Priority Setting and Equity in COVID-19 Pandemic Plans: A Comparative Analysis of eighteen African Countries

Planning with a gender lens: A gender analysis of pandemic preparedness plans from eight countries in Africa

Background

Health planning and priority setting with a gender lens can help to anticipate and mitigate vulnerabilities that women and girls may experience in health systems, which is especially relevant during health emergencies. This study examined how gender considerations were accounted for in COVID-19 pandemic response planning in a subset of countries in Africa.

Methods

Multi-country document review of national pandemic response plans (published before July 2020 and as of March 2022) from Ethiopia, Ghana, Kenya, Nigeria, Rwanda, South Africa, Uganda, and Zambia, supplemented with secondary data on gender representation on planning committees. A gender analysis framework informed the study design and the Morgan et al. matrix guided data extraction and analysis.

Results

All plans reflected implicit and explicit considerations of the impacts of the pandemic responses on women and girls. Through a gender lens, the implicit considerations focused on ensuring safety and protections (e.g., training, access to personal protective equipment) for community and facility-based health care workers and broad engagement of the community in risk communication. The explicit gender considerations, reflected in a minority of plans, focused on addressing gender-based violence and providing access to essential services (e.g., sexual and reproductive health care, psychosocial supports), products (e.g., menstrual hygiene products) and social protection measures. Women were underrepresented on the COVID-19 planning committees in all countries.

Conclusions

The plans reflected varying national efforts to develop pandemic responses that anticipated and reflected unique vulnerabilities faced by women, though subsequent plans reflected further consideration of gender-relevant impacts compared to initial plans. Embedding a gender lens in emergency preparedness planning furthers equity and could support anticipation and timely mitigation of negative outcomes for women and girls who are often further marginalized during health emergencies.

Priority setting in times of crises: an analysis of priority setting for the COVID-19 response in the Western Pacific Region

BACKGROUND

While priority setting is recognized as critical for promoting accountability and transparency in health system planning, its role in supporting rational, equitable and fair pandemic planning and responses is less well understood. This study aims to describe how priority setting was used to support planning in the initial stage of the pandemic response in a subset of countries in the Western Pacific Region (WPR).

METHODS

We purposively sampled a subset of countries from WPR and undertook a critical document review of the initial national COVID-19 pandemic response plans. A pre-specified tool guided data extraction and the analysis examined the use of quality parameters of priority setting, and equity considerations.

RESULTS

Nine plans were included in this analysis, from the following countries: Papua New Guinea, Tonga, The Philippines, Fiji, China, Australia, New Zealand, Japan, and Taiwan. Most commonly the plans described strong political will to respond swiftly, resource needs, stakeholder engagement, and defined the roles of institutions that guided COVID-19 response decision-making. The initial plans did not reflect strong evidence of public engagement or considerations of equity informing the early responses to the pandemic.

CONCLUSION

This study advances an understanding of how priority setting and equity considerations were integrated to support the development of the initial COVID-19 responses in nine countries in WPR and contributes to the literature on health system planning during emergencies. This baseline assessment reveals evidence of the common priority setting parameters that were deployed in the initial responses, the prioritized resources and equity considerations and reinforces the importance of strengthening health system capacity for priority setting to support future pandemic preparedness.

Stakeholder participation in the COVID-19 pandemic preparedness and response plans: A synthesis of findings from 70 countries

Stakeholder participation is a key component of a fair and equitable priority-setting in health. The COVID-19 pandemic highlighted the need for fair and equitable priority setting, and hence, stakeholder participation. To date, there is limited literature on stakeholder participation in the development of the pandemic plans (including the priority setting plans) that were rapidly developed during the pandemic. Drawing on a global study of national COVID-19 preparedness and response plans, we present a secondary analysis of COVID-19 national plans from 70 countries from the six WHO regions, focusing on stakeholder participation. We found that most plans were prepared by the Ministry of Health and acknowledged WHO guidance, however less than half mentioned that additional stakeholders were involved. Few plans described a strategy for stakeholder participation and/or accounted for public participation in the plan preparation. However, diverse stakeholders (including multiple governmental, non-governmental, and international organizations) were proposed to participate in the implementation of the plans. Overall, there was a lack of transparency about who participated in decision-making and limited evidence of meaningful participation of the community, including marginalized groups. The critical relevance of stakeholder participation in priority setting requires that governments develop strategies for meaningful participation of diverse stakeholders during pandemics such as COVID-19, and in routine healthcare priority setting.

National COVID-19 preparedness and response plans: a global review from the perspective of services for maternal, newborn, child and adolescent health and older people

INTRODUCTION

Infectious disease outbreaks have historically led to widespread disruptions in routine essential health services. Disruptions due to COVID-19 responses led to excess deaths, including among women and children. This review builds on earlier reviews of essential health services in national COVID-19 response and preparedness plans, focusing specifically on maternal, newborn, child, adolescent and ageing health (MNCAAH) in the context of renewed global emphasis on monitoring, recovering and strengthening these services.

METHODS

Using Google searches, we identified publicly available COVID-19 response and preparedness plans authored by a national government body or Public Health Institute from any country, territory and/or area, published between January 2020 and December 2022. We assessed whether each plan considered maintenance of MNCAAH services with related activities, costing or monitoring plans, and whether these considerations were integrated into the national incident management system for COVID-19.

RESULTS

We identified plans from 110 countries, representing 56% of our sample, in 10 languages. Most plans came from low-income and middle-income countries. Three quarters of dated documents were published between February and April 2020. 22% of plans referenced the impact of COVID-19 on MNCAAH, but only 13% included a planned activity for monitoring or mitigating this impact and less than 5% included relevant indicators, costing or integration of services in the incident management system.

CONCLUSION

We propose that unless content specifically related to the services and needs of these populations is integrated, these services will suffer in a future disruptive event. The COVID-19 response demonstrated the need for an interdisciplinary response to address the unforeseen impacts that arose, yet plans continue to have a narrow focus and a generic approach which may be limiting.

Disability inclusion in African health systems' responses during COVID-19: A scoping review

Background

People with disabilities often experience poorer access to healthcare because of multiple barriers even in non-crisis times, especially more so in low- and middle-income countries. The coronavirus disease 2019 (COVID-19) pandemic significantly constrained health systems, thus exacerbating access barriers. African health system responses to, and considerations made for people with disabilities during the pandemic have not been adequately examined to inform future inclusive practices during emergent and non-emergent periods.

Objectives

This review aimed to explore disability considerations and accommodations included by African governments in their health systems' responses during the COVID-19 pandemic.

Method

A scoping review was carried out of peer-reviewed published articles on the Web of Science, Academic Search Premier, MEDLINE, Africa-Wide Info, and CINAHL databases. A desktop search of African government websites for COVID-19 country plans and reports was also conducted. Deductive thematic analysis of included texts was performed to identify disability inclusiveness in the health responses.

Results

Ten peer-reviewed articles and three COVID-19 country plans or reports were included in the review. Data reflected a general finding that included countries that failed to effectively consider and include the healthcare needs of persons with disabilities during the pandemic.

Conclusion

Poor inclusion of persons with disabilities was effected in healthcare systems' responses during COVID-19 in Africa.

Contribution

This article contributed insights about gaps in healthcare systems' responses and highlighted development foci that could improve systems towards greater inclusivity of persons with disabilities' health needs in low- and middle-income countries.

Prioritisation processes for programme implementation and evaluation in public health: A scoping review

Background

Programme evaluation is an essential and systematic activity for improving public health programmes through useful, feasible, ethical, and accurate methods. Finite budgets require prioritisation of which programmes can be funded, first, for implementation, and second, evaluation. While criteria for programme funding have been discussed in the literature, a similar discussion around criteria for which programmes are to be evaluated is limited. We reviewed the criteria and frameworks used for prioritisation in public health more broadly, and those used in the prioritisation of programmes for evaluation. We also report on stakeholder involvement in prioritisation processes, and evidence on the use and utility of the frameworks or sets of criteria identified. Our review aims to inform discussion around which criteria and domains are best suited for the prioritisation of public health programmes for evaluation.

Methods

We reviewed the peer-reviewed literature through OVID MEDLINE (PubMed) on 11 March 2022. We also searched the grey literature through Google and across key websites including World Health Organization (WHO), US Centers for Disease Control and Prevention (CDC), European Centre for Disease Prevention and Control (ECDC), and the International Association of National Public Health Institutes (IANPHI) (14 March 2022). Articles were limited to those published between 2002 and March 2022, in English, French or German.

Results

We extracted over 300 unique criteria from 40 studies included in the analysis. These criteria were categorised into 16 high-level conceptual domains to allow synthesis of the findings. The domains most frequently considered in the studies were “burden of disease” (33 studies), “social considerations” (30 studies) and “health impacts of the intervention” (28 studies). We only identified one paper which proposed criteria for use in the prioritisation of public health programmes for evaluation. Few prioritisation frameworks had evidence of use outside of the setting in which they were developed, and there was limited assessment of their utility. The existing evidence suggested that prioritisation frameworks can be used successfully in budget allocation, and have been reported to make prioritisation more robust, systematic, transparent, and collaborative.

Conclusion

Our findings reflect the complexity of prioritisation in public health. Development of a framework for the prioritisation of programmes to be evaluated would fill an evidence gap, as would formal assessment of its utility. The process itself should be formal and transparent, with the aim of engaging a diverse group of stakeholders including patient/public representatives.

Essential health services delivery in South Africa during COVID-19: Community and healthcare worker perspectives

Background

Between May 2020 and February 2022, South Africa's health system bore strain as it battled mitigating the coronavirus pandemic. The country's pandemic response was scrutinized. This period also brought into focus pre-existing shortcomings in the healthcare system and its governing bodies. Contextually, there is a paucity in literature on the experiences of healthcare providers and users. This study aimed to contribute information on COVID-19, with the intention of providing guidance on preparing for future infectious disease outbreaks.

Methods

Cross sectional exploratory qualitative methodology was employed using semi-structured interviews and focus group discussions with community members (CM) and healthcare workers (HCW) from two South African study sites: (a) rural Bushbuckridge (run by Agincourt Health and Socio-Demographic Surveillance Site) and (b), Regions D and F in Johannesburg Metropole.

Results

After interviewing 42 CMs and 43 HCWs, it emerged that mandated process changes while minimizing COVID-19 exposure, necessitated healthcare personnel focusing on critical care treatment at the expense of less acute ones. COVID-19 isolation protocols, extensive absenteeism and HCWs with advanced skills being perceived as more adept to treat COVID-19 patients contributed to HCWs experiencing higher workloads. Fears regarding contracting and transmitting COVID-19, suffering financial losses, and not being able to provide adequate advice to patients were recurrent themes. Dissemination of relevant information among healthcare facility personnel and communities suffered due to breakdowns in communication.

Conclusion

Concessions and novel strategies to avail medication to patients had to be created. Since providence was lacking, government needs to formulate health intervention strategies that embrace health literacy, alternate methods of chronic medication dispensation, improved communication across health care platforms and the use of telehealth, to circumvent the threats of possible further infectious disease outbreaks.

Priority setting for pandemic preparedness and response: A comparative analysis of COVID-19 pandemic plans in 12 countries in the Eastern Mediterranean Region

Background

The COVID-19 pandemic has significantly disrupted health systems and exacerbated pre-existing resource gaps in the Eastern Mediterranean Region (WHO-EMRO). Active humanitarian and refugee crises have led to mass population displacement and increased health system fragility, which has implication for equitable priority setting (PS). We examine whether and how PS was included in national COVID-19 pandemic plans within EMRO.

Methods

An analysis of COVID-19 pandemic response and preparedness planning documents from a sample of 12/22 countries in WHO-EMRO. We assessed the degree to which documented PS processes adhere to twenty established quality parameters of effective PS.

Results

While all reviewed plans addressed some aspect of PS, none included all quality parameters. Yemen's plan included the highest number (9) of quality parameters, while Egypt's addressed the lowest (3). Most plans used evidence in their planning processes. While no plans explicitly identify equity as a criterion to guide PS; many identified vulnerable populations - a key component of equitable PS. Despite high concentrations of refugees, migrants, and IDPs in EMRO, only a quarter of the plans identified them as vulnerable.

Conclusion

PS setting challenges are exacerbated by conflict and the resulting health system fragmentation. Systematic and quality PS is essential to tackle long-term health implications of COVID-19 for vulnerable populations in this region, and to support effective PS and equitable resource allocation.

Examining priority setting in the national COVID-19 pandemic plans: A case study from countries in the WHO- South-East Asia Region (WHO-SEARO)

Background

The World Health Organization- South-East Asia Region (WHO-SEARO) accounted for almost 17% of all the confirmed cases and deaths of COVID-19 worldwide. While the literature has documented a weak COVID-19 response in the WHO-SEARO, there has been no discussion of the degree to which this could have been influenced/ mitigated with the integration of priority setting (PS) in the region's COVID-19 response. The purpose of this paper is to describe the degree to which the COVID-19 plans from a sample of WHO-SEARO countries included priority setting.

Methods

The study was based on an analysis of national COVID-19 pandemic response and preparedness planning documents from a sample of seven (of the eleven) countries in WHO-SEARO. We described the degree to which the documented priority setting processes adhered to twenty established quality indicators of effective PS and conducted a cross-country comparison.

Results

All of the reviewed plans described the required resources during the COVID-19 pandemic. Most, but not all of the plans demonstrated political will, and described stakeholder involvement. However, none of the plans presented a clear description of the PS process including a formal PS framework, and PS criteria. Overall, most of the plans included only a limited number of quality indicators for effective PS.

Discussion and conclusion

There was wide variation in the parameters of effective PS in the reviewed plans. However, there were no systematic variations between the parameters presented in the plans and the country's economic, health system and pandemic and PS context and experiences. The political nature of the pandemic, and its high resource demands could have influenced the inclusion of the parameters that were apparent in all the plans. The finding that the plans did not include most of the evidence-based parameters of effective PS highlights the need for further research on how countries operationalize priority setting in their respective contexts as well as deeper understanding of the parameters that are deemed relevant. Further research should explore and describe the experiences of implementing defined priorities and the impact of this decision-making on the pandemic outcomes in each country.

A qualitative evaluation of priority-setting by the Health Benefits Package Advisory Panel in Kenya

Kenya's Ministry of Health established the Health Benefits Package Advisory Panel (HBPAP) in 2018 to develop a benefits package for universal health coverage. This study evaluated HBPAP's process for developing the benefits package against the normative procedural (acceptable way of doing things) and outcome (acceptable consequences) conditions of an ideal healthcare priority-setting process as outlined in the study's conceptual framework. We conducted a qualitative case study using in-depth interviews with national-level respondents (n = 20) and document reviews. Data were analysed using a thematic approach. HBPAP's process partially fulfilled the procedural and outcome conditions of the study's evaluative framework. Concerning the procedural conditions, transparency and publicity were partially met and were limited by the lack of publication of HBPAP's report. While HBPAP used explicit and evidence-based priority-setting criteria, challenges included lack of primary data and local cost-effectiveness threshold, weak health information systems, short timelines and political interference. While a wide range of stakeholders were engaged, this was limited by short timelines and inadequate financial resources. Empowerment of non-HBPAP members was limited by their inadequate technical knowledge and experience in priority-setting. Finally, appeals and revisions were limited by short timelines and lack of implementation of the proposed benefits package. Concerning the outcome conditions, stakeholder understanding was limited by the technical nature of the process and short timelines, while stakeholder acceptance and satisfaction were limited by lack of transparency. HBPAP's benefits package was not implemented due to stakeholder interests and opposition. Priority-setting processes for benefits package development in Kenya could be improved by publicizing the outcome of the process, allocating adequate time and financial resources, strengthening health information systems, generating local evidence and enhancing stakeholder awareness and engagement to increase their empowerment, understanding and acceptance of the process. Managing politics and stakeholder interests is key in enhancing the success of priority-setting processes.

Human Respiratory Infections in Nigeria: Influenza and the Emergence of SARS-CoV-2 Pandemic

The increasing outbreak of zoonotic diseases presents challenging times for nations and calls for a renewed effort to disrupt the chain of events that precede it. Nigeria's response to the 2006 bird flu provided a platform for outbreak response, yet it was not its first experience with Influenza. This study describes the impact of SARS-CoV-2 on Influenza surveillance and, conversely, while the 1918 Influenza pandemic remains the most devastating (500,000 deaths in 18 million population) in Nigeria, the emergence of SARS CoV-2 presented renewed opportunities for the development of vaccines with novel technology, co-infection studies outcome, and challenges globally. Although the public health Intervention and strategies left some positive outcomes for other viruses, Nigeria and Africa's preparation against the next pandemic may involve prioritizing a combination of technology, socioeconomic growth, and active surveillance in the spirit of One Health.

Cash, COVID-19 and aid cuts: a mixed-method impact evaluation among South Sudanese refugees registered in Kiryandongo settlement, Uganda

OBJECTIVES

In this paper, we estimate the impact after 4-8 months of a large one-off unconditional cash transfer delivered to refugees during a time of dual shocks: the COVID-19 pandemic and cuts to monthly aid. We focus on four key outcomes: (1) health-seeking behaviour; (2) COVID-19 specific preventive health practices; (3) food security and (4) psychological well-being.

METHODS

We use both quantitative and qualitative data to understand the impact of a cash transfer in this context. Quantitatively, we use a baseline survey of 1200 households (Q4 2019) and follow-up with three rounds of phone surveys in Q2 and Q3 2021, capturing at least half the sample in each round. We exploit an experimental variation in the timing of the cash transfer to assess the effect of the cash transfer through ordinary least squares regressions of intention to treat. Controlling for key baseline characteristics, we analyse the effect of the cash transfer on health access, COVID-19 health practices, food security and psychological well-being. Qualitatively, we make use of a longitudinal, small-n sample of refugee respondents, each of whom we interviewed up to 15 times between February and September 2020 to understand change over time and to go deeper into key topics.

RESULTS

We do not find a statistically significant effect (6.2%, p=0.188) of receiving the cash transfer on preventative measures against COVID-19. However, households receiving the cash transfer were more food secure, with a 14.4% (p=0.011) improvement on the food security index, have better psychological well-being (24.5%, p=0.003) and are more likely to seek healthcare in the private health facilities (10.4%, p=0.057) as compared with control households. We do not find significant results on the value of food consumption. Overall, we find stronger treatment effects for households that were the first to receive the cash transfers.

CONCLUSION

Taken together, we find significant support for the importance of cash transfers to refugee households mitigating against declines in food security and mental well-being in the face of shocks.