Integrated health service delivery during COVID-19: a scoping review of published evidence from low-income and lower-middle-income countries

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

Background

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

Methods

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

Results

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

Conclusion

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

Defining and identifying the critical elements of operational readiness for public health emergency events: a rapid scoping review

INTRODUCTION

COVID-19 showed that countries must strengthen their operational readiness (OPR) capabilities to respond to an imminent pandemic threat rapidly and proactively. We conducted a rapid scoping evidence review to understand the definition and critical elements of OPR against five core sub-systems of a new framework to strengthen the global architecture for Health Emergency Preparedness Response and Resilience (HEPR).

METHODS

We searched MEDLINE, Embase, and Web of Science, targeted repositories, websites, and grey literature databases for publications between 1 January 2010 and 29 September 2021 in English, German, French or Afrikaans. Included sources were of any study design, reporting OPR, defined as immediate actions taken in the presence of an imminent threat, from groups who led or responded to a specified health emergency. We used prespecified and tested methods to screen and select sources, extract data, assess credibility and analyse results against the HEPR framework.

RESULTS

Of 7005 sources reviewed, 79 met the eligibility criteria, including 54 peer-reviewed publications. The majority were descriptive reports (28%) and qualitative analyses (30%) from early stages of the COVID-19 pandemic. Definitions of OPR varied while nine articles explicitly used the term 'readiness', others classified OPR as part of preparedness or response. Applying our working OPR definition across all sources, we identified OPR actions within all five HEPR subsystems. These included resource prepositioning for early detection, data sharing, tailored communication and interventions, augmented staffing, timely supply procurement, availability and strategic dissemination of medical countermeasures, leadership, comprehensive risk assessment and resource allocation supported by relevant legislation. We identified gaps related to OPR for research and technology-enabled manufacturing platforms.

CONCLUSIONS

OPR is in an early stage of adoption. Establishing a consistent and explicit framework for OPRs within the context of existing global legal and policy frameworks can foster coherence and guide evidence-based policy and practice improvements in health emergency management.

The Value Proposition of Coordinated Population Cohorts Across Africa

Building longitudinal population cohorts in Africa for coordinated research and surveillance can influence the setting of national health priorities, lead to the introduction of appropriate interventions, and provide evidence for targeted treatment, leading to better health across the continent. However, compared to cohorts from the global north, longitudinal continental African population cohorts remain scarce, are relatively small in size, and lack data complexity. As infections and noncommunicable diseases disproportionately affect Africa's approximately 1.4 billion inhabitants, African cohorts present a unique opportunity for research and surveillance. High genetic diversity in African populations and multiomic research studies, together with detailed phenotyping and clinical profiling, will be a treasure trove for discovery. The outcomes, including novel drug targets, biological pathways for disease, and gene-environment interactions, will boost precision medicine approaches, not only in Africa but across the globe.

COVID-19 pandemic in Bangladesh: A scoping review of governance issues affecting response in public sector

Background

On January 30, 2020, WHO declared COVID-19 as a Global Public Health Emergency. The first three COVID-19 cases in Bangladesh were confirmed on March 8, 2020. Thus, Bangladesh got substantial time to prepare the people and the health systems to respond to the outbreak However, neither the health ministry nor the government was found to rise to the occasion and provide the necessary stewardship for a coordinated and comprehensive response.

Objective

The importance of governance to mount an evidence-based pandemic response cannot be overemphasised. This study presents critical reflections on the Bangladesh government's COVID-19 response through a review of selected papers, with expert deliberations on the review findings to consolidate emerging lessons for future pandemic preparedness.

Study design

A scoping review approach was taken for this study.

Methods

Documents focusing on COVID-19 governance were selected from a repository of peer-reviewed articles published by researchers using data from Bangladesh (n = 11).

Results

Findings reveal Bangladesh's COVID-19 response to be delayed, slow, and ambiguous, reflecting poorly on its governance. Lack of governance capability in screening for COVID-19, instituting quarantine and lockdown measures in the early weeks, safety and security of frontline healthcare providers, timely and equitable COVID-19 testing, and logistics and procurement were phenomenal. The pandemic unmasked the weaknesses of the health system in this regard and "created new opportunities for corruption." The failure to harmonise coordination among the government's different agencies for the COVID-19 response, along with poor risk communication, which was not culture-sensitive and context-specific. Over time, the government initiated necessary actions to mitigate the pandemic's impact on the lives and livelihoods of the people. Diagnostic and case management services gained strength after some initial faltering; however, the stewardship functions were not seamless.

Conclusions

Shortage of healthcare workers, incapability of health facilities to cater to COVID-19 suspects and cases, absence of health system resilience, and corruption in procurement and purchases were limited the government's COVID-19 response. These need urgent attention from policymakers to better prepare for the next epidemic/pandemic.

Understanding how neglected tropical diseases programs in five Asia-Pacific countries adjusted to the COVID-19 pandemic: A qualitative study

BACKGROUND

Following the COVID-19 pandemic declaration, the World Health Organization recommended suspending neglected tropical diseases (NTD) control activities as part of sweeping strategies to minimise COVID-19 transmission. Understanding how NTD programs were impacted and resumed operations will inform contingency planning for future emergencies. This is the first study that documents how South-East Asian and Pacific NTD programs addressed challenges experienced during the COVID-19 pandemic.

METHODOLOGY/PRINCIPAL FINDINGS

Data was collected through semi-structured interviews with 11 NTD Program Coordinators and related personnel from Fiji, Papua New Guinea, The Philippines, Timor-Leste, and Vanuatu. Constructivist grounded theory methods were drawn on to generate an explanation of factors that enabled or hindered NTD program operations during the COVID-19 pandemic. The COVID-19 pandemic disrupted NTD programs in all countries. Some programs implemented novel strategies by partnering with services deemed essential or used new communications technology to continue (albeit scaled-back) NTD activities. Strong relationships to initiate cross-program integration, sufficient resources to implement adapted activities, and dedicated administrative systems were key enabling factors for recommencement. As the COVID-19 pandemic continued, exacerbating health resources scarcity, programs faced funding shortages and participants needed to find efficiencies through greater integration and activity prioritisation within their NTD units. Emphasising community-led approaches to restore trust and engagement was critical after widespread social anxiety and disconnection.

CONCLUSIONS/SIGNIFICANCE

Sustaining effective NTD programs during a global emergency goes beyond managing immediate activity disruptions and requires attention to how NTD programs can be better ensconced within wider health programs, administrative, and social systems. This study underscores the importance of pre-emergency planning that reinforces NTD control programs as a critical service at all health systems levels, accompanied by governance arrangements that increase NTD staff control over their operations and strategies to maintain strong community relationships. Ensuring NTD units are supported via appropriate funding, personnel, and bureaucratic resources is also required.

Assessing depression and anxiety among young adults after epidemics and pandemics: a cross-sectional study in Anyang, China

It has been well established that pandemics affect mental health, yet few studies have been conducted in China regarding this issue following COVID-19's gradual decline and the recent H1N1 influenza outbreak. In response to this research gap, this investigation explores the risk factors linked to depression and anxiety symptoms among young adults in this specific setting. Data were collected via an online cross-sectional survey of 385 young adults living in Anyang city, Henan Province, China, between June 15 and July 21, 2023. Respondents were assessed for anxiety and depression symptoms using the GAD-7 and PHQ-9 scales. Additionally, to examine the factors that influenced the study, we utilized an ordered logit regression model. Results revealed depression and anxiety prevalence rates of 33.3% and 21.6%, respectively. Several factors were found to increase the likelihood of depression and anxiety among young adults, including gender, age, education status, marital status, and attitudes towards epidemics. Participants' concerns about pandemics and viruses had a significant negative impact relationship on depression levels. Women report moderate to severe anxiety more frequently than men. An evident correlation can be observed between the educational attainment level and the influence of depression and anxiety.

A resilience view on health system resilience: a scoping review of empirical studies and reviews

BACKGROUND

Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature.

METHODS

We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation.

RESULTS

The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature.

CONCLUSIONS

Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

Healthcare resilience: a meta-narrative systematic review and synthesis of reviews

OBJECTIVES

The COVID-19 pandemic has tested global healthcare resilience. Many countries previously considered 'resilient' have performed poorly. Available organisational and system frameworks tend to be context-dependent and focus heavily on physical capacities. This study aims to explore and synthesise evidence about healthcare resilience and present a unified framework for future resilience-building.

DESIGN

Systematic review and synthesis of reviews using a meta-narrative approach.

SETTING

Healthcare organisations and systems.

PRIMARY AND SECONDARY OUTCOME MEASURES

Definitions, concepts and measures of healthcare resilience. We used thematic analysis across included reviews to summarise evidence on healthcare resilience.

RESULTS

The main paradigms within healthcare resilience include global health, disaster risk reduction, emergency management, patient safety and public health. Definitions of healthcare resilience recognise various hierarchical levels: individual (micro), facility or organisation (meso), health system (macro) and planetary or international (meta). There has been a shift from a focus on mainly disasters and crises, to an 'all-hazards' approach to resilience. Attempts to measure resilience have met with limited success. We analysed key concepts to build a framework for healthcare resilience containing pre-event, intra-event, post-event and trans-event domains. Alongside, we synthesise a definition which dovetails with our framework.

CONCLUSION

Resilience increasingly takes an all-hazards approach and a process-oriented perspective. There is increasing recognition of the relational aspects of resilience. Few frameworks incorporate these, and they are difficult to capture within measurement systems. We need to understand how resilience works across hierarchical levels, and how competing priorities may affect overall resilience. Understanding these will underpin interdisciplinary, cross-sectoral and multi-level approaches to healthcare resilience for the future.

PROSPERO REGISTRATION NUMBER

CRD42022314729.

Who are the vulnerable, and how do we reach them? Perspectives of health system actors and community leaders in Kerala, India

BACKGROUND

Among the core principles of the 2030 agenda of Sustainable Development Goals (SDGs) is the call to Leave no One behind (LNOB), a principle that gained resonance as the world contended with the COVID-19 pandemic. The south Indian state of Kerala received acclaim globally for its efforts in managing COVID-19 pandemic. Less attention has been paid, however, to how inclusive this management was, as well as if and how those "left behind" in testing, care, treatment, and vaccination efforts were identified and catered to. Filling this gap was the aim of our study.

METHODS

We conducted In-depth interviews with 80 participants from four districts of Kerala from July to October 2021. Participants included elected local self-government members, medical and public health staff, as well as community leaders. Following written informed consent procedures, each interviewee was asked questions about whom they considered the most "vulnerable" in their areas. They were also asked if there were any special programmes/schemes to support the access of "vulnerable" groups to general and COVID related health services, as well as other needs. Recordings were transliterated into English and analysed thematically by a team of researchers using ATLAS.ti 9.1 software.

RESULTS

The age range of participants was between 35 and 60 years. Vulnerability was described differentially by geography and economic context; for e.g., fisherfolk were identified in coastal areas while migrant labourers were considered as vulnerable in semi-urban areas. In the context of COVID-19, some participants reflected that everyone was vulnerable. In most cases, vulnerable groups were already beneficiaries of various government schemes within and beyond the health sector. During COVID, the government prioritized access to COVID-19 testing and vaccination among marginalized population groups like palliative care patients, the elderly, migrant labourers, as well as Scheduled Caste and Scheduled Tribes communities. Livelihood support like food kits, community kitchen, and patient transportation were provided by the LSGs to support these groups. This involved coordination between health and other departments, which may be formalised, streamlined and optimised in the future.

CONCLUSION

Health system actors and local self-government members were aware of vulnerable populations prioritized under various schemes but did not describe vulnerable groups beyond this. Emphasis was placed on the broad range of services made available to these "left behind" groups through interdepartmental and multi-stakeholder collaboration. Further study (currently underway) may offer insights into how these communities - identified as vulnerable - perceive themselves, and whether/how they receive, and experience schemes designed for them. At the program level, inclusive and innovative identification and recruitment mechanisms need to be devised to identify populations who are currently left behind but may still be invisible to system actors and leaders.

Examining the Impact of Key Factors on COVID-19 Vaccination Coverage in India: A PLS-SEM Approach

During the coronavirus disease 2019 (COVID-19) pandemic, numerous factors determined the performance of COVID-19 vaccination coverage. The purpose of this study is to examine the influence of factors such as government stewardship, planning and implementation, and community participation on COVID-19 vaccination coverage. This study applied partial least square structured equation modeling (PLS-SEM) by analyzing 187 responses from the stakeholders involved in vaccination programs in four select states of India. This study empirically validates a framework for improving vaccination coverage by confirming the significant impact of planning and implementation on vaccination coverage followed by government stewardship and community participation. Additionally, this study highlights the individual impact of each factor on vaccination coverage. Based on the findings, strategic recommendations were proposed that can be utilized for formulating policy-level actions to facilitate the vaccination program.

Global inequity creates local insufficiency: A qualitative study of COVID-19 vaccine implementation challenges in low-and-middle-income countries

INTRODUCTION

The COVID-19 pandemic has amplified pre-existing challenges to health promotion and care across the world, and particularly in low- and middle-income countries (LMICs). This qualitative study draws on data from a panel of immunisation experts and uses a novel framework of vaccine delivery domains to explore perspectives from those who live and work in these settings on the challenges to implementing COVID-19 vaccine programs in LMICs.

METHODS

We conducted a thematic content analysis of 96 participant free text replies to questions from Round I of a three-round Delphi consensus study amongst global experts on COVID-19 vaccine implementation.

RESULTS

Participant responses highlighted challenges to vaccine program implementation including issues related to equity; governance, decision-making, and financing; regulatory structures, planning, and coordination; prioritisation, demand generation, and communication; vaccine, cold chain, logistics, and infrastructure; service delivery, human resources, and supplies; and surveillance, monitoring, and evaluation.

CONCLUSION

We reflect on our findings in light of global efforts to address vaccine inequity and emphasise three key areas salient to improving vaccination efforts during novel infectious disease outbreaks: 1) Ensuring safe and sustainable service delivery in communities and at points of care; 2) Strengthening systems for end-to-end delivery of vaccines, therapeutics, diagnostics, and essential supplies; 3) Transforming structural paradigms towards vaccine equity.

Barriers against and strategies for malaria control during the COVID-19 pandemic in low- and middle-income countries: a systematic review

BACKGROUND

The COVID-19 pandemic has disrupted malaria control activities globally. Notably, high levels of excess malaria morbidity and mortality in low- and middle-income countries (LMICs) were reported. Although it is crucial to systematically understand the main causes of the disruption to malaria control and synthesize strategies to prepare for future pandemics, such studies are scarce. Therefore, this study aims to better identify barriers against and strategies for malaria control.

METHODS

Following the PRISMA guidelines and through searches of electronic databases and Google Scholar, a systematic literature review was conducted to identify studies pertaining to malaria control published between January 2020 and December 2021. Only studies that discussed reported barriers and/or strategies related to malaria were included for the review. The Mixed Methods Quality Appraisal Tool (MMAT) and the Authority, Accuracy, Coverage, Objectivity, Date and Significance (AACODS) checklist were used for quality appraisal. Key information such as literature type, study design, setting and population, interventions, outcomes, barriers, and strategies were extracted. With an existing framework of four dimensions (accessibility, affordability, availability, and acceptability) further subdivided by the supply and demand sides, this study synthesized information on barriers and strategies related to malaria control and further categorized the strategies based on the time frame.

RESULTS

From the 30 selected studies, 27 barriers and 39 strategies were identified. The lockdown measures, which mainly threatened geographic accessibility and availability of malaria control services, were identified to be the main barrier hindering effective mobilization of community health workers and resources. Among the identified strategies, clear risk communication strategies would alleviate psychosocial barriers, which challenged acceptability. Some strategies that cross-cut points across all four dimensions would, require systems-level integration to enhance availability and affordability of malaria control. The strategies were distinguished between short-term, for instant response, and mid to long-term for future readiness.

CONCLUSIONS

The pandemic resulted in complex barriers to malaria control, particularly imposing a double burden on LMICs. Identifying strategies to overcome said barriers provides useful insights in the decision-making processes for the current and future pandemic. Cross-cutting strategies that integrate all dimensions need to be considered. Health system strengthening and resilience strategy appropriate for country-specific context is fundamental.

Exploring indirect impacts of COVID-19 on local health systems from the perspectives of health workers and higher education stakeholders in the Philippines using a phenomenological approach

BACKGROUND

Our study aimed to explore the experiences of stakeholders from local government units, health facilities and higher education institutions on the delivery of non-COVID-19 health services after the initial wave of the pandemic.

METHODS

Twenty-nine public health workers, thirteen university staff, and four hospital administrators in the Philippines participated. Using a descriptive phenomenological approach, we analysed transcripts from six focus group discussions conducted online between March and June 2021.

FINDINGS

The COVID-19 pandemic made the routine health programs inaccessible due to hesitancy among patients to visit health facilities, a shift in public health priorities, and lack of students to augment the existing workforce.Public health workers reported stress and mental health exhaustion. Apart from fear of infection during service provision, public health workers and university staff experienced work overload, pressure to learn new technology, and webinar fatigue. Mental health problems have surfaced as health workers and young people have become more affected while support services remain insufficient.Public health workers have reported actions to maintain service delivery in the new normal such as use of telehealth and social media. However, issues on workforce wellbeing and digital equity posed adaptation challenges. Participants suggested partnership with higher education institutions as pivotal to position local health systems towards recovery.

INTERPRETATION

The rapid change in the service landscape highlights the importance of sustainable partnerships, effective workforce management, equitable digital innovations, and promoting mental wellbeing to preserve community, school, and occupational health and rebuild resilient local health systems in low-resourced areas.

FUNDING

This research is proudly supported by the Australia-ASEAN Council, Australian Government Department of Foreign Affairs and Trade.

Innovation for infection prevention and control-revisiting Pasteur's vision

Louis Pasteur has long been heralded as one of the fathers of microbiology and immunology. Less known is Pasteur's vision on infection prevention and control (IPC) that drove current infection control, public health, and much of modern medicine and surgery. In this Review, we revisited Pasteur's pioneering works to assess progress and challenges in the process and technological innovation of IPC. We focused on Pasteur's far-sighted conceptualisation of the hospital as a reservoir of microorganisms and amplifier of transmission, aseptic technique in surgery, public health education, interdisciplinary working, and the protection of health services and patients. Examples from across the globe help inform future thinking for IPC innovation, adoption, scale up and sustained use.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

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

The impact of COVID-19 on service delivery systems: evidence from a survey of United States refugee resettlement agencies

BACKGROUND

Key to the US refugee resettlement effort is the role of non-governmental organizations (NGOs) who receive, place, and provide transitional programs and referrals to new and recently resettled refugees. Yet only one rapid assessment study thus far examined the impact of COVID-19 on service delivery systems of US refugee resettlement agencies. This exploratory study describes the capability and preparedness of US refugee resettlement agencies to provide services and care to clients during the COVID-19 pandemic.

METHODS

Using both telephone interviews and an internet survey, we assessed the impact of COVID-19 on service delivery, agency capacity, and preparedness of 101 US refugee resettlement agencies. Descriptive statistics were used to describe the dataset, while chi-square (χ²) tests were used to examine relationships by resettlement agency size (number of employees in each agency).

RESULTS

Despite a temporary pause on refugee admissions, restrictive stay-at-home orders, and refugee travel restrictions, the majority of responding US refugee resettlement agencies continued to provide specialized services and care to resettled refugees and other immigrants. Among the more important findings was that agencies that continued to provide refugee services and care onsite in their existing facilities or office rather than moving such services offsite differed by agency size [χ² (9.494, n = 101), p < 0.05]. Almost all agencies (93.1%) strongly agreed or agreed that staff have timely access to COVID-19 information. Most of the refugee services were provided offsite (n = 72 agencies, some with multiple offices across the US).

CONCLUSIONS

US refugee resettlement agencies continued to perform admirably despite a lack of funding. Future research is underway to obtain a more balanced understanding of the impact of COVID-19 on practice or operations.