Promising practices: measures for health system adaptation

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

Number of healthcare workers recruited in Ghana in 2020

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.

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).

Total ICU bed occupancy rate in the Dominican Republic, November 2020 – June 2022

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.