A checklist to improve health system resilience to infectious disease outbreaks and natural hazards

Introduction

The ongoing COVID-19 pandemic has demonstrated the critical importance of resilient health systems in safeguarding global health security. In China, where the pandemic was first reported, for example, the health system was severely overwhelmed by the combination of a large surge of patients seeking care for respiratory symptoms and for other routine healthcare needs and reported lack of sufficient space, supplies and staff to treat patients. Additionally, over 90 000 health workers have reportedly been infected,1 and one study found that nosocomial transmission was suspected in 41% of patients with confirmed severe acute respiratory syndrome coronavirus 2 infection.2 The dynamics of this ongoing outbreak exemplify the importance of strengthening health systems to improve outbreak preparedness, response and recovery, a sentiment that has been echoed by the WHO’s Director General.

Unfortunately, this is not the first outbreak that has highlighted the role that vulnerable health systems can play in public health emergencies. Despite the ongoing outbreak of Ebola in the Democratic Republic of Congo occurring in a country with demonstrated expertise in controlling past Ebola outbreaks and widespread use of a candidate vaccine, to date approximately 5% of cases have occurred among healthcare workers3 and WHO has noted that healthcare facilities are serving as important drivers of disease transmission. Importantly, in both the Ebola and COVID-19 outbreaks, the human, economic and political tolls of these crises are being amplified by health systems’ inabilities to respond quickly and effectively.

Improving resilience within health systems can build on pre-existing strengths to enhance the readiness of health system actors to respond to crises, while also maintaining core functions. However, the notion of resilience has been the subject of much debate and the literature on this subject remains largely at the conceptual level. For example, a recent review found that more work is needed to translate the concept of ‘health systems resilience’ into specific capacities and capabilities that health systems actors, such as health facilities, need to take to be ready for infectious disease outbreaks and other public health emergencies.4 Another found that lack of detail around the conceptualisation of health system resilience ‘hinders the expansion of knowledge, the creation of reliable analytical tools and the effectiveness of communication’.5 However, efforts to better define the concept, such as the work done by Abimbola and Topp, can help ensure a ‘common understanding of the meaning of resilience’ and help facilitate working towards common goals.6

Following the 2014–16 Ebola epidemic in West Africa, WHO developed a framework to help measure country progress towards reaching the International Health Regulations (IHR, 2005) target that each country has the capacity to prevent, detect and respond to public health emergencies.7 The WHO Joint External Evaluation (JEE) process and the results of these assessments have since been adopted by >100 countries and are now being used to gauge global readiness for significant infectious disease outbreaks and other public health emergencies.8 While the JEE assesses several public health capacities critical to health security, including laboratory biosafety practices, national laboratory systems and antimicrobial resistance, it does not assess many of the capacities and capabilities necessary for health system preparedness and response.4 Health systems play a direct and invaluable role in supporting countries’ ability to respond quickly and efficiently to infectious disease outbreaks, including disease surveillance, detection and care of infected patients; they also play critical roles in mitigating the health impacts of other public health emergencies such as natural disasters and man-made catastrophes. Thus, it is critical that a health system’s readiness for these events is also considered as countries strive to assess their overall preparedness. However, frameworks or tools that comprehensively identify the health system capacities and capabilities required for effective outbreak preparedness and response; define the roles and responsibilities of key health system stakeholders, such as health facilities and health service delivery organisations and articulate actionable steps for enhancing health system resilience have not yet been developed.4 As a result, countries that undergo a JEE without also taking steps to more explicitly evaluate their health systems do not actually have a comprehensive assessment of their readiness for potential public health emergencies.

Using data gathered from a scoping literature review, interviews with key informants and stakeholders who attended a workshop held in Dhaka, Bangladesh, we developed a Health System Resilience Checklist (‘the checklist’) to be used by health facilities, health services delivery organisations and national governmental health authorities. The aim of the checklist is to help operationalise the concept of health systems resilience by allowing health system actors to measure the specific capacities and processes needed in order to ensure resilience in the face of both infectious disease outbreaks and natural hazards. The checklist is intended to be adapted and used in a broad set of countries as a component of ongoing processes to ensure that health actors, institutions and populations can mount an effective response to infectious disease outbreaks and natural hazards while also maintaining core healthcare services. However, additional research will need to be conducted to further refine and validate the checklist. The checklist is modelled in part after prior work to define health system resilience within the US domestic context.9 10

Methods

Findings

The final Health Systems Resilience Checklist is presented in online supplementary table 1. The checklist is meant to identify those capacities and capabilities necessary for health system resilience to infectious disease outbreaks as well as natural hazards. We focus consideration on infectious disease outbreaks that can have significant impacts on the functioning of a health system, including high-consequence infectious diseases, which require complex medical management and special infection control considerations for specific medical procedures (eg, aerosol-creating procedures like placement of central lines and intubation). For example, this would include outbreaks of viral haemorrhagic fevers such as Ebola and Lassa.

The checklist is divided into 10 thematic categories which were informed and refined by the scoping literature review,4 key informant interviews and pilot workshop checklist validation exercise. No thematic categories were added or removed by participants during the validation exercise. Each thematic category is accompanied by a list of specific capacities and capabilities (ie, ‘checklist items’) that were identified as important to achieving resilience within the larger theme. In total, only three checklist items were removed by working group members, as those were not viewed to be important for health system resilience within the context of Bangladesh’s health system. Forty checklist items were kept as originally written, and 53 were either modified or added.

The 10 thematic categories and their descriptions are:

1. Core health system capacities and capabilities: the capacities and capabilities needed to maintain core functioning during a public health emergency, such as access to maternal-child care.

2. Critical infrastructure and transportation: the infrastructure (eg, water, sanitation) and transportation that must be in place to ensure continued functioning during an emergency.

3. Financing: the presence of adequate resources to both maintain routine services and to respond to public health crisis.

4. Barriers to accessing health services: barriers that exist that might prevent individuals from accessing care routinely and during public health emergencies.

5. Communication, collaboration, coordination and partnerships: relationships that exist with response partners before and during a public health emergency.

6. Leadership and command structure: the leadership, command and incident management structures and policies needed to respond to a public health crisis.

7. Surge capacity: policies, practices and systems necessary to accommodate a surge of patients during a public health emergency.

8. Risk communication: policies and practices for communicating and engaging with the public about public health emergencies.

9. Workforce: the health workforce and associated capacities and capabilities, including training and support, needed to respond to a public health emergency.

10. Infection control: the infection control processes and procedures needed to prevent spread of disease and screen and treat patients within facilities.

The checklist items identified within each theme are divided up by the actor typically responsible for a given checklist item in most settings. For the purposes of this checklist, we identified two specific actor categories:

1. Facility-level actors: these include individual health facilities, such as clinics and hospitals, as well as larger health system networks and healthcare organisations.

2. Health official-level actors: these include provincial, regional or national-level health officials, such as ministries of health.

For some of the checklist items, there are actions necessary at both the facility and health official level. However, for others, there may not be a corresponding action for each actor.

The checklist items are phrased as statements such that users can use a Likert scale to indicate whether they believe a given capacity currently exists within their facility or institution (ie, 0=disagree, 1=somewhat agree, 2=strongly agree). The checklist also contains a column of suggested resources (see online supplementary appendix A for full citations of resources) that might help users better develop a given capacity or capability. The resources were identified through the data collection process and through prior knowledge of the research team. While many of the checklist items include the drafting or existence of plans, protocols or systems, it is also expected that these protocols or plans have been disseminated to the appropriate individuals who might need them during a public health emergency, and that all requisite personnel have been trained on how to use a given system. Finally, the checklist has been tiered according to how advanced a given capacity or capability is, based on the experience of the research team. The most feasible, fundamental core capacities/capabilities necessary for resilience are tiered as a 1, followed by tiers 2 and 3, which identify more advanced capacities/capabilities necessary for resilience. The tiers are presented in parenthesis next to the associated checklist item, but additional research will be needed to refine these tiers with experts working in health system development.

During the second workshop session, participants were asked to prioritise each of the checklist items (5=highest priority, 1=lowest priority). Those designated as a 4 or 5 meant that development of that checklist item(s) should be prioritised. Online supplementary table 2 presents the average and median score for each of the checklist items. Only eight of the checklist items had an average score of <4. The checklist items starred by two or more of the small working groups as highest priority for health system resilience are provided in table 1. Importantly, there was consistency among the four smaller working groups in both prioritisation scores and in which checklist items were starred as highest priority.

Discussion

Resilient health systems are important for supporting response efforts during an infectious disease outbreak or natural hazard, and help ensure the continued delivery of routine services needed by the community in non-emergency periods. However, health systems cannot achieve resilience without first identifying what capacities and capabilities are necessary to respond to these threats. We have created a health systems resilience checklist as a critical first step in advancing health system preparedness beyond just descriptions of high-level attributes to define specific capacities and capabilities. We recognise that many of the checklist items will require significant investments, including time, money and personnel, and are an enormous undertaking for most institutions. However, we hope the checklist will help ignite the strategic planning processes necessary for improving health system resilience to infectious disease outbreaks and natural hazards for the long-term.

One of the goals of our work to develop the checklist was to determine the extent to which efforts to advance health security address foundational work in health systems strengthening. To advance health security, it will be essential that existing efforts to ready countries is linked with health system-strengthening efforts. This approach could help strengthen foundational health system capacities and capabilities that are also needed to support public health responses to crises. Similarly, efforts to strengthen health systems can be significantly undermined if they do not adequately plan for potential crises such as infectious disease outbreaks and natural hazards.

The WHO’s JEE process has helped to motivate progress towards measurement of countries’ capacity to prevent, detect and respond to public health threats. Since 2016, it has been implemented in over 100 countries, with many more planning on completing one in the next few years. Despite this important progress, a previous review determined that the JEE tool does not adequately address capacities and capabilities specific to health systems,4 leaving a gap in its overall ability to measure global health security. Consequently, countries that undergo a JEE and make improvements based on their JEE results could remain unprepared for public health emergencies if they have not also adequately assessed the readiness of health facilities and other components of the broader health system.

Although events like the ongoing COVID-19 and Ebola crises illustrate the interconnectedness between health systems strengthening and health security, there is little overlap between programmatic efforts to advance health security and to strengthen health systems. In addition to a lack of inclusion of health systems perspectives within the JEE tool, often health system strengthening experts are largely unaware of the JEE process and other ongoing efforts to advance global health security. This lack of mutual awareness results in missed opportunities to build on the achievements of both disciplines to advance health system resilience.

The key to advancing health systems resilience will be to assess the extent to which health systems have the capacities and capabilities needed to respond to emergencies while also maintaining other routine services, that, if neglected, could lead to increased morbidity and mortality. This checklist represents the beginning of a process to define the specific capacities and capabilities that health systems require to be resilient in the face of infectious disease outbreaks and natural hazards. In developing this checklist, we aimed to advance thinking about health systems resilience beyond basic definitions of high-level attributes of resilient systems to imagining processes for transforming public health practice at the administrative, governmental and health facility levels. Additional workshops will be needed, including with frontline healthcare providers, to further refine and validate the checklist. Conducting similar workshops in other countries will also be necessary to assess the checklist’s adaptability across multiple country contexts.

Although the checklist includes some guidance for implementation, several of the recommended activities may still be quite challenging for health systems to execute and will likely require additional guidance and technical support, such as allocation of scarce resources during an emergency—an ethically fraught issue for health system stakeholders to address. As a practical matter, the feasibility of implementing each item will differ across various locations and contexts; even so, the checklist can still serve as a starting point for the development of more contextualised local action plans.

Finally, countries cannot build and maintain these capacities and capabilities without also addressing the structural, economical and political barriers that have hindered the development of resilient health systems across the globe. This includes, among many others, ensuring that all individuals have access to healthcare services12 and identifying and addressing social determinants of health.13 By addressing these fundamental gaps, countries can enhance the health system infrastructure that will be critical to operationalising this checklist and strengthening global health security.

Conclusions

Resilient health systems are critical to enabling robust responses to outbreaks and natural hazards while also sustaining baseline functions. The development of this checklist is an important first step in improving health system resilience to such threats, but additional research and resources will be necessary to further refine and prioritise the checklist items, and to pilot the checklist with frontline health facilities. This will help ensure its feasibility and durability for the long-term within the health systems-strengthening and health security fields.