Promising practices: measures for health system adaptation
|This is, in part, because of context and systems factors including a country’s previous experience with epidemics, its health system strength and structure, and the onset of SARS-CoV-2 in-country. These and other factors helped shape each country’s COVID-19 response, as well as its ability to continue delivering EHS in the first two years of the pandemic. However, these context and system factors cannot be easily changed during the onset of an infectious disease outbreak, and as a result this cross-country synthesis primarily focuses on the interventions countries implemented in response to COVID-19. A full list of cross-cutting interventions (called “promising practices”) that all or most countries implemented 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.
Cross-Country Promising Practices
This section describes four essential measures for health system adaptation that most of the countries implemented in some form. Despite substantial disruptions to health systems during the COVID-19 pandemic, these measures aimed to ensure ongoing access to COVID-19 care and EHS at the local level. Examples of these measures include:
- Changes to preexisting health facilities and the construction of new ones
- The development and widespread adoption of systems for remote care delivery
- Innovative ways to mobilize, deploy, and support health workers
Health systems and individual health facilities can adapt these measures to improve care delivery during future health emergencies.
Changing the way some health services were delivered enabled the maintenance of EHS as well as support for COVID-19 patients.
In all six countries, health systems changed the way they delivered EHS to continue to provide access to care while adapting to the new challenges posed by the COVID-19 pandemic. Service delivery adaptations that limited in-person interactions, such as separate wards or buildings for COVID-19 patients, were aimed to prevent disease transmission in health facilities. Innovations such as telemedicine and telemonitoring kept nonurgent patients away from health facilities entirely and minimized disruption to key services such as noncommunicable disease (NCD) care. Often, collaboration with private sector partners made these adaptations possible.
For example, Sri Lanka’s leading telecommunications provider, Dialog, donated mobile phones and broadband routers to government hospitals and quarantine centers to enable remote health services. Primary care providers in the public sector were given detailed guidelines on implementing telehealth services, including a remote consultation algorithm for screening and managing COVID-19 cases.
Within the first several months of the COVID-19 pandemic, health providers across the Dominican Republic adopted online platforms such as Zoom, Skype, and Webex for doctor training, patient consultations, and sharing of electronic medical records. In July 2020, the public health system began to offer online telemedicine consultations with primary care providers and specialists in pediatrics, family medicine, cardiology, and gynecology.1
In March 2020, Costa Rica created an 88-bed Specialized Care Center for Patients with COVID-19 (Centro Especializado de Atención de Pacientes con COVID-19, or CEACO) in the renovated National Rehabilitation Center. CEACO aimed to concentrate all COVID-19 resources in a single place, enabling the continued delivery of essential hospital services at other facilities.2
Thailand’s “New Normal Medical Services” initiative helped maintain access to EHS during the COVID-19 pandemic and identified a set of service delivery adaptations that could be scaled nationwide. Health workers triaged people with NCDs, resulting in less urgent cases receiving teleconsultations and drugs delivered by village health volunteers. Patients who needed to go to health facilities used designated patient pathways that ensured strict physical distancing. Ventilation systems were also upgraded for those who needed intensive care.3
Uganda maintained patient access to HIV treatment in 2020 and 2021 by providing six months of antiretroviral therapy refills instead of the standard 1-2 months, involving patient peer leaders in drug distribution, using community drug distribution points instead of pharmacies in health care facilities, and leveraging COVID-19 response resources to distribute medicines.4 These measures helped patients maintain adherence to HIV treatment in the face of mobility restrictions.
The Ghanaian health system adopted a variety of service delivery adaptations to maintain access to EHS. These included implementing appointment systems that manage facility capacities by triaging patients by severity. Administrators also rescheduled elective surgeries to enable health workers to focus their attention on COVID-19 patients.
Although the six countries saw an initial decline in outpatient visits early in the pandemic, most countries saw outpatient visit volumes recover in 2021 as various service delivery adaptations were implemented. The figure below summarizes how outpatient visit volumes changed in each country during the COVID-19 pandemic. Click on the country buttons below this visual to see how outpatient visit volumes changed in the early stages of the pandemic.
Interventions sought to increase the capacity of health workers, especially during pandemic surges.
To maintain access to EHS, especially during pandemic surges that risked overwhelming health facilities and staff, all six countries found innovative ways to mobilize and redeploy health workers for emergency response (see figure below). Some hired additional temporary and permanent health workers, especially for high-burden hospitals and communities; others shifted tasks to community health workers and redeployed existing workers to cover COVID-19 response needs. In addition, some health systems offered more support to frontline workers, such as salary increases, free transportation, and psychosocial support, to increase retention.
To maintain access to EHS alongside the delivery of critical care for COVID-19 patients, the government of Ghana engaged the services of over 50,000 permanent and 7,000 temporary health care workers in 2020 (see figure below). This expansion of the health workforce aimed to increase access to care across Ghana, especially in rural parts of the country that are typically underserved.5
In April 2020, Thailand’s government appointed nearly 40,000 contract nurses, frontline health workers, and other short-term workers in the health sector to civil-servant status (allowing for more benefits and compensation) to boost health worker retention during the COVID-19 pandemic.6 The government also doubled the level of compensation for health workers infected with COVID-19 and offered hazard allowances to those working in hospitals or quarantine facilities.7
During the COVID-19 pandemic, authorities in Uganda redistributed many health workers to enable the maintenance of EHS and to provide services associated with COVID-19 prevention, surveillance, and care. For example, some districts deployed health workers—including epidemiologists, doctors, anesthetists, nurses, laboratory technologists, psychiatric clinical officers, ambulance assistants, and drivers—on six-month contracts to COVID-19 treatment centers and to support districts and border staff in surveillance.8 In addition, Uganda mobilized its pre-existing network of over 10,000 community health workers—known as village health teams—that had been trained on infection prevention and control during Ebola outbreaks in 2018 and 2019 to perform surveillance activities, provide EHS, and support other aspects of the pandemic response.
Health system integration, new partnerships, and robust data infrastructure enabled the transfer of patients, resources, and supplies between health facilities.
In four of the countries, health systems had the operational flexibility and tools to transfer patients, resources, and supplies between health facilities depending on patient needs and capacity. In particular, data infrastructure and health system integration enabled management of patient transfers; centralization of key information from hospitals, clinics, laboratories, and pharmacies; and real-time data on the number of available beds and other equipment such as ambulances and ventilators, keeping hospitals from reaching capacity.
For example, Costa Rica’s public health system is both vertically and horizontally integrated, meaning it provides care at all levels (primary, secondary, and tertiary) as well as runs clinics and hospitals across different regions of the country.9 This integration enabled officials and providers to transfer patients and supplies across facilities. For example, the Costa Rica Social Security Fund established an Operational Coordination Council in which administrators of public health facilities met monthly to coordinate resources, patient movements, and care specialties according to demand.
In April 2020, the Dominican Republic’s Ministry of Public Health integrated the Ministry of Defense’s Command, Control, Communications, Computers, Cybersecurity and Intelligence Center (C5i) with the health system. The C5i platform centralized data from hospitals, clinics, laboratories, and pharmacies, enabling officials and facilities to see in real time the number of available beds, ventilators, and ambulances, and to distribute patients accordingly. With these data, the national health system was able to transfer patients to less occupied health centers depending on the complexity and severity of their cases.10 As a result, the Dominican Republic never exceeded the capacity of hospital or ICU beds for COVID-19 patients, even during surges of COVID-19 cases (see figure below).
Prior experience with epidemics enabled COVID-19 response.
All six countries have extensive experience responding to diseases with epidemic potential such as SARS, H1N1, MERS, HIV, and Ebola Virus Disease. As a result, countries already developed key pandemic response infrastructure such as rapid response teams, lab transport networks, and coordination structures before the COVID-19 pandemic. These preexisting systems boosted preparedness and enabled timely disease response.
For instance, health officials in Ghana acted quickly to stop the spread of SARS-CoV-2 using preexisting tools and systems such as the District Health Information Management System, which made it possible to share crucial data quickly with officials, health workers, and the public. Ghana also used the Surveillance Outbreak and Response Management and Analysis System (SORMAS), developed in Nigeria during the 2014–2015 West Africa Ebola outbreak, to track COVID-19 cases in real time and to adjust mitigation strategies accordingly.11
Since 2004, over 1,000 Surveillance and Rapid Response Teams of public health nurses and officers have been stationed across Thailand to rapidly detect and respond to emerging public health threats.12 During the COVID-19 pandemic, officials deployed many of these teams to support contact tracing, treatment, and quarantine. Also, the long-established national Field Epidemiology Training Program helped produce experts in disease outbreak investigation and control. Many of these experts were also stationed around the country to manage COVID-19 outbreaks, conduct contact tracing, and analyze epidemiological data.13
Uganda repurposed its outbreak coordination and laboratory capacity, built for diseases such as HIV and tuberculosis, for COVID-19 testing. Existing laboratory transport networks facilitated the rapid expansion of diagnostic testing capacity and systems for quality assurance.
SeNaSa National Health Insurance. Nuevo servicio de consulta médica en línea. Accessed December 14, 2022. https://www.arssenasa.gob.do/index.php/herramientas/telemedicina
Costa Rica puts into operation specialized center for COVID-19 patients. Nuestro País. April 2, 2022. https://www.elpais.cr/2020/04/02/costa-rica-pone-a-funcionar-centro-especializado-en-pacientes-covid-19/
Department of Medical Services Foundation (DMSF), Department of Medical Services Thailand, Asian Disaster Preparedness Center (ADPC), government of Japan. Thailand's New Normal Solutions for Building Resilience for Emerging Infectious Diseases (EID) in Healthcare Facilities. Nonthaburi, Thailand: DMSF; 2021. Accessed January 2, 2023. http://www.adpc.net/NNM/Mebook/EID_EN_31Mar_2206pm.pdf
Zakumumpa H, Tumwine C, Milliam K, Spicer N. Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda. BMC Health Serv Res. 2021;21:692. https://doi.org/10.1186/s12913-021-06607-w
Ghana Ministry of Health (MOH). Ghana Health Sector: 2021 Programme of Work. Accra, Ghana: MOH; 2021. Accessed February 6, 2023. https://www.moh.gov.gh/wp-content/uploads/2021/08/Ministry-of-Health-2021-APOW-6-July-2021-very-final-v2-1.pdf
Cash gifts okayed for government officials fighting Covid-19. The Nation Thailand. April 15, 2020. https://www.nationthailand.com/in-focus/30386099
Nittayasoot N, Suphanchaimat R, Namwat C, Dejburum P, Tangcharoensathien V. Public health policies and health-care workers' response to the COVID-19 pandemic, Thailand. Bull World Health Organ. 2021;99:312-318. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085624/
Margini F, Pattnaik A, Jordanwood T, Nakyanzi A, Byakika S. Uganda's Emergency Response to the COVID-19 Pandemic: A Case Study. Washington, DC: ThinkWell and Uganda Ministry of Health; 2020. Accessed December 1, 2022. https://thinkwell.global/wp-content/uploads/2020/09/Uganda-COVID-19-Case-Study-_18-Sept-20201.pdf
Sáenz Mdel R, Acosta M, Muiser J, Bermúdez JL. The health system of Costa Rica. Salud Publica Mex. 2011;53(suppl 2):S156-167. https://pubmed.ncbi.nlm.nih.gov/21877081/
Castillo A. C5i, el nuevo centro de inteligencia epidemiológica contra el COVID-19. Diario Libre. April 22, 2020. https://www.diariolibre.com/actualidad/c5i-el-nuevo-centro-de-inteligencia-epidemiologica-contra-el-covid-19-MC18386912
WHO Regional Office for Africa. SORMAS. Accessed February 13, 2023. https://innov.afro.who.int/emerging-technological-innovations/sormas-2045
Ungchusak K, Yingyong T, Ardkean W, et al. Chapter 9: Kingdom of Thailand: implementation of Thailand's SRRT (surveillance and rapid response team) for outbreak containment. In: Good Practices in Responding to Emerging Infectious Diseases: Experiences from the ASEAN Plus Three Countries. Accessed January 19, 2023. http://aseanplus3fetn.net/tree_cd_pdf/kingdomofthailand.pdf
World Health Organization (WHO). Joint Intra-Action Review of the Public Health Response to COVID-19 in Thailand. Geneva: WHO; 2020. Accessed January 19, 2023. https://www.who.int/publications/m/item/joint-intra-action-review-of-the-public health-response-to-covid-19-in-thailand