Academic Publication

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

Author:
Nature Medicine
Source:
Nature Medicine
Contributor:
Publication Year:
2021
  • SDG 3 - Good Health and Well-Being
  • SDG 9 - Industry, Innovation and Infrastructure

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.

Abstract

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.

Main

COVID-19 has caused an unprecedented global crisis, including millions of lives lost, public health systems in shock and economic and social disruption, disproportionately affecting the most vulnerable. As of April 2021, there are over 140 million confirmed cases and over three million COVID-19 deaths globally1. While vaccination has commenced in numerous countries, new outbreaks and variants continue to emerge. At the same time, the global distribution of vaccines is marred by challenges of equity on top of logistical complications. Millions more are therefore still at risk of dying, facing significant morbidity or losing their livelihoods given the uncertain economic outlook.

The pandemic has challenged local, national, regional and global capacities to prepare and respond. The various national strategies taken to control viral transmission are widely debated2,3. However, the relative success of these strategies depends largely on how an existing health system is organized, governed and financed across all levels in a coordinated manner4. The pandemic has exposed the limitations of many health systems, including some that have been previously classified as high performing and resilient5. A comprehensive analysis of the resilience of health systems during the pandemic can therefore pinpoint important lessons and help strengthen countries’ preparedness, response and approach to future health challenges.

While resilience is a core concept in disaster risk reduction, its application to health systems is relatively new. It has been defined broadly as institutions’ and health actors’ capacities to prepare for, recover from and absorb shocks, while maintaining core functions and serving the ongoing and acute care needs of their communities6,7. During a crisis, a resilient health system is able to effectively adapt in response to dynamic situations and reduce vulnerability across and beyond the system. Experience from previous epidemics, such as Ebola, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome, emphasized the links between resilience and thwarting new outbreak transmission8.

Health systems resilience literature stresses that efforts should focus not only on absorbing unforeseen shocks precipitated by emerging health needs, but also on ensuring continuity in health improvement, sustaining gains in systems functioning and fostering people centeredness, while delivering high-quality care9,10. As COVID-19 has overwhelmed health systems worldwide, debates around resilience have become more urgent, and there is a need to better understand the elements of national responses through a resilience lens11,12. Thus, in this perspective, we use an expanded health systems resilience framework centered on community engagement to examine 28 national responses to COVID-19. This analysis provides insights into the policies countries implemented and how these were implemented to tackle the pandemic.

Conceptual framework

Our conceptual framework (Fig. 1) is grounded in the World Health Organization’s (WHO) health systems framework13. We develop the framework elements by adding public health functions, including testing, contact tracing, disease surveillance and non-pharmaceutical public health interventions, which often operate separately from health service delivery. Yet, they are critical both to pandemic responses and to ongoing population health. Similarly, health information systems are vital functions for both public health and health systems as, ideally, they should be integrated to capture data at individual, health system and population levels.

Fig. 1: Determinants of health systems resilience framework.

Fig. 1: Determinants of health systems resilience framework.
The scheme illustrates the components of the resilient health systems framework we developed based on the WHO’s health systems building blocks framework. The five elements of resilient health systems are centered around community engagement as core to all elements of health systems resilience.

 

We centered our analysis on community engagement as core to all elements of health systems resilience (see Box 1 for more information on the analytical approach). To serve communities in a more equitable manner and promote healthy societies, resilience must be developed with these communities and according to their needs. There can be no health systems resilience without community engagement across domains14. We also acknowledge the critical role of coordination with non-health sectors as essential to providing necessary supports to address the social determinants of health. Underpinning these elements are health equity and outcomes. Resilient health systems should aim to generate positive physical and mental health outcomes for all, including vulnerable and marginalized groups. In many countries, COVID-19 mortality rates have been disproportionately higher among older populations, minority ethnic groups, socioeconomically deprived populations and low-wage and migrant workers, emphasizing the interconnectedness between equity and health outcomes15.

COVID-19 responses in 28 countries

Using our framework, we organized our results beginning with domains often viewed as external to health, which are nevertheless central determinants of health systems resilience—governance, finance, collaboration across sectors and community engagement—before exploring domains more closely associated with traditional views of health and health systems—health service delivery, health workforce, medical products and technologies and public health functions. We offer illustrative examples of selected countries for each domain in Tables 16. We analyzed 28 countries based on a purposive selection, including positive and negative outliers in relation to reported COVID-19 deaths per capita among highly populous countries, as well as a selection of countries in the middle ground (as of 6 November 2020). Figure 2 provides an overview of countries in our review.

Share

Suggested Articles

Child Health+4 more topics
Best of UNICEF Research 2021 Live Award Ceremony - with the participation of the Executive Director on 1 December | 9-10am EST / 3-4pm CET CLICK HERE TO REGISTER The event will celebrate research best practices at UNICEF, feature the 11 research finalists and award the top 3 research pieces with...
Contributor:
7 Likes
Education+2 more topics
Global Forum on AI for Children UNICEF invites you to join this virtual event on November 30 – December 1, 2021 to discuss practical approaches to child-centred AI policies and systems. Participants will have an opportunity to network, share their knowledge and learn from leading experts in the AI...
Contributor:
10 Likes