Methodology

Between April 2021 and August 2022, cross-country research partners (CCRPs) from the Brown University School of Public Health, the Johns Hopkins School of Public Health, and Makerere University School of Public Health led a mixed methods assessment of COVID-19 response strategies and of efforts to maintain EHS in six low- and middle-income countries during the first two years of the pandemic. They conducted the project in two phases:

• In Phase 1, CCRPs identified countries that showed preliminary evidence they could maintain EHS while also responding to the pandemic and controlling the spread of SARS-CoV-2. Six countries were selected across three regions (two countries each from Asia, Latin America, and sub-Saharan Africa) as being positive outliers relative to their peers. They were selected based on a set of quantitative COVID-19 response indicators (including age-standardized death rates, cases per million people, and cases per test) and EHS maintenance indicators (including disruption to DTP3 immunization). A literature and policy review, key informant interviews, and the transferability of findings also informed the country selection process. The table below shows the quantitative indicators assessed in each region. Click on the region buttons below this table to see countries’ performance on COVID-19 response and EHS maintenance indicators across each region. The countries selected for study are bolded in the table below.

• In Phase 2, in-country research partners (ICRPs) led deep-dive research into how those countries responded to COVID-19 and maintained or improved the delivery of EHS, and identified practices and policies that might have facilitated their success. The ICRPs performed a mixed methods analysis to identify best practices, key policies, and lessons learned from each country’s response to the pandemic and efforts to maintain EHS. This mixed methods approach included conducting key informant interviews, performing a literature and policy review, and examining national and subnational health data. The ICRPs were the INCAE Business School in Costa Rica, Fundación Plenitud in the Dominican Republic, University of Ghana School of Public Health, Institute for Health Policy in Sri Lanka, the National Health Foundation in Thailand, and Makerere University School of Public Health in Uganda (see the figure below). The research was guided by a Technical Advisory Group (TAG) consisting of a diverse range of technical experts and advisors from the Africa CDC, Bill & Melinda Gates Foundation, Harvard School of Public Health, National Centre for Infectious Diseases in Singapore, Pan American Health Organization, Resolve to Save Lives, World Bank, and WHO.

To identify promising practices across all six countries, research partners at the Brown School of Public Health and Johns Hopkins School of Public Health led an analysis of the deep-dive research performed by ICRPs for each of the six countries. Multiple researchers extracted and thematically coded beneficial practices and policies for COVID-19 response or maintenance of EHS or both from the ICRP final reports. These beneficial practices and policies, called “promising practices” in this synthesis, were organized into the three categories of interventions within the conceptual framework:

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

Researchers from Brown and Johns Hopkins, in collaboration with the respective ICRPs, reviewed the coded information for accuracy and country representation. Across the six countries, researchers tallied the countries that implemented the coded promising practices.

CCRPs identified an intervention or policy as a promising practice if there was thematic evidence it was implemented and reported as beneficial by three or more countries. This assessment focused on finding commonalities, rather than differences, across countries because each country’s final report and methodology differed slightly, so it could not be assumed that the absence of a theme was because of a real absence of such activities in the country. In addition, evidence that a promising practice was implemented across several countries increases the likelihood it could be replicable in other contexts. Finally, the fact that multiple countries reported a promising practice to be beneficial increased our confidence in the importance and potential replicability of that intervention.

The promising practices were validated through a collaborative review between the research coalition and the TAG. CCRPs then synthesized cross-cutting themes based on the promising practices and lessons learned to develop key insights and generalizable practices on health system resilience and preparedness for future health emergencies.