Assessing capacities and resilience of health services during the COVID-19 pandemic: Lessons learned from use of rapid key informant surveys

This article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict.' Problem Many countries lacked rapid and nimble data systems to track health service capacities to respond to COVID-19. They struggled to assess and monitor rapidly evolving service disruptions, health workforce capacities, health products availability, community needs and perspectives, and mitigation responses to maintain essential health services. Method Building on established methodologies, the World Health Organization developed a suite of methods and tools to support countries to rapidly fill data gaps and guide decision-making during COVID-19. The tools included: (1) a national "pulse” survey on service disruptions and bottlenecks;(2) a phone-based facility survey on frontline service capacities;and (3) a phone-based community survey on demand-side challenges and health needs. Use Three national pulse surveys revealed persisting service disruptions throughout 2020–2021 (97 countries responded to all three rounds). Results guided mitigation strategies and operational plans at country level, and informed investments and delivery of essential supplies at global level. Facility and community surveys in 22 countries found similar disruptions and limited frontline service capacities at a more granular level. Findings informed key actions to improve service delivery and responsiveness from local to national levels. Lessons learned The rapid key informant surveys provided a low-resource way to collect action-oriented health services data to inform response and recovery from local to global levels. The approach fostered country ownership, stronger data capacities, and integration into operational planning. The surveys are being evaluated to inform integration into country data systems to bolster routine health services monitoring and serve as health services alert functions for the future.

Assessing capacities and resilience of health services during the COVID-19 pandemic: Lessons learned from use of rapid key informant surveys.

This article is part of the Research Topic: 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict.' Problem: Many countries lacked rapid and nimble data systems to track health service capacities to respond to COVID-19. They struggled to assess and monitor rapidly evolving service disruptions, health workforce capacities, health products availability, community needs and perspectives, and mitigation responses to maintain essential health services. Method: Building on established methodologies, the World Health Organization developed a suite of methods and tools to support countries to rapidly fill data gaps and guide decision-making during COVID-19. The tools included: (1) a national "pulse" survey on service disruptions and bottlenecks; (2) a phone-based facility survey on frontline service capacities; and (3) a phone-based community survey on demand-side challenges and health needs. Use: Three national pulse surveys revealed persisting service disruptions throughout 2020-2021 (97 countries responded to all three rounds). Results guided mitigation strategies and operational plans at country level, and informed investments and delivery of essential supplies at global level. Facility and community surveys in 22 countries found similar disruptions and limited frontline service capacities at a more granular level. Findings informed key actions to improve service delivery and responsiveness from local to national levels. Lessons learned: The rapid key informant surveys provided a low-resource way to collect action-oriented health services data to inform response and recovery from local to global levels. The approach fostered country ownership, stronger data capacities, and integration into operational planning. The surveys are being evaluated to inform integration into country data systems to bolster routine health services monitoring and serve as health services alert functions for the future.

COVID-19 in the 47 countries of the WHO African region: a modelling analysis of past trends and future patterns.

BACKGROUND: COVID-19 has affected the African region in many ways. We aimed to generate robust information on the transmission dynamics of COVID-19 in this region since the beginning of the pandemic and throughout 2022. METHODS: For each of the 47 countries of the WHO African region, we consolidated COVID-19 data from reported infections and deaths (from WHO statistics); published literature on socioecological, biophysical, and public health interventions; and immunity status and variants of concern, to build a dynamic and comprehensive picture of COVID-19 burden. The model is consolidated through a partially observed Markov decision process, with a Fourier series to produce observed patterns over time based on the SEIRD (denoting susceptible, exposed, infected, recovered, and dead) modelling framework. The model was set up to run weekly, by country, from the date the first infection was reported in each country until Dec 31, 2021. New variants were introduced into the model based on sequenced data reported by countries. The models were then extrapolated until the end of 2022 and included three scenarios based on possible new variants with varying transmissibility, severity, or immunogenicity. FINDINGS: Between Jan 1, 2020, and Dec 31, 2021, our model estimates the number of SARS-CoV-2 infections in the African region to be 505·6 million (95% CI 476·0-536·2), inferring that only 1·4% (one in 71) of SARS-CoV-2 infections in the region were reported. Deaths are estimated at 439 500 (95% CI 344 374-574 785), with 35·3% (one in three) of these reported as COVID-19-related deaths. Although the number of infections were similar between 2020 and 2021, 81% of the deaths were in 2021. 52·3% (95% CI 43·5-95·2) of the region's population is estimated to have some SARS-CoV-2 immunity, given vaccination coverage of 14·7% as of Dec 31, 2021. By the end of 2022, we estimate that infections will remain high, at around 166·2 million (95% CI 157·5-174·9) infections, but deaths will substantially reduce to 22 563 (14 970-38 831). INTERPRETATION: The African region is estimated to have had a similar number of COVID-19 infections to that of the rest of the world, but with fewer deaths. Our model suggests that the current approach to SARS-CoV-2 testing is missing most infections. These results are consistent with findings from representative seroprevalence studies. There is, therefore, a need for surveillance of hospitalisations, comorbidities, and the emergence of new variants of concern, and scale-up of representative seroprevalence studies, as core response strategies. FUNDING: None.

Geospatial Clustering of Mobile Phone Use and Tuberculosis Health Outcomes Among African Health Systems.

BACKGROUND: While multiple studies have documented the impacts of mobile phone use on TB health outcomes for varied settings, it is not immediately clear what the spatial patterns of TB treatment completion rates among African countries are. This paper used Exploratory Spatial Data Analysis (ESDA) techniques to explore the clustering spatial patterns of TB treatment completion rates in 53 African countries and also their relationships with mobile phone use. Using an ESDA approach to identify countries with low TB treatment completion rates and reduced mobile phone use is the first step toward addressing issues related to poor TB outcomes. METHODS: TB notifications and treatment data from 2000 through 2015 that were obtained from the World Bank database were used to illustrate a descriptive epidemiology of TB treatment completion rates among African health systems. Spatial clustering patterns of TB treatment completion rates were assessed using differential local Moran's I techniques, and local spatial analytics was performed using local Moran's I tests. Relationships between TB treatment completion rates and mobile phone use were evaluated using ESDA approach. RESULT: Spatial autocorrelation patterns generated were consistent with Low-Low and High-Low cluster patterns, and they were significant at different p-values. Algeria and Senegal had significant clusters across the study periods, while Democratic Republic of Congo, Niger, South Africa, and Cameroon had significant clusters in at least two time-periods. ESDA identified statistically significant associations between TB treatment completion rates and mobile phone use. Countries with higher rates of mobile phone use showed higher TB treatment completion rates overall, indicating enhanced program uptake (p < 0.05). CONCLUSION: Study findings provide systematic evidence to inform policy regarding investments in the use of mHealth to optimize TB health outcomes. African governments should identify turnaround strategies to strengthen mHealth technologies and improve outcomes.

On the resilience of health systems: A methodological exploration across countries in the WHO African Region.

The need for resilient health systems is recognized as important for the attainment of health outcomes, given the current shocks to health services. Resilience has been defined as the capacity to "prepare and effectively respond to crises; maintain core functions; and, informed by lessons learnt, reorganize if conditions require it". There is however a recognized dichotomy between its conceptualization in literature, and its application in practice. We propose two mutually reinforcing categories of resilience, representing resilience targeted at potentially known shocks, and the inherent health system resilience, needed to respond to unpredictable shock events. We determined capacities for each of these categories, and explored this methodological proposition by computing country-specific scores against each capacity, for the 47 Member States of the WHO African Region. We assessed face validity of the computed index, to ensure derived values were representative of the different elements of resilience, and were predictive of health outcomes, and computed bias-corrected non-parametric confidence intervals of the emergency preparedness and response (EPR) and inherent system resilience (ISR) sub-indices, as well as the overall resilience index, using 1000 bootstrap replicates. We also explored the internal consistency and scale reliability of the index, by calculating Cronbach alphas for the various proposed capacities and their corresponding attributes. We computed overall resilience to be 48.4 out of a possible 100 in the 47 assessed countries, with generally lower levels of ISR. For ISR, the capacities were weakest for transformation capacity, followed by mobilization of resources, awareness of own capacities, self-regulation and finally diversity of services respectively. This paper aims to contribute to the growing body of empirical evidence on health systems and service resilience, which is of great importance to the functionality and performance of health systems, particularly in the context of COVID-19. It provides a methodological reflection for monitoring health system resilience, revealing areas of improvement in the provision of essential health services during shock events, and builds a case for the need for mechanisms, at country level, that address both specific and non-specific shocks to the health system, ultimately for the attainment of improved health outcomes.

Towards universal health coverage in the WHO African Region: assessing health system functionality, incorporating lessons from COVID-19.

The move towards universal health coverage is premised on having well-functioning health systems, which can assure provision of the essential health and related services people need. Efforts to define ways to assess functionality of health systems have however varied, with many not translating into concrete policy action and influence on system development. We present an approach to provide countries with information on the functionality of their systems in a manner that will facilitate movement towards universal health coverage. We conceptualise functionality of a health system as being a construct of four capacities: access to, quality of, demand for essential services and its resilience to external shocks. We test and confirm the validity of these capacities as appropriate measures of system functionality. We thus provide results for functionality of the 47 countries of the WHO African Region based on this. The functionality of health systems ranges from 34.4 to 75.8 on a 0-100 scale. Access to essential services represents the lowest capacity in most countries of the region, specifically due to poor physical access to services. Funding levels from public and out-of-pocket sources represent the strongest predictors of system functionality, compared with other sources. By focusing on the assessment on the capacities that define system functionality, each country has concrete information on where it needs to focus, in order to improve the functionality of its health system to enable it respond to current needs including achieving universal health coverage, while responding to shocks from challenges such as the 2019 coronavirus disease. This systematic and replicable approach for assessing health system functionality can provide the guidance needed for investing in country health systems to attain universal health coverage goals.

Building health system resilience in the context of primary health care revitalization for attainment of UHC: proceedings from the Fifth Health Sector Directors' Policy and Planning Meeting for the WHO African Region.

BACKGROUND: The recent 2018 Declaration of Astana recognized primary health care (PHC) as a means to achieve universal health coverage (UHC) and the health-related Sustainable Development Goals (SDGs). Following this declaration, country progress on operationalization of the PHC agenda and attainment of UHC has been stalled by the new challenges posed by the COVID-19 pandemic. The pandemic has also disrupted the continuity of essential health service provision and tested the resilience of the region's health systems. METHODS: In accordance with this, the WHO Regional Office for Africa convened the Fifth Health Sector Directors' Planning and Policy Meeting across the 47 Member States of the Region. The two-day forum focused on building health system resilience to facilitate service continuity during health threats, PHC revitalization, and health systems strengthening towards UHC. RESULTS: The Regional Forum provided evidence on building resilient health systems in the WHO African Region and engaged participants in meaningful and critical discussion. It is from these discussions that four key themes emerged: (1) working multisectorally/intersectorally, (2) moving from fragmentation to integration, (3) ensuring implementation and knowledge exchange, and (4) rethinking resilience and embracing antifragility. These discussions and associated groupings by thematic areas lend themselves to recommendations for the WHO. CONCLUSIONS: This paper details the proceedings and key findings on building resilient health systems, the four themes that emerged from participant deliberation, and the recommendations that have emerged from the meeting. Deliberations from the Regional Forum are critical, as they have the potential to directly inform policy and program design, given that the meeting convenes health sector technocrats, who are at the helm of policy design, action, and implementation.

The potential effects of widespread community transmission of SARS-CoV-2 infection in the World Health Organization African Region: a predictive model.

The spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been unprecedented in its speed and effects. Interruption of its transmission to prevent widespread community transmission is critical because its effects go beyond the number of COVID-19 cases and deaths and affect the health system capacity to provide other essential services. Highlighting the implications of such a situation, the predictions presented here are derived using a Markov chain model, with the transition states and country specific probabilities derived based on currently available knowledge. A risk of exposure, and vulnerability index are used to make the probabilities country specific. The results predict a high risk of exposure in states of small size, together with Algeria, South Africa and Cameroon. Nigeria will have the largest number of infections, followed by Algeria and South Africa. Mauritania would have the fewest cases, followed by Seychelles and Eritrea. Per capita, Mauritius, Seychelles and Equatorial Guinea would have the highest proportion of their population affected, while Niger, Mauritania and Chad would have the lowest. Of the World Health Organization's 1 billion population in Africa, 22% (16%-26%) will be infected in the first year, with 37 (29 - 44) million symptomatic cases and 150 078 (82 735-189 579) deaths. There will be an estimated 4.6 (3.6-5.5) million COVID-19 hospitalisations, of which 139 521 (81 876-167 044) would be severe cases requiring oxygen, and 89 043 (52 253-106 599) critical cases requiring breathing support. The needed mitigation measures would significantly strain health system capacities, particularly for secondary and tertiary services, while many cases may pass undetected in primary care facilities due to weak diagnostic capacity and non-specific symptoms. The effect of avoiding widespread and sustained community transmission of SARS-CoV-2 is significant, and most likely outweighs any costs of preventing such a scenario. Effective containment measures should be promoted in all countries to best manage the COVID-19 pandemic.