Cross-Country Synthesis: COVID-19 Response and Maintenance of Essential Health Services

Introduction

Between March 2020 and December 2021, there were more than 281 million confirmed cases of COVID-19 and over 5 million COVID-19 deaths globally.¹ During the first two years of the COVID-19 pandemic, health systems around the globe focused their efforts and resources on implementing pandemic response measures to slow the spread of infections and to treat those with COVID-19. Also, fear of COVID-19 infection among health workers, transportation and mobility restrictions, stockouts of essential health commodities, and other challenges put additional strain on health systems.

As a result, the delivery of essential health services (EHS), such as routine immunizations and maternal health services as well as critical care such as treatment for cancer and HIV, was often disrupted. As shown in the figure below, the World Health Organization (WHO) conducted a series of Pulse Surveys across 84 countries from 2020 to 2022 and found that nearly 90% of countries reported interruptions in the delivery of EHS between March and June 2020.²

Studies have found that countries around the world—even ones with high-performing and well-resourced health systems—reported excess mortality and morbidity from preventable causes because of these disruptions caused by the pandemic.³ As shown in the figure below, COVID-19 has been estimated to have caused nearly 22 million excess deaths worldwide as of May 2023.⁴

In many countries, emergency response efforts quickly overwhelmed the delivery of key EHS in 2020 and 2021². Researchers believe that declines in access to and use of EHS during the COVID-19 pandemic could reverse decades of progress in population health outcomes, particularly in low- and middle-income countries.⁵

As the world prepares for future health emergencies, there is much to learn from countries’ efforts to contain the spread of SARS-CoV-2 (the virus that causes COVID-19) and to maintain access to EHS. To that end, this research identified six countries that demonstrated ability to maintain EHS while also implementing measures to reduce SARS-CoV-2 infections: Costa Rica, the Dominican Republic, Ghana, Sri Lanka, Thailand, and Uganda. These countries offer promising practices and policies applicable in other contexts to strengthen preparedness for future health emergencies.

Conceptual framework for understanding promising practices

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 our research, we aim to derive lessons learned about the drivers of a successful pandemic response while maintaining EHS and have developed a conceptual framework that categorizes the drivers into two groups: context and system factors and interventions, and outcomes (see figure below).

The following pages discuss cross-country interventions, which we call “promising practices,” that emerged in three or more of the six positive outlier countries. The promising practices we highlighted are (1) adaptable to other countries and other types of health emergencies, and (2) focused on building resilience,⁶ or enabling health systems to deliver high-quality, people-centered care while absorbing the shocks that large-scale health crises such as the COVID-19 pandemic can cause.⁷

We have organized these promising practices into three categories:

• National, governmental, and population-level measures
• Measures for health system adaptation
• Patient-level measures

A full list of the promising cross-country practices, as well as corresponding examples from positive outlier countries, can be found in the table below. Click on the blue cells of the table to see examples of the promising practices in each country.