Resilient Health Systems Research Articles

Cancer Care Disparities: Overcoming Barriers to Cancer Control in Low- and Middle-Income Countries.

The rising global burden of cancer disproportionately affects low- and middle-income countries (LMICs), which account for over half of new patients and cancer deaths worldwide. However, LMIC health systems face profound challenges in implementing comprehensive cancer control programs because of limited health care resources and infrastructure. This analytical review explores contemporary evidence on barriers undermining cancer control efforts in resource-constrained LMIC settings. We conducted a comprehensive literature review of peer-reviewed evidence on cancer control challenges and solutions tailored to resource-limited settings. We provide a conceptual framework categorizing these barriers across the cancer care continuum, from raising public awareness to palliative care. We also appraise evidence-based strategies proposed to overcome identified obstacles to cancer control in the published literature, including task-shifting to nonspecialist health workers, strategic prioritization of high-impact interventions, regional collaborations, patient navigation systems, and novel financing mechanisms. Developing strong primary care delivery platforms integrated with specialized oncology care, alongside flexible and resilient health system models tailored to local contexts, will be critical to curb the rising tide of cancer in resource-limited settings. Urgent global commitments and investments are needed to dismantle barriers and expand access to prevention, early detection, diagnosis, treatment, and palliation services for all patients with cancer residing in LMICs as an ethical imperative. The review elucidates priority areas for policy actions, health systems strengthening, and future research to guide international efforts toward more equitable cancer control globally.

Big data for epidemic preparedness in southeast Asia: An integrative study

This integrative study explores the pivotal role of big data in enhancing epidemic preparedness and response strategies in Southeast Asia. The region, characterized by its diverse socio-economic landscape and frequent exposure to infectious disease threats, necessitates innovative approaches to mitigate the impact of epidemics. Big data, with its vast and varied sources, offers unprecedented opportunities to revolutionize epidemic surveillance, prediction, and management. Drawing on a comprehensive review of literature and case studies, this paper delves into the multifaceted applications of big data in epidemic preparedness. It examines the utilization of diverse data sources, including social media, mobile phones, and IoT devices, for real-time monitoring of disease outbreaks and trends. Moreover, it elucidates the role of advanced analytics techniques, such as machine learning and data visualization, in informing timely and targeted response strategies. Furthermore, this study underscores the importance of collaborative efforts and partnerships in leveraging big data for epidemic preparedness. It explores successful initiatives that have demonstrated the effectiveness of data sharing and interdisciplinary collaboration in enhancing epidemic response capabilities across borders. However, the integration of big data into epidemic preparedness initiatives presents various challenges, including data quality issues, privacy concerns, and the need for robust infrastructure and expertise. Addressing these challenges requires concerted efforts from governments, healthcare organizations, and the private sector. In conclusion, this study advocates for continued research, investment, and policy support to harness the full potential of big data in epidemic preparedness. By embracing innovative technologies and fostering collaboration, Southeast Asia can build resilient health systems capable of effectively combating emerging infectious disease threats.

Health systems response to climate change adaptation: a scoping review of global evidence

BackgroundThe health system plays a critical role in safeguarding the well-being of communities in the face of health risks associated with climate change. This review maps evidence on health systems' adaptation to climate risk and barriers to effective adaptation.MethodsThis review followed the recommendations by Arksey and O’Malley for conducting scoping review. Search for records was conducted in PubMed, Central, Web of Science, JSTOR, Google, and Google Scholar. Only peer-reviewed papers published in English language were included in this review. All the 63 included studies were critically appraise d.ResultsWe found that efforts are being made to create resilient health systems by incorporating climate change into health policies. Investments are being made in innovative technologies, climate-resilient health infrastructure, enhancing healthcare delivery, developing the capacity of climate specialists and agencies to provide high-quality evidence for resilient health systems. We also found that several obstacles prevent health system adaptation to climate risk, including poor policy implementation and evaluation. The obstacles are further exacerbated by financial constraints, including poverty, a lack of political commitment, inadequate data, and deficient healthcare systems, especially in developing countries. There is also a lack of integration of climate change into mental health actions and the health and safety of healthcare workers.ConclusionEfforts to develop resilient health systems against climate risks are underway, but persistent obstacles, including inadequate policy implementation, resource limitations, and a lack of integration of climate change into critical health domains, hinder comprehensive adaptation measures, particularly in developing nations.

Non-Fungible Tokens (NFTs) in Healthcare: A Systematic Review.

Amid global health challenges, resilient health systems require continuous innovation and progress. Stakeholders highlight the critical role of digital technologies in accelerating this progress. However, the digital health field faces significant challenges, including the sensitivity of health data, the absence of evidence-based standards, data governance issues, and a lack of evidence on the impact of digital health strategies. Overcoming these challenges is crucial to unlocking the full potential of digital health innovations in enhancing healthcare delivery and outcomes. Prioritizing security and privacy is essential in developing digital health solutions that are transparent, accessible, and effective. Non-fungible tokens (NFTs) have gained widespread attention, including in healthcare, offering innovative solutions and addressing challenges through blockchain technology. This paper addresses the gap in systematic-level studies on NFT applications in healthcare, aiming to comprehensively analyze use cases and associated research challenges. The search included primary studies published between 2014 and November 2023, searching in a balanced set of databases compiling articles from different fields. A review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework and strictly focusing on research articles related to NFT applications in the healthcare sector. The electronic search retrieved 1902 articles, ultimately resulting in 15 articles for data extraction. These articles span applications of NFTs in medical devices, pathology exams, diagnosis, pharmaceuticals, and other healthcare domains, highlighting their potential to eliminate centralized trust sources in health informatics. The review emphasizes the adaptability and versatility of NFT-based solutions, indicating their broader applicability across various healthcare stages and expansion into diverse industries. Given their role in addressing challenges associated with enhancing data integrity, availability, non-repudiation, and authentication, NFTs remain a promising avenue for future research within digital health solutions.

Leveraging community health workers for COVID-19 response in Democratic Republic of Congo, Nigeria, Senegal, and Uganda: roles, barriers, and facilitators

BackgroundThe Corona Virus Disease 2019 (COVID-19) pandemic overwhelmed health systems and disrupted the delivery of health services globally. Community Health Workers (CHWs) play a critical role in linking communities to health systems, supporting the prevention and control of diseases in many low- and middle-income countries. However, their roles, barriers, and facilitators in the response and control of the COVID-19 pandemic have not been well documented. We described the roles of CHWs in the COVID-19 response, including the barriers and facilitators.MethodsA cross-sectional study design was used to assess the COVID-19 response in the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda. This involved 110 key informant interviews with policymakers, health facility managers, district health managers, and CHWs to understand the role of CHWs in the COVID 19 response, selected purposively. The total sample size was based on information saturation in each of the countries. A document review on the COVID-19 response was also conducted. We searched Google, Google Scholar, and PubMed for published and grey literature. Data from the selected documents were extracted into a Google master matrix in MS Excel and analyzed thematically.ResultsIn COVID-19 Control, CHWs supported community-based surveillance, contact tracing, risk communication, community mobilization, and home-based care. To support the continuity of other non-COVID-19 services, the CHWs conducted community mobilization, sensitizations, outreaches, referrals, and patient follow-ups. CHWs were challenged by movement restrictions, especially in the initial stages of the lockdown, inadequate PPE, increased workload, low allowances, and motivation. CHW were facilitated by trainings, the development of guidelines, development partners’ support/funding, and the provision of personal protective equipment (PPE) and tools.ConclusionCHWs supported both the COVID-19 control and continuity of non-COVID-19 health care during the COVID-19 pandemic. CHWs are a critical resource that must be adequately supported to build resilient health systems.

We Need a Combination of Approaches to Evaluate Health System Resilience Comment on "Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic".

Health system resilience has become a desirable health system attribute in the current permacrisis environment. The article by Saulnier and colleagues reviews the literature on health system resilience and refines the concept, pinpointing dimensions of resilience governance that have not reached consensus, or that are missing from the literature. In this commentary we complement the findings by discussing different conceptual frameworks for understanding resilience and introducing resilience testing, a method to assess health system resilience using a hypothetical shock scenario. Resilience testing is a mixed-methods approach that combines a review of existing data with a structured workshop, where health system experts collaboratively assess the resilience of their health system. The new method is proposed as a tool for policy-making, as the results can identify attributes of the current health system that may hinder or boost a resilient response to the next crisis.

THE EFFECT OF PANDEMICS AND EPIDEMICS ON SOCIO-ECONOMIC RIGHTS AND SUSTAINABLE DEVELOPMENT: LESSONS AND RECOMMENDATIONS FOR AFRICA

The recent COVID-19 pandemic highlighted the importance of socio-economic rights and sustainable development not only in Africa but globally. This article discusses the relationship between socio-economic rights and sustainable development. This is followed by a discussion on the impact of pandemics and epidemics on socio-economic rights and the significant effect they can have on the realisation and enjoyment of such rights. Focusing on Africa, the discussion turns to the impact of pandemics and epidemics on sustainable development before looking at the lessons learned from such pandemics and epidemics. Because the recommendations flow from the lessons, these are discussed together. The main recommendation is that a human rights-based approach should be adopted not only in sustainable development but also in any post-pandemic recovery efforts and programmes. Other recommendations include building resilient health systems, addressing the root causes of poverty and inequality, prioritising investment in digital technologies and improving social protection systems, among others.

Singapore's COVID-19 crisis decision-making through centralization, legitimacy, and agility: an empirical analysis

Decision-making during health crises differs from routine decision-making and is constrained by ambiguity about evolving epidemiological situations, urgency of response, lack of evidence, and fear. Recent analyses of governance and decision-making during COVID-19, focusing on leadership qualities, involvement of specific stakeholders, and effective resource management, do not adequately address a persisting gap in understanding the determinants of decision-making during health crises at the national level. We undertook a study to understand the processes and characteristics of decision-making during the COVID-19 pandemic in Singapore. We used a case study approach and collected empirical evidence about public health decision-making, using a combination of key informant interviews and focus group discussions with stakeholders from government, academia and civil society organizations. We argue that administrative centralization and political legitimacy played important roles in agile governance and decision-making during the pandemic in Singapore. We demonstrate the role of the Singapore government's centralization in creating a unified and coherent governance model for emergency response and the People's Action Party's (PAP) legitimacy in facilitating people's trust in the government. Health system resilience and financial reserves further facilitated an agile response, yet community participation and prioritization of vulnerable migrant populations were insufficient in the governance processes. Our analysis contributes to the theory and practice of crisis decision-making by highlighting the role of political and administrative determinants in agile crisis decision-making. This study is funded by the U.S. Centers for Disease Control and Prevention through a Cooperative Research Agreement (NU2HGH2020000037).

Evidence of health system resilience in primary health care for preventing under-five mortality in Rwanda and Bangladesh: Lessons from an implementation study during the Millennium Development Goal period and the early period of COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic led to disruptions of health service delivery in many countries; some were more resilient in either limiting or rapidly responding to the disruption than others. We used mixed methods implementation research to understand factors and strategies associated with resiliency in Rwanda and Bangladesh, focussing on how evidence-based interventions targeting amenable under-five mortality that had been used during the Millennium Development Goal (MDG) period (2000-15) were maintained during the early period of COVID-19. We triangulated data from three sources - a desk review of available documents, existing quantitative data on evidence-based intervention coverage, and key informant interviews - to perform a comparative analysis using multiple case studies methodology, comparing contextual factors (barriers or facilitators), implementation strategies (existing from 2000-15, new, or adapted), and implementation outcomes across the two countries. We also analysed which health system resiliency capabilities were present in the two countries. Both countries experienced many of the same facilitators for resiliency of evidence-based interventions for children under five, as well as new, pandemic-specific barriers during the early COVID-19 period (March to December 2020) that required targeted implementation strategies in response. Common facilitators included leadership and governance and a culture of accountability, while common barriers included movement restrictions, workload, and staff shortages. We saw a continuity of implementation strategies that had been associated with success in care delivery during the MDG period, including data use for monitoring and decision-making, as well as building on community health worker programmes for community-based health care delivery. New or adapted strategies used in responding to new barriers included the expanded use of digital platforms. We found implementation outcomes and strong resilience capabilities, including awareness and adaptiveness, which were related to pre-existing facilitators and implementation strategies (continued and new). The strategies and contextual factors Rwanda and Bangladesh leveraged to build 'everyday resilience' before COVID-19, i.e. during the MDG period, likely supported the maintained delivery of the evidence-based interventions targeting under-five mortality during the early stages of the pandemic. Expanding our understanding of pre-existing factors and strategies that contributed to resilience before and during the pandemic is important to support other countries' efforts to incorporate 'everyday resilience' into their health systems.

Strengthening Healthcare Supply Chains: A Comprehensive Strategy for Resilience in the Face of Natural Disasters

Effective and uninterrupted management of the healthcare supply chain and healthcare system preparedness for natural disasters (e.g., pandemics, earthquakes, forest fires, etc.) is essential to ensure that victims receive critical healthcare services and products with minimal disruption, even in the event of damage to transport and logistics infrastructure as a result of significant disasters. The article examines this issue using the example of Vital Health Systems, a prominent hospital system with multiple facilities across a wide region. The qualitative data for the study was collected through interviews and focus groups with key stakeholders in Vital Health Systems, including supply chain managers, procurement specialists, frontline staff, etc. The quantitative data for the study were based on reports, internal documentation and archival documents, industry reports, market research, government databases. Analysis of the supply chain resilience of Vital Health Systems to natural disasters was carried out using the PESTLE framework, based on which a comprehensive risk reduction strategy was proposed. This strategy, while rooted in theory, is highly practical and feasible, with measures to optimise stocks, creation of alternative transport routes and logistics networks, and use of technological solutions. Organisational and managerial proposals for minimising supply chain disruptions for Vital Health Systems in the event of natural disasters are based on the theory of transformational leadership, Denison’s organisational culture, Levitt’s diamond model, and McKinsey’s theory of strategic horizons. The role of healthcare professionals, supply chain managers, procurement specialists, and researchers in healthcare management and disaster preparedness is crucial in implementing these strategies.

Analysis of anthropometric outcomes in Indian children during the COVID-19 pandemic using National Family Health Survey data

BackgroundDisruptions in food, health, and economic systems during the COVID-19 pandemic may have adversely affected child health. There is currently limited research on the potential effects of the COVID-19 pandemic on stunting, wasting, and underweight status of young children.MethodsWe examine the short-term associations between the pandemic and anthropometric outcomes of under-5 children (n = 232,920) in India, using data from the National Family Health Survey (2019–2021). Children surveyed after March 2020 are considered as the post-COVID group, while those surveyed earlier are considered as pre-COVID. Potential biases arising from differences in socioeconomic characteristics of the two groups are mitigated using propensity score matching methods.ResultsPost-COVID children surveyed in 2020 and 2021 have 1.2% higher underweight rates, 1.2% lower wasting rates, 0.1 lower height-for-age z-scores (HAZ), and 0.04 lower weight-for-height z-scores as compared with matched pre-COVID children. Post-COVID children surveyed in 2020 have 1.6%, 4.6%, and 2.4% higher stunting, underweight, and wasting rates, respectively, and 0.07 lower HAZ, as compared with matched pre-COVID children. Reductions in nutritional status are largest among children from households in the poorest wealth quintiles.ConclusionsThese findings indicate a trend towards a recovery in child anthropometric outcomes in 2021 after the initial post-pandemic reductions. The resilience of health and food systems to shocks such as COVID-19 should be strengthened while immediate investments are required to decrease child malnutrition and improve broader child health outcomes.

Has the COVID-19 pandemic changed existing patterns of non-COVID-19 health care utilization? A retrospective analysis of six regions in Europe

Abstract Background Resilience of national health systems in Europe remains a major concern in times of multiple crises and as more evidence is emerging relating to the indirect effects of the COVID-19 pandemic on health care utilization (HCU), resulting from de-prioritization of regular, non-pandemic healthcare services. Most extant studies focus on regional, disease specific or early pandemic HCU creating difficulties in comparing across multiple countries. We provide a comparatively broad definition of HCU across multiple countries, with potential to expand across regions and timeframes. Methods Using a cross-country federated research infrastructure (FRI), we examined HCU for acute cardiovascular events, elective surgeries and serious trauma. Aggregated data were used in forecast modelling to identify changes from predicted European age-standardized counts via fitted regressions (2017–19), compared against post-pandemic data. Results We found that elective surgeries were most affected, universally falling below predicted levels in 2020. For cardiovascular HCU, we found lower-than-expected cases in every region for heart attacks and displayed large sex differences. Serious trauma was the least impacted by the COVID-19 pandemic. Conclusion The strength of this study comes from the use of the European Population Health Information Research Infrastructure’s (PHIRI) FRI, allowing for rapid analysis of regional differences to assess indirect impacts of events such as pandemics. There are marked differences in the capacity of services to return to normal in terms of elective surgery; additionally, we found considerable differences between men and women which requires further research on potential sex or gender patterns of HCU during crises.

Githinji Gitahi: developing resilient health systems for universal coverage.

Githinji Gitahi talks to Gary Humphreys about the value of cross-sectoral collaboration and health system assessment in the drive towards universal health coverage (UHC).

The Recent 2023 Earthquake in Nepal: A Global Health Perspective.

As a seismic hotspot, Nepal has endured many catastrophic earthquakes, including the 2023 Jajarkot quake. These quakes worsen the existing fragilities, resulting in difficulties in accessing healthcare, outbreaks of infectious diseases, mental health problems, and nutritional shortfalls. The article examines the complex web of health consequences, such as infectious and non-infectious diseases and malnutrition, highlighting the need for a global health lens in tackling these issues. It also reveals the long-term health effects, such as mental health disorders and increased disease susceptibility, that emerge after the quake and the importance of enhancing coordination and communication, enforcing building codes, and assisting affected communities in response to the seismic hazards. The article identifies mitigation strategies, community involvement, and international cooperation as key elements in building resilience against future quakes. It discusses the role of climate change in seismic risks and the need for research, innovation, and adaptability in global health interventions, suggesting measures such as strengthening primary healthcare, preventing avoidable health problems through education, and improving supply chains. The article calls for a holistic approach to building resilient health systems, emphasizing community engagement, prevention, and preparedness to protect the health of vulnerable groups in seismic regions.

Delivering HIV and TB services amidst the COVID-19 pandemic in Indonesia: a qualitative study of challenges and mitigation strategies

Background Indonesia has the second-highest burden of tuberculosis (TB) globally and is experiencing one of the fastest-growing HIV epidemics worldwide. The COVID-19 pandemic disrupted access to essential health services, including those for TB and HIV, due to health system overload, social distancing measures, and negative economic repercussions on the health sector and the population. An in-depth understanding of these challenges and the health system responses to mitigate the negative impact of the pandemic on TB and HIV services is crucial to building health system resilience and preparing for future emergencies. Methods This qualitative study, conducted in two cities in Indonesia, explored the impact of the COVID-19 pandemic on TB and HIV services including mitigation strategies to sustain the provision of testing and treatment in the midst of the pandemic. Between February and June 2022, semi-structured interviews were conducted with 16 healthcare workers and 16 clients at nine health centers (puskesmas), three hospitals, and one Community Center for Lung Health in Bandung and Yogyakarta. Themes were identified from transcripts using open and selective coding and then refined. Results Extraordinary measures were implemented in health facilities to sustain TB and HIV service delivery, and prevent the spread of COVID-19, including testing of clients for COVID-19 before receiving medical care, physical distancing when visiting healthcare facilities, revised schedules for medicine dispensing, involvement of community health workers and peers in community outreach activities such as the home delivery of medicines, and the use of telemedicine. Challenges encountered during the implementation of these strategies included medicine stock-outs, health worker overload, lack of sufficient client-provider interaction and technical difficulties when implementing telemedicine, and the risk or fear of exposure to COVID-19 among the community health workers and peers. Conclusions Significant efforts were made to mitigate disruptions to TB and HIV services during the COVID-19 pandemic. However, some challenges were encountered. Key policy recommendations to strengthen pandemic preparedness include investing in local manufacturing and robust drug supply networks to prevent medicine shortages, and supporting community health workers to alleviate workload issues, reduce the risk of disease exposure, and explore the potential for a financial incentive system. Equally vital is the need to invest in staff training and education, as well as implementing user-friendly telemedicine technologies.

Conference of the Parties (COP) 28 Takeaways at the Intersection of Health, Climate, and Food.

The 28th session of the Conference of the Parties (COP 28) to the UN Framework Convention on Climate Change brought together 85 000 climate stakeholders to leverage solutions and accelerate climate actions in 4 key areas: energy transition; issue of funding and financing of climate actions; emphasis on nature, people's lives, and livelihoods; and ensuring inclusivity for all. This commentary highlights insights at the intersection of health, climate, and food gained by the author from participating in COP 28 events. The objective is to inform policymakers, researchers, and practitioners on emerging opportunities to scale specific, measurable, achievable, relevant, and time-based (SMART) climate actions that prioritize health and boost the resilience of food and public health systems.

A Critical Analysis of Safe Abortion Road Map in Nepal.

Abortion was legalized by the 2002 Muluki Ain to combat the surging rates of maternal mortality and morbidity. By 2021, the Maternal Mortality Rate plummeted to 151 from 539 in 1996. The decline in the abortion-related maternal mortality attributes to the implication of progressive abortion policies that includes expanded safe abortion services introduction of medical abortion, constitutional recognition of abortion, the mandates by Safe Motherhood and Reproductive Health Rights Act, and free-of-cost abortion services in government health facilities. This review study delves into exploring the contemporary abortion policies and its implications on women's access to safe abortion services as well as the factors that affect the access. This study incorporates findings from extensive desk review of abortion services in Nepal. The 2021 safe abortion services Program Implementation Guideline aims to expand safe abortion sites; however, the Nepal's challenging geography ensues its inequitable distribution, especially in mountainous area. Policy provisions on information and financial accessibility to abortion are well navigated by the Safe Motherhood and Reproductive Health Rights Act and regulation but consistent to sporadic gaps in its implementation were comprehended in this study. This paper further discussed the Safe Motherhood and Reproductive Health Rights Act's regressive mandate of 28-week gestational limit at any condition and the role of gender in abortion decision-making under the pretext of factors influencing safe abortion services. The review study recommends strategies: improving capacity for abortion services under federalism, combating stigma, improving the private sector's readiness, and building a resilient health system.

Evaluation of preparedness and response competency of healthcare administrative staff of the public hospitals during the Covid-19 pandemic and its impact on the resilience of health system in Greece

Introduction: The role of health systems and hospital administrative system in Covid-19 pandemic period is of utmost importance. Objective: The scope of study is to assess the preparedness, response competencies of administrative staff and resilience of health system as well as to highlight the need of modernizing the role of the above three com¬ponents. Methods: 175 executives from public hospitals of the seven Regional Health Authorities in Greece partici¬pated in an online survey. Demographic, occupational data were collected and presented with correlations of individual variables. Results: The mental working condition of staff became much worse. The 96,7% of participants believed that the country does not implement a pandemic preparedness plan while 83,3% think that this plan has not been updated. Also, 38.9% of participants had no idea whether the strengthening of health system resilience is a current preoccu¬pation of health policy makers. Conclusions: Measures of new managements are considered necessary for a suc¬cessful reform effort. The organization of health systems and development of medical countermeasures are suggested as essential for the preparedness and response of Healthcare Administrative Staff of the Public Hospitals as well as the resilience of Greek Health System.

Socioeconomic and sociodemographic correlations to COVID-19 variability in the United States in 2020.

The COVID-19 pandemic provided an additional spotlight on the longstanding socioeconomic/health impacts of redlining and has added to the myriad of environmental justice issues, which has caused significant loss of life, health, and productive work. The Centers for Disease Control and Prevention (CDC) reports that a person with any selected underlying health conditions is more likely to experience severe COVID-19 symptoms, with more than 81% of COVID-19-related deaths among people aged 65 years and older. The effects of COVID-19 are not homogeneous across populations, varying by socioeconomic status, PM2.5 exposure, and geographic location. This variability is supported by analysis of existing data as a function of the number of cases and deaths per capita/1,00,000 persons. We investigate the degree of correlation between these parameters, excluding health conditions and age. We found that socioeconomic variables alone contribute to ~40% of COVID-19 variability, while socioeconomic parameters, combined with political affiliation, geographic location, and PM2.5 exposure levels, can explain ~60% of COVID-19 variability per capita when using an OLS regression model; socioeconomic factors contribute ~28% to COVID-19-related deaths. Using spatial coordinates in a Random Forest (RF) regressor model significantly improves prediction accuracy by ~120%. Data visualization products reinforce the fact that the number of COVID-19 deaths represents 1% of COVID-19 cases in the US and globally. A larger number of democratic voters, larger per-capita income, and age >65 years is negatively correlated (associated with a decrease) with the number of COVID cases per capita. Several distinct regions of negative and positive correlations are apparent, which are dominated by two major regions of anticorrelation: (1) the West Coast, which exhibits high PM2.5 concentrations and fewer COVID-19 cases; and (2) the middle portion of the US, showing mostly high number of COVID-19 cases and low PM2.5 concentrations. This paper underscores the importance of exercising caution and prudence when making definitive causal statements about the contribution of air quality constituents (such as PM2.5) and socioeconomic factors to COVID-19 mortality rates. It also highlights the importance of implementing better health/lifestyle practices and examines the impact of COVID-19 on vulnerable populations, particularly regarding preexisting health conditions and age. Although PM2.5 contributes comparable deaths (~7M) per year, globally as smoking cigarettes (~8.5M), quantifying any causal contribution toward COVID-19 is non-trivial, given the primary causes of COVID-19 death and confounding factors. This becomes more complicated as air pollution was reduced significantly during the lockdowns, especially during 2020. This statistical analysis provides a modular framework, that can be further expanded with the context of multilevel analysis (MLA). This study highlights the need to address socioeconomic and environmental disparities to better prepare for future pandemics. By understanding how factors such as socioeconomic status, political affiliation, geographic location, and PM2.5 exposure contribute to the variability in COVID-19 outcomes, policymakers and public health officials can develop targeted strategies to protect vulnerable populations. Implementing improved health and lifestyle practices and mitigating environmental hazards will be essential in reducing the impact of future public health crises on marginalized communities. These insights can guide the development of more resilient and equitable health systems capable of responding effectively to similar future scenarios.

A rapid mixed-methods assessment of Libya’s primary care system

BackgroundLibya has experienced decades of violent conflict that have severely disrupted health service delivery. The Government of National Unity is committed to rebuilding a resilient health system built on a platform of strong primary care.AimCommissioned by the government, we set out to perform a rapid assessment of the system as it stands and identify areas for improvement.Design and settingWe used a rapid applied policy explanatory-sequential mixed-methods design, working with Libyan data and Libyan policymakers, with supporting interview data from other primary care policymakers working across the Middle East and North Africa region.MethodWe used the Primary Health Care Performance Initiative framework to structure our assessment. Review of policy documents and secondary analysis of WHO and World Bank survey data informed a series of targeted policymaker interviews. We used deductive framework analysis to synthesise our findings.ResultsWe identified 11 key documents and six key policymakers to interview. Libya has strong policy commitments to providing good quality primary care, and a high number of health staff and facilities. Access to services and trust in providers is high. However, a third of facilities are non-operational; there is a marked skew towards axillary and administrative staff; and structural challenges with financing, logistics, and standards has led to highly variable provision of care.ConclusionIn reforming the primary care system, the government should consolidate leadership, clarify governance structures and systems, and focus on setting national standards for human resources for health, facilities, stocks, and clinical care.