Infrastructure, logistical organization, and governance required to ensure the effective delivery of quality health care.

The final component of the 4 S framework focuses on “systems,” or the infrastructural and logistical organization required to ensure the effective delivery of high-quality health care. Much has been written regarding the importance of health systems strengthening, especially in resource-limited settings that have been disproportionately neglected historically. Prior outbreaks, including the 2014 Ebola epidemic in West Africa, have also demonstrated the acute importance of prioritizing health system strengthening in the most vulnerable and resource-constrained communities.

Thus far, the COVID-19 pandemic has already placed HICs under unprecedented strain. This has only elevated concerns about the potentially catastrophic effects that COVID-19 could have on LMICs, which are already resource-limited at baseline. The acute threat that COVID-19 poses for chronically underfunded and fragile health systems could exacerbate the vulnerabilities faced in these settings. Nonetheless, the broader systems in place in these settings that have prioritized effective “containment” strategies have shown some promise, implementing lockdowns from Nigeria to Rwanda to South Africa. Further, initiatives such as the African Task Force for Coronavirus Preparedness and Response model have been adopted to provide a continental response to COVID-19, demonstrating the potential that a united front can improve collective capacity for diagnostics, cross-border activity policy, supply-chain management, and effective social distancing measures. Nonetheless, there is concerning evidence from a recent 182-country analysis that there is great variability in each country’s capacity and preparedness to prevent, detect, and respond to outbreaks in general, which something as acute and pervasive as COVID-19 will likely further unveil.

The following five cases help to elucidate lessons learned from prior public health crises, underscoring the need for continual investment in health system strengthening; unique adaptation of interventions into different social, cultural, and political environments; and prospects for stronger international collaborations to assure improved global readiness for pandemic threats such as COVID-19 and those to come.

Case Study #1: Cholera epidemic in Haiti

Haiti is the poorest country in the Western Hemisphere. It has the highest population density in the region and insufficient sanitation for many of its citizens. In 2010, this situation was exacerbated by the catastrophic earthquake and subsequent political crises. Consequently, the country’s health and economic infrastructures were devastated. One and a half million people lost their homes, leading to the construction of temporary sheltered camps with poor or no access to clean water. This is the context in which, nine months later, the cholera epidemic emerged.

On October 18, 2010, the Haitian Ministry of Health (MSPP) was notified of an alarmingly high number of cases of individuals with watery diarrhea. Fearing a cholera epidemic, Haitian investigators were sent to the area where they identified the first families affected, performed laboratory tests, and confirmed the causal agent to be a serotype of Vibrio cholerae.

The MSPP responded immediately to the situation. A surveillance system and other public health measures were established early on. New emergency treatment centers were established, with 95% testing rates resulting in a flattening of the mortality curve within 3 months of the first reported case. The last cholera case was reported in January 2019. The elimination of cholera in Haiti will be officially recognized by the World Health Organization if no new cases are declared within two more years. The lessons learnt during this cholera outbreak offer some guidance into public health interventions utilized during an epidemic in low-resource settings and may assist in the fight against COVID-19.

Battling cholera in Haiti was a significant public health challenge due to a variety of contextual constraints. Clean drinking water, proper handwashing and practicing hygienic defecation were key to stopping the spread of the disease. However, approximately half of the Haitian population did not have access to clean water or proper sanitary installations. The Haitian government and partners understood that it would be ineffective to ask the population to use resources they were unable to access and that providing access to these basic services was an essential component of the overall response to the epidemic. They organized an education campaign on water and sanitation coupled with distribution of chlorine water purification tablets. In addition, a task force including NGOs and government, under the leadership of the local National Department of Drinking Water and Sanitation, was established to increase access to clean water and sanitation. Although numerous international investments were pledged, many did not come to fruition which further complicated efforts to combat the spread.

The cholera epidemic in Haiti highlights the necessity for governments and partners to provide investments during this time of COVID-19 and beyond that assure essential, basic needs are met and individuals have improved agency to follow public health recommendations. As was highlighted in this cholera case study, each country must take into consideration specific challenges related to the local context, which may require going beyond the standard recommendations and the need for adaptation.

Case Study #2: HIV in Malawi

Malawi is one of the 25 poorest countries in the world and has high HIV seroprevalence (9.2% in 2018). In the 30 years following the first case of HIV confirmed in 1985, nearly 850,000 Malawians died of AIDS. At the peak of the epidemic in the 1990s and early 2000s, the government of Malawi mobilized domestic and international partnerships and implemented its first National HIV and AIDS Policy in 2003, which mandated its National AIDS Commission to administer a multisectoral “public health-based response that integrates principles of prevention, treatment, care, support, and impact mitigation as mutually reinforcing elements of a comprehensive response to HIV/AIDS."

Despite these commitments, the epidemic claimed many lives, hampering human capacity, agricultural productivity, and economic development in the country. Consequently, the national HIV response in Malawi was crippled by critical workforce shortages, inadequate health facilities, and poverty. With fewer than 200 physicians nationwide, the health system relied heavily on non-physician cadres like Health Surveillance Assistants (HSAs, similar to CHWs), Nurses and Midwives, and Clinical Officers. Thus, the national program remained predominantly donor-funded.

Through incremental policies to strengthen its public health infrastructure, Malawi's Ministry of Health began to decentralize its antiretroviral treatment (ART) programs in 2004 and scale up into a coordinated national response, which enabled more efficient HIV testing, counseling, and treatment in accordance with World Health Organization (WHO) guidelines. These initiatives reduced and stabilized adult HIV prevalence (16% at peak and 10.6% in 2010), although disease burden remained higher in women (13%) than in men (8%).

Still, Malawi operated an independent prevention of mother-to-child transmission (PMTCT) program, which objectively lagged far behind the ART program. PMTCT in Malawi and many high-burden LMICs suffered poor patient enrollment, high attrition rates, and logistical inefficiencies despite increased resource allocations. Complex WHO guidelines made PMTCT much more challenging compared to the simplified regimens available in HICs. Acknowledging the realities of its failing PMTCT program and incorporating lessons from the relative success of the ART program, Malawi pioneered a pragmatic and progressive modification to the WHO guideline for PMTCT in 2010 by recommending voluntary lifelong HIV treatment for all HIV-positive pregnant and breastfeeding women as a means to prevent new infections in a high-fertility LMIC (Option B+). They integrated PMTCT into the ART program, integrated antenatal and ART data into a unified registry, and scaled up logistics and supply chain systems to allow access in remote communities. To address human resource needs, the new Option B+ PMTCT/ART program adopted task-shifting initiatives, which trained and allowed HSAs to perform testing and simple laboratory testing in antenatal clinics. Additionally, the Ministry of Health formulated new national HIV treatment guidelines to integrate all aspects of testing, treatment, counseling, and mental health services. This new regimen was highly successful, leading the WHO to recommend Malawi’s Option B+ in their subsequent guidelines.

While HIV remains highly prevalent in Malawi, this feat in the global HIV narrative highlights several systems-level health delivery lessons for today’s COVID-19 and other emerging public health threats. The challenges revealed by the global COVID-19 pandemic, like availability of test kits, PPE, staff shortages, and economic disruptions, have the potential to be exacerbated in resource-limited settings such as Malawi. However, the HIV response in Malawi serves as a concrete reminder for how public health strengthening with data-driven initiatives, flexible human resource management and task shifting, and coordinated and decentralized logistics can help to mitigate the burden of suffering.

Case Study #3: Ebola in the Democratic Republic of Congo

The Democratic Republic of Congo (DRC) is a large African state bordered by central, eastern, and southern African states. Although the DRC is home to vast arable lands and numerous minerals, it ranks among the poorest countries in the world. The roots of this incongruence can be traced back to its colonial history. The DRC was first colonized as a personal estate of the Belgian crown, King Leopold, among the starkest examples of colonial extraction. Despite achieving independence in 1960, the DRC had never known a democratic transition until 2019. The Congolese people had grown up in a country with USD $24 trillion worth of untapped resources but with most of them living on less than USD $2 per day. There was optimism within the country about the anticipated democratic transition. However, in 2018, an Ebola outbreak began in the eastern regions of the DRC. After consulting with international partners and public health experts, the government decided against including the regions affected by Ebola in the much-anticipated nationwide vote. This decision, although reasonable from a public health standpoint, meant that over one million Congolese could not participate in choosing their president. Importantly, these regions were loyal to one of the opposition candidates, Martin Fayulu. When Martin Fayulu lost the election, as expected, people cried foul play. What ensued was political and medical anarchy. Locals accused Ebola response teams of being part of a conspiracy. The instability laid the ground for attacks on Ebola outposts and members of the response team.

As a lesson for the current COVID-19 outbreak, it is imperative to take into consideration the social, economic, and political reasons for which some members of the public might not be willing nor able to abide by national public health recommendations. At the same time, it is important to uphold the public’s ability to continue to participate in political decision-making. Government policies related to the pandemic must be informed by the socioeconomic, political, and cultural context in which they are implemented.

Case Study #4: Diversion of Health System Resources, Ebola in West Africa

It is important to also consider the downstream health effects of social distancing efforts during a pandemic. One poignant example is the increase in maternal mortality that was seen both during and after the 2014 Ebola crisis that promulgated throughout West Africa. A study in Liberia found a 50% decrease in antenatal care access and a 33% decrease in reported deliveries, as well as a significant decrease in deliveries and Cesarean sections done by skilled birth attendants. Healthcare facilities diverted resources to fighting Ebola and women avoided them due to the Ebola risk. A similar study in Sierra Leone, a country with the world’s highest maternal mortality ratio, also showed decreases in antenatal services, postnatal visits, and healthcare facility-based births, along with a 34% increase in maternal mortality for those who gave birth at healthcare facilities. Overall, throughout the Ebola epidemic, fewer women accessed healthcare facilities, and the women who did also experienced higher rates of mortality. This does not account for the increase in maternal mortality due to the increase in home births. Countries with high baseline maternal mortality ratios also experienced some of the worst increases in maternal mortality, perpetuating existing patterns of systemic injustice.

In HICs, where a high proportion of deliveries are conducted at healthcare facilities, the COVID-19 pandemic is likely to lead to an unprecedented shift in presentations. With emerging hospital policies preventing partners from attending births and the significant fear around being at healthcare facilities, we may see a rise in home births, including amongst women who may live too far from a healthcare facility should they encounter an emergency at home. It is important that we learn from the challenges faced by women and the healthcare system during the Ebola crisis and work to prevent a devastating increase in maternal mortality during the COVID-19 pandemic. Additionally, we must think creatively about the challenges the many overburdened healthcare systems around the world are encountering, not just in caring for COVID-19 patients, but all patients.

Case Study #5: Supply Chains

As has been suggested throughout this curriculum, there is a wealth of media coverage, hospital policy changes, and national debate regarding the lack of the medical necessities (e.g. PPE, tests, hospital beds, ventilators) required to combat a pandemic of this nature. While many of these reports focus on the “stuff” in the 4 S framework, the supply chain required to produce and distribute this “stuff” requires a “systems”-level focus. Why are medical systems not able to get the “stuff” that they need? The root of the problem is often a weakness in the supply chain, or the sequence of processes involved in the production and distribution of a commodity.

In the US, supply chain weaknesses have manifested in a number of ways; masks and hospital beds are two examples. With masks, most manufacturing was moved abroad, largely to China, over two decades ago to decrease costs of production. As long as predictions for demand were accurate (e.g., projections on cases of influenza per year, number of procedures over a specific time frame) this move appeared to be a prudent business decision. However, such a supply chain has broken down in crisis. In China, where the pandemic hit first, mask production was slowed, and they also needed to preserve more of this locally-produced supply amidst the crisis. There were additional political tensions surrounding trade that further complicated the supply chain of masks. Factories in the US are being converted to mask production, but there will be a delay to convert operations before mass production is possible.

The shortfall in surge capacity arises not only from spread-out manufacturing but also from deliberate limitations to hospital capacity. The number of hospital beds in the U.S. has decreased by about half a million over the last 50 years. One aspect leading to decreasing beds has been medical or surgical improvements that shortened hospital stays, but it also involved regulations on the ‘business of healthcare.’ More beds usually meant more income for hospitals, so there was increasing governmental regulation. Hospitals now often function at ~95% capacity, especially during influenza season. While decreasing beds may help to decrease costs, it can also negatively impact the ability of a city, state, or country to respond, especially when local surge capacity plans fail to adequately estimate the demand that a pandemic of this nature may require. In Brazil, for example, the medical supply chain is facing significant challenges during this pandemic. Initially, according to the Health Minister, some state-imposed quarantine measurements prevented transportation of essential medical supplies, including oxygen. Subsequently, the government ensured that airports and main highways remained open to deliver and distribute medications, products, and supplies. Like most countries, Brazil is also facing high demand for PPE and other products, and international supply chains are becoming more expensive given high global demand. Thus, many national industries are changing their production lines to make PPE and medical products. For example, a Brazilian brewing company will make more than 3 million face shields and 1 million units of alcohol gel. Vehicle or plane assembly companies, paper companies, and a technology company organized themselves to produce ventilators in a large-scale collaboration project. Hospitals are creating crowdfunding to buy the appropriate materials and products. Also, universities are working together to produce better, fast, and/or low-cost tests, masks, and ventilators. At the same time, they are producing alcohol gel and test kits. Makerspaces and engineers are working together to print 3D materials to fix hospital equipment. Companies, investors and associations also united to congregate different solutions in one place and to make it easy to donate, help, ask for help, and share on social media.

Supply chain challenges are likely to continue for the duration of the pandemic. While they have affected HICs profoundly, LMICs are likely to face equal or greater challenges. When bidding becomes internationally competitive, those with the most money are likely to win the needed supplies. Internationally, the U.S. has already been accused of out-bidding its allies, including Brazil, France, and Germany. This bidding war is also happening inside the U.S. as states compete against each other and the federal government for the same PPE supplies, raising concerns that wealthier states will fare better than smaller, poorer states. Challenges with supply chains are likely to continue for months and will encompass the availability of PPE, ventilators, test kits, and vaccines. They will continue to play a key role in the COVID-19 pandemic, and will likely determine who gets essential resources and who does not.

Thought Questions:

  • How could the U.S. and Brazil change their supply chains to be better prepared for a pandemic in the future?

  • If you were in the government, what regulations would you put on the make-shift supply chains of essential medical supplies to ensure their quality?

In summary, these diverse systems-level case studies illuminate lessons from prior epidemics. They emphasize the importance of considering the political, economic, and social history within a setting that affects a health system’s ability to function and a government’s ability to govern in the setting of an outbreak. They further provide examples of how systems – such as robust supply chains – are needed for the current crisis and beyond. Looking ahead, it is promising that innovations exist not only to educate individuals, but also to provide the support needed to implement acquired knowledge. As COVID-19 continues to evolve, there will be important systems-level lessons to learn, including the tradeoffs between a more centralized versus decentralized approach to implementation and the tradeoff between individual rights and public health measures.

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