Strengthening Health Systems Using Innovative Digital Health Technologies in Africa.

While effective health systems are needed to advance Universal Health Coverage and actualize the health Sustainable Development Goals, information system verticalization remains a challenge among African health systems. Most investments are vertical, partner-driven and program-specific with limited system-wide impacts. Poor linkages exist amongst different solutions as they are not designed to capture robust data across multiple programmatic areas. To address these challenges, the World Health Organization Africa Regional Office has proposed the adoption of a Digital Health Platform (DHP) to streamline different solutions to a cohesive whole. The DHP presents a pragmatic approach of bringing multiple platforms together using recognized standards to create a national infostructure, which bridges information solutions toward healthy and sustainable outcomes. It has capacities to curate accurate, high fidelity and timely data feedback loops needed to strengthen and continuously improve program delivery, monitoring, management, and informed decision-making at every level of the health system regardless of location. This paper contributes to the ongoing regional conversations on the need to harness innovative digital solutions to improve healthcare delivery in Africa.

Developing technical support and strategic dialogue at the country level to achieve Primary Health Care-based health systems beyond the COVID-19 era.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Pursuing the objectives of the Declaration of Alma-Ata for Primary Health Care (PHC), the World Health Organization (WHO) and global health partners are supporting national authorities to improve governance to build resilient and integrated health systems, including recovery from public health stressors, through the long-term deployment of WHO country senior health policy advisers under the Universal Health Coverage Partnership (UHC Partnership). For over a decade, the UHC Partnership has progressively reinforced, via a flexible and bottom-up approach, the WHO's strategic and technical leadership on Universal Health Coverage, with more than 130 health policy advisers deployed in WHO Country and Regional Offices. This workforce has been described as a crucial asset by WHO Regional and Country Offices in the integration of health systems to enhance their resilience, enabling the WHO offices to strengthen their support of PHC and Universal Health Coverage to Ministries of Health and other national authorities as well as global health partners. Health policy advisers aim to build the technical capacities of national authorities, in order to lead health policy cycles and generate political commitment, evidence, and dialogue for policy-making processes, while creating synergies and harmonization between stakeholders. The policy dialogue at the country level has been instrumental in ensuring a whole-of-society and whole-of-government approach, beyond the health sector, through community engagement and multisectoral actions. Relying on the lessons learned during the 2014-2016 Ebola outbreak in West Africa and in fragile, conflict-affected, and vulnerable settings, health policy advisers played a key role during the COVID-19 pandemic to support countries in health systems response and early recovery. They brought together technical resources to contribute to the COVID-19 response and to ensure the continuity of essential health services, through a PHC approach in health emergencies. This policy and practice review, including from the following country experiences: Colombia, Islamic Republic of Iran, Lao PDR, South Sudan, Timor-Leste, and Ukraine, provides operational and inner perspectives on strategic and technical leadership provided by WHO to assist Member States in strengthening PHC and essential public health functions for resilient health systems. It aims to demonstrate and advise lessons and good practices for other countries in strengthening their health systems.

Drug resistant tuberculosis: Implications for transmission, diagnosis, and disease management.

Drug resistant tuberculosis contributes significantly to the global burden of antimicrobial resistance, often consuming a large proportion of the healthcare budget and associated resources in many endemic countries. The rapid emergence of resistance to newer tuberculosis therapies signals the need to ensure appropriate antibiotic stewardship, together with a concerted drive to develop new regimens that are active against currently circulating drug resistant strains. Herein, we highlight that the current burden of drug resistant tuberculosis is driven by a combination of ongoing transmission and the intra-patient evolution of resistance through several mechanisms. Global control of tuberculosis will require interventions that effectively address these and related aspects. Interrupting tuberculosis transmission is dependent on the availability of novel rapid diagnostics which provide accurate results, as near-patient as is possible, together with appropriate linkage to care. Contact tracing, longitudinal follow-up for symptoms and active mapping of social contacts are essential elements to curb further community-wide spread of drug resistant strains. Appropriate prophylaxis for contacts of drug resistant index cases is imperative to limit disease progression and subsequent transmission. Preventing the evolution of drug resistant strains will require the development of shorter regimens that rapidly eliminate all populations of mycobacteria, whilst concurrently limiting bacterial metabolic processes that drive drug tolerance, mutagenesis and the ultimate emergence of resistance. Drug discovery programs that specifically target bacterial genetic determinants associated with these processes will be paramount to tuberculosis eradication. In addition, the development of appropriate clinical endpoints that quantify drug tolerant organisms in sputum, such as differentially culturable/detectable tubercle bacteria is necessary to accurately assess the potential of new therapies to effectively shorten treatment duration. When combined, this holistic approach to addressing the critical problems associated with drug resistance will support delivery of quality care to patients suffering from tuberculosis and bolster efforts to eradicate this disease.

Promoting equity in health emergencies through health systems strengthening: lessons learned from disability inclusion in the COVID-19 pandemic.

Discriminatory health systems and inequalities in service provision inevitably create barriers for certain populations in a health emergency. Persons with disabilities have been disproportionately affected by the COVID-19 pandemic. They commonly experience three increased risks - of contracting the disease, of severe disease or death, and of new or worsening health conditions. These added risks occur due to a range of barriers in the health sector, including physical barriers that prevent access to health facilities and specific interventions; informational barriers that prevent access to health information and/or reduce health literacy; and attitudinal barriers which give rise to stigma and exclusion, all of which add to discrimination and inequality. Furthermore, national health emergency preparedness and planning may fail to consider the needs and priorities of persons with disabilities, in all their diversity, thus leaving them behind in responses. This commentary discusses the importance of inclusive health systems strengthening as a prerequisite for accessible and comprehensive health emergency preparedness and response plans that reach everyone. Lessons learned relating to disability inclusion in the COVID-19 pandemic can inform health systems strengthening in recovery efforts, addressing underlying barriers to access and inclusion, and in turn improving preparedness for future health emergencies.

COVID-19 vaccine delivery: an opportunity to set up systems for the future [version 1, peer review: 2 approved with reservations]

The race to develop safe and effective SARS-COV-2 vaccines has moved with unprecedented speed. There are now multiple promising candidates seeking emergency use authorization from the United States Food and Drug Administration and a host of candidates positioned for approval worldwide. Attention has now turned to allocation, distribution and verification of these vaccines, yet this focus exposes that the underlying infrastructure for global delivery and monitoring is threadbare and unevenly distributed. This presents both a barrier and an opportunity to deploy sustainable infrastructure. Major global stakeholders must convene quickly, collaborate, and collectively invest in global standards, legal models, common vocabularies and interoperable biometric-supported digital health technologies. As the COVID-19 vaccine effort scales, governments, private sector and NGOs have the chance to place lasting resources needed for equitable and effective delivery that can pay dividends into the future. Copyright © 2020. Weintraub R et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Improving management of vaccine supply chains: A multi-methods evaluation of vSTEP in Zambia.

BACKGROUND: Equipping supply chain professionals at all levels of the health care systems with essential leadership and management skills is essential to achieving global immunization targets. Numerous and diverse professional development initiatives have been established to support vaccine supply chain managers in Gavi-eligible countries. However, COVID-19 catalyzed rapid innovation in approaches to support leadership development in times of rapid change, and systematic evaluation of these approaches can inform future workforce development strategies to ensure resilient health systems. Therefore, we sought to evaluate outcomes and short-term impact of the fully virtual Strategic Training Executive Program 2.0 (vSTEP 2.0) program in Zambia on participant engagement, skill development, and application of new skills to improve supply chain performance. METHODS: We used a multi-method design to describe the outcomes and short-term impact of vSTEP 2.0 at three levels: (1) delegate response to the training experience (including participation, completion, and satisfaction); (2) delegate change in leadership skill (including achievement of learning objectives and change in competencies); and (3) application of new skills to impact supply chain performance. RESULTS: The program achieved high levels of engagement and an 83% graduation rate despite the length and rigor of the program. High satisfaction was evidenced by positive feedback from delegates on the quality and relevance of the program, especially in the context of COVID response (100% would "definitely" recommend). Delegates demonstrated significant growth in all domains of leadership competencies and applied their learnings to address a complex challenge in supply chain performance in their home organization. DISCUSSION: These findings demonstrate a strong appetite for leadership development support among vaccine supply chain professionals, especially in times of rapid change such as during the COVID response. These results also demonstrate the feasibility and impact of a fully virtual model for leadership development, with implications well beyond the COVID-19 pandemic.

COVID-19 vaccine delivery: an opportunity to set up systems for the future.

The race to develop safe and effective SARS-COV-2 vaccines has moved with unprecedented speed. There are now multiple promising candidates seeking emergency use authorization from the United States Food and Drug Administration and a host of candidates positioned for approval worldwide. Attention has now turned to allocation, distribution and verification of these vaccines, yet this focus exposes that the underlying infrastructure for global delivery and monitoring is threadbare and unevenly distributed. This presents both a barrier and an opportunity to deploy sustainable infrastructure. Major global stakeholders must convene quickly, collaborate, and collectively invest in global standards, legal models, common vocabularies and interoperable biometric-supported digital health technologies. As the COVID-19 vaccine effort scales, governments, private sector and NGOs have the chance to place lasting resources needed for equitable and effective delivery that can pay dividends into the future.

Global surgery is an essential component of global health.

Global surgery as an essential component of global health. Global surgery is the study and practice of improving access to timely, quality, and affordable surgical care. It emphasizes horizontal health systems strengthening through addressing a range of health challenges in surgical care that improve health outcomes, particularly in vulnerable populations. Global surgery specifically contributes to achievement of the Sustainable Development Goals 2030 (SDGs) by addressing the elimination of poverty (SDG 1), ensuring good health and well-being (SDG 3), promoting decent work and economic growth (SDG 8), and reducing inequalities (SDGs 5 and 10). Global surgery issues transcend national boundaries and intersect with other global health issues such as migration and the COVID-19 pandemic. These issues are nested in a highly politicised environment, therefore power and politics should be considered when identifying problems and solutions. Despite evidence of its importance, the global surgery network has not generated substantial attention and resources compared to other global health networks. Global surgery can further increase its effectiveness through linking with health systems strengthening agendas, and identifying unified solutions to improve access to quality surgical care in low- and middle-income countries. Global surgery is indispensable in the achievement of health and well-being for all.

Health sector reform at the COVID cross-roads: Public goods or health markets - An agenda for health systems research.

The debate around approaches to health sector reform is one of the foundational questions around which the discipline of health policy and systems research has grown. In the immediate postwar period, health and health care were recognized as areas of market failure, requiring state action in the provision of free or subsidized services. In the eighties and nineties, due to both geopolitical and ideological reasons, this understanding changed, leading to a wave of market-based health sector reforms. An academic discourse built around neoliberal economics initiated, shaped, and legitimized these reforms. Faced with worsening health outcomes and costs of care after a decade of such reforms, there was a partial reversal of policy toward improving health sector performance that relied on nonmarket solutions built around notions of solidarity, trust, and rights. In India, this took the form of the National Rural Health Mission. Examples of health systems research that supported this direction of change are discussed. In the last decade, a second wave of health sector reforms sought to make markets work by repositioning government as purchaser of health care from private providers through insurance and contracts. There is little evidence that this worked. The need to rely on public services to cope with the COVID-19 pandemic, further questioned this direction of reform. We emphasize the need to expand and develop a framework of health systems and policy studies that are more appropriate to the achievement of universal health care, health equity, and health rights in the Indian context.

Addressing Gaps for Health Systems Strengthening: A Public Perspective on Health Systems' Response towards COVID-19.

Strengthening the health systems through gaps identification is necessary to ensure sustainable improvements especially in facing a debilitating outbreak such as COVID-19. This study aims to explore public perspective on health systems' response towards COVID-19, and to identify gaps for health systems strengthening by leveraging on WHO health systems' building blocks. A qualitative study was conducted using open-ended questions survey among public followed by in-depth interviews with key informants. Opinions on Malaysia's health systems response towards COVID-19 were gathered. Data were exported to NVIVO version 12 and analysed using content analysis approach. The study identified various issues on health systems' response towards COVID-19, which were then mapped into health systems' building blocks. The study showed the gaps were embedded among complex interactions between the health systems building blocks. The leadership and governance building block had cross-cutting effects, and all building blocks influenced service deliveries. Understanding the complexities in fostering whole-systems strengthening through a holistic measure in facing an outbreak was paramount. Applying systems thinking in addressing gaps could help addressing the complexity at a macro level, including consideration of how an action implicates other building blocks and approaching the governance effort in a more adaptive manner to develop resilient systems.

COVID-19 Preparedness and Response Plans from 106 countries: a review from a health systems resilience perspective.

Coronavirus disease (COVID-19) has exposed long-standing fragmentation in health systems strengthening efforts for health security and universal health coverage while these objectives are largely interdependent and complementary. In this prevailing background, we reviewed countries' COVID-19 Preparedness and Response Plans (CPRPs) to assess the extent of integration of non-COVID-19 essential health service continuity considerations alongside emergency response activities. We searched for COVID-19 planning documents from governments and ministries of health, World Health Organization (WHO) country offices and United Nations (UN) country teams. We developed document review protocols using global guidance from the WHO and UN and the health systems resilience literature. After screening, we analysed 154 CPRPs from 106 countries. The majority of plans had a high degree of alignment with pillars of emergency response such as surveillance (99%), laboratory systems (96%) and COVID-19-specific case management (97%). Less than half considered maintaining essential health services (47%); 41% designated a mechanism for health system-wide participation in emergency planning; 34% considered subnational service delivery; 95% contained infection prevention and control (IPC) activities and 29% considered quality of care; and 24% were budgeted for and 7% contained monitoring and evaluation of essential health services. To improve, ongoing and future emergency planning should proactively include proportionate activities, resources and monitoring for essential health services to reduce excess mortality and morbidity. Specifically, this entails strengthening subnational health services with local stakeholder engagement in planning; ensuring a dedicated focus in emergency operations structures to maintain health systems resilience for non-emergency health services; considering all domains of quality in health services along with IPC; and building resilient monitoring capacity for timely and reliable tracking of health systems functionality including service utilization and health outcomes. An integrated approach to planning should be pursued as health systems recover from COVID-19 disruptions and take actions to build back better.

Rising cholera cases: Harnessing the momentum of COVID-19 to strengthen Nigeria's health systems.

Recently, there has been a surge in cholera cases in Nigeria. With the exhausting health resources and the overwhelming attention towards COVID-19, Nigeria is in danger of worsening the epidemiological profile of cholera in the country. Thus, it is pertinent to address the surge to prevent further weakening of the country's health system. In this paper, we, therefore, explore the various interrelated factors accounting for the surge in Nigeria. It is therefore suggested that multifaceted public health strategies be employed that leverage the current level of disease preparedness and response capacities to the COVID-19 pandemic to reduce the impacts of cholera. These measures will not only help in strengthening the country's health system but also enhance the achievement of the relevant strategies toward eradicating cholera.

Making the investment case for national regulatory authorities.

Well-functioning national regulatory authorities (NRAs) ensure access to safe, effective, quality-assured, and affordable medical products. However, the benefits of their work are often unseen and difficult to attribute, thereby making NRAs undervalued and under-resourced, particularly in low- and middle-income countries. This paper offers three key arguments NRAs and other stakeholders can use to advocate for greater investment in regulatory systems strengthening-medical products regulation effectively safeguards public health; effective regulation improves health system's efficiency by increasing access to affordable medical products, contributing to universal health coverage; and robust regulation strengthens local pharmaceutical manufacturing and bolsters pharmaceutical trade. NRAs' critical role in health systems is indisputable, yet they need to better promote their value to receive the requisite resources to function effectively.

Optimizing Pandemic Preparedness and Response Through Health Information Systems: Lessons Learned From Ebola to COVID-19.

Strengthening health systems and maintaining essential service delivery during health emergencies response is critical for early detection and diagnosis, prompt treatment, and effective control of pandemics, including the novel coronavirus disease 2019 (COVID-19). Health information systems (HIS) developed during recent Ebola outbreaks in West Africa and the Democratic Republic of the Congo (DRC) provided opportunities to collect, analyze, and distribute data to inform both day-to-day and long-term policy decisions on outbreak preparedness. As COVID-19 continues to sweep across the globe, HIS and related technological advancements remain vital for effective and sustained data sharing, contact tracing, mapping and monitoring, community risk sensitization and engagement, preventive education, and timely preparedness and response activities. In reviewing literature of how HIS could have further supported mitigation of these Ebola outbreaks and the ongoing COVID-19 pandemic, 3 key areas were identified: governance and coordination, health systems infrastructure and resources, and community engagement. In this concept study, we outline scalable HIS lessons from recent Ebola outbreaks and early COVID-19 responses along these 3 domains, synthesizing recommendations to offer clear, evidence-based approaches on how to leverage HIS to strengthen the current pandemic response and foster community health systems resilience moving forward.

Clinical management and mortality among COVID-19 cases in sub-Saharan Africa: A retrospective study from Burkina Faso and simulated case analysis.

BACKGROUND: Absolute numbers of COVID-19 cases and deaths reported to date in the sub-Saharan Africa (SSA) region have been significantly lower than those across the Americas, Asia and Europe. As a result, there has been limited information about the demographic and clinical characteristics of deceased cases in the region, as well as the impacts of different case management strategies. METHODS: Data from deceased cases reported across SSA through 10 May 2020 and from hospitalized cases in Burkina Faso through 15 April 2020 were analyzed. Demographic, epidemiological and clinical information on deceased cases in SSA was derived through a line-list of publicly available information and, for cases in Burkina Faso, from aggregate records at the Centre Hospitalier Universitaire de Tengandogo in Ouagadougou. A synthetic case population was probabilistically derived using distributions of age, sex and underlying conditions from populations of West African countries to assess individual risk factors and treatment effect sizes. Logistic regression analysis was conducted to evaluate the adjusted odds of survival for patients receiving oxygen therapy or convalescent plasma, based on therapeutic effectiveness observed for other respiratory illnesses. RESULTS: Across SSA, deceased cases for which demographic data were available were predominantly male (63/103, 61.2%) and aged >50 years (59/75, 78.7%). In Burkina Faso, specifically, the majority of deceased cases either did not seek care at all or were hospitalized for a single day (59.4%, 19/32). Hypertension and diabetes were often reported as underlying conditions. After adjustment for sex, age and underlying conditions in the synthetic case population, the odds of mortality for cases not receiving oxygen therapy were significantly higher than for those receiving oxygen, such as due to disruptions to standard care (OR 2.07; 95% CI 1.56-2.75). Cases receiving convalescent plasma had 50% reduced odds of mortality than those who did not (95% CI 0.24-0.93). CONCLUSIONS: Investment in sustainable production and maintenance of supplies for oxygen therapy, along with messaging around early and appropriate use for healthcare providers, caregivers and patients could reduce COVID-19 deaths in SSA. Further investigation into convalescent plasma is warranted until data on its effectiveness specifically in treating COVID-19 becomes available. The success of supportive or curative clinical interventions will depend on earlier treatment seeking, such that community engagement and risk communication will be critical components of the response.