Perspective: Lessons from COVID-19 of countries in the European region in light of findings from the health system response monitor.

Introduction: Decision-makers initially had limited data to inform their policy responses to the COVID-19 pandemic. The research community developed several online databases to track cases, deaths, and hospitalizations; however, a major deficiency was the lack of detailed information on how health systems were responding to the pandemic and how they would need to be transformed going forward. Approach: In an effort to fill this information gap, in March 2020, the European Observatory on Health Systems and Policies, the WHO European Regional Office and the European Commission created the COVID-19 Health System Response Monitor (HSRM) to collect and organise up-to-date information on how health systems, mainly in the WHO European Region, were responding to the COVID-19 pandemic. Findings: The HSRM analysis and broader Observatory work on COVID-19 shone light on a range of health system challenges and weaknesses and catalogued policy options countries put in place during the pandemic to address these. Countries prioritised policies on investing in public health, supporting the workforce, maintaining financial stability, and strengthening governance in their response to COVID-19. Outlook: COVID-19 is likely to continue to impact health systems for the foreseeable future; the ability to cope with this pressure, and other shocks, depends on having good information on what other countries have done so that health systems develop adequate policy options. In support of this, the country information on the COVID-19 HSRM will remain available as a repository to inform decision makers on options for actions and possible measures against COVID-19 and other public health emergencies. Building on its previous work on health systems resilience, the European Observatory on Health Systems and Policies will sustain its focus on analysing key issues related to the recovery from the pandemic and making health systems more resilient. This includes policy knowledge transfer between countries and systematic resilience testing, aiming at contributing to an improved understanding of health system response, recovery, and preparedness. Contribution to the literature in non-technical language: The COVID-19 Health System Response Monitor (HSRM) was the first database in the WHO European Region to collect and organise up-to-date information on how health systems were responding to the COVID-19 pandemic. The HSRM provides a repository of policies which can be used to inform decision makers in health and other policy domains on options for action and possible measures against COVID-19 and other public health emergencies. This initiative proved particularly valuable, especially during the early phases of the pandemic, when there was limited information for countries to draw on as they formulated their own policy response to the pandemic. Our perspectives paper highlights some key challenges within health systems that the HSRM was able to identify during the pandemic and considers policy options countries put in place in response. Our research contributes to literature on emergency responses and recovery, health systems performance assessment, particularly health system resilience, and showcases the Observatory experience on how to design such a data collection tool, as well as how to leverage its findings to support cross-country learning.

Perspective: Lessons from COVID-19 of countries in the European region in light of findings from the health system response monitor

Introduction Decision-makers initially had limited data to inform their policy responses to the COVID-19 pandemic. The research community developed several online databases to track cases, deaths, and hospitalizations;however, a major deficiency was the lack of detailed information on how health systems were responding to the pandemic and how they would need to be transformed going forward. Approach In an effort to fill this information gap, in March 2020, the European Observatory on Health Systems and Policies, the WHO European Regional Office and the European Commission created the COVID-19 Health System Response Monitor (HSRM) to collect and organise up-to-date information on how health systems, mainly in the WHO European Region, were responding to the COVID-19 pandemic. Findings The HSRM analysis and broader Observatory work on COVID-19 shone light on a range of health system challenges and weaknesses and catalogued policy options countries put in place during the pandemic to address these. Countries prioritised policies on investing in public health, supporting the workforce, maintaining financial stability, and strengthening governance in their response to COVID-19. Outlook COVID-19 is likely to continue to impact health systems for the foreseeable future;the ability to cope with this pressure, and other shocks, depends on having good information on what other countries have done so that health systems develop adequate policy options. In support of this, the country information on the COVID-19 HSRM will remain available as a repository to inform decision makers on options for actions and possible measures against COVID-19 and other public health emergencies. Building on its previous work on health systems resilience, the European Observatory on Health Systems and Policies will sustain its focus on analysing key issues related to the recovery from the pandemic and making health systems more resilient. This includes policy knowledge transfer between countries and systematic resilience testing, aiming at contributing to an improved understanding of health system response, recovery, and preparedness. Contribution to the literature in non-technical language The COVID-19 Health System Response Monitor (HSRM) was the first database in the WHO European Region to collect and organise up-to-date information on how health systems were responding to the COVID-19 pandemic. The HSRM provides a repository of policies which can be used to inform decision makers in health and other policy domains on options for action and possible measures against COVID-19 and other public health emergencies. This initiative proved particularly valuable, especially during the early phases of the pandemic, when there was limited information for countries to draw on as they formulated their own policy response to the pandemic. Our perspectives paper highlights some key challenges within health systems that the HSRM was able to identify during the pandemic and considers policy options countries put in place in response. Our research contributes to literature on emergency responses and recovery, health systems performance assessment, particularly health system resilience, and showcases the Observatory experience on how to design such a data collection tool, as well as how to leverage its findings to support cross-country learning.

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges.

This paper conducts a comparative review of the (curative) health systems' response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the 'Health System Response Monitor' platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy "flexible" intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care.

The Devil Is in the Data: Can Regional Variation in Amenable Mortality Help to Understand Changes in Health System Performance in Poland?

The contribution of health systems to health is commonly assessed using levels of amenable mortality. Few such studies exist for Poland, with analyses of within-the-country patterns being particularly scarce. The aim of this paper is to analyse differences in amenable mortality levels and trends across Poland's regions using the most recent data and to gain a more nuanced understanding of these differences and possible reasons behind them. This can inform future health policy decisions, particularly when it comes to efforts to improve health system performance. We used national and regional mortality data to construct amenable mortality rates between 2002 and 2019. We found that the initially observed decline in amenable mortality stagnated between 2014 and 2019, something not seen elsewhere in Europe. The main driver behind this trend is the change in ischemic heart disease (IHD) mortality. However, we also found that there is a systematic underreporting of IHD as a cause of death in Poland in favour of heart failure, which makes analysis of health system performance using amenable mortality as an indicator less reliable. We also found substantial geographical differences in amenable mortality levels and trends across Poland, which ranged from -3.3% to +8.1% across the regions in 2014-2019. These are much bigger than variations in total mortality trends, ranging from -1.5% to -0.2% in the same period, which suggests that quality of care across regions varies substantially, although some of this effect is also a coding artefact. This means that interpretation of health system performance indicators is not straightforward and may prevent implementation of policies that are needed to improve population health.

What have European countries done to prevent the spread of COVID-19? Lessons from the COVID-19 Health system response monitor.

Although some European countries imposed measures that successfully slowed the transmission of Covid-19 during the first year of the pandemic, others struggled, either because they acted slowly or implemented measures ineffectively. In this paper we consider the European experience with public health measures designed to prevent transmission of COVID-19. Based on literature and country responses described in the COVID-19 Health System Response Monitor from March 2020 to December 2020, we consider some critical aspects of public health policy responses. These include the importance of public health capacity that can scale up surveillance and outbreak control, including effective testing and contract tracing, of clear messaging based on an understanding of human behaviour, policies that address the undesirable consequences of necessary measures, such as support for those isolating or unable to earn, and the ability to implement at pace and scale a major vaccine rollout. We conclude that for countries to be successful at preventing COVID-19 transmission, there is a need for a clear strategy with explicit goals and a whole systems approach to implementation.

Lessons learned from the Baltic countries' response to the first wave of COVID-19.

The Baltic countries of Estonia, Latvia, and Lithuania shared a similar response to the first wave of the COVID-19 pandemic. Using the information available on the COVID-19 Health System Response Monitor platform, this article analyzed measures taken to prevent transmission, ensure capacity, provide essential services, finance the health system, and coordinate their governance approaches. All three countries used a highly centralized approach and implemented restrictive measures relatively early, with a state of emergency declared with fewer than 30 reported cases in each country. Due to initially low COVID-19 incidence, the countries built up their capacities for testing, contact tracing, and infrastructure, without a major stress test to the health system throughout the spring and summer of 2020, yet issues with accessing routine health care services had already started manifesting themselves. The countries in the Baltic region entered the pandemic with a precarious starting point, particularly due to smaller operational budgets and health workforce shortages, which may have contributed to their escalated response aiming to prevent transmission during the first wave. Subsequent waves, however, were much more damaging. This article focuses on early responses to the pandemic in the Baltic states highlighting measures taken to prevent virus transmission in the face of major uncertainties.

Health system resilience during the pandemic: it’s mostly about governance

Governance is the most important enabler of health system functioning. It provides a foundation and lever for resource generation, financing, and service delivery and ensures they operate well and in coordination with the rest of the system. It also extends beyond the health system through interactions between levels and actors. While there is no unanimously accepted framework for assessing governance, country examples can be used to illustrate how governance has contributed to health systems resilience during the crisis. Good governance prior to the pandemic, underpinned by strong state capacity, political leadership and community engagement, is keyto responding resiliently during a novel infectious disease outbreak, such as COVID-19.

Health system resilience during the pandemic: it’s mostly about governance

Governance is the most important enabler of health system functioning. It provides a foundation and lever for resource generation, financing, and service delivery and ensures they operate well and in coordination with the rest of the system. It also extends beyond the health system through interactions between levels and actors. While there is no unanimously accepted framework for assessing governance, country examples can be used to illustrate how governance has contributed to health systems resilience during the crisis. Good governance prior to the pandemic, underpinned by strong state capacity, political leadership and community engagement, is keyto responding resiliently during a novel infectious disease outbreak, such as COVID-19.

Nordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic.

This paper explores and compares health system responses to the COVID-19 pandemic in Denmark, Finland, Iceland, Norway and Sweden, in the context of existing governance features. Content compiled in the Covid-19 Health System Response Monitor combined with other publicly available country information serve as the foundation for this analysis. The analysis mainly covers early response until August 2020, but includes some key policy and epidemiological developments up until December 2020. Our findings suggest that despite the many similarities in adopted policy measures, the five countries display differences in implementation as well as outcomes. Declaration of state of emergency has differed in the Nordic region, whereas the emphasis on specialist advisory agencies in the decision-making process is a common feature. There may be differences in how respective populations complied with the recommended measures, and we suggest that other structural and circumstantial factors may have an important role in variations in outcomes across the Nordic countries. The high incidence rates among migrant populations and temporary migrant workers, as well as differences in working conditions are important factors to explore further. An important question for future research is how the COVID-19 epidemic will influence legislation and key principles of governance in the Nordic countries.

Strengthening health systems resilience: Key concepts and strategies

Health system resilience is key to coping with catastrophic events, such as the economic crisis and the coronavirus (COVID-19) pandemic, but there is much confusion about what resilience means, how to strengthen it and how to assess it. For operational and assessment purposes, and to foster a more consistent understanding and use of the key concepts, we adopt the following definitions of health system resilience and shock: Health system resilience is the ability to prepare for, manage (absorb, adapt and transform) and learn from shocks. Shock is a sudden and extreme change which impacts on a health system, and is thus different from the predictable and enduring health system stresses, such as population ageing. A shock cycle has four stages: Stage 1: Preparedness;Stage 2: Shock onset and alert;Stage 3: Shock impact and management;and Stage 4: Recovery and learning. Based on the existing literature and emerging evidence from the ongoing COVID-19 pandemic, we identify strategies for enhancing resilience and map them on to the key health systems functions: Governance: effective and participatory leadership with strong vision and communication;coordination of activities across government and key stakeholders;an organizational learning culture that is responsive to crises;effective information systems and flows;and surveillance enabling timely detection of shocks and their impact. Financing: ensuring sufficient monetary resources in the system and flexibility to reallocate and inject extra funds;ensuring stability of health system funding through countercyclical health financing mechanisms and reserves;purchasing flexibility and reallocation of funding to meet changing needs;and comprehensive health coverage. Resources: appropriate level and distribution of human and physical resources;ability to increase capacity to cope with a sudden surge in demand;and motivated and well-supported workforce. Service delivery: alternative and flexible approaches to deliver care. Assessing how each function is placed in terms of the strategies above can allow a country to identify the potential sources of vulnerability and plan for further action (to enhance resilience or the capacity to respond). Resilience can also be assessed after the crisis, providing an evaluation of the handling of the crisis. Assessment of health system resilience is crisis- and context-specific. It is important to employ a range of both quantitative and qualitative metrics that allow evaluation of particular aspects of health system resilience in order to provide a meaningful overall assessment. Analysing experiences of other countries provides useful lessons for policy-makers implementing resilience-enhancing strategies. It is particularly important to learn in the aftermath of the shock and make the link between recovering from the shock to preparedness for future shocks, which is an area often neglected once the health system returns to post-shock 'normality'.