Worldwide, millions of people have died from COVID-19, and every country in the world has been affected. The 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.
- 90 percent of countries have experienced interruptions to essential health services since the start of the COVID-19 pandemic 1
- Over 83 million confirmed COVID-19 cases were reported globally throughout 2020 2
- In 2020, global childhood vaccination coverage dropped to levels not seen since the 1990s 3
The World Health Organization (WHO) and Global Health Security Agenda have developed useful frameworks for assessing epidemic and pandemic preparedness and response, which we have adapted for this research. Through the Exemplars in COVID-19 Response work, we aim to derive lessons learned about the drivers of a successful response and have developed a conceptual framework that breaks down the drivers into three consecutive groups: context and system factors, interventions, and 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, and continue to have, 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 will focus 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 to their provision of essential health services. The research will focus 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 SARS-CoV-2 that is easily transmitted and presents in highly variable ways. Some patients die from the disease, some get seriously ill and recover completely, some experience long-term negative health effects, and some experience minimal or no symptoms (although they are still contagious). SARS-CoV-2 spreads primarily through respiratory droplets, which makes the virus difficult to control without high rates of compliance with stringent behavioral measures, such as masking and social distancing. Because people with COVID-19 are infectious before they have symptoms, and because they can transmit the virus even if they remain asymptomatic, simply testing and isolating symptomatic cases is insufficient to prevent the spread of the disease; this is a key difference between SARS-CoV-2 and SARS or MERS.
Without social distancing and other measures to control its transmission, the novel coronavirus spreads exponentially. Like all viruses, as SARS-CoV-2 spreads, it mutates (although the SARS-CoV-2 virus has mutated more slowly than influenza viruses). Some of these mutations have led to the evolution of variants with higher rates of transmission, greater disease severity, and the ability to reduce protection from vaccines or prior infection.
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. An example of this is the demonstrated spike in gender-based violence.
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 and elsewhere are exploring some hypotheses:
- Countries with a greater ability to control or close their borders, such as island nations and small countries, can better prevent introduction of the virus or limit its spread.
- Countries with high levels of social cohesion and trust in government and the health system are better equipped to enact a swift and effective policy response.
- Health systems with centralized decision-making authority and those whose political leaders prioritized data-based decision making and emphasized the importance of public health communications are better equipped to enact a swift and effective policy response.
- Governments that provide strong social safety nets and/or programs targeted at supporting vulnerable populations can reduce the overall health and economic impacts of a 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, experience with recent epidemics or pandemics, obesity rates, and the effectiveness of disease-detection platforms.
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, we are conducting 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 aim 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 will complement a comprehensive study of countries across sub-Saharan Africa, Latin America, and Asia. Positive outlier countries will be 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 contain the pandemic while maintaining essential health services.
Detection is the First Step Toward Containing Local Outbreaks
Testing is critical to identify, isolate, and appropriately treat 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. 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 has been disrupted around the world as countries implement strict social distancing policies and divert health care workers and other resources to respond to COVID-19. Fear of contracting the virus has 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 are distributed worldwide, global attention shifts 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 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 prevent and manage 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.4 The panel has released their final report and a valuable set of recommendations for improving global pandemic preparedness that we hope will direct the global agenda going forward.
Exemplars in COVID-19 Response Technical Advisory Group (TAG) Members:
Our Technical Advisory Group (TAG) consists of a diverse range of experts to guide our Exemplars research in the COVID-19 response topic area:
- Dr. Jarbas Barbosa da Silva, Assistant Director of the Pan American Health Organization (PAHO), Link to Bio
- Dr. Scott F. Dowell, Deputy Director for Surveillance & Epidemiology, Bill & Melinda Gates Foundation, Link to Bio
- Dr. Tom Frieden, President and CEO of Resolve to Save Lives, Former Director of the US Centers for Disease Control and Prevention, Link to Bio
- Dr. Margaret Kruk, Professor of Health Systems at the Harvard T.H. Chan School of Public Health and Director at QuEST Network, Link to Bio
- Dr. Yee-Sin Leo, Executive Director, National Centre for Infectious Diseases, Singapore
- Dr. John Nkengasong, Director of the Africa Centres for Disease Control and Prevention, WHO Envoy on COVID-19, Link to Bio
- Dr. Gina Samaan, COVID-19 Incident Management Team Pillar Lead / PIP Framework Team Lead, WHO
- Dr. Solomon Zewdu, Deputy Director, Health, Africa Office Bill & Melinda Gates Foundation
- Dr. Feng Zhao, Practice Manager, Strategy, Operations and Global Engagement, World Bank, Link to Bio
WHO. (2020, August). “Pulse Survey on continuity of essential health services during the COVDI-19 pandemic: interim report.” https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1.
Our World in Data. (2021, May). COVID-19 Data Explorer. https://github.com/CSSEGISandData/COVID-19.
Bill & Melinda Gates Foundation. (2020, September). 2020 Goalkeepers Report. https://www.gatesfoundation.org/goalkeepers/report/2020-report.
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.