Worldwide, millions of people have died from COVID-19, and every country in the world has been affected. This pandemic has also triggered the worst global economic crisis since the Great Depression, exacerbated preexisting inequities, and set back progress on many other key health indicators. Learning from the COVID-19 pandemic will help countries prepare for future crises by strengthening health systems to be more resilient.1
- 84% of countries surveyed by the WHO from November 2022 to January 2023 reported continued interruptions to essential health services.1
- As of June 30, 2023, the estimated excess mortality due to COVID-19 is approximately 24.4 million individuals globally.2
- As of June 30, 2023, over 13 billion COVID-19 vaccine doses have been administered worldwide.3
The World Health Organization (WHO) and Global Health Security Agenda have developed useful frameworks for assessing epidemic and pandemic preparedness and response, which have been adapted for this research. Through the Exemplars in COVID-19 Response work, we aimed to derive lessons learned about the drivers of a successful response and have developed a conceptual framework that categorizes the drivers into two groups: context and system factors, and interventions, which also includes outcomes.
Click through to explore the detailed components of the conceptual framework.
Contextual and System Factors: Each exemplar country entered into the pandemic with a variety of contextual factors that had an impact on the course of COVID-19 within their borders. Examples of these factors include healthcare system indicators such as healthcare access, affordability, and underlying disease burden, in addition to unique political and cultural factors that may have influenced the country’s COVID-19 response or continuation of essential health services, such as trust in government.
Interventions: The interventions that each country put in place to combat COVID-19 and maintain essential health services, can be further broken down into population-level, health system-level, and patient-level interventions. Our research focused on how countries chose to implement and prioritize certain interventions over others.
Outcomes: Exemplar countries were selected initially on the basis of their COVID-19 specific outcomes as well as the continuity of their provision of essential health services. The research focused on exploring the extent to which the interventions put in place (in addition to country context) led to the COVID-19 and essential health services outcomes observed. While important, this research does not delve deeply into social and economic outcomes, nor other health outcomes which can be challenging to measure in real-time.
COVID-19 is a respiratory disease caused by the SARS-CoV-2 virus that is easily transmitted and presents in highly variable ways. The health effects vary and patients may experience little to no symptoms (though they can still be contagious), severe symptoms with complete recovery or long-term health effects, or even death. SARS-CoV-2 is primarily spread through small liquid particles preventing transmission requires multiple layers of protection, including non-pharmaceutical interventions, such as masking and social distancing. Because people infected with SARS-CoV-2 can transmit the virus even when they aren’t experiencing symptoms, strategies that rely on testing and isolating symptomatic cases are insufficient to prevent the spread of the disease; this is a key difference between SARS-CoV-2 and SARS or MERS.4,5,6
Without social distancing and other measures to control its transmission, the virus can spread rapidly, particularly in populations without immunity from prior infection or vaccination. When SARS-CoV-2 infects a person, it makes imperfect copies of itself that contain tiny mutations. Most of these minor mutations are inconsequential and enable the tracking of transmission chains using phylogenetic analysis. However, some mutations can lead to the evolution of new viral variants with higher rates of transmission, greater disease severity, and the ability to reduce protection from vaccines or prior infection. Further detail of the comparison between COVID-19 and other infectious disease outbreaks and epidemics are detailed below in Table 1.
Table 1: Comparison table of past global pandemics and epidemics
The downstream effects of COVID-19 are not limited to the health of infected individuals. Quarantining, social distancing, and other pandemic-related behavioral changes have caused unparalleled disruption to daily lives around the world. In addition, the need for advanced medical care for patients with severe disease, personal protective equipment for health care workers, and masks for the public have all put pressure on global supply chains. Across global populations, the COVID-19 pandemic has also exacerbated social inequities and imposed substantial economic hardships—especially on the most vulnerable. The COVID-19 pandemic has exacerbated inequities and has contributed to a variety of negative downstream impacts, including economic hardship, learning loss due to school closures, social isolation, mental health challenges, and increased rates of gender-based violence (GBV).1,7
We began by examining lessons learned and case studies from past epidemics and developing new case studies on countries that performed well at the start of the COVID-19 pandemic.
In addition, the research coalition conducted a set of thematic research projects to understand innovative solutions that have been implemented in countries around the world to address critical aspects of the COVID-19 response. By studying these aspects within the pandemic response, we aimed to contribute in near real time to the global evidence base to support the revision of policies and implementation of strategies during the COVID-19 pandemic.
These thematic efforts were complemented a comprehensive study of countries led by Brown University School of Public Health, Johns Hopkins Bloomberg School of Public Health and Makerere University School of Public Health across sub-Saharan Africa, Latin America, and Asia. Positive outlier countries were evaluated in depth, with research into the interventions they used to address COVID-19 and the successes and challenges they encountered as they sought to control the pandemic while maintaining essential health services.
Detection is the First Step Toward Containing Local Outbreaks
Testing is critical to identifying, isolating, and appropriately treating infected individuals and their contacts. It is also critical for reasons beyond diagnosis. Surveillance testing enables a country to collect data that informs public health understanding of the outbreak and supports planning and decision-making in the coming weeks and months. A strong surveillance strategy includes testing a representative set of samples from the population to make inferences as efficiently as possible.8 Strong surveillance systems also assess testing capacity to strike a balance between getting the data needed to inform public health decisions while allocating enough tests for clinical care. Our research focused on four countries— the Democratic Republic of the Congo, Nigeria, Senegal, and Uganda—and their testing experiences to understand lessons learned in COVID-19.
Maintaining and Strengthening Essential Health Services Is Critical
COVID-19 has demonstrated the global consequences of underinvestment in health systems. Access to essential health services was disrupted around the world as countries implemented strict social distancing policies and diverted health care workers and other resources to respond to COVID-19. Fear of contracting the virus also led people to avoid health care facilities. Our research focused on how four countries in sub-Saharan Africa— the Democratic Republic of the Congo, Nigeria, Senegal, and Uganda— have addressed the challenge of maintaining essential health services during the COVID-19 pandemic.
Leveraging Lessons from the Past to Deliver COVID-19 Vaccines
As vaccines to prevent COVID-19 infection were distributed worldwide, global attention shifted from vaccine development to other logistical, political, and social challenges: deploying new technologies, accessing high-risk populations, building community confidence, and addressing vaccine hesitancy. Low-resource settings have some systemic barriers that may further complicate vaccine distribution, such as limited surveillance infrastructure, strained supply chains, and an overstretched workforce. As lower- and middle-income countries prepare to scale up the roll out of COVID-19 vaccines, harnessing strategies for success from the implementation of other recent vaccines, such as meningitis A, yellow fever, and Ebola, provides valuable support to health officials and decision-makers.
Factors Contributing to Expansion of COVID-19 Digital Tools
Digital tools, when implemented at scale, have some advantages over traditional, paper-based systems. They enable decision-makers to access data in real time and create efficiencies for practitioners that are especially critical during the COVID-19 pandemic. As a result, COVID-19 has the potential to be a catalytic opportunity for digital health. Our research focused on seven countries where digital health tools were implemented during the pandemic, including tools for community health workers, modules for the health management information systems, and end-to-end surveillance platforms.
Strengthening and Maintaining Resilient Health Systems
Resilient health systems promote good health and allow for the prevention and management of endemic diseases while maintaining a level of preparedness that enables them to adapt and surge as needed when a new threat arises. National health systems should be connected to and supported by global and regional coordination mechanisms and surveillance systems. Public-private partnerships for funding, procurement, coordination of vaccines, treatments, and personal protective equipment—from development through distribution—also have a role to play in supporting and bolstering the health system during an emergency.
In July 2020, the WHO Director- General commissioned an Independent Panel for Pandemic Preparedness and Response.9 PRET (Preparedness and Resilience for Emerging Threats), an initiative launched by the WHO, has been working to improve disease pandemic preparedness among Member States by implementing learnings and collective action utilized during the COVID-19 and other public health emergencies. Over 50 Member States have implemented PRET workshops and simulation exercises, and an additional 46 countries plan to implement similar PRET activities by end of 2023.10
This is a challenging question to which there is no single answer. Studies on the factors that contribute to a country’s ability to successfully control COVID-19 and mitigate its effects are ongoing. Researchers at Exemplars in Global Health, in collaboration with external research partners found some practices that countries utilized for an effective COVID-19 response:
- Multisectoral collaboration and partnerships helped bolster countries’ responses to the pandemic, especially by enabling health systems to share and coordinate information, resources, and personnel.
- Many countries benefited from pre-pandemic investment in their health systems. For instance, they had expanded universal health coverage, strengthened the health workforce, and/or created access to financing for system-wide health emergencies.
- Countries with a long-standing investment in health systems strengthening and preparedness (e.g., infrastructure, workforce), and prior epidemics (SARS, MERS, HIV, Ebola) experience were efficient in mobilizing resources and responding to COVID-19.
- Countries with high degrees of public trust in government and science along with strong leadership, governance structures, and political will were better equipped to enact a swift and effective policy response.
- Health systems with substantial progress towards UHC or other existing health financing mechanisms were able to mitigate disruption to essential health services delivery more effectively.
- Governments that provide strong social safety nets and/or programs targeted at supporting vulnerable populations were able to reduce the overall health and economic impacts of the pandemic.
Other context-specific factors that contribute to a country’s ability to control the virus and mitigate its effects include the age structure of the population, existing partnerships with the private sector and international agencies, obesity rates, and the efficacy of disease-detection platforms.
Our COVID-19 Response Research Partners
- COVID-19 Surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: Strengths, Weaknesses and Key Lessons
- Spread and seasonality of COVID-19 pandemic confirmed cases in sub-Saharan Africa: experience from Democratic Republic of Congo, Nigeria, Senegal, and Uganda
- Uptake of COVID-19 vaccines and associated factors among adults in Uganda: a cross-sectional survey
- Interventions for Continuity of Essential Health Service Delivery during the COVID-19 Response in Uganda, March 2020-April 2021
- Private sector engagement in the COVID-19 response: experiences and lessons from the DRC, Nigeria, Senegal and Uganda
- Lessons learned from implementing digital health tools to address COVID-19 in LMICs
- COVID-19: Identifying countries with indicators of success in responding to the outbreak
- Learn from the lessons and don’t forget them’: identifying transferable lessons for COVID-19 from meningitis A, yellow fever and Ebola virus disease vaccination campaigns
- Testing capacity for COVID-19 can be improved: Experiences and Lessons from the Democratic Republic of Congo, Nigeria, Senegal and Uganda
- COVID-19 Outbreak Control Strategies and their Impact on the Provision of Essential Health Services in Ghana
- Supplement articles
- Cross-Country Synthesis
- Sri Lanka
- Dominican Republic
- Multisectoral Commentary
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WHO. Fourth round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic: November 2022-January 2023. Geneva: WHO; 2023. Accessed June 26, 2023. Fourth round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic: November 2022–January 2023 (who.int)
The Economist. (2023, Aug). The Pandemic’s True Death Toll. https://www.economist.com/graphic-detail/coronavirus-excess-deaths-estimates
Our World in Data. (2021, May). COVID-19 Data Explorer. https://github.com/CSSEGISandData/COVID-19.
Killerby ME, Biggs HM, Midgley CM, Gerber SI, Watson JT. Middle East Respiratory Syndrome Coronavirus Transmission. Emerg Infect Dis. 2020 Feb;26(2):191-198. doi: 10.3201/eid2602.190697. PMID: 31961300; PMCID: PMC698683.
Centers for Disease Control and Prevention. (2020, Aug). MERS clinical features. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/mers/clinical-features.html
Severe acute respiratory syndrome (SARS). Johns Hopkins Medicine. (2020, January). https://www.hopkinsmedicine.org/health/conditions-and-diseases/severe-acute-respiratory-syndrome-sars
Dlamini N. J. (2021). Gender-Based Violence, Twin Pandemic to COVID-19. Critical Sociology, 47(4-5), 583–590. https://doi.org/10.1177/0896920520975465
Morgan OW, Aguilera X, Ammon A, Amuasi J, Fall IS, Frieden T, Heymann D, Ihekweazu C, Jeong EK, Leung GM, Mahon B, Nkengasong J, Qamar FN, Schuchat A, Wieler LH, Dowell SF. Disease surveillance for the COVID-19 era: time for bold changes. Lancet. 2021 Jun 19;397(10292):2317-2319. doi: 10.1016/S0140-6736(21)01096-5. Epub 2021 May 14. PMID: 34000258; PMCID: PMC8121493.
WHO. (2020, July). "Independent evaluation of global COVID-19 response announced." https://www.who.int/news/item/09-07-2020-independent-evaluation-of-global-covid-19-response-announced.
WHO. Preparedness and Resilience for Emerging Threats (PRET). https://www.who.int/initiatives/preparedness-and-resilience-for-emerging-threats