Assessing COVID-19 through the lens of health systems' preparedness: time for a change

Utilizing disease transmission and response capacities to optimize covid-19 control in Malaysia

OBJECTIVES

Public Health Social Measures (PHSM) such as movement restriction movement needed to be adjusted accordingly during the COVID-19 pandemic to ensure low disease transmission alongside adequate health system capacities based on the COVID-19 situational matrix proposed by the World Health Organization (WHO). This paper aims to develop a mechanism to determine the COVID-19 situational matrix to adjust movement restriction intensity for the control of COVID-19 in Malaysia.

METHODS

Several epidemiological indicators were selected based on the WHO PHSM interim guidance report and validated individually and in several combinations to estimate the community transmission level (CT) and health system response capacity (RC) variables. Correlation analysis between CT and RC with COVID-19 cases was performed to determine the most appropriate CT and RC variables. Subsequently, the CT and RC variables were combined to form a composite COVID-19 situational matrix (SL). The SL matrix was validated using correlation analysis with COVID-19 case trends. Subsequently, an automated web-based system that generated daily CT, RC, and SL was developed.

RESULTS

CT and RC variables were estimated using case incidence and hospitalization rate; Hospital bed capacity and COVID-19 ICU occupancy respectively. The estimated CT and RC were strongly correlated [ρ = 0.806 (95% CI 0.752, 0.848); and ρ = 0.814 (95% CI 0.778, 0.839), p < 0.001] with the COVID-19 cases. The estimated SL was strongly correlated with COVID-19 cases (ρ = 0.845, p < 0.001) and responded well to the various COVID-19 case trends during the pandemic. SL changes occurred earlier during the increase of cases but slower during the decrease, indicating a conservative response. The automated web-based system developed produced daily real-time CT, RC, and SL for the COVID-19 pandemic.

CONCLUSIONS

The indicators selected and combinations formed were able to generate validated daily CT and RC levels for Malaysia. Subsequently, the CT and RC levels were able to provide accurate and sensitive information for the estimation of SL which provided valuable evidence on the progression of the pandemic and movement restriction adjustment for the control of Malaysia.

Multimodal data fusion using sparse canonical correlation analysis and cooperative learning: a COVID-19 cohort study

Through technological innovations, patient cohorts can be examined from multiple views with high-dimensional, multiscale biomedical data to classify clinical phenotypes and predict outcomes. Here, we aim to present our approach for analyzing multimodal data using unsupervised and supervised sparse linear methods in a COVID-19 patient cohort. This prospective cohort study of 149 adult patients was conducted in a tertiary care academic center. First, we used sparse canonical correlation analysis (CCA) to identify and quantify relationships across different data modalities, including viral genome sequencing, imaging, clinical data, and laboratory results. Then, we used cooperative learning to predict the clinical outcome of COVID-19 patients: Intensive care unit admission. We show that serum biomarkers representing severe disease and acute phase response correlate with original and wavelet radiomics features in the LLL frequency channel (cor(Xu1, Zv1) = 0.596, p value < 0.001). Among radiomics features, histogram-based first-order features reporting the skewness, kurtosis, and uniformity have the lowest negative, whereas entropy-related features have the highest positive coefficients. Moreover, unsupervised analysis of clinical data and laboratory results gives insights into distinct clinical phenotypes. Leveraging the availability of global viral genome databases, we demonstrate that the Word2Vec natural language processing model can be used for viral genome encoding. It not only separates major SARS-CoV-2 variants but also allows the preservation of phylogenetic relationships among them. Our quadruple model using Word2Vec encoding achieves better prediction results in the supervised task. The model yields area under the curve (AUC) and accuracy values of 0.87 and 0.77, respectively. Our study illustrates that sparse CCA analysis and cooperative learning are powerful techniques for handling high-dimensional, multimodal data to investigate multivariate associations in unsupervised and supervised tasks.

Leadership's perceptions of palliative care during the COVID-19 pandemic: a qualitative study

CONTEXT

Palliative care played a leading role in the COVID-19 pandemic. However, little is known regarding health system leadership's perceptions.

BACKGROUND

This study aimed to explore the perceptions, understanding, and utilization of palliative care before compared to during the COVID-19 pandemic among health system leadership.

METHODS

Semi-structured, in-depth interviews were conducted with leaders in a large healthcare system based in Massachusetts, United States.

RESULTS

22 in-depth interviews were completed at four facilities. Emerging themes included the role of palliative care before compared to during the COVID-19 pandemic, facilitators and barriers to palliative care delivery, and recommendations for future practice. Participants reported that the COVID-19 pandemic increased palliative care utilization, reinforced positive perceptions of the specialty, and emphasized its role in maximizing healthcare efficiency. Many participants found palliative care financing to be a barrier to delivery; some had an inaccurate understanding of how palliative care is reimbursed. When asked about their recommendations for improving future practice, participants noted improvements in coordination within the healthcare system and education of healthcare providers and future physicians in primary palliative care skills.

CONCLUSIONS

Our findings suggest that health leadership increasingly understand the value of palliative care and its critical role within the health system and during future public health emergencies; this was further reinforced during the COVID-19 pandemic. Healthcare leadership recognize and highlight the need to increase investments in this specialty, both financially and educationally. In doing so, health care costs will be lowered, patient satisfaction will increase, and care will be better coordinated.

The response of the Military Health System (MHS) to the COVID-19 pandemic: a summary of findings from MHS reviews

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic caused major disruptions to the US Military Health System (MHS). In this study, we evaluated the MHS response to the pandemic to understand the impact of the pandemic response in a large, national, integrated healthcare system providing care for ~ 9 million beneficiaries.

METHODS

We performed a narrative literature review of 16 internal Department of Defense (DoD) reports, including reviews mandated by the US Congress in response to the pandemic. We categorized the findings using the Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities, and Policy (DOTMLPF-P) framework developed by the DoD to assess system efficiency and effectiveness.

RESULTS

The majority of the findings were in the policy, organization, and personnel categories. Key findings showed that the MHS structure to address surge situations was beneficial during the pandemic response, and the rapid growth of telehealth created the potential impact for improved access to routine and specialized care. However, organizational transition contributed to miscommunication and uneven implementation of policies; disruptions affected clinical training, upskilling, and the supply chain; and staffing shortages contributed to burnout among healthcare workers.

CONCLUSION

Given its highly integrated, vertical structure, the MHS was in a better position than many civilian healthcare networks to respond efficiently to the pandemic. However, similar to the US civilian sector, the MHS also experienced delays in care, staffing and materiel challenges, and a rapid switch to telehealth. Lessons regarding the importance of communication and preparation for future public health emergency responses are relevant to civilian healthcare systems responding to COVID-19 and other similar public health crises.

The application of policy composite indicators to predicting the health risk and recovery: a global comparative investigation

OBJECTIVES

There emerges increasing doubt regarding whether the policy composite indicators are applicable to the COVID-19 pandemic. A few early studies demonstrate that the association between some composite indicators of policy preparedness and the risk of COVID-19 is statistically insignificant, and the relation between any composite indicators and recovery process (e.g., vaccination coverage) remains unexplored. To examine the relation between composite indicators and pandemic risk (as well as the vaccination coverage) with robustness, this study applies different policy preparedness indicators by using data from multi-sources.

STUDY DESIGN

A cross-sectional analysis was performed.

METHOD

Regression analysis is adopted to examine the relation between four policy preparedness indicators (i.e., [1] International Health Regulations core capacity index, [2] Global Health Security Index, [3] epidemic preparedness index, and [4] World Governance Index) and COVID-19-confirmed cases/death/vaccination coverage at different time points. The linear regression is performed, and the spatial distribution of indicators are illustrated.

RESULTS

Countries with higher ranking in policy preparedness indexes can experience less severity of pandemic risk (e.g., confirmed cases and mortality) and faster recovery process (e.g., higher vaccination coverage). However, slight disparity in effectiveness exists across different indicators.

CONCLUSION

Results show that the policy preparedness indicators have predictive value of the confirmed cases, mortality, and vaccination coverage of COVID-19 pandemic, given sufficiently long-time span is observed.

Coping strategies for COVID-19 primary care: a mixed method study

This article aims to analyse the COVID-19 coping strategies adopted by municipal health managers in two regions. A mixed method study of the sequential explanatory type was carried out with municipal health managers and primary care coordinators. The quantitative stage was developed with the application of an instrument to 42 managers to identify coping actions and associations with demographic and epidemiological data of COVID-19 in the municipalities. The results aimed at the definition of 15 participants and the collection of data in the qualitative stage, enabling approximation of the meta inferences of the study. Of the actions implemented, there were immediate actions to monitor cases, organize new care flows and encourage the population to adopt nonpharmacological measures. Regional articulation was the device that allowed for expansion and municipal autonomy for testing, reducing contamination and deaths among citizens. Municipal coping strategies that focused on the surveillance of cases and expansion of testing showed positive outcomes in terms of the number of infections and deaths from COVID-19.

Comparative effectiveness of financing models in development assistance for health and the role of results-based funding approaches: a scoping review

Over the past three decades, there has been an unprecedented growth in development assistance for health through different financing models, ranging from donations to results-based approaches, to improve health in low- and middle-income countries. Since then, the global burden of disease has started to shift. However, it is still not entirely clear what the comparative effect of the different financing models is. To assess the effect of these financing models on various healthcare targets, we systematically reviewed the peer-reviewed and gray literature. We identified 19 studies and found that results-based financing approaches have an overall positive impact on institutional delivery rates and numbers of healthcare facility visits, though this impact varies greatly by context.Donors might be better served by providing a results-based financing scheme combining demand and supply side health-related schemes. It is essential to include rigorous monitoring and evaluation strategies when designing financing models.

Healthcare adjustments and concerns: a qualitative study exploring the perspectives of healthcare providers and administrative staff during the COVID-19 pandemic in Saudi Arabia

Background

Healthcare systems have modified their strategies to manage their staff, supplies, and space to deal systematically with the COVID-19 pandemic. This research aimed to explore the nature of hospital adjustments and the concerns of healthcare providers and administrative staff working in Governmental and private hospitals throughout the Qassim Region of the Kingdom of Saudi Arabia (KSA) during the pandemic.

Methods

A qualitative phenomenological study using semi-structured in-depth interviews were conducted with 75 purposively selected healthcare providers and administrative staff working at three main hospitals in the Qassim Region, KSA. The maximum variation sampling technique was utilized. Recruitment of participants was continued until data saturation was reached. All interviews were audiotaped, transcribed verbatim, and analyzed thematically.

Results

Four core themes were identified in this paper: (1) changes in hospital policy and procedures, (2) workforce management, (3) the well-being of the workforce, and (4) apprehensions and expectations of the workforce. The participants showed satisfaction with timely administrative decisions and new policies during the COVID-19 pandemic. Furthermore, the psychological health of healthcare professionals was affected more than their physical state. Finally, the providers perceived the emergence of multiple concerns in the coming months.

Conclusion

Although healthcare providers were initially overwhelmed, they gradually accepted new administrative policies. Numerous innovative interventions effectively reduced their physical workload and increased their productivity, but they remained significantly affected by a wide range of psychological disorders, with a high prevalence of obsessive-compulsive disorder. There were some concerns about the new SARS-CoV-2 variant, but the majority were optimistic.

Impact of COVID-19 pandemic on surgical outcomes after hepatopancreatobiliary (HPB) surgery

COVID-19 pandemic has disrupted healthcare systems worldwide, causing the postponement or cancellation of millions of elective surgeries. It is essential for hepatopancreatobiliary (HPB) surgeons to well understand the perioperative risk and management of HPB surgery during the COVID-19 pandemic, including the impact of preoperative COVID-19 infection and timing of surgery, the impact of COVID-19 infection on postoperative mortality, the postoperative pulmonary complications in patients with perioperative COVID-19 infection, and the postoperative complications without pulmonary involvement. Perioperative COVID-19 infection increases the risk of postoperative mortality and pulmonary complications in patients undergoing abdominal surgery. Furthermore, in some regions, the COVID-19 vaccine's availability is still limited, leading to an increase in the number of cases and potential medical collapse, which could hinder the improvement of HPB postoperative mortality rates. The timing of surgery for COVID-19 positive patients should be carefully considered, balancing the potential risks of delay with the risks of surgery during the infection.

Examining the Global Nursing Regulatory Response to the COVID-19 Pandemic

Background

During the COVID-19 pandemic, nursing regulatory bodies (NRBs) worldwide adopted a variety of measures to bolster the nursing workforce and ensure patient safety.

Purpose

To examine the plethora of actions undertaken by the global nursing community in response to the public health emergency so that NRBs can increase transparency and better prepare for future crises.

Methods

In early 2021, the National Council of State Boards of Nursing developed an online survey to capture data on the global regulatory response to the COVID-19 pandemic. The survey focused on five specific domains: (a) governance, (b) telehealth practices, (c) nurse mobility, (d) prelicensure education, and (e) the disciplinary process. The instrument was translated into 11 languages before being deployed to 150 non-U.S. regulatory representatives. Frequencies and proportions were generated for all fixed-item responses, and descriptive content analyses were applied to translated open-text responses.

Results

Regulators representing 27 jurisdictions provided valid responses to the survey. Most jurisdictions reported that components of nursing education were adapted in some way during the pandemic. More than half (53.8%, n = 14) of respondents indicated that changes were made to clinical and didactic curricula to ensure students graduated on time. About one-third (30.8%, n = 8) of representatives revealed that their jurisdiction had made changes to telehealth regulations, with many granting telehealth-specific nursing licenses. Most jurisdictions (88.5%, n = 23) also reported fewer or about the same number of regulatory complaints compared to before the pandemic.

Conclusions

The results of this study highlight the range of actions nursing regulators worldwide adopted, which may be drawn upon to inform best practices to ensure jurisdictions are ready for the next public health emergency.

Post-COVID-19 condition in the German working population: A cross-sectional study of 200,000 registered stem cell donors

BACKGROUND

The SARS-CoV-2 pandemic has strained health systems worldwide, and infection numbers continue to rise. While previous data have already shown that many patients suffer from symptoms for months after an acute infection, data on risk factors and long-term outcomes are incomplete, particularly for the working population.

OBJECTIVES

We aimed to provide information on the prevalence of post-COVID-19 conditions in a subset of the German working-age population (18-61 years old) and to analyze risk factors.

METHODS

We conducted an online survey with a health questionnaire among registered potential stem cell donors with or without a self-reported history of polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection. Logistic regression models were used to examine the risks of severity of acute infection, sex, age, body mass index, diabetes mellitus, and arterial hypertension medication on post-COVID-19 symptoms.

RESULTS

A total of 199,377 donors reported evaluable survey questionnaires-12,609 cases had a history of SARS-CoV-2 infection and 186,768 controls had none. Overall, cases reported physical, cognitive, and psychological complaints more frequently compared to controls. Increased rates of complaints persisted throughout 15 months postinfection, for example, 28.4%/19.3% of cases/controls reported fatigue (p <0.0001) and 9.5%/3.6% of cases/controls reported loss of concentration (p <0.0001). No significant differences were observed in the frequency of reported symptoms between 3 and 15 months postinfection. Multivariate analysis revealed a strong influence of the severity of the acute SARS-CoV-2 infection episode and age on the risk for post-COVID-19 conditions.

CONCLUSION

We report the prevalence of post-COVID-19 conditions in mainly unvaccinated individuals with SARS-CoV-2 infections between February 2020 and August 2021. The severity of the acute course and age were major risk factors. Vaccinations may reduce the risk of post-COVID-19 conditions by reducing the risk of severe infections.

2008 economic crisis impact on perinatal and infant mortality in Southern European countries

INTRODUCTION

The study of crisis events provides important lessons to prepare for upcoming events. The Great Recession's impact on perinatal health in Europe can provide relevant insights into the healthcare and social protection systems' response to the protection of the health of the most vulnerable groups.

OBJECTIVE

To assess time trends and international disparities in perinatal mortality rates (PMR) and infant mortality rates (IMR), following the Great Recession, and their association with socioeconomic indicators in Portugal, Greece, Italy and Spain.

METHODS

Associations were assessed through generalised linear models for all four countries. A Poisson joinpoint regression model was applied to explore PMR and IMR trend changes between 2000 and 2018. Country disparities were analysed using mixed-effects multilevel models.

RESULTS

IMR and PMR have decreased overall in the four selected countries between 2000 and 2018. Still, whereas in Spain, Italy and Portugal the decreasing pace was attenuated after 2009, in Greece a positive trend was found after the 2008 crisis. IMR and PMR were significantly associated with socioeconomic indicators in all four countries. National disparities in the evolution of IMR and PMR were significantly associated with most socioeconomic indicators between 2000 and 2018.

CONCLUSION

Our results confirm the impact of the Great Recession on PMR and IMR trends in all four countries, taking recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility and stagnation of IMR and PMR into account. The association with socioeconomic indicators stresses the need to strengthen social protection and healthcare systems to better protect the population's health from the earliest days.

Patient-reported Benefits and Limitations of Mobile Health Technologies for Diabetes in Pregnancy: A Scoping Review

OBJECTIVES

For women with pre-existing and gestational diabetes, pregnancy involves specialized and intensive medical care to optimize maternal and infant outcomes. Medical management for patients with diabetes in pregnancy typically occurs via frequent face-to-face outpatient appointments. COVID-19-induced barriers to face-to-face care have identified the need for high-quality, patient-centred virtual health-care modalities, such as mobile health (mHealth) technologies. Our aim in this review was to identify the patient-reported benefits and limitations of mHealth technologies among women with diabetes in pregnancy. We also aimed to determine how the women's experiences aligned with the best practice standards for patient-centred communication.

METHODS

The framework presented by Arksey and O'Malley for conducting scoping reviews, with refinements by Levac et al, was used to guide this review. Relevant studies were identified through comprehensive database searches of MEDLINE, Embase, Emcare and PsycINFO. Thomas and Harden's methods for the thematic synthesis of qualitative research in systematic reviews guided the synthesis of patient-reported benefits and limitations of mHealth technology.

RESULTS

Overall, 19 studies describing the use of 16 unique mHealth technologies among 742 women were included in the final review. Patient-reported benefits of mHealth included convenience, support of psychosocial well-being and facilitation of diabetes self-management. Patient-reported limitations included lack of important technological features, perceived burdensome aspects of mHealth and lack of trust in virtual health care.

CONCLUSIONS

Women with diabetes report some benefits from mHealth use during pregnancy. Codesigning future technologies with end users may help address the perceived limitations and effectiveness of mHealth technologies.

The necessity revealed by COVID-19 pandemic: Paradigm shift of Iran's healthcare system

Background

COVID-19 pandemic has resulted in drastic changes around the world, revealing vulnerable aspects of healthcare systems. This study aimed to explore how Iranian healthcare system experienced the paradigm shift during the pandemic and determine the aspects that need improvement during the pandemic era.

Method

This qualitative study was conducted in 2021. A framework analysis approach was used to analyze the content of the 19 semi-structured interviews with the healthcare system experts from Shiraz University of Medical Sciences (SUMS). The interviews' audio files changed into transcript after each session and data was saturated at the 19 interview. To increase the trustworthiness of the study, Guba and Lincoln's criteria including credibility, transferability, dependability, and confirmability were used. Goldsmith's five-step framework analysis was used applying MAX QDA version 10 software.

Result

Eight main themes and 20 subthemes were explored. The main themes included "strengthening the electronic health infrastructure," "research for evidence-based decision making," "dedicated financing to the pandemic," "prevention of disruption in the effective provision of services and medicines," "enriching the authority of the Ministry of Health by focusing on interactions," "recruiting, managing and empowering health human resources with attention to financial and non-financial incentives," "reforming educational approaches in training students in medical universities," as well as "lessons learned from neglected aspects."

Conclusion

To be ready to respond to a possible future pandemic and for a paradigm shift, bold steps must be taken to make fundamental changes in various aspects of the healthcare system including e-health development, evidence-based decision making, dedicated budgets for pandemics, reinforcement of interactions at the national and international level, as well as sufficient attention to healthcare workers from all financial, non-financial and educational aspects.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

The safety and acceptability of using telehealth for follow-up of patients following cancer surgery: A systematic review

INTRODUCTION

Although virtual consultations have played an increasing role in delivery of healthcare, the COVID-19 pandemic has hastened their adoption. Furthermore, virtual consultations are now being adopted in areas that were previously considered unsuitable, including post-operative visits for patients undergoing major surgical procedures, and surveillance following cancer operations. This review aims to examine the feasibility, safety, and patient satisfaction with virtual follow-up appointments after cancer operations.

METHODS

A systematic review was conducted along PRISMA guidelines. Studies where patients underwent surgical resection of a malignancy with at least one study arm describing virtual follow-ups were included. Studies were assessed for quality. Outcomes including adverse events, detection of recurrence and patient and provider satisfaction were assessed and compared for those undergoing virtual or in-person post-operative visits.

RESULTS

Eleven studies, with 3369 patients were included. Cancer types included were gynecological, colorectal, esophageal, lung, thyroid, breast, prostate and major HPB resections. Detection of recurrence and readmission rates were similar when comparing virtual consultations with in-person visits. Most studies showed high patient and healthcare provider satisfaction with virtual consultations following cancer resection. Concerns were raised about the integration of virtual consultations into workflows in fee-for-service settings, where reimbursement for virtual care may be an issue.

CONCLUSION

Virtual follow-up care can provide timely and safe consultations in surgical oncology. Virtual consultations are as safe as in-person visits for assessing complications and recurrence. Where appropriate, virtual consultations can safely be integrated into the post-operative care pathway for those undergoing resection of malignancy.

Donor support for Health Policy and Systems Research: barriers to financing and opportunities for overcoming them

BACKGROUND

The vast investments that have been made in recent decades in new medicines, vaccines, and technologies will only lead to improvements in health if there are appropriate and well-functioning health systems to make use of them. However, despite the growing acceptance by major global donors of the importance of health systems, there is an enthusiasm gap when it comes to disbursing funds needed to understand the intricacies of how, why and when these systems deliver effective interventions. To understand the reasons behind this, we open up the black box of donor decision-making vis-à-vis Health Policy and Systems Research (HPSR) financing: what are the organizational processes behind the support for HPSR, and what are the barriers to increasing engagement?

METHODS

We conducted 27 semi-structured interviews with staff of major global health funders, asking them about four key issues: motivations for HPSR financing; priorities in HPSR financing; barriers for increasing HPSR allocations; and challenges or opportunities for the future. We transcribed the interviews and manually coded responses.

RESULTS

Our findings point to the growing appreciation that funders have of HPSR, even though it is often still seen as an 'afterthought' to larger programmatic interventions. In identifying barriers to funding HPSR, our informants emphasised the perceived lack of mandate and capacities of their organizations. For most funding organisations, a major barrier was that their leadership often voiced scepticism about HPSR's long time horizons and limited ability to quantify results.

CONCLUSION

Meeting contemporary health challenges requires strong and effective health systems. By allocating more resources to HPSR, global donors can improve the quality of their interventions, and also contribute to building up a stock of knowledge that domestic policymakers and other funders can draw on to develop better targeted programmes and policies.

The Role of Natural Language Processing during the COVID-19 Pandemic: Health Applications, Opportunities, and Challenges

The COVID-19 pandemic is the most devastating public health crisis in at least a century and has affected the lives of billions of people worldwide in unprecedented ways. Compared to pandemics of this scale in the past, societies are now equipped with advanced technologies that can mitigate the impacts of pandemics if utilized appropriately. However, opportunities are currently not fully utilized, particularly at the intersection of data science and health. Health-related big data and technological advances have the potential to significantly aid the fight against such pandemics, including the current pandemic's ongoing and long-term impacts. Specifically, the field of natural language processing (NLP) has enormous potential at a time when vast amounts of text-based data are continuously generated from a multitude of sources, such as health/hospital systems, published medical literature, and social media. Effectively mitigating the impacts of the pandemic requires tackling challenges associated with the application and deployment of NLP systems. In this paper, we review the applications of NLP to address diverse aspects of the COVID-19 pandemic. We outline key NLP-related advances on a chosen set of topics reported in the literature and discuss the opportunities and challenges associated with applying NLP during the current pandemic and future ones. These opportunities and challenges can guide future research aimed at improving the current health and social response systems and pandemic preparedness.

Interrupted Access to and Use of Family Planning Among Youth in a Community-Based Service in Zimbabwe During the First Year of the COVID-19 Pandemic

The COVID-19 pandemic has had serious impacts on economic, social, and health systems, and fragile public health systems have become overburdened in many countries, exacerbating existing service delivery challenges. This study describes the impact of the COVID-19 pandemic on family planning services within a community-based integrated HIV and sexual and reproductive health intervention for youth aged 16-24 years being trialled in Zimbabwe (CHIEDZA). It examines the experiences of health providers and clients in relation to how the first year of the pandemic affected access to and use of contraceptives.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

A qualitative study of hospital and community providers’ experiences with digitalization to facilitate hospital-to-home transitions during the COVID-19 pandemic

Background

The COVID-19 pandemic has triggered substantial changes to the healthcare context, including the rapid adoption of digital health to facilitate hospital-to-home transitions. This study aimed to: i) explore the experiences of hospital and community providers with delivering transitional care during the COVID-19 pandemic; ii) understand how rapid digitalization in healthcare has helped or hindered hospital-to-home transitions during the COVID-19 pandemic; and, iii) explore expectations of which elements of technology use may be sustained post-pandemic.

Methods

Using a pragmatic qualitative descriptive approach, remote interviews with healthcare providers involved in hospital-to-home transitions in Ontario, Canada, were conducted. Interviews were analyzed using a team-based rapid qualitative analysis approach to generate timely results. Visual summary maps displaying key concepts/ideas were created for each interview and revised based on input from multiple team members. Maps that displayed similar concepts were then combined to create a final map, forming the themes and subthemes.

Results

Sixteen healthcare providers participated, of which 11 worked in a hospital, and five worked in a community setting. COVID-19 was reported to have profoundly impacted healthcare providers, patients, and their caregivers and influenced the communication processes. There were several noted opportunities for technology to support transitions.

Interpretation

Several challenges with technology use were highlighted, which could impact post-pandemic sustainability. However, the perceived opportunities for technology in supporting transitions indicate the need to investigate the optimal role of technology in the transition workflow.

"When all else fails you have to come to the emergency department": Overarching lessons about emergency care resilience from frontline clinicians in Pacific Island countries and territories during the COVID-19 pandemic

The COVID-19 pandemic continues to test health systems resilience worldwide. Low- and middle-income country (LMIC) health care systems have considerable experience in disasters and disease outbreaks. Lessons from the preparedness and responses to COVID-19 in LMICs may be valuable to other countries.This policy paper synthesises findings from a multiphase qualitative research project, conducted during the pandemic to document experiences of Pacific Island Country and Territory (PICT) frontline clinicians and emergency care (EC) stakeholders. Thematic analysis and synthesis of enablers related to each of the Pacific EC systems building blocks identified key factors contributing to strengthened EC systems.Effective health system responses to the COVID-19 pandemic occurred when frontline clinicians and 'decision makers' collaborated with respect and open communication, overcoming healthcare workers' fear and discontent. PICT EC clinicians demonstrated natural leadership and strengthened local EC systems, supporting essential healthcare. Despite resource limitations, PICT cultural strengths of relational connection and innovation ensured health system resilience. COVID-19 significantly disrupted services, with long-tail impacts on non-communicable disease and other health burdens.Lessons learned in responding to COVID-19 can be applied to ongoing health system strengthening initiatives. Optimal systems improvement and sustainability requires EC leaders' involvement in current decision-making as well as future planning.

Search strategy and selection criteria

Search strategy and selection criteria We searched PubMed, Google Scholar, Ovid, WHO resources, Pacific and grey literature using search terms 'emergency care', 'acute/critical care', 'health care workers', 'emergency care systems/health systems', 'health system building blocks', 'COVID-19', 'pandemic/surge event/disease outbreaks' 'Low- and Middle-Income Countries', 'Pacific Islands/region' and related terms. Only English-language articles were included.

Funding

Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Copyright of the original work on which this publication is based belongs to WHO. The authors have been given permission to publish this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of WHO. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant. RM is supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship and a Monash Graduate Excellence Scholarship. GOR is supported by a NHMRC Early Career Research Fellowship. CEB is supported by a University of Queensland Development Research Fellowship. None of these funders played any role in study design, results analysis or manuscript preparation.

Measuring, Modeling, and Forecasting the Mental Wealth of Nations

The COVID-19 pandemic has exposed the deep links and fragility of economic, health and social systems. Discussions of reconstruction include renewed interest in moving beyond GDP and recognizing "human capital", "brain capital", "mental capital", and "wellbeing" as assets fundamental to economic reimagining, productivity, and prosperity. This paper describes how the conceptualization of Mental Wealth provides an important framing for measuring and shaping social and economic renewal to underpin healthy, productive, resilient, and thriving communities. We propose a transdisciplinary application of systems modeling to forecast a nation's Mental Wealth and understand the extent to which policy-mediated changes in economic, social, and health sectors could enhance collective mental health and wellbeing, social cohesion, and national prosperity. Specifically, simulation will allow comparison of the projected impacts of a range of cross-sector strategies (education sector, mental health system, labor market, and macroeconomic reforms) on GDP and national Mental Wealth, and provide decision support capability for future investments and actions to foster Mental Wealth. Finally, this paper introduces the Mental Wealth Initiative that is harnessing complex systems science to examine the interrelationships between social, commercial, and structural determinants of mental health and wellbeing, and working to empirically challenge the notion that fostering universal social prosperity is at odds with economic and commercial interests.

The predictors of COVID-19 mortality among health systems parameters: an ecological study across 203 countries

Background

Health systems responsiveness is the key to addressing infectious disease threats such as pandemics. The paper outlines an assessment of health systems resilience by exploring the association of health systems and Global Health Security (GHS) parameters with case load and mortality resulting from COVID-19 across 203 countries using an ecological design.

Methodology

Correlation analysis was performed to assess the relationship of each of the indicators with COVID 19 cases and deaths per million population. Stepwise multiple regression models were developed to determine the predictors of COVID-19 cumulative cases and deaths per million population separately.

Results

Global health security indicators seemed to have a strong association when analyzed individually but those did not necessarily translate into less burden of cases or deaths in the multivariable analysis. The predictors of cumulative deaths per million population included general government expenditure on health as a proportion of general government expenditure, responsiveness of the system to prevent the emergence and release of pathogens and governance related voice and accountability.

Conclusion

To conclude, health financing parameters and preventive activities with regard to emergence of pathogens were better predictors of cumulative COVID-19 cases and deaths per million population compared to other health systems and global health security indicators.

Health financing parameters are better predictors of cumulative COVID-19 cases and deaths per million population compared to other health systems and global health security indicators.

More robust and valid indicators are required to assess the performance of health system.

Optimising the balance of acute and intermediate care capacity for the complex discharge pathway: Computer modelling study during COVID-19 recovery in England

Objectives

While there has been significant research on the pressures facing acute hospitals during the COVID-19 pandemic, there has been less interest in downstream community services which have also been challenged in meeting demand. This study aimed to estimate the theoretical cost-optimal capacity requirement for ‘step down’ intermediate care services within a major healthcare system in England, at a time when considerable uncertainty remained regarding vaccination uptake and the easing of societal restrictions.

Methods

Demand for intermediate care was projected using an epidemiological model (for COVID-19 demand) and regressing upon public mobility (for non-COVID-19 demand). These were inputted to a computer simulation model of patient flow from acute discharge readiness to bedded and home-based Discharge to Assess (D2A) intermediate care services. Cost-optimal capacity was defined as that which yielded the lowest total cost of intermediate care provision and corresponding acute discharge delays.

Results

Increased intermediate care capacity is likely to bring about lower system-level costs, with the additional D2A investment more than offset by substantial reductions in costly acute discharge delays (leading also to improved patient outcome and experience). Results suggest that completely eliminating acute ‘bed blocking’ is unlikely economical (requiring large amounts of downstream capacity), and that health systems should instead target an appropriate tolerance based upon the specific characteristics of the pathway.

Conclusions

Computer modelling can be a valuable asset for determining optimal capacity allocation along the complex care pathway. With results supporting a Business Case for increased downstream capacity, this study demonstrates how modelling can be applied in practice and provides a blueprint for use alongside the freely-available model code.

The Approach to the COVID-19 Pandemic in Georgia-A Health Policy Analysis

Objectives: This study aimed to analyze key COVID-19 pandemic-related policies and national strategic responses in light of Georgia’s political, socioeconomic and cultural backgrounds.

Methods: We applied a policy triangle framework for policy analysis, performed document and media content analysis, and described pandemic trends statistically.

Results: Early introduction of stringent restrictive measures largely prevented a first wave in March–May 2020. This was communicated as a success story, prompting a public success perception. With unpopular restrictions lifted and hesitancy to embrace evidence-informed policymaking ahead of nationwide parliamentary elections, SARS-CoV-2 infection spread rapidly and was met with an insufficiently coordinated effort. Facing health system capacity saturation an almost complete lockdown was re-introduced in late 2020. Factors as delayed immunization campaign, insufficient coordination and, again, little evidence-informed policymaking eventually led to another devastating COVID-19 wave in summer of 2021.

Conclusion: Georgia’s pandemic health policy response was adversely impacted by a volatile political environment. National pandemic preparedness and response might benefit from an independent body with appointment procedures and operations shielded from political influences to effectively inform and communicate evidence-based pandemic policy.

Documenting response to COVID-individual and systems successes and challenges: a longitudinal qualitative study

Background

This study aimed to document the evolution of perceptions of frontline healthcare workers (FHCW) regarding their well-being and the quality of health systems' response to the COVID-19 pandemic over four months in Pakistan.

Methods

We conducted this prospective longitudinal qualitative study during the four months (June–September 2020) coinciding with the peak and trough of the first wave of Pakistan's COVID-19 pandemic. We approached frontline healthcare workers (physicians and nurses) working in emergency departments (ED) in two hospitals using the WhatsApp group of the Pakistan Society of Emergency Physicians (PSEM). Participants were asked to self-record their perception of their wellness and their level of satisfaction with the quality of their hospitals' response to the pandemic. We transcribed, translated, and analysed manually using MAXQDA 2020 software and conducted the thematic analysis to identify themes and sub-themes.

Results

We invited approximately 200 FHCWs associated with PSEM to participate in the study. Of the 61 who agreed to participate, 27 completed the study. A total of 149 audio recordings were received and transcribed. Three themes and eight sub-themes have emerged from the data. The themes were individual-level challenges, health system-level challenges, and hope for the future. Sub-themes for individual-level challenges were: fear of getting or transmitting infection, feeling demotivated and unappreciated, disappointment due to people’s lack of compliance with COVID-19 protocols, physical exhaustion, and fatigue. For the healthcare system, sub-themes were: Infrastructure, logistics, management, and communications response of the hospital/healthcare system and financial stressors. For sub-themes under hope for the future were the improved disease knowledge and vaccine development. The overall perceptions and experiences of FHCWs evolved from fear, grief, and negativity to hope and positivity as the curve of COVID-19 went down.

Conclusion

This study shows that the individuals and systems were not prepared to deal with the challenges of the COVID-19 pandemic. The findings highlight the challenges faced by individuals and health systems during the wake of the Covid-19 pandemic. The healthcare workers were emotionally and physically taxed, while the health systems were overwhelmed by COVID-19. The overall perceptions of FHCWs evolved with time and became negative to positive as the curve of COVID-19 went down during the first wave of COVID-19 in Pakistan.

Barriers and facilitators of access to maternal, newborn and child health services during the first wave of COVID-19 pandemic in Nigeria: findings from a qualitative study

BACKGROUND

COVID-19 pandemic may have affected the utilization of maternal and newborn child health services in Nigeria but the extent, directions, contextual factors at all the levels of healthcare service delivery in Nigeria is yet to be fully explored. The objective of the study was to explore the barriers and facilitators of access to MNCH services during the first wave of COVID-19 pandemic in Nigeria.

METHODS

A qualitative study was conducted among different stakeholder groups in 18 public health facilities in Nigeria between May and July,2020. In-depth interviews were conducted among 54 study participants (service users, service providers and policymakers) selected from across the three tiers of public health service delivery system in Nigeria (primary health centers, secondary health centers and tertiary health centers). Coding of the qualitative data and identification of themes from the transcripts were carried out and thematic approach was used for data analyses.

RESULTS

Barriers to accessing MNCH services during the first wave of COVID-19-pandemic in Nigeria include fear of contracting COVID-19 infection at health facilities, transportation difficulties, stigmatization of sick persons, lack of personal protective equipment (PPE) /medical commodities, long waiting times at hospitals, shortage of manpower, lack of preparedness by health workers, and prioritization of essential services. Enablers to access include the COVID-19 non-pharmacological measures instituted at the health facilities, community sensitization on healthcare access during the pandemic, and alternative strategies for administering immunization service at the clinics.

CONCLUSION

Access to MNCH services were negatively affected by lockdown during the first wave of COVID-19 pandemic in Nigeria particularly due to challenges resulting from restrictions in movements which affected patients/healthcare providers ability to reach the hospitals as well as patients' ability to pay for health care services. Additionally, there was fear of contracting COVID-19 infection at health facilities and the health systems inability to provide enabling conditions for sustained utilization of MNCH services. There is need for government to institute alternative measures to halt the spread of diseases instead of lockdowns so as to ensure unhindered access to MNCH services during future pandemics. This may include immediate sensitization of the general public on modes of transmission of any emergent infectious disease as well as training of health workers on emergency preparedness and alternative service delivery models.

Taking Systems Thinking to the Global Level: Using the WHO Building Blocks to Describe and Appraise the Global Health System in Relation to COVID-19

Adequately preparing for and containing global shocks, such as COVID-19, is a key challenge facing health systems globally. COVID-19 highlights that health systems are multilevel systems, a continuum from local to global. Goals and monitoring indicators have been key to strengthening national health systems but are missing at the supranational level. A framework to strengthen the global system-the global health actors and the governance, finance, and delivery arrangements within which they operate-is urgently needed. In this article, we illustrate how the World Health Organization Building Blocks framework, which has been used to monitor the performance of national health systems, can be applied to describe and appraise the global health system and its response to COVID-19, and identify potential reforms. Key weaknesses in the global response included: fragmented and voluntary financing; non-transparent pricing of medicines and supplies, poor quality standards, and inequities in procurement and distribution; and weak leadership and governance. We also identify positive achievements and identify potential reforms of the global health system for greater resilience to future shocks. We discuss the limitations of the Building Blocks framework and future research directions and reflect on political economy challenges to reform.

Seroprevalence of SARS-CoV-2 among high-density communities and hyper-endemicity of COVID-19 in Vietnam

OBJECTIVE

To assess the magnitude of active and recovering COVID-19 patients among at-risk communities and to identify the factors associated with positive serology.

METHODS

Four hundred and eighty-three close contacts of COVID-19 patients residing in Ho Chi Minh City, Vietnam, during the fourth wave of the COVID-19 epidemic (September and October 2021) were included. Five weeks after exposure to a COVID-19 patient, they underwent a serology test using the BIOSYNEX COVID-19 BSS kit.

RESULTS

The median age of participants was 37 years. A total of 34.6% individuals presented at least one clinical symptom between the time of contact with the COVID-19 patient and inclusion in study. A total of 1.7% unvaccinated individuals tested positive for SARS-CoV-2 using real-time PCR, and 9.5% had evidence of recent infection (positive PCR and/or IgM). A further 26.7% unvaccinated individuals presented evidence of a past infection (positive IgG only). Socio-demographic characteristics, vaccination status and clinical symptoms were not associated with a positive IgM test.

CONCLUSION

This is the first serosurvey conducted during the fourth wave of the epidemic in Vietnam. It revealed a seropositivity rate higher than in previous studies and confirmed the hyperendemicity of SARS-CoV-2. Testing using rapid serological tests proved to be a reliable, easy-to-use method and enabled a rapid estimation of the burden of COVID-19.

The COVID-19 pandemic and disruptions in a district quality improvement initiative: Experiences from the CLEVER Maternity Care programme

BACKGROUND

 Many health systems were poorly prepared for the coronavirus disease 2019 (COVID-19) pandemic and found it difficult to protect maternity and reproductive health services. The aim of the study was to explore the influence of the COVID-19 pandemic on the ability of maternity healthcare providers to maintain the positive practices introduced by the CLEVER Maternity Care programme and to elicit information on their support needs.

METHODS

 This multimethod study was conducted in midwife-led obstetric units (MOUs) and district hospitals in Tshwane District, South Africa and included a survey questionnaire and qualitative reports and reflections by the CLEVER implementation team. Two five-point Likert-scale items were supplemented by open-ended questions to provide suggestions on improving health systems and supporting healthcare workers.

RESULTS

 Most of the 114 respondents were advanced midwives or registered nurses (86%). Participants from MOUs rated the maintenance of quality care practices significantly higher than those from district hospitals (p = 0.0130). There was a significant difference in perceptions of support from the district management between designations (p = 0.0037), with managers having the most positive perception compared with advanced midwives (p = 0.0018) and registered nurses (p = 0.0115). The interpretation framework had three main themes: working environment and health-system readiness; quality of patient care and service provision; and healthcare workers' response to the pandemic. Health-facility readiness is described as proactive, reactive or lagging.

CONCLUSION

 Lessons learned from this pandemic should be used to build responsive health systems that will enable primary healthcare workers to maintain quality patient care, services and communication.

[COVID-19 response capacity implementation in a Brazilian hospital]

After the declaration of a public health emergency of international importance, hospitals have become a benchmark in the response to the pandemic. It is important to assess health professionals' response capacity to the COVID-19 pandemic at a referral hospital in Pernambuco, in northeastern Brazil. This study deals with qualitative evaluative research, of the case study type. Three methods were used to identify critical events: interviews with 18 healthcare professionals who had worked on the "front line" of care for people with COVID-19; direct observation in the sectors of this hospital; and literature review. The interviews were transcribed and analyzed using MaxQDA Analytics pro 2020® software, using the Actor-Network Theory for analysis; and to interpret the critical events the categories of resilience: absorption, adaptation and transformation. It was found that the response capacity of professionals was influenced by five critical events: the arrival of cases, new ways to connect the patients with their social support network, social and personal impact on the daily life of professionals, insufficient supplies, essential equipment and confirmatory tests, and shortage and illness of professionals. In everyday experiences, the response capacity of professionals has led to a process of priority adaptation, which can accelerate important changes in the health system.

Towards a national strategy for the provision of spiritual care during major health disasters: A qualitative study

Background

Spirituality is beneficial to health. Evidence around the benefits of Spiritual care (SC) is advancing, and training is becoming part of healthcare professional development. As the COVID‐19 crisis showed, during major health disasters (MHDs), the demand for SC grows exponentially, while the burden of care and focus on preserving life often hamper its provision. Nonetheless, existing health emergency strategic frameworks lack preparedness for the provision of SC.

Aim

The aim of this study was to identify the components for a National Strategy (NS) for the provision of SC during MHDs.

Methods

Descriptive, cross‐sectional, qualitative phenomenological design based on individual, semi‐structured e‐interviews with nursing managers and National Health Service/volunteer chaplains based in England. Thematic analysis of 25 e‐interview data was performed based on a dialogic collaborative process.

Results and Discussion

Eleven themes were identified as components of the proposed NS. From these components, specific recommendations for practical actions are provided. An integrated framework approach and smart investments in resources, staff training and technologies should be led by the paradigm of culturally competent and compassionate care.

Conclusion

The need to have strategic frameworks, both national and local, that better equip a country healthcare sector to prevent, face, and recover from MHDs is paramount. Catering for the spiritual needs of the affected population should be a key aspect of any health emergency strategy to ensure the preservation of quality care.

Adequate provision of Spiritual care (SC) is more needed yet challenging during health disasters.

With the COVID‐19 crisis, SC strategic planning proved essential.

Collaboration, communities' inclusivity, and training are key strategic elements.

Governments investments should look at advanced technologies, and material and human resources.

"Well, I Signed Up to Be a Soldier; I Have Been Trained and Equipped Well": Exploring Healthcare Workers' Experiences during COVID-19 Organizational Changes in Singapore, from the First Wave to the Path towards Endemicity

(1) Background: As COVID-19 transmission continues despite vaccination programs, healthcare workers (HCWs) face an ongoing pandemic response. We explore the effects of this on (1) Heartware, by which we refer to morale and commitment of HCWs; and identify how to improve (2) Hardware, or ways of enabling operational safety and functioning. (2) Methods: Qualitative e-diary entries were shared by HCWs during the early phases of the outbreak in Singapore from June to August 2020. Data were collected via an online survey of n = 3616 HCWs of all cadres. Nine institutions—restructured hospitals (n = 5), affiliated primary partners (n = 2) and hospices (n = 2)—participated. Applied thematic analysis was undertaken and organized according to Heartware and Hardware. Major themes are in italics (3) Results: n = 663 (18%) HCWs submitted a qualitative entry. Dominant themes undermining (1) Heartware consisted of burnout from being overworked and emotional exhaustion and at times feeling a lack of appreciation or support at work. The most common themes overriding morale breakers were a stoic acceptance to fight, adjust and hold the line, coupled with motivation from engaging leadership and supportive colleagues. The biggest barrier in (2) Hardware analysis related to sub-optimal segregation strategies within wards and designing better protocols for case detection, triage, and admissions criteria. Overall, the most cited enabler was the timely and well-planned provision of Personal Protective Equipment (PPE) for front-liners, though scope for scale-up was called for by those not considered frontline. Analysis maps internal organizational functioning to wider external public and policy-related narratives. (4) Conclusions: COVID-19 surges are becoming endemic rather than exceptional events. System elasticity needs to build on known pillars coupling improving safety and care delivery with improving HCW morale. Accordingly, a model capturing such facets of Adaptive Pandemic Response derived from our data analyses is described. HCW burnout must be urgently addressed, and health systems moved away from reactive “wartime” response configurations.

Pandemic preparedness systems and diverging COVID-19 responses within similar public health regimes: a comparative study of expert perceptions of pandemic response in Denmark, Norway, and Sweden

BACKGROUND

National responses to the COVID-19 pandemic depend on national preparedness systems that must be understood as components of global public health emergency preparedness systems, governed and coordinated through the World Health Organization's 2005 International Health Regulations. The pandemic has raised the question of why countries belonging to similar public health regimes, coordinated through the same global system, responded differently to the same threat. Comparing the responses of Denmark, Sweden and Norway, countries with similar public health regimes, the paper investigates to what degree national differences in COVID-19 policy response reflect significant differences in the policy preferences of national expert groups.

RESULTS

We employ a structured case comparison of Denmark, Norway, and Sweden to analyze their' politico-administrative pandemic preparedness systems and policy responses during the first wave of the COVID-19 pandemic. We use the results of an interdisciplinary expert survey completed in 2020 to analyze expert perceptions in two ways. First, we analyze expert perceptions of COVID-19 responses while controlling for national COVID-19 trajectories and experts' characteristics. Second, we analyze the distribution and effect of dominant global expert-held ideas across countries, showing the importance of dominant ideas for experts' perceptions and preferences for COVID-19 response.

CONCLUSION

The study finds no evidence indicating that COVID-19 policy variation between the most similar cases of Denmark, Norway, and Sweden are the result of differences in the policy preferences of national expert groups. Instead, our study highlights the importance of other factors than cross-national expert dissensus for explaining variation in pandemic response such as the politico-administrative organization of pandemic preparedness systems. Further, we find that expert support for dominant ideas such as a 'focused protection strategy' is associated with consistent policy preferences across locational, disciplinary, and geographic affiliations. Recognition of the latter should be a part of future discussions about how global ideas of pandemic preparedness are diffused transnationally and embedded in national politico-administrative systems.

Cost estimates of COVID-19 clinical management in Myanmar

Objective

This study aims to estimate the cost of clinical management of COVID-19 infected patients based on their severity by exploring the resources used in health care provision in Myanmar.

Methods

A multicenter retrospective cost analysis of COVID-19 patients was performed using the micro-costing approach from the perspective of the health system. It covered two cost components, namely direct and indirect cost of treating a patient. Input data and their quantities were obtained from COVID-19 Standard Treatment Guidelines of Ministry of Health and Sports, and administrative and financial records of resource utilization of three designated health facilities in Yangon Region. Valuation of these resources was based on the price list from the Procurement Section of the Ministry.

Results

This study estimated the unit cost of clinical management of COVID-19 infected patients with no symptom to be 953,552 MMK(717 USD), with mild-moderate symptoms to be 1,155,222 MMK(869 USD) and with severe-critically ill conditions to be 5,705,052 MMK(4290 USD). Average cost for a patient par day was 86,687 MMK(65 USD) for asymptomatic patients, 105,020 MMK(79 USD) for mild-moderate patients and 283,252 MMK(214 USD) for severe-critically ill patients. Since the first case detected till December 31, 2020, COVID-19 clinical management cost was accounted for 139 Billion MMK (104 Million USD) for total 124,630 confirmed cases.

Conclusions

COVID-19 pandemic has caused health systems to incur the significant health care expenses. Timely implementation of the sustainable, affordable and efficient policy for COVID-19 responses is of utmost important for every nation especially in the face of a pandemic. This study provides the fundamental inputs for strategic planning, for future economic evaluations of different policy interventions, and policy recommendations for health systems to remain resilient during and after the COVID-19 pandemic in Myanmar.

Achieving Resilience in Primary Care during the COVID-19 Pandemic: Competing Visions and Lessons from Alberta

The COVID-19 pandemic has tested the resilience of health systems broadly and primary care (PC) specifically. This paper begins by distinguishing the technical and political aspects of resilience and then draws on a documentary analysis and qualitative interviews with health system and PC stakeholders to examine competing resilience-focused responses to the pandemic in Alberta, Canada. We describe the pre-existing linkages between the province's central service delivery agency and its independent PC clinics. Together, these central and independent elements make up Alberta's broader health system, with the focus of this paper being on PC's particular vision of how resilience ought to be achieved. We describe two specific, pandemic-affected areas of activity by showing how competing visions of resilience emerged in the central service delivery agency and independent PC responses as they met at the system's points of linkage. At the first point of linkage, we describe the centralized activation of an incident management system and the replies made by independent PC stakeholders. At the second point of linkage, we describe central efforts to disseminate infection prevention and control guidance to PC clinics and the improvisational efforts of staff at those independent clinics to operationalize the guidance and ensure continuity of operations. We identify gaps between the resilience visions of the central agency and independent PC, drawing broadly applicable policy lessons for improving responses in present and future public health emergencies. Finding ways to include PC in centralized resilience policy planning is a priority.

The long psychological shadow of COVID-19 upon healthcare workers: A global concern for action

INTRODUCTION

The outbreak of COVID-19 has posed unprecedented psychological pressure upon every National Health Service in the world. In Piedmont, one of the most affected areas in Italy, 4550 healthcare workers were assessed online in May-June 2020, after the acute outbreak of March-April 2020, that compelled the Italian government to enforce, what was then, the first total lockdown in the Western world.

METHODS

Socio-demographic information of healthcare workers was gathered along with responses to: General Anxiety Disorder-7, Impact of Event Scale-Revised, Beck Depression Inventory-II, Peritraumatic Dissociative Experiences Questionnaire. Information about the need for psychological support was also gathered.

RESULTS

The regression models predicted the presence of moderate to severe symptoms for all the conditions assessed. Almost half of healthcare workers presented at least one clinically relevant symptom, and among them one in every four expressed the need of receiving psychological support.

CONCLUSIONS

Evidence calls for an increase of psychological services within the National Health System in Italy so as to guarantee for healthcare workers the psychological support necessary to cope with the long shadow of COVID-19, whose long-term impact is likely to reveal itself more strongly the more the acute stage of it is passed.

LIMITATIONS

The assessment of the psychological symptoms was performed without knowing the life and professional situations of the sample, and their medical records. Healthcare workers from only one region in Italy were involved, and some professionals (e.g. self-employed healthcare workers) were not included.

Leveraging vertical COVID-19 investments to improve monitoring of cancer screening programme - A case study from Bangladesh

Cancer screening programs from majority of the low- and middle-income countries (LMICs) report screening coverage as the only performance indicator, and that too measured through population-based sample surveys. Such information is unreliable and has very little value in assessing programmatic quality and impact. Regular monitoring of key process and outcome indicators based on data collected through a robust information system is essential to ensure quality of a screening programme. Fragmented health systems, limited resources and absence of a culture of systematic evaluation are the major hindrances for most of the LMICs to build electronic information systems to manage screening. The COVID-19 pandemic has created an impetus for the countries to customize the freely available District Health Information Software (DHIS2) to collect electronic data to track the outbreaks and manage containment measures. In the present article we present Bangladesh as an exemplar LMIC that has a (DHIS2) based integrated health information system gradually upgraded to collect individual data of the participants to the national cervical cancer screening program. Such efforts paid rich dividends as the screening program was switched from opportunistic to a population-based one. Moreover, the electronic system could report impact of the pandemic on cancer screening on a monthly basis. The aggregate number of women screened in the year 2020 was 14.1% less compared to 2019. The monthly rate of screening during peak of the outbreak was only 5.1% of the previous year. The rate rapidly recovered as the program intensified screening in the hard-to-reach regions less affected by the pandemic and expanded the outreach services. Other LMICs may emulate Bangladesh example. Customizing the information system developed for pandemic surveillance to collect cancer screening data will help them build back the screening programs better.

Research capacity training for surveillance and response in the Indo-Pacific: a case study of implementation

SETTING

Surveillance and response workforce in the Indo-Pacific region, including Papua New Guinea (PNG), Solomon Islands, Fiji, Eastern Indonesia and Timor-Leste.

OBJECTIVE

To evaluate the implementation of a modified WHO SORT IT research training programme which included a workplace-based research project. The training was designed for surveillance and response frontline workforce in the Indo-Pacific region.

DESIGN

This was a programme evaluation using mixed methods. Fifty-three health and biosecurity workers from Fiji, Indonesia, PNG, Solomon Islands and Timor-Leste participated in the research training programme.

RESULTS

Implementation of the programme was modified to reflect the context of participant countries. Work-place research projects focused on priority issues identified by local policy makers and in-country stakeholders. Self-reported research skills showed a significant increase (P < 0.01) after the completion of training. Participants reported high scores for satisfaction with training.

CONCLUSIONS

This case study provides lessons learnt for future research training, and demonstrates that the SORT IT model can be modified to reflect the context of implementation without compromising purpose or outcomes.

Smartphone-Enabled Personalized Diagnostics: Current Status and Future Prospects

Smartphones are becoming increasingly versatile thanks to the wide variety of sensor and actuator systems packed in them. Mobile devices today go well beyond their original purpose as communication devices, and this enables important new applications, ranging from augmented reality to the Internet of Things. Personalized diagnostics is one of the areas where mobile devices can have the greatest impact. Hitherto, the camera and communication abilities of these devices have been barely exploited for point of care (POC) purposes. This short review covers the recent evolution of mobile devices in the area of POC diagnostics and puts forward some ideas that may facilitate the development of more advanced applications and devices in the area of personalized diagnostics. With this purpose, the potential exploitation of wireless power and actuation of sensors and biosensors using near field communication (NFC), the use of the screen as a light source for actuation and spectroscopic analysis, using the haptic module to enhance mass transport in micro volumes, and the use of magnetic sensors are discussed.

Health care workers and migrant health: Pre- and post-COVID-19 considerations for reviewing and expanding the research agenda

The main purpose of this article is to review several ways in which health care workers could either impact migrant health or be directly impacted by migration and, based on this, suggest the expansion of the current research agenda on migration and health to address a range of topics that are currently either neglected, insufficiently researched, or researched from different perspectives. To ground this suggestion and emphasize the complexity and significance of migrant health research, we start by briefly reviewing several migration-related notions including the process of migration and its key facilitators and benefits; existing barriers to the provision of migrant health care; and the intricate links between health systems, health professionals, and migrant health. The three areas of research examined in this article address (i) the specific role of health workers in providing care to migrants and refugees and their capacity to do so, (ii) the health problems experienced by health workers who become migrants or refugees, and (iii) the precarious employment conditions experienced by both migrant and non-migrant health care workers. After summarizing the current available evidence on these topics, we discuss key information gaps and strategies to address them, while also incorporating several relevant COVID-19 pandemic considerations and research implications. Expanding the focus of research studies on migration and health could not only enhance the results of current strategies by supplying additional information to support their implementation but also spearhead the development of new solutions to the migrant health problem.

Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries

Health systems resilience is key to learning lessons from country responses to crises such as coronavirus disease 2019 (COVID-19). In this perspective, we review COVID-19 responses in 28 countries using a new health systems resilience framework. Through a combination of literature review, national government submissions and interviews with experts, we conducted a comparative analysis of national responses. We report on domains addressing governance and financing, health workforce, medical products and technologies, public health functions, health service delivery and community engagement to prevent and mitigate the spread of COVID-19. We then synthesize four salient elements that underlie highly effective national responses and offer recommendations toward strengthening health systems resilience globally.

Multidimensional Conditions of the First Wave of the COVID-19 Epidemic in the Trans-Industrial Region. An Example of the Silesian Voivodeship in Poland

The successive phases of the global COVID-19 pandemic show some differences from the first wave in 2020. The most important of these is some experience in responding to its spread and in applying vaccines. However, new, more aggressive variants of COVID-19 mean that the pandemic is often taking on the nature of the one experienced by societies a year ago. So, the knowledge about the first wave of the COVID-19 pandemic is still up-to-date—significantly where the essential determinants of its spread have not changed. The article presents the Silesian Voivodeship case in Southern Poland, distinguished by different geographical conditions compared to the entire country. The authors showed the relationship between the spread of the COVID-19 epidemic and the characteristic attributes of the analysed area (post-)mining functions or urban shrinkage. The article conducted a dependence study using the Pearson correlation coefficient and the signs table method. In turn, the authors used thematic cartography to present the results of the analysis. It turned out that two attributes, namely (post-)mining and urban shrinkage, are essential in spreading the epidemic with the region analysed. This conclusion may be essential in implementing national and regional policies related to reducing the COVID-19 pandemic. However, a limitation in the scope of the presented applications is the fact that mining regions, such as the Silesian (Śląskie) Voivodeship, are currently less numerous in the world than, for example, those that develop based on services.