Building Resilient Health Systems Research Articles

A story of (in)coherence: climate adaptation for health in South African policies.

Climate adaptation strengthens and builds the resilience of health systems to future climate-related shocks. Adaptation strategies and policies are necessary tools for governments to address the long-term impacts of climate change and enable the health system to respond to current impacts such as extreme weather events. Since 2011 South Africa has national climate change policies and adaptation strategies, yet there is uncertainty about: how these policies and plans are executed; the extent to which health policies include adaptation; and the extent of policy coherence across sectors and governance levels. A policy document analysis was conducted to examine how South African climate change, development and health policy documents reflect the health adaptation response across national and Western Cape levels and to assess the extent of coherence across key health and environment sector policy documents, including elements to respond to health-related climate risks, that can support implementation. Our findings show that overall there is incoherence in South African climate adaptation within health policy documents. Although health adaptation measures are somewhat coherent in national level policies, there is limited coherence within Western Cape provincial level documents and limited discussion on climate adaptation, especially for health. Policies reflect formal decisions and should guide decision-makers and resourcing, and sectoral policies should move beyond mere acknowledgement of adaptation responses to a tailored plan of actions that are institutionalized and location and sector specific. Activities beyond documents also impact the coherence and implementation of climate adaptation for health in South Africa. Clear climate risk-specific documents for the health sector would provide a stronger plan to support the implementation of health adaptation and contribute to building health system's resilience.

7.M. Workshop: Rethinking health system resilience for Europe: Health System Functions in a time of Permacrisis

Abstract Health system resilience has become a concept of growing interest among academics, policy and decision makers, practitioners and health service managers over the past decade, given the notable increase in catastrophic events, or shocks, that directly impact health systems. The focus on health system resilience intensified following the global economic crash in 2008 and more recently with the Covid-19 pandemic. Understanding health system resilience has never been more essential. Learning from past shocks is important for health system resilience, building back better rather than reverting to the status quo, thereby poising health systems for better preparedness in the future. In many European countries hardest hit by the financial crisis there were limited learnings and the health system remained in a state of “semi-crisis” when faced with the next shock, the Covid-19 pandemic. However, in contrast to the austerity years, this period was characterised by an influx of funding and resources to the health service, and in many countries this empowered agile decision-making and allowed for innovative service provision. Also in contrast to the financial shock, there was no recovery period following the pandemic, with the onset of the cost-of-living crisis following quickly. This raises the question of whether health systems are entering a state of permacrisis and, if so, what can be done to promote and support health system resilience. The objective of this session is to improved understanding and practice of health system resilience by exploring recent experiences of managing shocks across several health system functions and drawing on country experiences. This session explores and evaluates health system functions that must individually and collectively be addressed in order for health systems to become resilient and sustainable. To accomplish this, four topics will be addressed: 1) building health system resilience in and through service delivery in Europe; 2) the critical role of financing in the development of health system resilience in Europe; 3) how international health system austerity responses impacted health system and workforce resilience, and 4) rethinking health system resilience and reviewing the relationships between absorption, adaptation and transformation in shock and everyday health system resilience drawing on the Irish experience. Bringing together these presentations will allow a collective examination by the audience and presenters of the key challenges and lessons for European health systems alongside some reflection on the development of theory. Each presenter will be given a strict deadline of 10 minutes by the chair and then the audience will be invited to debate the problems identified and strategies proposed to review learnings and next steps for building better understanding and practice of health system resilience across Europe. Key messages • This session will improve understanding of the concept and application of health system resilience to European health systems to allow for better handling of shocks. • Strategies for building health system resilience across financing, governance, service delivery and human resources derived from country studies will be identified, debated and evaluated.

Building health system resilience in and through service delivery

Abstract Introduction The ability of a health system to deliver services during and in the aftermath of a shock depends on the capacity of all other health system functions (governance, health workforce, physical infrastructure and finances). Countries have differing service delivery approaches (e.g., more or less emphasis on outpatient vs. hospital care), which influences how they respond to a shock. However, despite the differences in health system organisation of service delivery and the type of shock, there are common approaches that countries can take to increase the resilience of service delivery and deal with fluctuations in demand and supply. Methods A framework for understanding the impact of a shock on service delivery was developed by the European Observatory on Health Systems and Policies, and used as an analytical tool to examine the relationship between service delivery and resilience. Findings Shocks can impact the demand for and supply of services in different ways. For example, an epidemic/pandemic shock such as Covid-19 may lead to surges in demand and crowd out routine care, while a war or conflict shock (e.g., Ukraine since February 2022) may lead to (local) supply shortages as well as surges in demand, necessitating setting up new infrastructure and transferring of patients. However, health systems also responded to shocks in ways that have increased the resilience of service delivery. These include flexible decision making, innovations in digital health and better planning and management across care settings. Conclusions Flexible policies that can increase health service supply flows, rather than one-off increases, are needed to respond to unexpected changes. Furthermore, it is the linking of the impact of shocks on service delivery that ultimately influences the final health system goal of improved health. Finally, shocks can impact service delivery even after a shock, with the opportunity to transform into a more efficient and resilient health system.

Health Diplomacy as a Tool to Build Resilient Health Systems in Conflict Settings—A Case of Sudan

Attacks on health have become a significant concern for non-belligerents of war, including healthcare personnel and facilities, as witnessed in the ongoing Sudan conflict. About 1.5 billion people in fragile and conflict-affected settings (FCAS) have a heightened need for essential health services. Conflicts often lead to the disruption of the building blocks of health systems, a lack of access to health facilities, the failure of essential medical supply chains, the collapse of political, social and economic systems, the migration of health care workers, and upsurges in illness. While health indicators often decline in conflict, health can also bring peace and harmony among communities. An investment in building resilient health systems and health diplomacy is a neutral starting point for mitigating the repercussions of conflicts. The international commitment towards Sustainable Development Goals (SDGs) provides the impetus to emphasise the relationship between health and peace with the amalgamation of SDG 3, SDG 16, and SDG 17. The inspection of how health diplomacy should be used as a ‘tool for peace’ and not as leverage in conflict settings must be reiterated by the international community.

Building Resilient Health Systems: Key Strategies and Need for Greater Conceptual Clarity

Building Resilient Health Systems: Key Strategies and Need for Greater Conceptual Clarity

Liberia health system's journey to long-term recovery and resilience post-Ebola: a case study of an exemplary multi-year collaboration.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict' Liberia is one of the three countries worst hit by the 2014-2016 West Africa Ebola Virus disease (EVD) outbreak, during which it recorded over 10,000 cases, including health workers. Estimates suggest that the non-EVD morbidity and mortality resulting from the collapse of the health system exceeded the direct impact of EVD. Lessons from the outbreak were clear, not only for Liberia but also for the regional and global communities: that building health system resilience through an integrated approach is an investment in population health and wellbeing, as well as economic security and national development. It is therefore no surprise that Liberia made recovery and resilience a national priority from the time the outbreak waned in 2015. The recovery agenda provided the platform for stakeholders to work toward the restoration of the pre-outbreak baseline of health system functions while aiming to build a higher level of resilience, informed by lessons from the Ebola crises. Based on the co-authors' experiences of on-the-ground country-support work, this study sought to provide an overview of the Liberia Health Service Resilience project (2018-2023) funded by KOICA, and propose a set of recommendations for national authorities and donors, derived from the authors' perceptions of best practices and key challenges associated with the project. We used both quantitative and qualitative approaches to generate the data represented in this study by reviewing published and unpublished technical and operational documents, and datasets derived through situational and needs assessments and routine monitoring and evaluation activities. This project has contributed to the implementation of the Liberia Investment Plan for Building a Resilient Health System and the successful response to the COVID-19 outbreak in Liberia. Although limited in scope, the Health Service Resilience project has demonstrated that health system resilience could be operationalized by applying a catchment and integrated approach and encouraging multi-sectoral collaboration, partnership, local ownership, and promoting the Primary Health Care approach. Principles applied in this pilot could guide the operationalization of health system resilience efforts in other resource-limited settings similar to Liberia and beyond.

Multisectoral action towards sustainable development goal 3.d and building health systems resilience during and beyond COVID-19: Findings from an INTOSAI development initiative and World Health Organization collaboration.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. As the world faces global health crises such as pandemics, epidemics, climate change and evolving disease burdens and population demographics, building strong and resilient public health systems is of critical importance. The need for an integrated approach to building health system resilience; the widening of inequalities; and fears of vulnerable populations being left behind are critical issues that require Supreme Audit Institutions (SAIs) enquiry as independent public oversight bodies. Each country has a Supreme Audit Institution with a remit to audit public funds as an effective, accountable, and inclusive institution. Government audits are key components of effective public financial management and Good Governance. SAIs contribute to the quality of government engagement and better state-society relations through their work. As SAIs provide independent external oversight and contribute to follow up and review of national targets linked to the Sustainable Development Goals (SDGs) in their respective countries, they can play an important role in national recovery efforts. WHO and INTOSAI Development Initiative (IDI) have been collaborating in facilitating SAIs' audits of strong and resilient national public health systems linked to the national target of SDG 3.d in 40 countries across Africa, Americas, Asia and Oceania between 2021 and 2022. This paper aims to convey key lessons learned from the joint multisectoral collaboration for facilitating the 3.d audits that can contribute to building health systems resilience in ongoing recovery efforts. The collaboration included facilitation of the audits through professional education and audit support using a health systems resilience framework. The 3.d audits are performance audits and follow IDI's SDG Audit Model (ISAM). Following the ISAM implies that the SAI should focus on a whole-of-government approach, policy coherence and integration, and assess both government efforts at 'leaving no one behind' and multi-stakeholder engagement in implementing the chosen national SDG target linked to 3.d. WHO's Health Systems Resilience team has supported IDI and SAIs by delivering training sessions and reviewing working papers and draft reports of the SAIs from a health systems resilience perspective. IDI has provided the technical expertise on performance audits through its technical team and through in-kind contributions from mentors from many SAIs in the regions participating in the audit. In the 3.d audit, SAIs can ask how governments are acting to enhance capacity in some or all of the following, depending on their own national context and risk: forecasting, preventing and preparing for public health emergencies (PHEs) and threatsadapting, absorbing and responding to PHEs and threatsmaintaining essential health services in all contexts (including during emergencies/crises). The audits are expected to highlight current capacities of health systems resilience; the extent to which a whole-of-government approach and policy coherence have been utilised; and government efforts related to multistakeholder engagement and leaving no one behind in building health systems resilience related to progressing towards achieving the national target linked to 3.d by 2030. An overall positive achievement noted was that undertaking a complex health audit in the middle of a pandemic is possible and can contribute to building health systems resilience and recovery efforts. In their review of audit plans, draft summaries, and other work by the SAIs, both WHO and IDI have observed that SAIs have used the training and supplementary materials and applied various parts of it in their audits. This collaboration also demonstrates key considerations needed for successful partnership across multisectoral partners at global, regional and national levels. Such considerations can be applied in different contexts, including socioeconomic and health system recovery, to ensure whole-of-society and whole-of-government action in building health systems resilience and monitoring and evaluation to maintain and accelerate progress towards the national target linked to SDG3.d, health security and universal health coverage (UHC), as well as broader socioeconomic development.

The human cost of economic sanctions and strategies for building health system resilience: A scoping review of studies in Iran.

This review aimed to analyse the impacts of international economic sanctions on the overall health status of Iranians and the health system performance of Iran, in addition to identifying effective strategies for making the health system resilient to sanctions. A scoping review. Three databases and grey literature were reviewed, and additional papers were identified in the lists of references. Two authors reviewed papers to check duplications and screen through inclusion/exclusion criteria. Furthermore, a narrative approach was employed to synthesise the findings. Given overall health impacts, economic sanctions are believed to have adverse effects on Iranian's health and cause significant financial hardships in accessing healthcare services. These hardships mostly affect those in marginalised and vulnerable groups. Economic sanctions degrade Iran's health system by negatively impacting health services' availability. The detrimental effects of sanctions on economic and social circumstances were also documented. Economic sanctions could also adversely affect health research and education. Most strategies identified for health system resilience to sanctions are related to the health system governance. Even if essential medicines and supplies are exempted from the sanction regime, the impact of economic sanctions on public health is unavoidable. The quantification of the effect economic sanctions on different health-related areas needs by further research. The measures identified for dealing with sanction can be considered in other countries but more work is needed to explore how health of people can be resilient against negative consequences of sanctions.

High level of infection prevention and control in surveyed hospitals in Colombia, 2021.

This study aimed to determine the performance of infection prevention and control (IPC) programs in eight core components in level 2 and level 3 hospitals across all provinces in Colombia. This cross-sectional study used self-assessed IPC performance data voluntarily reported by hospitals to the Ministry of Health and Social Protection during 2021. Each of the eight core components of the World Health Organization's checklist in the Infection Prevention and Control Assessment Framework contributes a maximum score of 100, and the overall IPC performance score is the sum of these component scores. IPC performance is graded according to the overall score as inadequate (0-200), basic (201-400), intermediate (401-600) or advanced (601-800). Of the 441 level 2 and level 3 hospitals, 267 (61%) reported their IPC performance. The median (interquartile range [IQR]) overall IPC score was 672 (IQR: 578-715). Of the 267 hospitals reporting, 187 (70%) achieved an advanced level of IPC. The median overall IPC score was significantly higher in private hospitals (690, IQR: 598-725) than in public hospitals (629, IQR: 538-683) (P < 0.001). Among the core components, scores were highest for the category assessing IPC guidelines (median score: 97.5) and lowest for the category assessing workload, staffing and bed occupancy (median score: 70). Median overall IPC scores varied across the provinces (P < 0.001). This countrywide assessment showed that 70% of surveyed hospitals achieved a self-reported advanced level of IPC performance, which reflects progress in building health system resilience. Since only 61% of eligible hospitals participated, an important next step is to ensure the participation of all hospitals in future assessments.

Achieving Universal Health Coverage in Low- and Middle-Income Countries: Challenges for Policy Post-Pandemic and Beyond.

Achieving universal health coverage (UHC) is critical for ensuring equity, improving health, and protecting households from financial catastrophe. The COVID-19 pandemic derailed the progress made across primary health targets. This article aims to review the policy challenges to achieve UHC in a post-pandemic world. A narrative review of 118 peer reviewed and grey literature was conducted. A total of 77 published articles were identified using an electronic search in PubMed and Scopus and a bibliographic search of relevant literature. Another 41 Reports, websites, blogs, news articles, and data were manually sourced from international agencies (WHO, World Bank, IMF, FAO, etc.), government agencies, and non-government organizations. The challenges were identified and discussed under five broad findings: i) weak public health care systems ii) challenges to building resilient health systems, iii) health care financing and financial risk protection, iv) epidemiological and demographic challenges, and v) governance and leadership. LMICs in Africa and South Asia face significant challenges to achieving UHC by 2030. As countries recover from the pandemic's aftermath, significant investments and innovations are needed to ensure progress toward UHC. Efficient resource mobilization through internal accruals, international cooperation, and resource sharing is needed.

Resiliency of the Iranian healthcare facilities against the Covid-19 pandemic: challenges and solutions

BackgroundHealth care facilities are responsible for preventing and controlling diseases and must be resilient enough to deal with crises. The Iranian health care facilities have faced challenges in managing COVID-19 pandemic. The purpose of this study was to identify the challenges faced by the Iranian health care facilities during the Covid-19 epidemic and to provide solutions.MethodsThis qualitative study was conducted with a phenomenological approach and using semi-structured interviews with 59 healthcare policy makers, managers, and employees, and medical university faculty members. The participants were selected through purposive and snowball sampling. Thematic analysis was used to analyze the data.ResultsOverall, 43 challenges to the resilience of health care facilities during the Covid-19 pandemic were identified and grouped into 8 themes (i.e., leadership and management, planning, organizational culture, organizational learning, employee management, customer management, resource management, and process management. The most important resilience challenges were: fragmented management system; poor leadership; incompatible health network structure; lack of a national holistic plan; poor case detection; insufficient resources; inefficient information system; negative attitude of managers and employee; organizational inertia; failure to build on lessons learned from crises; low workforce preparedness; lack of community-based management; and improper monitoring and evaluation. Managers should use community-based, evidence-based, and integrated management to build health system resilience against COVID-19, have sufficient knowledge and experience to organize operations, use appropriate and effective coordination models, develop a creative and participatory culture, reengineer processes, and provide necessary resources.ConclusionThe Iranian health care facilities face challenges that prevent them from becoming resilient, responsive, and efficient in managing COVID-19. Policy makers and managers should increase the resilience of health care facilities to shocks and crises by using the suggested measures.

Building health system resilience and pandemic preparedness using wastewater-based epidemiology from SARS-CoV-2 monitoring in Bengaluru, India.

The COVID-19 pandemic was a watershed event for wastewater-based epidemiology (WBE). It highlighted the inability of existing disease surveillance systems to provide sufficient forewarning to governments on the existing stage and scale of disease spread and underscored the need for an effective early warning signaling system. Recognizing the potentiality of environmental surveillance (ES), in May 2021, COVIDActionCollaborative launched the Precision Health platform. The idea was to leverage ES for equitable mapping of the disease spread in Bengaluru, India and provide early information regarding any inflection in the epidemiological curve of COVID-19. By sampling both networked and non-networked sewage systems in the city, the platform used ES for both equitable and comprehensive surveillance of the population to derive precise information on the existing stage of disease maturity across communities and estimate the scale of the approaching threat. This was in contrast to clinical surveillance, which during the peak of the COVID-19 pandemic in Bengaluru excluded a significant proportion of poor and vulnerable communities from its ambit of representation. The article presents the findings of a sense-making tool which the platform developed for interpreting emerging signals from wastewater data to map disease progression and identifying the inflection points in the epidemiological curve. Thus, the platform accurately generated early warning signals on disease escalation and disseminated it to the government and the general public. This information enabled concerned audiences to implement preventive measures in advance and effectively plan their next steps for improved disease management.

One Health Operationalisation in a Local Health System: Learnings from an Urban City of India, Ahmedabad

One Health (OH) implementation relies on collaboration across sectors and actors; however, there is a lack of understanding on the required level of integration/collaboration. In the context of globalisation and destabilisation at the interfaces of the human-animal-environment implementation of OH, building health system resilience is mercurial for countries of the Global South like India. The RICOHA (Research to explore Intersectoral Collaborations for One Health Approach) study, conducted from 2017 to 2020 in Ahmedabad, India, attempted to shed light on One Health implementation and practice. It encapsulated the intersectoral network strength, actors and system factors of the current health system (human & animal), and the degree of collaboration and factors responsible for OH implementation in the local context. It also captured the zoonotic disease awareness level and practices in the community, especially among cattle handlers. Due to a lack of data on the disease burden, initiating the OH implementation process was challenging. Thus, the RICOHA project explored possible strategies to operationalise OH in the selected study settings. This study documented prioritisation of zoonotic diseases, potential OH actors, their power-influence relation and pattern of intersectoral collaboration in the multifaceted health system. Finally, different OH strategies and OH enabling factors were documented and validated.© The Authors 2023

An overview of Iran's actions in response to the COVID-19 pandemic and in building health system resilience.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. The considerable human, social, and economic impacts of COVID-19 have demonstrated a global lack of health system resilience, highlighting gaps in health system capacities due to fragmented approaches to health system financing, planning, and implementation. One of the key actions for ensuring equitable essential health services in all countries in normal situations as well as emergencies is through strengthening the primary healthcare (PHC) system. In the context of the unfolding pandemic, the Iranian Ministry of Health and Medical Education (MoHME) undertook a variety of strategic actions to ensure the sustainability of health services during the current health emergency and to promote health system resilience against future shocks. Right after the Alma-Ata declaration in 1978, MoHME pursued the PHC philosophy incorporating the principles within the WHO health system framework and its six building blocks. In response to the evolving pandemic, MoHME put in place several interventions to ensure the maintenance of essential health services in addition to the provision of response. Some interventions were new, informed by global experience with COVID-19, while others leveraged existing strengths within the existing health system. Those were taking a whole-of-government approach; leveraging the PHC capacity; supporting the workforce; strengthening preparedness and response; improving access to medicines, vaccines, and health products; and leveraging the health information system into the pandemic response. Health system strengthening that promotes resilience is imperative for governments as health systems are fundamental to sustainable socioeconomic development. In recognition of this, the WHO Eastern Mediterranean Regional Office (EMRO) has recently outlined regional priorities for advancing universal health coverage (UHC) and ensuring health security. Iran's approach both prior to and during the pandemic is strongly aligned with those regional priorities, which are "primary health care-oriented models; enhancing health workforce; promoting equity; enabling environment for research; improving access to countermeasures; and fostering health system resilience."

The EU response to NCDs: a content analysis on building resilient post-COVID health systems

Abstract Background Non-communicable diseases (NCDs) impose a heavy burden on healthcare systems of countries in the European Union (EU). An estimated 91.3% of all deaths and 86.6% of DALYs in the EU-28 were attributable to NCDs. It is imperative that the EU act on mitigating this challenging health issue and help create trajectories for building resilient health systems. Using qualitative analysis, this study examines the question of how the European Commission 2019-2024 is planning to mitigate the impact of NCDs on health systems, while taking into account the COVID-19 pandemic. Methods Content analysis was applied to understand how NCDs are framed and how an EU narrative is constructed to mitigate the impact of NCDs on health systems by the European Commission. A total of 44 documents were analysed, including speeches, press releases, newsletters, statements and policy documents. In vivo coding was performed using the software package ATLAS.ti 9. Unique codes were simplified and clustered into descriptive themes with a high level of abstraction. Results This study identified five main themes: ‘health plan', ‘COVID-19', ‘future direction', ‘collaboration and solidarity', and ‘persuasion'. Themes show that the Commission is emphasising the impact of the pandemic and the relevance of policies tackling NCDs for developing EU-wide resilient health systems. By calling for more cross- and multi-sectoral collaboration, like creating a European Health Union, the Commission hopes to create the right climate for a European framework for cooperation, which can help develop harmonised and resilient EU health systems. Conclusions Although increasing health systems resilience is high on the Commission’s agenda, it seems that there are no actionable points for Member States in terms of addressing national health policy. We recommend the Commission looks towards eliminating this observed disconnect and creating actionable points in line with Member States’ health systems’ capabilities. Key messages • Our findings show emphasis is placed on EU-wide health policies, more robust health systems, and the collective power of the EU. However, there are no concrete actions coupled with these concepts. • COVID-19 highlighted the limitations of national policy for protecting health systems against cross-border health threats. It tested the Commission’s resolve in pushing for more European cooperation.

4.A. Workshop: Lessons from the response to COVID-19 to inform strengthening of Essential Public Health Functions

Abstract Internationally, the COVID-19 pandemic has increased disease burden and mortality, impacted mental health and wellbeing and delayed diagnosis and treatment of non-COVID care. It has been argued that, had sufficient funding of Public Health, including pandemic preparedness, been in place historically, many shortcomings of the pandemic response could have been mitigated. Thus, strengthening Public Health systems is on the agenda of governments internationally. Areas of specific interest are, emergency preparedness, international cooperation and solidarity, promoting vaccination uptake, health equity and community engagement, health literacy and misinformation (particularly online), planning for future workforce requirements and harnessing digitalization in health to address communicable and non-communicable disease threats. The Essential Public Health Functions (EPHFs) provide a comprehensive, cost effective and operational approach to strengthening Public Health and are recognized by the WHO as key to building health system resilience. In a recent report, the WHO has proposed an approach to operationalizing the EPHFs, identifying key enablers that can be applied within specific country contexts. This workshop will describe the national and international research undertaken by the Irish Health Information and Quality Authority (HIQA) and the WHO at the request of the Department of Health to inform reform of the delivery model of Public Health in Ireland. HIQA and WHO will present the evidence base in terms of the value of EPHFs for health system strengthening, the findings of research to describe changes in Public Health structures and lessons learned in Ireland and across 12 countries during the COVID-19 pandemic, a description of the current state of delivery of the EPHFs within Ireland, and the results of a consultation survey distributed by the Department of Health in Ireland, investigating the experiences of organisations involved in the delivery of Public Health in light of the pandemic. The presenters will allow ample time for audience engagement and discussion with the expert panel to enable shared learning and to discuss the applicability of these findings to the reform and strengthening of the delivery of the EPHFs. The workshop objectives are to: • Describe the current evidence base in terms of the value of EPHFs for health system strengthening and the key enablers to support their application at country level. • Describe the recent changes and lessons learned regarding the delivery of the EPHFs during the COVID-19 pandemic in 12 countries. • Describe the delivery of the EPHFs in the Irish system in light of experience with COVID-19 and with awareness of current and future health system stressors. • Describe Public Health organisations’ experiences of delivering the EPHFs in Ireland in light of the pandemic. • Provide insights into how the delivery of the EPHFs could be reformed and strengthened for the future. Key messages • Lessons from the Public Health response to COVID-19, internationally and in Ireland will be discussed. • The workshop will provide a space to share ideas on reform and strengthening EPHF delivery.

Strategies for developing preparedness and building legacy – learning from the experience of building Health System Resilience in Ireland

Abstract Health system resilience to shocks is perhaps the biggest global challenge facing health systems in the 21st Century. Health systems face an increasing prevalence and likelihood of a broad range of shocks (including economic crises, pandemics, climate-related events, political upheavals, mass migration, conflicts and cyberterrorism) that can each undermine the ability of a health system to function well. In particular, the twin processes of dealing with the legacy of a health system shock and preparing for the next shock are distinct but related challenges that face policy makers today. In this presentation the authors will present key findings on improving preparedness and building a constructive legacy drawing from: • the results of a recent systematic review on how health system resilience has been measured in high income countries over the last twenty years; • the results of a recent realist review exploring the legacy of the economic crisis for the resilience of the response of the health system to COVID-19, and • analysis of interviews with Irish policy makers, managers and analysts as they reflect on the different shocks encountered by the Irish system over the last fourteen years. Triangulating these findings, the authors will reflect on the merits and challenges of measuring resilience and what the focus should be moving forward. Key strategies and approaches will be outlined to best prepare a system for a shock and to leave a positive legacy for the future.

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.

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. 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. 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.

Building Health System Resilience in Africa During the COVID-19 Pandemic

Many essential health services have been paused because of the COVID-19 pandemic. To ensure that adequate health delivery is not impeded during the COVID-19 pandemic, this study aimed to describe the strategies for building health system resilience in Africa during the COVID-19 pandemic. The integration of COVID-19 care into routine healthcare delivery across African countries should be prioritized. Investment in human and material resources for the health sector should be prioritized by policymakers. Adequate community engagement should be prioritized across all communities in Africa. Investment in leadership development training across all health sectors would promote initiative-driven decision making and promote infection control practices in health facilities.

The Importance of Community Social Capital in Building Sustainable and Resilient Health Systems

Community resilience has been recognised and promoted as a vision and strategy for strengthening health systems in the post-COVID-19 era. The paper sets out the importance of health promotion and building social capital to achieve this goal; it briefly describes the concepts of community ownership, collective efficacy, community capacity and community competence as key categories for managing this process. We conclude with a call for reflection on the need for a clear understanding of these elements for a renewed vision of sustainable and resilient health systems.