considerable fear among national as well as international actors, a social crisis and an economic system failure. This social crisis was entertained by communities’ suspicion of an 'Ebola-business'. In response to these problems, policy actors identified three sets of solutions: the temporary external funds generated by the Ebola response; the availability of experienced health workers in the Ebola control team; and the overproduction of health graduates in the labour market. We also found that the politics agenda was dominated by two major factors: the global health security agenda and the political and financial interests of national policy actors. Although the opening of the policy window has improved human resources, finance and logistics, and infrastructures pillars of the health system, it, however, disproportionally focuses on epidemic preparedness and response. and neglects patients’ financial affordability of essential health services.

Conclusion

Domestic policy entrepreneurs must realise that agenda-setting of health issues in the Guinean context strongly depends on the construction of the problem definition and how this is influenced by international actors.

After the Astana declaration: is comprehensive primary health care set for success this time?

Primary health care (PHC) strengthening in order to achieve the Sustainable Development Goal has again, 40 years after the Alma-Ata declaration, been declared a priority by the global health community. Despite initial progress the Alma-Ata vision of Health for All by the year 2000 was not realised. In this analysis we (1) examine the challenges that comprehensive PHC faced after the Alma-Ata declaration, (2) provide an analysis of the current opportunities and threats to comprehensive PHC strengthening on the global, national and community level and (3) review the most important policy recommendations and related evidence to address these threats for success of the Astana declaration. Factors that are predominantly opportunities are the treasure of historical lessons from the past 40 years, the increased attention to social and environmental determinants of health, the global economic growth and new technologies, in particular digital medicine, which also have the potential to revolutionise community involvement. Factors that are currently predominantly threats are insecurity, conflicts and disease outbreaks; lack of sustained political commitment and inappropriate monitoring and evaluation structures; inappropriate and unsustainable financing models; insufficient health workforce recruitment, employment and retention; missing support of physicians and their professional organisations; inadequately addressing the needs of the community and not giving attention to gender equity. In contrast to the policy and evidence context in 1978 when Alma-Ata was passed there are today policy recommendations and a large body of evidence that can address the threats to comprehensive PHC-and turn them into opportunities.

Harmonization of Biosafety and Biosecurity Standards for High-Containment Facilities in Low- and Middle-Income Countries: An Approach From the Perspective of Occupational Safety and Health

Following the global-level Ebola virus disease (EVD) outbreak during 2014–2016, international collaboration with multiorganizational participation has rapidly increased. Given the greater priorities for research and development (R&D) outcomes despite the quantitative and qualitative lack of high-containment laboratory facilities in low- and middle-income countries (LMICs), where biological targets for investigation are located near their natural habitats, occupational readiness for health workers' safety has not been well-addressed, where limited global expert human resources are being deployed to high-containment laboratories including biosafety level 4 (BSL-4) facilities for case management and medical investigations. Pursuing scientific and managerial success to make laboratories efficient and productive, most laboratory safety policies have focused on the functionality of technical skills or performance, procedural methodologies, and supervision over the employees to collaborate in LMICs. The experts dispatched from advanced countries bring a long list of scientific tasks with high-tech devices, supplies, and training programs to introduce their collaboration with local partners in LMICs. However, the dispatched experts would subsequently realize their list becomes endless to establish their basic functions required in high-containment laboratories to ensure qualified scientific outcomes in LMICs. Under such circumstances where dual or multiple policies and standards accommodated pose dilemmas for operational procedures to ensure biosafety and biosecurity, all the frontline experts from both LMICs and advanced countries may be exposed to significant risks of life-threating infection of highly pathogenic agents like EVD, without any pragmatic measures or road maps to establish valued international collaboration, pursuing its sustainability. Given the fact mentioned above, we conducted a quick review of the key biosafety and biosecurity management documents, relevant policy analyses, and research to understand the current status and, if any, measures to dissolve critical dilemmas mentioned above. As a result, we found that occupational safety and health (OSH) aspects had not been sufficiently addressed, particularly in the context of international BSL-4 collaboration in LMICs. Moreover, consideration of OSH can be one of the key drivers to make such collaborative interventions more pragmatic, safer to reorient, harness disease-based vertical approaches, and harmonize policies of biosafety and biosecurity, particularly for collaborations organized in resource-limited settings.