Promising practices: national, governmental, and population-level measures

Prior experience with epidemics and other public health emergencies encouraged the countries we examined to intervene in early 2020 to contain the spread of SARS-CoV-2. The public health and social measures they implemented included:

• Testing for diagnosis and detection
• Contact tracing
• Personal protective measures
• Risk communication
• Surveillance
• Vaccination

For example, Ghana’s COVID-19 response focused primarily on testing, tracing, and treating suspected cases and high-risk individuals (known as the “3T strategy”). However, officials also implemented many public health and social measures as part of the health system’s immediate response, such as border closures and suspending in-person classes across the education system. On March 30, 2020, officials established partial lockdowns in COVID-19 “hotspots,” mostly in Greater Accra and Greater Kumasi. They asked about 6 million people to stay home except to shop for essential goods (such as food, medicine, and water), visit public toilets, or go to the bank.³

In early 2020, Sri Lanka implemented a “zero-COVID” strategy with two prongs: 1) preventing the entry of the novel coronavirus via effective border security and 2) if any cases did slip through, acting aggressively to stop any local outbreaks by implementing strict contact tracing and isolation. The objective of this strategy was to prevent any local transmission of the virus so communities’ economic and social activity could resume behind protected borders. The figure below summarizes Sri Lanka’s zero-COVID strategy.

Sri Lanka’s strategy for eliminating COVID-19 at the population and patient levels

As shown in the chart below, each of the six countries in this analysis were often able to scale up testing capacity in response to surges in COVID-19 cases. Click on the country buttons below this visual to see how COVID-19 testing changed in response to surges in COVID-19 cases for each country.

Even before Uganda confirmed its first case of COVID-19 in March 2020, officials imposed a variety of public health and social measures, such as school closures and mobility restrictions.⁴ After COVID-19 was detected in Uganda, the country’s National COVID-19 Task Force (NTF) activated district task forces to coordinate subnational and local pandemic response activities such as surveillance, contact tracing, and isolation. The NTF’s response plan emphasized risk communication and community engagement to promote public health and social measures.

Robust vaccination efforts

In addition, several countries focused on the early procurement and rollout of vaccines when they became available. These countries vaccinated health workers first to support the health system, and then focused on delivering the vaccine to the broader population. Review the figure below to understand overall COVID-19 vaccination levels and the course of vaccine rollout in each country (note that COVID-19 vaccination coverage was not part of the country selection process for this work).

For instance, Costa Rica was one of the first countries in Latin America to launch a mass COVID-19 vaccination campaign and to achieve broad coverage for those eligible to be vaccinated. By December 2021, over 65% of the country’s population had received all doses of the vaccine.⁵ Community health workers (asistente técnico de atención primaria, or ATAPs) delivered many of these vaccines, especially to people living in rural and isolated areas.⁶ Private sector partners helped establish vaccination centers in places such as shopping centers and stadiums and donated key infrastructure such as refrigerated trucks for vaccine transport and distribution.⁷

Despite initial delays in the launch of Thailand’s COVID-19 vaccination campaign, the country rapidly rolled out the COVID-19 vaccine throughout the second half of 2021 and 2022. In June 2021, just 2% of the country’s population were fully vaccinated (received two vaccine doses) and by August 2022, over 75% of the country was fully vaccinated⁸. Vaccine rollout was aided by the Ministry of Public Health’s Mor Prom (Doctor’s Ready) app, which enabled users to make appointments for vaccination, track vaccine availability, and report side effects⁹.

When the Dominican Republic began its COVID-19 vaccination campaign in February 2021, officials leveraged existing immunization structures such as the Expanded Program on Immunizations to deliver vaccines nationwide. They also launched a digital platform (VacúnateRD/Get Vaccinated DR) to provide public information related to the COVID-19 vaccine, such as the location of vaccination centers.¹⁰ The private sector also played a key role in providing vaccination facilities and transporting vaccine doses.

In most of the positive outlier countries, strong partnerships between academia and government helped with data-driven decision-making, documentation, and policy translation during the first two years of the COVID-19 pandemic. Collaborations between local research entities and health decision-makers enabled the regular analysis of COVID-19 surveillance data and informed local and national guidance on public health and social measures.

For example, in March and April 2020, researchers at the Dominican Republic’s Technological Institute of Santo Domingo developed a predictive model for COVID-19’s epidemiological behavior, enabling ongoing case management, data analysis, and health planning. The country’s director of epidemiology used this model to manage the country’s COVID-19 response and reduce the burden of hospitalizations.¹¹

Uganda’s National Task Force established an interdisciplinary scientific advisory committee whose members—including researchers from Makerere University’s schools of public health, medicine, and statistics; the country’s Medical Research Council; and the Uganda Virus Research Institute—translated new and evolving data into evidence-based policies and strategies for pandemic response.¹²

All six countries demonstrated the importance of strong public–private partnerships for effective COVID-19 response and EHS maintenance. Private sector partners helped obtain personal protective equipment (PPE) such as masks, disinfectants, and other key supplies for health workers and vulnerable communities, which helped keep health workers and others safe from infection and enabled EHS delivery inside and outside of health facilities. Private sector partners also helped scale up national and local capacity for testing and vaccine delivery.

The Costa Rican Social Security Fund established temporary partnerships to expand drug service delivery when mobility was particularly restricted, to improve access to treatment for patients who could not visit a health center. In addition, Costa Rica’s Local Supply Initiative for Personal Protective Equipment (ALEPP), a collaboration between the Costa Rican Chamber of Commerce, the Costa Rican Social Security Fund, and academic institutions, helped essential workers procure key protective equipment.

ALEPP coordinated local supply chains to boost production of PPE; for example, it enabled Grupo Vargas, a manufacturer of packaging materials, to produce more than 600,000 plastic face shields for health workers.¹³

In Thailand, private companies sponsored the development of negative-pressure isolation rooms and intensive care units in public hospitals.¹⁴ Similarly, in Sri Lanka and several other countries of study, private laboratories partnered with the public sector to expand the country’s PCR testing capacity.

Five of the countries used contingency funds or other preexisting financing mechanisms to support emergency preparedness and response. These mechanisms allowed countries to deploy capital quickly to build or improve necessary infrastructure (such as infectious disease treatment facilities and quarantine centers), compensate health workers, obtain key testing supplies and vaccines, and provide social and economic support to vulnerable populations.

For instance, in 2016, officials in Costa Rica created a US$200 million contingency fund to prepare for natural disasters or health emergencies In 2020, this fund enabled rapid adaptation to the pandemic¹⁵ as officials used that emergency funding to hire (and pay overtime to) health workers, boost the physical capacity of existing health facilities, and equip a new specialized facility for COVID-19 patients (Centro Especializado de Atención de Pacientes con COVID-19, or CEACO) with ventilators and beds in the intensive care units.¹⁶

Thailand allocated funding from its central budget for overtime and risk compensation for health workers, vaccines, and costs associated with quarantine. Emergency loans from internal and external sources paid for the procurement of key supplies, vaccine research and development, and other pandemic-related expenses such as social and financial support for vulnerable populations.¹⁷ Thailand’s National Health Security Office, which manages the country’s universal health coverage program, also directed funding toward the country’s pandemic response. Because officials established a discretionary fund for COVID-19 response separate from the rest of the country’s health budget, funding for essential health service delivery remained stable throughout the pandemic, which helped with continuity of services.

Four of the countries expanded UHC or other preexisting funding schemes to improve access to COVID-19 care as well as EHS. The expansion of UHC schemes for low-income and vulnerable people (such as migrant workers) likewise boosted community health and well-being throughout the early phase of the pandemic.

For example, as a part of the country’s push to provide economic relief to those hit hardest by the pandemic financial downturn, the board of directors of Costa Rica’s Social Security Fund extended health insurance coverage to unemployed workers through the end of June 2021.

At the beginning of the COVID-19 pandemic, the Dominican Republic extended the national Family Health Insurance scheme, which protects unemployed people, informal workers, and workers who earn less than the minimum wage, to cover 2 million additional people (roughly 20% of the population). By December 2020, the Family Health Insurance scheme covered 96% of the population.¹⁸

As demonstrated in the figure below, research from the Institute for Health Metrics and Evaluation shows that all six countries experienced initial disruptions to routine immunization services during the COVID-19 pandemic, with recovery to previous levels by the end of 2020. The analysis uses DTP3 immunization rates as a proxy for the maintenance of essential health services. This indicator refers to the monthly number of doses of the diphtheria, tetanus, and pertussis vaccine given to children younger than one year of age. Click on the country buttons below this visual to see how DTP3 immunization rates changed in each country over the course of 2020.

To maintain access to routine immunizations and other EHS, five of the countries established policies prioritizing the delivery of EHS in 2020 and 2021. New guidelines and policies for service delivery focused on reducing exposure to COVID-19 in health facilities and limiting patient contact with health facilities altogether.

For example, Ghana’s Ministry of Health and Ghana Health Services kept health facilities open to all patients throughout the COVID-19 pandemic. They minimized transmission of the virus that causes COVID-19 by requiring extensive symptom screening at facility entrances, adopting an appointment system to minimize patient crowding, and enabling health workers to deliver essential services such as antenatal care and routine immunizations in patients’ homes. Health officials also developed guidelines for the care of people living with HIV in the COVID-19 context (delivering services via telemedicine, for example).

The Sri Lankan Ministry of Health took proactive measures to ensure the maintenance of maternal and child health services from the beginning of the COVID-19 pandemic, and officials specifically instructed all medical officers of health to keep their clinics open to deliver these services. Officials also issued guidelines for hospitals to expand the availability of Mithuru Piyasa, “friendly havens” in health facilities for survivors of gender-based violence.¹⁹

In April 2020, the Ugandan Ministry of Health established a committee focused on the continuity of EHS.²⁰ Members included Ministry of Health officials, district government representatives, public health authorities, and international partners such as UNICEF and WHO. The committee oversaw all efforts to maintain access to—and adapt service delivery for—EHS.