Health System Response Research Articles

Surgery and COVID-19: a rapid scoping review of the impact of the first wave of COVID-19 on surgical services

ObjectivesTo understand how surgical services have been reorganised during and following public health emergencies, particularly the first wave of the COVID-19 pandemic, and the consequences for patients, healthcare providers and...

National Health Systems Response to COVID-19 Outbreak, Iraq an Example

This article describes chronologically the development of COVID-epidemic in Iraq, mainly Basra Province, and the response of the national and provincial health system response to control this crisis. It points some strengths and weaknesses of this response. In addition, it mentions some of the opportunities that need to get benefit from, including following an evidence-based approach in epidemic control management. Some of the international assessments' results showed that the performance of Iraqi health system come at the tail of the sorted list of international health systems. This necessitates conducting a scientific systematic evaluation to the national performance to precisely quantify structural and process strengths and weaknesses.

Impact of RNA degradation on influenza diagnosis in the surveillance system

BackgroundThe continuous evolution of influenza viruses is monitored by the World Health Organization Global Influenza Surveillance and Response System. Sample quality is essential for surveillance quality. MethodsTo evaluate the RNA degradation of clinical samples, influenza-like illness samples were collected from four sentinel hospitals, and seasonal influenza was tested by real-time reverse transcription polymerase chain reaction and quantified by digital reverse transcription polymerase chain reaction at different time points. ResultsRNA degradation was observed in the majority of samples eight days after sample collection. A significant and faster rate of RNA content reduction was observed in low viral load samples (<10 copies/µl) than in high viral load samples (>10 copies/μl), stored at 2 to 8°C for up to eight days. RNase P (RNP) RNA, which is a key indicator to evaluate sample collection quality, was detected. Sample collection quality was uneven in different hospitals. ConclusionLow viral load samples increase the risk of false negatives due to RNA degradation to undetectable levels.

An innovative leadership development initiative to support building everyday resilience in health systems.

Effective management and leadership are essential for everyday health system resilience, but actors charged with these roles are often underprepared and undersupported to perform them. Particular challenges have been observed in interpersonal and relational aspects of health managers’ work, including communication skills, emotional competence and supportive oversight. Within the Resilient and Responsive Health Systems (RESYST) consortium in Kenya, we worked with two county health and hospital management teams to adapt a package of leadership development interventions aimed at building these skills. This article provides insights into: (1) the content and co-development of a participatory intervention combining two core elements: a complex health system taught course, and an adapted communications and emotional competence process training; and (2) the findings from a formative evaluation of this intervention which included observations of the training, individual interviews with participating managers and discussions in regular meetings with managers. Following the training, managers reported greater recognition of the importance of health system software (values, belief systems and relationships), and improved self-awareness and team communication. Managers appeared to build valued skills in active listening, giving constructive feedback, ‘stepping back’ from automatic reactions to challenging emotional situations and taking responsibility to communicate with emotional competence. The training also created spaces for managers to share experiences, reflect upon and nurture social competences. We draw on our findings and the literature to propose a theory of change regarding the potential of our leadership development intervention to nurture everyday health system resilience through strengthening cognitive, behavioural and contextual capacities. We recommend further development and evaluation of novel approaches such as those shared in this article to support leadership development and management in complex, hierarchical systems.

An integrated socially responsible-efficient approach toward health service network design.

Despite the fact that medical responses are crucial for saving precious lives during any humanitarian crisis (e.g., the COVID-19 pandemic), healthcare infrastructure in many communities are partially covered or are not covered yet. In order to strengthen the health system response to such crisis, especially in low- to middle-income communities, this paper extends a novel multi-objective model for designing a health service network under uncertainty which simultaneously considers efficiency, social responsibility, and network cost. For efficiency, a modified data envelopment analysis model is introduced and inserted into the proposed model to decrease the inefficiency of healthcare facilities belonging to the different tiers of the health system. For social responsibility, two measures of job creation and balanced development are incorporated into the extended model. This is not only considered to cope with the increased numbers of patients and disaster victims to healthcare facilities but also to deal with the challenge of the economy and the livelihoods of people during the crisis. Moreover, a novel mixed possibilistic-flexible robust programming (MPFRP) approach is developed to protect the considered network against uncertainty. To show the applicability of the extended model, a real-world case study is presented. The results reveal that contrary to fuzzy programming models, the MPFRP performs well in terms of social responsibility (72%), cost (8%), and efficiency (28%) and is able to make a trade-off between these three measures. In this study, the resilience level of the designed network is not addressed while disregarding any short-term stoppage owing to internal or external sources of disruption in designing may bring about a considerable loss.

Spatial variability in factors influencing maternal health service use in Jimma Zone, Ethiopia: a geographically-weighted regression analysis

BackgroundPersisting within-country disparities in maternal health service access are significant barriers to attaining the Sustainable Development Goals aimed at reducing inequalities and ensuring good health for all. Sub-national decision-makers mandated to deliver health services play a central role in advancing equity but require appropriate evidence to craft effective responses. We use spatial analyses to identify locally-relevant barriers to access using sub-national data from rural areas in Jimma Zone, Ethiopia.MethodsCross-sectional data from 3727 households, in three districts, collected at baseline in a cluster randomized controlled trial were analysed using geographically-weighted regressions. These models help to quantify associations within women’s proximal contexts by generating local parameter estimates. Data subsets, representing an empirically-identified scale for neighbourhood, were used. Local associations between outcomes (antenatal, delivery, and postnatal care use) and potential explanatory factors at individual-level (ex: health information source), interpersonal-level (ex: companion support availability) and health service-levels (ex: nearby health facility type) were modelled. Statistically significant local odds ratios were mapped to demonstrate how relevance and magnitude of associations between various explanatory factors and service outcomes change depending on locality.ResultsSignificant spatial variability in relationships between all services and their explanatory factors (p < 0.001) was detected, apart from the association between delivery care and women’s decision-making involvement (p = 0.124). Local models helped to pinpoint factors, such as danger sign awareness, that were relevant for some localities but not others. Among factors with more widespread influence, such as that of prior service use, variation in estimate magnitudes between localities was uncovered. Prominence of factors also differed between services; companion support, for example, had wider influence for delivery than postnatal care. No significant local associations with postnatal care use were detected for some factors, including wealth and decision involvement, at the selected neighbourhood scale.ConclusionsSpatial variability in service use associations means that the relative importance of explanatory factors changes with locality. These differences have important implications for the design of equity-oriented and responsive health systems. Reductions in within-country disparities are also unlikely if uniform solutions are applied to heterogeneous contexts. Multi-scale models, accommodating factor-specific neighbourhood scaling, may help to improve estimated local associations.

Providing health services effectively during the first wave of COVID-19: A cross-country comparison on planning services, managing cases, and maintaining essential services

The COVID-19 pandemic triggered abrupt challenges for health care providers, requiring them to simultaneously plan for and manage a rise of COVID-19 cases while maintaining essential health services. Since March 2020, the COVID-19 Health System Response Monitor, a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, has documented country responses to COVID-19 using a structured template which includes a section on provision of care. Using the information available on the platform, this paper analyzes how countries planned services for potential surge capacity, designed patient flows ensuring separation between COVID-19 and non-COVID-19 patients, and maintained routine services in both hospital and ambulatory settings. Despite very real differences in the organization of health and care services, there were many similarities in country responses. These include transitioning the management of COVID-19 mild cases from hospitals to outpatient settings, increasing the use of remote consultations, and cancelling or postponing non-urgent services during the height of the first wave. In the immediate future, countries will have to continue balancing care for COVID-19 and non-COVID-19 patients to minimize adverse health outcomes, ideally with supporting guidelines and COVID-19-specific care zones. Looking forward, policymakers will have to consider whether strategies adopted during the COVID-19 pandemic will become permanent features of care provision.

Impact of the COVID-19 pandemic and related control measures on cancer diagnosis in Catalonia: a time-series analysis of primary care electronic health records covering about five million people

ObjectiveCancer care has been disrupted by the response of health systems to the COVID-19 pandemic, especially during lockdowns. The objective of our study is to evaluate the impact of the...

A Systematic Mapping Review of Family Perspectives About Received Mental Health Interventions

Purpose: Families experience their own journey in adjusting to the role of carer. The purpose of this review was to understand from the perspective of families and carers which practices, and health system responses meet their needs in supporting people who experience mental health challenges. Methods: A systematic evidence mapping review was conducted, through searching five electronic databases to identify peer-reviewed studies, written in English and published between the years 2010 and 2020, that prioritized the perspectives of families. Results: Fifty-five studies met the inclusion criteria and were mapped according to the country of author, year, methodology, who delivered, and intervention mode and format. Discussion: The review demonstrated a diversity of interventions with growing numbers of studies considering the view and experiences of carers. There is evidence of increasingly active participation of carers in designing, leading, or facilitating interventions, recognizing the importance of coproduction in tailoring family and carer support.

Pharmacists leadership in a medication shortage response: Illustrative examples from a health system response to the COVID-19 crisis.

As medication experts, clinical pharmacists play an active and dynamic role in a medication shortage response. Supplementing existing guidelines with an actionable framework of discrete activities to support effective medication shortage responses can expand the scope of pharmacy practice and improve patient care. Dissemination of best practices and illustrative, networked examples from health systems can support the adoption of innovative solutions. In this descriptive report, we document the translation of published shortage mitigation guidelines into system success through broad pharmacist engagement and the adaption and implementation of targeted strategies. The profound, wide‐reaching medication shortages that accompanied the coronavirus disease 2019 (COVID‐19) pandemic are used to highlight coordinated but distinct practices and how they have been combined to expand the influence of the pharmacy enterprise.

Prema-chandra Athukorala Comment on Rethinking “Economic Fundamentals” in an Era of Global Physical Shocks: Insights from the Philippines Experience with COVID-19

Prema-chandra Athukorala Comment on Rethinking “Economic Fundamentals” in an Era of Global Physical Shocks: Insights from the Philippines Experience with COVID-19

Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response.

SummaryObjectives : Telehealth implementation is a complex systems-based endeavour. This paper compares telehealth responses to (COrona VIrus Disease 2019) COVID-19 across ten countries to identify lessons learned about the complexity of telehealth during critical response such as in response to a global pandemic. Our overall objective is to develop a health systems-based framework for telehealth implementation to support critical response. Methods : We sought responses from the members of the International Medical Informatics Association (IMIA) Telehealth Working Group (WG) on their practices and perception of telehealth practices during the times of COVID-19 pandemic in their respective countries. We then analysed their responses to identify six emerging themes that we mapped to the World Health Organization (WHO) model of health systems. Results : Our analysis identified six emergent themes. (1) Government, legal or regulatory aspects of telehealth; (2) Increase in telehealth capacity and delivery; (3) Regulated and unregulated telehealth; (4) Changes in the uptake and perception of telemedicine; (5) Public engagement in telehealth responses to COVID-19; and (6) Implications for training and education. We discuss these themes and then use them to develop a systems framework for telehealth support in critical response. Conclusion : COVID-19 has introduced new challenges for telehealth support in times of critical response. Our themes and systems framework extend the WHO systems model and highlight that telemedicine usage in response to the COVID-19 pandemic is complex and multidimensional. Our systems-based framework provides guidance for telehealth implementation as part of health systems response to a global pandemic such as COVID-19.

A Paradox of Best Healthcare Systems and Large COVID-19 Burden: Review of 1 Year of COVID-19 Epidemiology and Public Health Response in Europe

Background: Europe continues to be the global epicentre of COVID-19 virus. This study focuses on the epidemiology of COVID-19 in Europe and investigates the public health response in severely-hit European countries.Methods: European Centre for Disease Prevention and Control, Oxford COVID-19 Government Response Tracker and Health System Response Monitor were referred to extract data. The relationship between stringency index and COVID-19 cases, and between speed of stringency implementation and growth of cases was examined using linear regression.Findings: The case-fatality ratio (CFR) of Europe (2.34%) was almost equal to the global CFR (2.2%), and higher than CFR observed in South-East Asia (1.53%). United Kingdom, Russia, France, Italy, Spain, and Germany together, accounted for 61.14% of cases and 65.61% of deaths in Europe. Significant relationship was observed between growth of COVID-19 cases and late substantive stringency imposed by countries. Population aged 65 and above (r=0.897, pInterpretation: A third wave along with sluggish vaccine rollouts, concerns over AstraZeneca's COVID-19 vaccine and spread of new variants in Europe has necessitated a reinforcement of infection prevention practices and responsible behaviour as a part of “the new normal”.Funding Statement: This study is non-funded.Declaration of Interests: No conflict of interest has been declared by the author(s).

Adaptive Health Financing: Budgetary and Health System Responses to Combat COVID-19

Health financing policies are an essential element of health system responses to COVID-19. Sound policies help ensure there are sufficient resources to combat COVID-19, that the resources are disbursed rapidly, and that resources are spent in an effective manner. The effective implementation of such policies depends on budget and health officials working together closely to bring about co-ordinated actions. This policy brief analyses how OECD member countries have adapted health financing policies to combat COVID-19, and how such policies may need to continue to adapt as the pandemic evolves. It reviews how countries have provided additional budgetary resources to the health sector to combat COVID-19. It also maps out the key areas of joint action by budget and health officials to plan, implement and review the necessary health financing measures needed to combat COVID-19.

A systematic review of health sector responses to the coincidence of disasters and COVID-19

BackgroundIn December 2019, the Chinese city of Wuhan reported a novel pneumonia caused by COVID-19. While the COVID-19 pandemic has been increasingly affecting the world, the occurrence of disasters resulted in complex emergencies. The present review is aimed to identify the literature focused on health system response to coincidence of COVID-19 and disasters as well as describing their finding, implications and lessons-learned.MethodsThis study was conducted and reported based on PRISMA guideline. The databases of Web of Sciences, PubMed, Scopus, Google Scholar and World Health Organization Library were searched. The inclusion criteria were all forms of published articles which investigated the coincidence of disasters and COVID-19 pandemic. Using the title and abstract screening, the selections of studies were performed by two researchers. Once, the relevant papers were finalized, the analysis was done in two parts of descriptive analysis and implications for health systems.ResultsOut of 1245 studies generated by initial search, a number of 13 articles was selected for final analysis. Earthquake was the most frequent disaster which its coincidence with COVID-19 was studied by researchers (31%). The implications of researchers for healthcare system were explained in three sections of climatic events, earthquakes and all hazard approach in relation to COVID-19.ConclusionExtracting the lessons learned from the regions affected by disasters at the time of COVID-19 pandemic can be helpful for healthcare professionals and policy-makers to improve their preparedness and response during disasters and a serious pandemic such as COVID-19. Further research is needed to identify the factors which strengthen the preparedness of health system for the dual risk of natural hazards and pandemics.

Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysis

BackgroundCOVID-19 spread rapidly in Brazil despite the country's well established health and social protection systems. Understanding the relationships between health-system preparedness, responses to COVID-19, and the pattern of spread of the epidemic is particularly important in a country marked by wide inequalities in socioeconomic characteristics (eg, housing and employment status) and other health risks (age structure and burden of chronic disease).MethodsFrom several publicly available sources in Brazil, we obtained data on health risk factors for severe COVID-19 (proportion of the population with chronic disease and proportion aged ≥60 years), socioeconomic vulnerability (proportions of the population with housing vulnerability or without formal work), health-system capacity (numbers of intensive care unit beds and physicians), coverage of health and social assistance, deaths from COVID-19, and state-level responses of government in terms of physical distancing policies. We also obtained data on the proportion of the population staying at home, based on locational data, as a measure of physical distancing adherence. We developed a socioeconomic vulnerability index (SVI) based on household characteristics and the Human Development Index. Data were analysed at the state and municipal levels. Descriptive statistics and correlations between state-level indicators were used to characterise the relationship between the availability of health-care resources and socioeconomic characteristics and the spread of the epidemic and the response of governments and populations in terms of new investments, legislation, and physical distancing. We used linear regressions on a municipality-by-month dataset from February to October, 2020, to characterise the dynamics of COVID-19 deaths and response to the epidemic across municipalities.FindingsThe initial spread of COVID-19 was mostly affected by patterns of socioeconomic vulnerability as measured by the SVI rather than population age structure and prevalence of health risk factors. The states with a high (greater than median) SVI were able to expand hospital capacity, to enact stringent COVID-19-related legislation, and to increase physical distancing adherence in the population, although not sufficiently to prevent higher COVID-19 mortality during the initial phase of the epidemic compared with states with a low SVI. Death rates accelerated until June, 2020, particularly in municipalities with the highest socioeconomic vulnerability. Throughout the following months, however, differences in policy response converged in municipalities with lower and higher SVIs, while physical distancing remained relatively higher and death rates became relatively lower in the municipalities with the highest SVIs compared with those with lower SVIs.InterpretationIn Brazil, existing socioeconomic inequalities, rather than age, health status, and other risk factors for COVID-19, have affected the course of the epidemic, with a disproportionate adverse burden on states and municipalities with high socioeconomic vulnerability. Local government responses and population behaviour in the states and municipalities with higher socioeconomic vulnerability have helped to contain the effects of the epidemic. Targeted policies and actions are needed to protect those with the greatest socioeconomic vulnerability. This experience could be relevant in other low-income and middle-income countries where socioeconomic vulnerability varies greatly.FundingNone.TranslationFor the Portuguese translation of the abstract see Supplementary Materials section.

AFTER 20 YEARS OF SUSTAINED REDUCTION, RECENT TRENDS IN CARDIOVASCULAR DISEASE BURDEN HAVE STAGNATED OR REVERSED TO INCREASE IN THE REGION OF THE AMERICAS

Objective: To assess the levels, trends, and socio-demographic inequalities of the Cardiovascular diseases (CVD) burden in countries of the Americas, with the ultimate purpose of providing evidence to guide programmatic interventions and health system responses in the context of the World Health Organization's HEARTS Initiative, and the Resolve To Save Life's Global Cardiovascular Health Program. Design and method: This descriptive population-based study used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. We examined disability-adjusted life-years (DALYs), years lived with disabilities (YLDs), years of life lost (YLLs) due to premature mortality from all-CVDs, and cause-specific CVDs using crude, age-specific, and age-standardized rates per 100,000 population by sex in 37 countries of the Americas. We assessed trends of outcome measures by estimating the average annual percentage change from 1990 to 2017 and quantified cross-country social-demographic inequalities in CVD burden. Results: In the Region of the Americas, age-standardized DALYs due to CVD decreased by -1.9% per year (95% UI -2.0 to -1.7) from 5,263.7 years (95% UI 5,143.1–5,390.0) per 100,000 population in 1990 to 3,159.4 years (3,047.1–3,280.4) in 2017. YLLs accounted for 87% of DALYs. Despite this progress, reduction rates decelerated in 2007–2013 and stagnated to -0.1% per year (95% UI -0.5 to 0.3) in 2013–2017. Ischemic heart disease (IHD) and stroke accounted for 80% of all-CVD DALYs. IHD exhibited similar trend patterns, but stroke showed an increasing trend since 2015. In 2017, CVD burden varied across countries from 1,812 years/100 000 (1,594–2,033) in Peru to 8,662 years/100 000 (7,404–10,029) in Haiti. From 2010 to 2017, reduction rates decelerated in all countries but Peru, trends stagnated in 8 countries and reversed to upward in 10 countries. Conclusions: The deceleration of decreasing trends in CVD burden in 18 countries, and the stagnation and reversed to increasing trends in 18 out of 37 countries of the Americas in recent years, indicates the need for reinvigorated efforts to reduce the CVD burden. The socio-demographic inequalities across countries pose challenges to these efforts. Countries with less favorable progress should be targeted for strengthening their national programs.

Monitoring the health and healthcare provision for refugees in collective accommodation centres: Results of the population-based survey RESPOND.

To date, the integration of refugees in German health surveys is insufficient. The survey RESPOND (Improving regional health system responses to the challenges of forced migration) aimed to collect valid epidemiological data on refugee health status and healthcare provision. The core elements of the survey consisted of a population-based sampling procedure in Baden-Württemberg, multilingual questionnaires and a face-to-face approach of recruitment and data collection in collective accommodation centres with multilingual field teams. In addition, data on the geographical locations of accommodation centres and their structural quality were obtained. The results indicate a high overall health burden. The prevalence of depression (44.3%) and anxiety symptoms (43.0%) was high. At the same time, high unmet needs were reported for primary (30.5%) and specialist (30.9%) care. Despite sufficient geographical accessibility of primary care services, frequent ambulatory care sensitive hospitalisations, i.e. hospitalisations that could potentially have been avoided through primary care (25.3%), as well as subjective deficits in the quality of care, suggest barriers to accessing healthcare services. Almost half of all refugees (45.3%) live in accommodation facilities of poor structural quality. Collecting valid data on the health situation of refugees is possible through a combination of targeted sampling, multilingual recruitment and survey instruments as well as personal recruitment. The presented approach could complement established procedures for conducting health surveys and be extended to other federal states.

Ethnicity and Language Differences in Patient Experience: an Analysis of the HCAHPS Survey.

Although there has been a rising emphasis on patient-centered care, limited research has assessed differences in patient experience based on ethnicity and language. This study examined differences in quality of care (N = 6945) using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Data were collected between January 2014 and April 2019. Bivariate and multivariate analyses assessed relationships between ethnicity/language with individual items capturing specific components of care and global hospital evaluations using regression modeling. Compared to English-speaking non-Hispanic White patients, Spanish-speaking Hispanic/Latinx patients reported more positive interactions with nurses, physicians, and the hospital environment and reported a better understanding of care after discharge. Findings also indicated that Spanish-speaking Hispanic/Latinx patients were more satisfied with their experience compared to non-Hispanic White patients. Spanish-speaking Hispanic/Latinx patients were more satisfied with specific components of care and also scored higher in a measure of the global patient experience. Findings suggest the need for setting clear expectations for health care encounters and adapting health system responses to better capture factors driving Hispanic/Latinx patient satisfaction.

Prioritising \u2018already-scarce\u2019 intensive care unit resources in the midst of COVID-19: a call for regional triage committees in South Africa

BackgroundThe worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context.DiscussionBeyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation.ConclusionWe propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.