Anna Koziel • Ha Thi Hong Nguyen • Alejandro Gonzalez-Aquines A way forward for building resilient health systems Lessons learned from Eastern Europe and the South Caucasus A way forward for building RESILIENT HEALTH SYSTEMS © 2023 International Bank for This work is a product of the staff of the World Bank with external contri- Reconstruction and Development / butions. The findings, interpretations, and conclusions expressed in this The World Bank work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. 1818 H Street NW, Washington DC 20433 This publication was produced with financial support from the European Telephone: 202-473-1000 Union. Its contents are the sole responsibility of World Bank staff and do Internet: www.worldbank.org not necessarily reflect the views of the European Union. The World Bank does not guarantee the accuracy of the data included in Rights and Permissions this work. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. ii A way forward for building RESILIENT HEALTH SYSTEMS Table of Contents Acknowledgements v Abbreviations vi Introduction 1 About this report 1 Defining health system resilience 2 Health system resilience in the five countries 5 Health systems’ baseline characteristics and preparedness for shocks 5 Lessons from the countries’ responses to the COVID-19 pandemic 8 Going forward: key areas for building strong and resilient health systems 12 Conclusions 19 References 20 Annex: Summary of case studies 23 Armenia 23 Azerbaijan 25 Georgia 27 Moldova 29 Ukraine (pre-war) 30 iii A way forward for building RESILIENT HEALTH SYSTEMS List of Figures: Figure 1: Resilience framework 2 Figure 2: Trend of new COVID-19 cases, deaths, and excess 4 mortality Figure 3: Universal Health Coverage Index in 2019 5 Figure 4: Change in nurses/midwives and doctors per capita 6 between 2000 and 2020 Figure 5: Global Health Security Index in 2019 7 Figure 6: Cross-sectoral approach for the pandemic response in 9 Azerbaijan Figure 7: Change in proportion of women who completed 8 11 antenatal visits in Georgia Figure 8: Action cycle of the Human Resources for Health (HRH) 15 Action Framework Figure 9: Digital technologies drive the health and care paradigm 18 Figure 10: Key public health indicators for Armenia 23 Figure 11: Key public health indicators for Azerbaijan 25 Figure 12: Key public health indicators for Georgia 27 Figure 13: Key public health indicators for Moldova 29 Figure 14: Key public health indicators for Ukraine 30 iv A way forward for building RESILIENT HEALTH SYSTEMS Acknowledgements This report was prepared by Anna Koziel (Senior Health Specialist), Ha Thi Hong Nguyen (Senior Health Specialist) and Alejandro Gonzalez-Aquines (Consultant), supported by Jamele Rigolini (Lead Economist) leading the regional work on resilience for the Eastern Partnership countries, under the guidance of Tania Dmytraczenko (Practice Manager for Europe and Central Asia within Health, Nutrition and Population) and Fadia Saadah (Regional Director for Europe and Central Asia, across Human Develop- ment). Inputs to the country cases were provided with the support from the World Bank team: Olena Doroshenko, Elvira Anadolu, Parviz Ahmadov, Yoshini Naomi Rupasinghe, Adanna Deborah Ugochi Chukwuma, Volkan Cetinkaya, Christine Lao Pena, Nino Moroshkina, Ahmet Levent Yener and Caryn Bredenkamp. The team is grateful for the peer review and guidance provided by Mersedeh Tariverdi. This work is a product of the staff of the World Bank with external contri- butions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colours, denominations, and other infor- mation presented or shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. The note was made possible by the funding from DG NEAR’s Europe 2020 Trust Fund. Its contents are the sole responsibility of World Bank staff and do not necessarily reflect the views of the European Union. v A way forward for building RESILIENT HEALTH SYSTEMS Abbreviations ECA Europe and Central Asia EU European Union GHWA Global Health Workforce Alliance HRH Human Resources for Health IHISA Integrated Health Information System of Armenia MIDAS Medical Institution Data Analysis System NHIC National Health Insurance Company OECD Organisation for Economic Co-operation and Development OOP Out-of-pocket PHC Primary health care SAGE Scientific Advisory Group for Emergencies UHC Universal Health Coverage UNFPA United Nations Population Fund WHO World Health Organization vi A way forward for building RESILIENT HEALTH SYSTEMS Introduction The COVID-19 pandemic brought unprecedented an opportunity to reflect on the countries’ responses challenges to governments and health systems and identify lessons that can be learned to improve worldwide. After being identified in Wuhan, China, health systems. These lessons are useful not only for the SARS-COV-2 virus spread rapidly across borders shocks of the magnitude of this pandemic, but also and was declared a pandemic on March 11, 2020.1 for local and regional shocks that require health sys- Governments began to act using the best avail- tems to meet the population’s health care needs in able resources and evidence to reduce the spread the midst of everyday challenges. of the virus and protect the population from severe illness due to COVID-19 infection. As the pandemic developed, governments were tested on building About this report and maintaining good communication channels and trust with the public to ensure effective strat- This report looks at resilience through national health egies to control the virus. At the same time, health system lenses, and provides lessons to strengthen systems were placed at the center of the response, health systems for future shocks. The findings are in most cases leading multisectoral groups to coor- based on case studies from five countries in Eastern dinate actions to increase the system capacity and Europe and the South Caucasus (Armenia, Azerbai- cope with the surging demand for health care. jan, Georgia, Moldova and Ukraine), as well as focus group discussions with the population and health Health systems implemented changes at all health care workers in Georgia, Armenia, and Moldova. The care levels to meet public health needs, including following section provides the definition and exam- governance functions and pathways of care. The ples of health system resilience. This is followed by virus’ rapid mutation led to multiple waves of cases descriptions of the baseline characteristics of the and deaths due to COVID-19. Health needs were five Eastern European and South Caucasus coun- constantly changing, not only because of the rise of tries’ health systems pre-pandemic performance, people requiring specialized care, such as supple- which determined most of their capacity and deci- mentary oxygen or ventilation support, but also due sions to deal with the shock. The rest of this report to disruption to essential and programmed health reviews key baseline characteristics of the health care. Therefore, some countries decided to modify systems in the countries, which are followed by les- their governance functions by decentralizing or (re) sons from the countries’ responses to the pandemic centralizing health functions (that is, surveillance (a summary of each country case study is provided and response coordination). Similarly, care path- in Annex A). The report concludes with recommen- ways were also adapted to increase the efficiency dations for building the strong and resilient health of the system’s resources. For instance, hotels were systems needed to protect human capital through used as COVID-19 centers for non-severe cases, shocks and crises. and health care staff (that is, physiotherapists and dentists) were trained to become involved in COV- ID-19-related care, such as vaccinations.2 Health system resilience continues to be tested as countries face new crises. The countries’ efforts to handle the challenges brought about by the pan- demic have placed resilience at the center of the health system agenda. Resilience is now being tested by new challenges, such as the direct and indirect consequences of the war in Ukraine, and will be tested in the future as further shocks emerge. As countries continue to build stronger and more resil- ient health systems, the COVID-19 pandemic brings 1 WHO, 2020 1 2 Sagan et al., 2021 A way forward for building RESILIENT HEALTH SYSTEMS Defining health system resilience The definition of resilience in the health sector has The initial assessments were performed using a silos evolved based on countries’ experiences of deal- approach to health system building blocks. How- ing with shocks. The concept of resilience has been ever, the rapid changes and persistent progress of adopted from physical science, which defines resil- the pandemic demanded a more dynamic and col- ience as capacity to adapt after a disturbance.3 Over laborative approach. Countries were obliged to learn the last two decades, the concept of resilience in from the emerging evidence to respond, adapt and health systems has been defined after economic build back better, to reduce the burden of the pan- and humanitarian crises, natural disasters and, more demic and protect lives and human capital (Box 1). recently, disease outbreaks. The Ebola outbreak underscored the concept of resilience, resulting in The pandemic also brought to the forefront the it being considered an essential feature of health long-neglected importance of public health for systems. Kruk et al. (2015) provided a definition of ensuring health system resilience. Not surprisingly, health system resilience that has since prevailed in the World Health Organization (WHO) outlined ele- the literature: “the capacity of health actors, institu- ments in health systems that play a fundamental tions, and populations to prepare for and effectively role in building resilience, all of them strongly related respond to crises; maintain core functions when a to public health, such as investing in essential public crisis hits; and, informed by lessons learned during health functions (Box 2), building a strong primary the crisis, reorganize if conditions require it.”4 In other health care foundation, investing in institutionalized words, health system resilience can be achieved mechanisms for whole-of-society engagement, when the health system’s functions of financing, increasing domestic and global investment in health information, delivery, and design and institutional system foundations and all-hazards emergency risk arrangements – including health governance – are management, addressing pre-existing inequities.5 prepared to respond, adapt and build back better Moreover, the WHO highlights the need to increase from a crisis (Figure 1). investments in public health functions to strengthen their performance during normal times and prepar- The COVID-19 pandemic put health systems resil- edness for shocks. ience in the spotlight, providing countries with emerging evidence for better preparedness and Learning from countries’ responses to COVID-19 is response to shocks. Over half the literature on eval- pivotal to protecting human capital in the event of uating and building health system resilience has shocks and crises. The responses of the five Eastern been produced since the onset of the pandemic. European and South Caucasus countries (Arme- Figure 1: Resilience framework Financing Ability to finance rapid expansion of emergency and response programs Governance and Design PREPARE Clear Governance structure in place within and across sectors to respond to crises Data and Information RESPOND Program and response designs adequately cover all Ability to identify rapidly magnitude and impacts of ADAPT population groups & BUILD BACK Balance of programs across territory and population Ability to monitor and evaluate quality of response BETTER groups Presence of feedback loops from monitoring & evaluation of responses to design and implementation changes Delivery Adequate tools (software, equipment and infrastructure) to respond to shocks and crises Performing of regular drills and contingency planning exercises 3 Norris et al., 2008 2 4 Kruk et al., 2015 5 WHO, 2021 A way forward for building RESILIENT HEALTH SYSTEMS Box 1. Health system resilience in the United Kingdom and Italy Italy and the United Kingdom were two of the most affected countries in Western Europe, with death tolls of 2,657.7 and 2,521.03 per million population, respectively, higher than Germany (1,576.23) or the Netherlands (1,239.32). The main reasons for the disproportionate number of deaths compared to other Western European peers were the delay in implementing control measures, not suspending massive events, the high proportion of elderly persons in the population, and the lack of appropriate infrastructure and health care personnel. However, evidence generated from the initial response and the international experience of dealing with COVID-19 enabled improvements to control of the spread of the virus over the next waves. The measures included the following. Effective political leadership and cross-party consensus. Leadership played a critical role in the response to the pandemic. Decisions such as implementing lockdowns or mobility restrictions were usually criticized and opposed by certain political parties. In the United Kingdom, the implementation of the All-Part Group on Coro- navirus facilitated discussion and agreement on the pandemic’s response. Strengthening monitoring systems. Both countries have developed robust monitoring systems with weekly reports on the number of cases and deaths due to COVID-19. Moreover, the United Kingdom collected data on ethnicity and immigration status, enabling comprehensive analysis of the impact of the pandemic on minority groups. Implementing scientific advisory groups to make evidence-based decisions. The United Kingdom used its already existing Scientific Advisory Group for Emergencies (SAGE) to evaluate the emerging evidence and trans- fer the information to policymakers and the public. On the other hand, Italy established a new expert advisory group during the COVID-19 pandemic. Ensuring enough and stable funds. The Government of the United Kingdom mobilized funding from both unearmarked and earmarked resources to ensure adequate funding for the COVID-19 response. Another mech- anism implemented by the governments of Italy and the United Kingdom was selling bonds. Implementing flexible approaches to using the health workforce. Innovations in skill-mixing enabled the United Kingdom and Italy to increase their capacity to conduct public health interventions. For instance, dentists with sedation skills supported the National Health Service during COVID-19 surges in the United Kingdom, and members of the public were trained to administer vaccines or assist in vaccination programs. In Italy, volunteers were recruited to support the delivery of medication and food to vulnerable groups and those self-isolating. Developing efficient vaccination programs. By mid-2021, the European Union (EU) had already secured 4.65 billion doses to cover an EU population of 446 million people. Although the program's roll-out was slow, by the end of July 2021 over 70 percent of adults had already been vaccinated against COVID-19. In the UK, the vac- cination roll-out started on December 8, 2020, and by August 2021, over 75 percent of adults had already had two COVID-19 vaccine doses administered. Sources: GOV.UK, 2021; Sagan et al., 2021 Box 2. Public health functions critical for health system resilience The role of public health has evolved from a narrow focus on communicable diseases at local level to compre- hensive approaches to protecting nations from disease outbreaks and implementing policies that protect public health. The WHO outlines ten Essential Public Health Operations to build more robust public health services and capac- ities; all of these have been shown to have played significant roles during the COVID-19 pandemic: (1) Surveillance of population health and wellbeing; (2) Monitoring and response to health hazards and emer- gencies; (3) Health protection including environmental occupational, food safety and others; (4) Health promo- tion including action to address social determinants and health inequity; (5) Disease prevention, including early detection of illness; (6) Assuring governance for health and wellbeing; (7) Assuring a sufficient and competent public health workforce; (8) Assuring sustainable organizational structures and financing; (9) Advocacy commu- nication and social mobilization for health; and (10) Advancing public health research to inform policy practice. Source: World Health Organization, no date. 3 A way forward for building RESILIENT HEALTH SYSTEMS nia, Azerbaijan, Georgia, Moldova, and Ukraine) to Figure 2: Trend of new COVID-19 cases, deaths, COVID-19 provide important lessons for building and excess mortality health system resilience. These countries main- tained low COVID-19 cases and deaths during the first pandemic wave, but not in subsequent waves (Figure 2). By the time of writing this report, the evolution of the pandemic in these countries has followed four waves linked to different COVID-19 variants and control measures implemented at national and local levels. Since the first cases were reported in these countries, the governments have made significant efforts to protect the population from COVID-19, and the health systems are operat- ing efficiently. Vaccines have been the most effective public health measure to control the spread of the virus and reduce deaths. The COVID-19 pandemic led to a scientific breakthrough in the production of vac- cines at an unprecedented time. The rapid organ- ization of governments and the pharmaceutical industry led to the saving of almost half a million lives of people aged 60 and over in the WHO Euro- pean Region population within a year of the vaccine roll-out.6 Although vaccines were still in their initial steps of procurement, distribution, and application at the time of the data collection for this report, there are important lessons (described below) from Eastern Europe and the South Caucasus countries related to ensuring enough supply and vaccination acceptance among the population. Source: Johns Hopkins University CSSE COVID-19 Data 6 Meslé et al., 2021 4 A way forward for building RESILIENT HEALTH SYSTEMS Health system resilience in the five countries Health systems’ baseline character- gia (2.9) had fewer hospital beds than the ECA aver- age (4.71), demonstrating potential excess hospital istics and preparedness for shocks capacity in Eastern Partnership countries. The five countries share common characteristics of health systems inherited from the Soviet Union. Performance in the Universal Health Coverage Since 1991, these countries have experienced a (UHC) Index was below the ECA regional average. All series of reforms to adapt their health systems the countries are committed to implementing UHC to the population’s needs, as explained below. and have made substantial efforts to achieve this Although the countries have made important goal, ensuring that individuals and communities are efforts to improve their health system performance, protected from impoverishment from health care low public investment in health, high out-of-pocket expenditure and can access essential, quality health (OOP) payments, and staff shortages were their services across the life course. However, according main health system weaknesses before the COVID- to the last measurement of the UHC Index7 in 2019, 19 pandemic hit. there are still gaps in ensuring UHC compared to the regional average of 79.22 (Figure 3). The under- Health expenditure and key inputs vary significantly performance on the UHC Index reflected the lack of among the five countries, as shown in Table 1. All comprehensive health coverage, creating barriers the countries increased their health expenditure as to access to quality care throughout the COVID-19 a share of GDP between 2000 and 2019, apart from pandemic. Georgia, where health expenditure was 7.19 percent in 2000 and 6.6 percent in 2019. Although in 2019 Figure 3: Universal Health Coverage Index in 2019 Armenia's health expenditure was above the EU13 90 and Europe and Central Asia (ECA) average, it also 80 70 had the highest OOP payments (84.28 percent). In 60 all the countries, OOP health expenditure was more 50 than double the 17.62 percent average for ECA in 40 30 2019, and almost double the EU13 average (23.26 20 percent). All the countries, apart from Moldova (2.6), 10 had more doctors per 1,000 population than the 0 EU13 average (2.83), while the number of nurses per va A ne ia n a gi ja EC en do ai ai or 1,000 population was greater than the EU13 (6.12) kr rm rb ol Ge U M ze A only in Azerbaijan (6.43), and Ukraine (6.67). Lastly, A only Armenia (4.2 per 1,000 population) and Geor- Note: ECA: Europe and Central Asia average. Source: World Bank Data, 2019. Data for the EU average is not available. Table 1: Key health financing and input indicators from the five studied countries Health expenditure OOP as % of health Doctors per 1,000 Nurses per 1,000 Hospital beds per Country as % of GDP expenditure population population 1,000 population Armenia 10.0 84.3 2.9 4.4 4.2 Azerbaijan 3.5 72.5 3.5 6.4 4.8 Georgia 7.1 47.7 7.1 5.2 2.9 Moldova 6.6 40.1 2.6 3.9 5.7 Ukraine 7.1 51.1 3.0 6.7 7.5 EU13 6.3 23.3 2.8 6.1 6.4 ECA 9.4 17.6 4.3 7.8 4.7 EU13 includes Cyprus, Czechia, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, and Slovenia. ECA: Europe and Central Asia. Source: World Bank (2020 or latest available) and Health for All Database (2019 or latest available). GDP: gross domestic product, OOP: out-of-pocket payments. 7 The UHC Index is computed as the geometric means of 14 tracer indicators classified in four categories: 1) reproductive, maternal, new-born, 5 and child health; 2) infectious diseases; 3) noncommunicable diseases; and 4) service capacity and access. A way forward for building RESILIENT HEALTH SYSTEMS Countries have undergone several reforms in the facilities within 3 kilometers, almost a quarter (24 organization of public health and the financing of percent) reported traveling over 10 kilometers to health care services since the collapse of the Soviet access the closest pharmacy. Likewise, in Georgia, Union. One of the first functions that was decentral- the UHC program introduced in 2013 was skewed ized was surveillance of infectious diseases. Georgia toward hospital care and provided limited outpa- was the first country to implement this change in tient drug coverage. As a result, in 2018, 96 percent 1995, followed by Moldova in 2009. In 2007, Geor- of pharmaceutical expenditure came from house- gia introduced a Law on Public Health that defined holds’ budgets.8 PHC capacity was to be further the role of funding sources (central and local) in the improved during the pandemic to enhance the coun- annual budget. In Armenia, after 2013, the National tries’ response and reduce the burden in hospitals. Centre for Disease Control and Prevention absorbed most public health functions. To finance health care The health workforce was limited, with the number services, Moldova established the National Health of nurses significantly reduced In the last two dec- Insurance Company in 2001 as a state non-profit ades. Although the countries had similar levels of entity with financial autonomy. The National Health doctors per 1,000 population to the EU13 aver- Insurance Company is responsible for the Manda- age, the number of nurses was below the EU13 tory Health Insurance, monitoring and managing average for most of the countries. Only Azerbai- the volume, quality, and costs of contracted health jan and Ukraine reported higher levels than the 6.1 services. Azerbaijan transferred financing respon- nurses per 1,000 population in the EU13. Addition- sibility to the State Agency for Mandatory Health ally, most of the countries saw falling numbers of Insurance, while the organization and management nurses between 2000 and 2020 (or the latest avail- of public health services providers were assigned able year), while the number of doctors per 1,000 to the Administration of the Regional Medical Divi- increased in Armenia and Georgia (Figure 4). sions. In 2016, Ukraine experienced several struc- tural reforms, including the creation of a Center for Figure 4: Change in nurses/midwives and doctors Public Health with decentralized centers at regional per 1000 between 2000 and 2020 (oblast) levels, co-financed by local administrations. 100% Additionally, the ownership of most laboratories 80% was transferred to regional administrations; this was later changed during the pandemic (see section 60% on Lessons from the response below). 40% The health systems in the five countries were cen- 20% tered on hospital care. The five countries have wit- nessed a significant reduction in the number of 0% hospital beds over the last two decades; nonethe- -20% less, excess hospital capacity remained a feature of countries like Ukraine and Moldova. However, sur- -40% plus infrastructure for inpatient care did not always Armenia Azerbaijan Georgia Moldova Ukraine translate into adequate capacity to deliver effec- Nurses and midwives per 1,000 Doctors per 1,000 tive care. For example, though Ukraine has one of Note: 2020 or latest year available. Source: World Bank Data, 2020. the highest numbers of hospital beds per 100,000 population, the facilities designated for treating During focus group discussions, health care workers COVID-19 patients were not able to meet public highlighted the problem of staff shortages. Nurses health needs during the first wave due to a lack of from Armenia stressed that there were periods essential equipment (such as therapeutic oxygen). during the pandemic when two nurses had to care Moreover, hospital beds are usually concentrated in for 42 patients. In Georgia, nurses attending focus urban areas, particularly the capital cities. Unequal groups mentioned doing the work of three per- distribution of hospital beds and limited hospital sons in one without receiving financial compensa- resources to provide care for patients with COVID- tion. Similarly, doctors in Armenia highlighted staff 19 hindered some countries' capacity to increase shortages as one of the main problems when deal- their hospital capacity efficiently. ing with COVID-19 and its effects on hospital staff: “We only have one doctor left and the Head Physi- Coverage of primary health care (PHC) services, cian. We have a staff of two to cover a vast territory, particularly drug coverage, was low and depended and it is very difficult to work. There is great need highly on OOP payments. In Armenia, despite 97 for family doctors because people are stressed and percent of the population having access to PHC want to see their doctors for any problem.” Although 8 Curatio International Foundation, 2021 6 A way forward for building RESILIENT HEALTH SYSTEMS staff shortages were a well-known issue before remains a major challenge. Since 2010, Armenia COVID-19, the pandemic exacerbated the need for has introduced, piloted, and scaled up an e-health a strong health workforce, which has been critical system, the Integrated Health Information System for responding to COVID-19. of Armenia (IHISA), which replaced the former Med- ical Institution Data Analysis System (MIDAS) elec- The countries had aging health workforces con- tronic system that utilized offline data exchange. centrated mainly in cities. The health workforce in The system is required at all licensed health facil- most countries is aging, which in the context of the ities; however, some of the main challenges to COVID-19 pandemic has meant an increased risk of increasing the use of the IHISA include integration infection that limited their availability to be part of with other systems (specifically procurement and the response. In Moldova, over half the healthcare financial management) and the lack of incentive workforce is over 50 years old or already retired; how- to use the system outside results-based financing. ever, the number of doctors has remained relatively Similarly, Georgia introduced an electronic informa- stable, with a less than 5 percent increase between tion system integrating human and animal health 2000 and 2019, as shown in Figure 4. The lack of surveillance and bringing the “One Health” concept young health professionals was also emphasized into cross-sectoral disease surveillance as early as during interviews with healthcare staff. For instance, 2015. The country also introduced several registries a doctor from a rural hospital in Moldova stated: for routine statistics, including cancer, perinatal, “At my age, I had some thoughts of retiring at first and hepatitis C. Ukraine made important progress [when the pandemic started], but I understood no before the pandemic to digitalize health. As the one would be left to work in my place.” On the other pandemic developed, the country took significant hand, health care staff are concentrated mainly in extra steps to put in place efficient data systems for big cities, leaving rural and remote areas with low decision-making. numbers of nurses and doctors. The changes in the health workforce observed in recent years and their The COVID-19 pandemic tested the countries’ unequal distribution emphasize the need for com- health systems’ resilience. The key indicators in prehensive strategic planning for human resources Table 1 highlight the low investment in health as a for health, particularly for nurses involved in key share of the countries’ GDP and significant reliance functions in response to COVID-19, including testing on OOP expenditure, putting the populations at suspected cases and vaccinating against the virus. risk of impoverishment due to health costs. Simi- larly, the countries’ preparedness for pandemics in Various efforts have been made to develop health 2019 was lower than the regional average (Box 3). information systems, although full digitalization Consequently, the pandemic became a major test Box 3. Public health preparedness for pandemics from the perspective of health security The Global Health Security (GHS) Index comprises six categories and is calculated based on sub-indicators Figure 5: Global Health Security Index in 2019 involving health, political, security, and socioeconomic 80 Europe and factors. The six categories are (1) prevention of the Central Asia emergence or release of pathogens, (2) early detection 70 and reporting for epidemics of potential international Armenia 60 concern, (3) rapid response to and mitigation of the spread of an epidemic, (4) sufficient and robust health 50 Azerbaijan sector to treat the sick and protect health workers, (5) 40 commitments to improving national capacity, financ- ing, and adherence to norms, and (6) overall risk envi- 30 Georgia ronment and country vulnerability to biological threats. 20 According to the GHS index calculated for 2019 (Figure 10 Moldova 6), only Armenia had a better overall score (63.2) than 0 Ukraine its peers and the ECA average (50.7). All the countries Overall Score Prevent Detect Respond Health Norms Risk scored lower than the ECA average on the overall risk environment and vulnerability to biological threats, which takes into account the political and security risk, infrastructure adequacy, and public health vulnerabili- ties, which are critical factors for handling the COVID- 19 pandemic. Source: Bell et al. 2021 Source: GHS Index 7 A way forward for building RESILIENT HEALTH SYSTEMS of resilience for the countries’ health systems. The ical equipment to reduce external dependency on following section draws upon the lessons learned essential equipment from the response to the pandemic based on case studies and interviews conducted in the five East- Designing tailored communications strategies tar- ern European and South Caucasus countries. geting the different population sectors. Communi- cation channels are crucial for informing the public Lessons from the countries’ responses and health workers about governments’ strategies to reduce the burden of a health crisis. Although to the COVID-19 pandemic official government channels were available to pro- vide updates about the pandemic, misinformation The countries implemented a variety of strate- was prevalent among social media users. Doctors gies to reduce the impact of COVID-19. Measures from Moldova agreed on the need to implement included strategies to reduce viral transmission, effective communication campaigns about COVID- increase health systems' capacity, digitalize health 19 to increase the level of protection against the and information, and governance interventions to virus among the public. Similarly, medical staff from delegate power and resources. While these meas- hospitals in Armenia reported that patients arrived ures were critical in the pandemic response, fac- late to receive health care because of a lack of trust tors such as trust and communication proved to be in hospitals and information about COVID-19; inter- equally important to ensure an effective pandemic views with patients further emphasized this prob- response. Based on the case studies developed lem, as seen in the quote. from the five selected countries, and interviews with frontline actors in the COVID-19 response, this report "Well, we see the figures, we read the information, draws upon eight lessons to inform recommenda- but you cannot say, not everything you see and tions on preparing health systems for future shocks. know is true. […] The COVID figures are exaggerated as always, I do not believe that there are such great Aiming for long-term sustainability while imple- figures." menting short-term measures. Health financing Yerevan, female patient, unvaccinated, registered employee was one of the first and most important short-term measures in response to the crisis. For instance, Vaccine hesitancy was an additional barrier to the Armenia increased health care workers’ salaries implementation of effective communication strat- during the COVID-19 pandemic. However, in some egies. In Armenia, a poll conducted in March 2021 instances it is unknown how long and far the budget found that only a third of respondents were willing will continue to provide financial support, particu- to get vaccinated.9 Consequently, in collaboration larly when the support is allocated from donor with the WHO, the government developed a com- funding. Rapid funding allocation to the health care munications strategy that involved training media sector also enabled countries to reprofile existing representatives to present information on COVID- facilities and build infrastructure when needed. 19 to the public. Medical staff were also trained to As mentioned previously, Ukraine reprofiled select provide general information about COVID-19 and hospitals to exclusively deliver COVID-19 care. Mol- protocol compliance. These interventions contrib- dova designated referral facilities for COVID-19 uted to a ten-percentage-point increase in the care, accompanied by a review of intensive care unit proportion of Armenians willing to get a COVID-19 capabilities and infrastructure in support of interna- vaccine,10 highlighting the need to develop tailored tional partners. strategies that take into account the diverse per- spectives in society and involve key actors in dis- Although most of these measures have alleviated seminating information to increase adherence to the impact during the crisis, a systematic strategy evidence-based recommendations. is vital for ensuring long-term sustainability, par- ticularly to ensure that there is enough funding to Investing in long-term trust building for a fast prepare for and respond to crises, and to develop and consistent response. Trust is a crucial element health workforces to ensure that local production during times of uncertainty, and the pandemic of medical consumables meets international stand- showed how lack of trust can deter effectiveness in ards. Georgia provides an example of implement- response to a crisis. In Ukraine, for example, one of ing actions for long-term sustainability as, during the elements interfering with political trust was the the pandemic, the country safeguarded long-term political turbulence experienced during the pan- oxygen supply by importing power generators that demic that led to multiple changes in the Ministry produce oxygen as a by-product. Likewise, Azerbai- of Health leadership. In the focus groups in Arme- jan and Georgia increased local production of med- nia, patients expressed lack of trust in the reported 9 CIVILNET, 2021 8 10 Ghalechian, 2021 A way forward for building RESILIENT HEALTH SYSTEMS figures “Well, we see the figures, we read the infor- platform that provided access to essential health mation, but you cannot say, not everything you see services during the pandemic and information and know is true. […] The COVID figures are exag- about e-services from other sectors, such as com- gerated as always, I do not believe that there are merce, education, food, and entertainment. Moreo- such great figures.” Similarly, patients’ hesitancy to ver, the Ministry of Health worked with other sectors be vaccinated arose from lack of trust, referring to to ensure cross-sectoral coordination (Figure 6). For doubts about the effectiveness of the vaccines and instance, the health sector worked with the educa- beliefs that people would die or develop other dis- tion sector to design infection control measures in eases after getting vaccinated. schools and universities, and with the Ministry of Internal Affairs to ensure that the public followed Although trust from societies in health systems and social mobility measures, which received support governments may be weak due to previous experi- from the Ministry of Emergency Situations and the ences, the COVID-19 pandemic showed that trust Ministry of Defense. The Committee of Border Con- could also be built when public communication is trol ensured the enforcement of prevention meas- clear, coherent, and supported by evidence from ures at entry ports. Lastly, the Ministry of Foreign behavioral science. For instance, in Azerbaijan, the Affairs had a crucial role in the vaccine roll-out as Ministry of Health collaborated with the WHO and it collaborated with international partners to secure UNICEF to conduct behavioral insights research enough COVID-19 vaccines, emphasizing the rel- to assess public perceptions, behaviors, trust, and evance of cooperation for guaranteeing an effec- knowledge about COVID-19. Following the assess- tive response. The benefits of this collaborative ment, the WHO Country Office developed and approach to the pandemic contributed to building supported two communications campaigns for the inter-agency trust and coordination (Box 4). general public, including campaigns targeted at children and translated into local languages.11 Figure 6: Cross-sectoral approach for the pandemic response in Azerbaijan Implementing multisectoral cooperation for an effective response. The COVID-19 pandemic Ministry affected the health and other sectors, such as edu- of cation and finance. Consequently, governments Education adopted whole-of-government approaches for responding to the shock comprehensively. For Ministry Ministry instance, in Georgia and Armenia, the creation of of Foreign of Internal the Interagency Coordination Council and the Com- A airs A airs mandant Office facilitated coordination in response Ministry to the pandemic. In Moldova, the government intro- of Health duced the National Extraordinary Commission for Public Health, with representatives from all min- istries and departments to ensure an integrated Committee Ministry of approach, multisectoral mobilization, and coordina- Security and of Border tion of the response to the crisis. Emergency Control Situations In Azerbaijan, collaboration among various sectors enabled the implementation of a “one-stop” digital Source: Based on country note. Box 4. Multisectoral preparedness and response committees to improve health governance, trust, and policy coherence Countries created coordinating committees with representatives from various sectors to strengthen intersec- toral governance and coordination during the COVID-19 pandemic. For instance, Finland, Lithuania, and North Macedonia utilized special government emergency committees. Serbia created the Operational Intersectoral Headquarter, and Estonia the interagency working group. These committees ensured a whole-of-government approach to the pandemic, enabling multiple agencies (and political parties) to agree on the decisions to reduce the burden of the pandemic and improve communication across sectors. Furthermore, intersectoral approaches to public health challenges – including those related to wider social determinants of health – enable joint fund- ing activities to stimulate multisectoral projects and partnerships. Sources: Sagan et al. 2021; WHO Regional Office for Europe, 2018 11 WHO Country Office in Azerbaijan, 2020 9 A way forward for building RESILIENT HEALTH SYSTEMS Taking advantage of the opportunity presented by a patient-centered perspective by ensuring access shocks to push through difficult reform measures. to essential healthcare services regardless of loca- Reforms stalled or delayed can benefit from shocks tion and protecting the general public from the as they underline the need for change. The COVID- virus. For example, at the established Task Force 19 pandemic highlighted the need for a coordinated for immunization, the inter-sectoral team system- system with strong primary health care: conse- atically reviewed feedback from patient surveys, quently, in Azerbaijan, mandatory health insurance inquiries to the COVID-19 hotline, and third-party was expanded from covering only three pilot areas monitoring activities of COVID-19 vaccination and representing over 65 percent of the population in adopting respective measures to address identified March 2020 to covering the whole population by challenges. April 2021, resulting in mandatory health insur- ance that now covers a comprehensive list of 2,550 Minimizing unavoidable trade-offs while respond- medical services that include emergency and ter- ing to shocks. The pre-existing excess hospi- tiary care. Similarly, Georgia expanded the benefits tal capacity became a positive factor during the package of primary health care services, strength- COVID-19 pandemic as it enabled a swift increase ened the capacities of PHC teams, and improved in the availability of beds for patients. However, this the coordination and use of diagnostic and special- comes at the expense of absorbing a significant ized services. These changes to PHC services are percentage of available resources during “normal” intended to increase access by the remote and rural times. In Armenia, despite a reduction of over 60 population through digital services, ensuring uni- percent in hospital beds between 1990 and 2019, versal access to health care. inpatient care still absorbs 42.3 percent of the health budget.12 Another trade-off experienced by the Ukraine had a different experience of organization five countries was between life and livelihoods. For of critical roles in responding to the pandemic. The instance, reducing social mobility by closing non-es- government re-centralized some of the public func- sential services to control the spread of the virus tions (epidemiological surveillance, disease control, negatively affected the countries’ and households’ and emergency response) to increase the efficiency finances. Although these trade-offs are inevitable of the response to the pandemic. The reforms and after a shock like COVID-19, countries can still better reorganization of health system functions in these prepare by augmenting health system capacity countries during the COVID-19 pandemic enabled through innovative delivery care modes and imple- the implementation of substantial changes during menting adaptative financing mechanisms to make times of hardship. Moreover, these actions followed use of resources more efficient (Box 5). Box 5. Innovating the delivery of care and financing mechanisms during COVID-19 Measures to reduce the spread of COVID-19 served as an opportunity for health systems to innovate health care delivery. In the United Kingdom, the Derbyshire Community Health Services placed technology at the center of delivering various services. For example, community nursing teams adopted virtual handovers by MS Teams, while speech-language therapy was provided by telephone or video calls. Similarly, the immunization team developed an online e-booking system and introduced drive-through sessions to reduce crowding and the risk of infection. Innovation in care delivery was also observed for the management of wounds through the introduction of the Silhouette® 3D wound imaging and information system, a system comprising a camera that captures the wound image, software that creates a 3D model of the wound, and an online database that stores the information obtained. The introduction of these models of care improved collaboration between health care professionals by exchanging and maximizing the use of information for better decision-making. Changes in the use and mode of health care delivery during the pandemic required modifications in how the ser- vices were financed. In Bulgaria, the lower use of outpatient services led to a financial loss for providers. There- fore, the country replaced activity-based payments with budgets. Similarly, hospitals received a budget of at least 85 percent of the last year's turnover regardless of activity level while introducing fee-for-service payments for providing health care for patients with COVID-19. In Germany, hospitals were compensated by introducing per diem payments for unoccupied beds based on the previous year's activity. The payments differed by the complexity of patients treated, ranging from EUR 190 to EUR 760. By November 2020, the per diem payments were restricted to non-psychiatric acute hospitals with intensive care. Sources: Care Quality Commission, 2021; Waitzberg et al., 2021 12 Lavado et al., 2018 10 A way forward for building RESILIENT HEALTH SYSTEMS Ensuring the continuity of essential services while Figure 7: Change in proportion of women who responding to the emergency. Continuous moni- completed 8 antenatal visits in Georgia toring of essential health services during shocks is February March April May June vital for addressing the adverse ripple effects of the 0% actions imposed to deal with the shocks. While vir- tually every country has experienced forgone care -2% for essential services during the pandemic, there is -4% a large variation in its magnitude, suggesting that forgone care can be partially avoidable with appro- -6% priate measures. A survey of people aged 50 and above in European and selected countries indicated -8% that the unweighted proportions of unmet health -10% care needs ranged from 4.2 percent in Spain to 22.9 percent in Israel (for forgoing medical treatment), -12% from 1.5 percent in Bulgaria to 50.4 percent in Lux- emburg (for postponed scheduled medical appoint- -14% ments) and from 0.7 percent in Bulgaria to 11.1 Note: Change between February and June 2019 and 2020. Source: Staff calculations based on administrative data. percent in Lithuania (for denied medical appoint- ments).13 During the COVID-19 pandemic, health also evident in antenatal visits in Georgia, where the systems provided and expanded health care for number of women completing eight antenatal visits patients at the expense of discharging non-COVID declined in 2020 compared to 2019 (Figure 7). To patients or restricting elective care. For example, in increase the rate of antenatal visits, Georgia used Georgia, the government defined three stages for the Perinatal Registry, developed in 2015, which was standby readiness according to the number of cases an instrumental backbone for such services to reach in the country: 1,050 beds in the first stage, 2,000 out to all pregnant women (if they were detected beds in the second stage, and 4,000 beds in the promptly) and provided educational as well as indi- third stage. When the threshold of cases was met, vidual and group consultative services using the hospitals were notified and required to discharge Zoom® platform. These examples show how infor- patients and empty beds within 48-96 hours and mation systems with up-to-date data are crucial accept COVID-19 patients. Also, publicly funded for closely monitoring health services and providing elective procedures were postponed from Novem- policymakers with quality information to implement ber 2020 until March 2021. actions that reduce the burden of forgone care and establish innovative delivery models of care. Although the actions implemented by govern- ments to reduce the spread of COVID-19 resulted Digitalizing data for agile decision-making. Though in forgone care, the general public's fear of getting most countries had information systems before the infected also contributed to a reduction in essen- pandemic, these systems were boosted during the tial health care delivery. In Moldova, for instance, response to the shock. In Armenia, the already-ex- information from the National Health Insurance isting e-health system (ArMed) was complemented Company (NHIC) showed a decrease in outpatient with analytical functions to contribute to pandemic visits of almost 60 percent in certain groups of management and monitor vaccination activities. In patients (Table 2). The impact on forgone care was Moldova, the authorities worked with the United Table 2. Forgone care in Moldova: number of patients with chronic diseases who accessed care services 2019 to 2020 Condition 2019 2020 difference (%) Cancer 22,119 18,586 -15.97% Diabetes 9,062 4,995 -44.88% Hepatitis chronic 725 420 -42.07% Hepatitis viral chronic 3,142 1,269 -59.61% Cataracts 4,367 3,294 -24.57% Sprain/strains 237 173 -27.00% Heart attack (chronic or over four 410 224 -45.37% weeks) Note: Change between February and June 2019 and 2020. Source: Staff calculations based on administrative data. 13 OECD, 2021 11 A way forward for building RESILIENT HEALTH SYSTEMS Nations Population Fund (UNFPA) to develop a mance in normal times, as well as for enhancing dashboard that presented real-time data on a set preparedness for and response to future shocks – of key indicators (such as the number of infections including national and localized health emergencies. and deaths) disaggregated by age, sex, geographi- The rest of this section presents recommendations cal location, and date. Despite the availability of this for improving these three key areas. real-time data platform, Moldova lacked a single health information system, posing risks to data Key area 1. Core health system functions quality and accuracy. In Azerbaijan, the Ministry of Health and the Administration of the Regional Preparing for and responding to shocks requires Medical Divisions (TABIB) developed and used a investing in health systems. Although system func- single database for COVID-19 surveillance. These tions are broad and investments could be made at data systems were found to be crucial for agile deci- different levels, depending on the country’s need, sion-making. They emphasized the need to move three functions stood out during the pandemic and from paper-based to digital data to ensure the rapid are crucial as countries bounce back from and pre- availability of information, not only for hospital care pare for future shocks: crisis-sensitive service deliv- but also for monitoring supply of medical equip- ery, primary health care, and health care financing. ment, human resources for health, and forgone care (as shown above). Develop crisis-sensitive delivery of care while reducing health care backlog. Ensuring the conti- nuity of essential services, such as cancer screening Going forward: key areas for building and antenatal care, is needed in times of crisis to strong and resilient health systems minimize the threat of forgone care to the human capital of current and future generations. Fear of The lessons above reveal three critical areas for infection and restrictions imposed to control the building strong and resilient health systems: core spread of the virus hindered patients from seeking functions, human resources, and health care tech- health care, irrespective of the severity of symp- nologies and information systems. These areas are toms. As shown above, care provision fell during crucial for ensuring efficient health system perfor- the pandemic, even for conditions like cancer and Table 3: Measures implemented to reduce the backlog of elective services due to the COVID-19 pandemic Strategy area 2019 Outsourcing / private • Purchasing private capacity to help work through waiting lists. partnerships • Extending hours of care to nights and weekends and paying staff overtime. Extending hours of care / • Increased flexibility for hospitals to negotiate working hours for staff and insourcing remove limits on overtime. • Extending activity-based funding to incentivize an increase in volume and/or Payment design and incentives complexity. • Uplifts to physician overtime rates to incentivize the catch-up of services. • Expanding diagnostic capacity by upgrading equipment and facilities in Upgrading infrastructure hospitals and establishing community diagnostic centers. and adding bed capacity • Adding overflow / ‘on-demand' beds to flexibly scale staffing and bed capacity up or down according to demand. • Centralized waiting list coordination to better use resources across the system System coordination and redirect resources/patients. • Hospital or regional collaboration to share capacity/reallocate patients. • Clinical validation and quality assurance of waiting lists. Waiting-list management • Pre-triage clinics for long-waiters – identifying other forms of support and removing people who can be seen elsewhere from waiting lists. • Extending the patient choice policy, which allows patients to go to a private Waiting-time targets/ hospital or receive care in other regions if care guarantees cannot be met locally. guarantees • Implementing new care guarantees or waiting-time targets. • A range of initiatives aimed at reducing demand for elective care (for example, Demand/capacity referral optimization, improved self-management and surgical hubs). management and flow • Shifting more services to day-case procedures and implementing 'early recovery from surgery' programs/rehabilitation and step-down care. Source: Based on Reed, Schlepper, and Edwards, 2022. 12 A way forward for building RESILIENT HEALTH SYSTEMS heart disease. As countries bounce back from the Kingdom, mathematical models helped not only to pandemic, interventions should be linked to build- define the need to implement lockdowns but also to ing a system that provides crisis-sensitive delivery determine the priority groups for vaccination, which of care, meaning that people can still access health contributed to reducing the impact of COVID-19 in care despite the conditions imposed by the shock. the country.14 Examples of how this can be possible have been present throughout the pandemic and the use of Countries should also develop national and sub-na- technology was a central pillar: for instance, the pro- tional health emergency plans to maintain health vision of remote care using telemedicine or collec- care delivery during the crisis. The plans will serve tion and analysis of real-time data were both crucial not only to prepare better and respond but also to for ensuring continuity of care and decision-making. ensure essential health services are not disrupted Other crisis-sensitive strategies included expand- to the extent witnessed during the COVID-19 pan- ing or revising the hospital capacity for health care demic: this disruption is currently creating substan- delivery and recruiting additional health workers. tial pressures in health systems worldwide. Hospitals and primary health care clinics should develop busi- A resilient health system enables consistent recov- ness continuity plans to minimize health care deliv- ery of its functions. Though all health systems are ery disruption while meeting the surge in capacity suffering backlogs due to the COVID-19 pan- needs during crises. Lastly, countries should identify demic, the response to recover the forgone care is a operational targets and crisis standards of care for determining factor of the resilience capacity of the health care delivery (Box 6). system. Countries have adapted lessons from the pandemic to reduce forgone care and recover the Invest in primary health care. The primary level of level of activity seen before COVID-19. For instance, care played a significant role during the COVID-19 in Austria and Ireland waiting lists are being updated pandemic, as it was responsible for treating less through pre-triage clinics for long-waiters to iden- severe cases and served as a gatekeeper for access- tify alternative forms of support when appropriate. ing COVID tests and vaccines. Moreover, primary care In the Netherlands, a centralized data hub with real- played a prominent role in the immediate response time data has been introduced to evaluate demand to the crisis by functioning as pre-hospital triage, for inpatient care and redistribute capacity accord- helping to determine which patients could receive ingly. Additional strategies are shown in Table 3. In health care at home or in facilities for non-severe addition to these measures, modeling will continue cases, and reducing the pressure at higher care facil- playing a crucial role. For instance, in the United ities. Primary health care also served as a connector Box 6. Hospitals’ crisis standards of care Crisis standards of care refer to the health care delivered when a pervasive or catastrophic disaster makes it impossible to meet the usual health care standards. Hick et al. provide examples of these standards, which should be adapted to the countries and hospitals’ context and include the following: Element Standard of care • Incident command plan for integrating subject matter experts Command • Mechanism for requesting outside resources • Information shared between hospitals and key stakeholders Coordination • Coordination of best practices with other hospitals • Resource allocation that includes whom to consult if triage decisions Clinical outside normal practices are required • Resource allocation for drug and blood shortages • Redeployment of staff Staff • Sequential use of staff to use the next best-qualified staff Space • Planning to expand and adapt spaces Supplies • Standard approach to medication and other shortages • Tiered approach to medication and other shortages Services • Preserved resources for core services (such as burns and trauma care) Special • Plan to group infectious patients during a large-scale event Source: Hick et al., 2022 14 Pagel and Yates, 2022 13 A way forward for building RESILIENT HEALTH SYSTEMS between local, regional, and national authorities by enhance working conditions for health care workers. providing the data used to identify outbreaks and impose tighter measures to prevent the spread of Implement agile payment models to guarantee the COVID-19. Despite the substantial role of primary continuous delivery of health care. Though allo- health care during the pandemic, its potential for cating the necessary funding to health systems is improving the health system's performance has vital for better responses to crises, flexible payment been underestimated due to the concentration of models are also needed to guarantee the rapid pro- resources on in-hospital care. Primary health care is vision of the financial resources required to respond fundamental for achieving better health outcomes to the shock, for instance, to cover the additional and reducing inequalities in access to care15 and is expenses of hospital providers due to reconfigura- considered the cornerstone for achieving universal tion of facilities to respond to the crisis. health coverage.16 However, many resources are still allocated to hospital care, resulting in weak primary In the first year of the COVID-19 pandemic, various care networks. approaches were taken to overcome the unexpected additional expenditure and revenue shortfalls of Strengthening primary health care requires a com- health care providers. For example, in Germany, prehensive approach. Optimizing primary health designated facilities for patients with COVID-19 care is not only about increasing financial invest- experienced losses due to new beds being needed ments; further measures involve adopting a multi- for elective care; consequently, the payment model disciplinary team-based approach, improving the was changed to per diem payments adjusted for health workforce,17 and investing in human resources case mix and type of hospital. In addition, payment and information technology tools supporting care systems should take into account the introduction integration. Additional funding is needed to opti- of new forms of health care delivery (such as con- mize the existing PHC infrastructure and enable sultations by telemedicine) to maintain the sustain- access to essential services, such as ensuring PHC ability of this service. In Belgium, Czechia, Denmark, facilities have basic services and the necessary Estonia, Italy, Lithuania, Romania, and Slovenia, the medical equipment. Furthermore, the increasing rise of telemedicine motivated the introduction of burden of noncommunicable diseases, such as dia- fee-for-service payments to reimburse and pro- betes and hypertension, means that health systems mote remote health care.18 must be able to address long-term patient care needs during normal times of crises. Services deliv- The best payment model will depend on already-ex- ered and drugs prescribed at the primary level of isting payment mechanisms and the changes care should be covered by mandatory health insur- imposed by the shock, and there is a need for flex- ance, leading to increased use of PHC services and ibility and adaptability to change, inherent char- improved health outcomes. Multidisciplinary teams acteristics of resilience. Good governance in pay- involving social care and community members can ments may also support the cash flow of the health help better manage patients' conditions by devel- facilities, supporting daily management. In Poland, oping tailored strategies to improve individuals' monthly payments from the National Insurance health (Box 7). Lastly, improving health workforces Fund to the health facilities were modified to two aligns with the strategic planning mentioned below monthly payments to increase cash flows, enabling (see Human Resources) and further emphasizes the facilities to motivate health workers and purchase need for financial and non-financial incentives to necessary health equipment. Box 7. Multidisciplinary primary health care practices in deprived areas (France) The Avenir Santé Villejean Beauregard association manages the Multiprofessional Health Center (MSP) Rennes North/West, a team of primary health care professionals working together to facilitate and improve care coordination, promote disease prevention and health education, and strengthen the links between medical and social actors. The primary health care team works with the community to organize weekly newsletters distributed among neighborhood members with information about the COVID-19 pandemic and the reorgan- ization of primary health care services. These newsletters also include information on self-manage- ment of chronic conditions and materials for mental health support. The information is translated into several languages appropriate for the community's demographics. Source: OECD, 2021 15 Starfield, Shi and Macinko, 2005 14 16 Binagwaho and Ghebreyesus, 2019 17 Barış et al., 2021 18 Waitzberg et al., 2021 A way forward for building RESILIENT HEALTH SYSTEMS Key Area 2. Human resources mation on human resources for health will help to identify currently underserved areas and allocate Health care workers are at the forefront of health enough health care personnel to cover the popu- systems. Irrespective of the severity of the shock lation's health needs. Moreover, strengthened data and the infrastructure available, human resources systems enable forecasting of the health workforce are expected to adapt to the crisis, maintain their required, due to shifts in the population structure activity levels, and deliver care to those in need. and demands arising from the development of At the same time, the continuous pressure and medical technologies. The Human Resources for changes in the delivery of care caused by a shock Health Action Framework (Figure 8), developed increase stress among health workers, leading to by the Global Health Workforce Alliance (GHWA), burnout, unsatisfied health personnel, and, eventu- provides a pathway for developing strategic plan- ally, increasing turnover. ning for the health workforce.19 The pandemic has already exposed the weaknesses in this sector, such Develop strategic planning of human resources as the unequal distribution and aging of health care for health. Strategic planning for the health work- workers presented in the lessons above. Countries force will ensure the right number and distribution should now develop effective strategies and mon- of health care workers, increasing access to and itoring systems centered on building resilience quality of care. Although staff shortages have been among health care workers, such as ensuring ade- a prevailing problem in health systems, the COVID- quate distribution, providing training to address 19 pandemic revealed that inadequate planning of communities’ health needs, and involving them in human resources for health can have devastating the decision-making process of human resources consequences as the population's health needs are for health planning and management.20 unable to be met. Immediate actions to cope with the increased demand caused by the pandemic Build the capacity of health care workers con- involved recruiting retired personnel or hiring senior cerning health technologies. During the COVID-19 medical students. While these actions alleviated the pandemic, countries witnessed a surge in health health care burden, they are just temporary meas- care technologies, such as telemedicine and smart- ures that give countries time to develop sustaina- phone applications, to maintain service delivery due ble approaches to improve the recruitment, retain- to social-mobility restrictions. The employment of ment, and distribution of health care workers that health technologies in health systems requires a will translate into better access to care. Additionally, health workforce trained to operate these new tools strategic planning involves providing the health for service delivery and management efficiently. workforce with the skills they need to meet the Pushback against new technologies is common population’s health demands and guarantee care among health professionals due to negative per- following the best available evidence and medical ceptions and mistrust of the technologies' effec- technologies. tiveness.21 Therefore, countries must ensure that the health care workforce has skills and trust in the Designing strategies to improve the health care implemented health technologies by developing workforce is not possible without the availability of capacity-building programs across all levels of care. up-to-date and quality data on this sector. Infor- Figure 8: Action cycle of the Human Resources for Health (HRH) Action Framework Source: Based on Global Health Workforce Alliance 2022. 19 Global Health Workforce Alliance, 2022 15 20 Pacqué-Margolis, Ng and Kauffman, 2011 21 Socha-Dietrich, 2021 A way forward for building RESILIENT HEALTH SYSTEMS Box 8. Competency development program to facilitate digital health care systems (Denmark) A program of five one-day modules (Leading in Digitalization) was conducted among the secondary health care workforce in Central Region Denmark. The modules included: (1) an introductory module; (2) citizens and digitalization; (3) culture and communication; (4) implementation; and (5) a conclud- ing module. Participants gain experience through activities involving participation, communication, implementa- tion, and digital imagination. In a follow-up questionnaire participants' self-scores improved in navi- gating the digital transformation of health systems, critical thinking on the processes in which digital solutions are implemented, and understanding how to manage digitalization. Source: Villumsen et al., 2021 Technologies should boost health care performance; leaving, just behind retirement.26 Failing to improve otherwise, they will create additional barriers to care working conditions and protect the human work- delivery. The characteristics of the utilized health force will weaken health systems and decrease its technologies are crucial for ensuring they increase capacity to respond to future shocks. service delivery performance. For instance, health professionals perceive technologies improving Improving working conditions should start at the feedback, speed, and workflow as efficient. Moreo- primary level of care. As countries make efforts to ver, health workers have also emphasized the need reach universal health care, clinics at the primary for training and familiarity with health technologies level of care play a significant role. As described to reduce the initial anxiety in employing them.22 above, primary health care is the cornerstone for Capacity-building programs are emerging on health achieving universal health care and should be ade- technologies and have proven effective in increas- quately equipped to ensure personnel at this level ing the health workforce's digital skills and cultivat- of care have the resources to efficiently work as ing a “digital mindset,” enabling them to navigate, the population’s first contact with the health care understand, and manage the digitalization of the system. Additional strategies to improve working health system (Box 8).23 conditions include improving non-financial condi- tions that directly affect job satisfaction and staff Improve working conditions and protect health retention, including free parking, training oppor- care staff’s mental health. The pandemic revealed tunities, vouchers, full-time and permanent posts, the need to improve the number of health care pro- and child care on-site to improve the attractiveness fessionals and the conditions in which they develop of employment.27 Lastly, improving working con- their practices. Primary health care clinics and hos- ditions involves coordinating health care between pitals were unprepared to protect their staff with the primary, secondary, and tertiary levels of care. sufficient personal protective equipment or essen- The need for better care coordination was further tial drugs like therapeutic oxygen. The impact of heightened during the pandemic, and it is crucial to COVID-19 on health care workers’ mental health leverage technology in the health sector to achieve was unprecedented, leading to high rates of burn- this goal. out. For example, in Italy, around half (49 percent) of health workers reported symptoms related to Key area 3. Health care technologies and informa- post-traumatic stress disorder; in Spain, the number tion systems reached 57 percent. Digitalization of health is essential to improve Along with burnout, physical working conditions and data quality and care delivery. The COVID-19 pan- reduced job satisfaction are the main reasons for demic increased demand for real-time, quality data leaving the profession.24 Although countries intro- for decision-making on public health measures, duced measures to improve working conditions, such as updating social restrictions and reallocat- such as increased salaries and one-off bonuses, ing resources based on hospital activity levels to investments in the health workforce should com- improve care delivery. Moreover, countries experi- prise elements beyond financial incentives and enced the digitalization of services to enable better address the main concerns, which vary between coordination among providers and levels of care. countries and types of workers.25 In the United Investing in the digitalization of health will improve Kingdom, for example, one in nine nurses left the performance and increase resilience in health sys- profession from July 2021 to June 2022, with lack tems. of a work-life balance being the second reason for 22 Odendaal et al., 2020 16 23 Villumsen et al., 2021 24 Parisi et al., 2021 25 Palmer and Rolewicz, 2022a 26 Parlmet and Rolewicz, 2022b 27 Reed, Schlepper and Edwards, 2022 A way forward for building RESILIENT HEALTH SYSTEMS Integrate information systems and enable infor- integrating information systems, data must be mation exchange across providers. Countries relied standardized to avoid inaccuracy and increase the on information systems to make informed decisions analysis and use of the information.28 throughout the pandemic. However, when a unique central system was lacking, countries saw the devel- Improve monitoring and evaluation of health care opment of multiple information systems, risking the delivery to ensure continuity of services. Efficient quality and usefulness of the information. Infor- monitoring systems enable fast and informed deci- mation systems should be capable of sharing data sion-making, which is critical for protecting the across providers and levels of care to facilitate data population’s health amid shocks and crises. Health exchange and the making of informed decisions for systems need to closely monitor and evaluate patients and the population. In addition, integrat- health care delivery during the preparedness activ- ing information systems requires a person-centered ities for, response to, and recovery from a shock. As lens, ensuring that patients and end-users, includ- witnessed during the COVID-19 pandemic, coun- ing medical and managerial staff, have capabilities tries with systems to monitor key health indicators, and trust in the systems. Guaranteeing information such as hospital bed availability, could increase hos- exchange across providers and care levels will trans- pital capacity or impose additional social distancing late into better coordination and delivery of care. measures to reduce the risk of infection. The infor- mation from monitoring systems was also used to Standardization of data collection is essential for reorganize routine health services after observation integrating information systems. The case stud- of a decline in the health-seeking behavior of certain ies from the studied countries revealed that health groups during the pandemic, such as the number information systems in these countries are at differ- of pregnant women receiving antenatal care. While ent levels of development, and thus the process of data availability is crucial, it is equally essential to integrating data should be customized. The WHO's ensure that reporting mechanisms are in place and Best Practices and Challenges for Health Infor- information is provided to decision-makers to make mation Systems report provides alternatives for decisions driven by real-time data. ensuring good practice in managing and integrat- ing information. One strategy, for instance, involves Countries should leverage the efforts and invest- linking information between existing registers (such ments to monitor and evaluate health services as cancer and mortality registers) by using identifi- during the pandemic and expand these systems ers or national geocoding or creating a central data- to routine health care delivery. The Roadmap to base compiling all the information. An alternative to Monitoring Health Services Delivery by the WHO these options is to rebuild the national health infor- European Region outlines critical steps to be cov- mation system entirely, strengthening the system ered while implementing monitoring systems (Table and improving monitoring, planning, management, 4).29 It is important for countries to develop detailed and research. Regardless of the chosen path toward frameworks and determine a set of indicators to Table 4: Steps for development and implementation of monitoring systems for health services Step 2019 • Define the purpose and objectives of a monitoring framework Defining the framework • Define the scope of the monitoring framework (such as primary health care, tracer conditions) • Agree on the maximum number of indicators • Consider a core list and an additional list of indicators • Scan the availability of data Reviewing indicators • Agree on the criteria for including indicators • Agree on the proportions of indicators covering each of the framework's areas • Convene a consultation on the proposed indicators • Prepare a final list of indicators • Disseminate the indicators to providers Preparing for data collection • Develop an electronic tool for data collection • Develop an electronic data repository • Collect data for the identified indicators Collecting data • Validate findings • Consult stakeholders / steering committees on the findings Analyzing and reporting back • Disseminate the data through an online platform Source: Based on WHO Regional Office for Europe, 2017 Source: Based on WHO Regional Office for Europe, 2017 Michelsen et al., 2015 28 17 WHO Regional Office for Europe, 2017 29 A way forward for building RESILIENT HEALTH SYSTEMS measure the performance of essential services, for approaches and low returns on investment. As example, those related to patients with chronic health systems move towards digitalization, health conditions. As witnessed during the pandemic, care will be transferred to patients and the popu- electronic methods of collecting data are crucial lation, who will increase the control of their health for improving data availability and rapid exchange with the support of digital technologies that pro- of information among decision-makers. The health vide access to accurate information to self-man- system’s resilience capacity mainly depends on age their conditions and make informed decisions performance during normal times. Implementing alongside health care providers.31 This transition efficient monitoring and evaluating health services will accelerate the move towards reducing the cost during normal times will provide countries with of care while improving quality of life by delivering information to improve their performance and pre- efficient care outside hospitals (Figure 9). Though pare for future shocks. financial investments are critical, these should come along with modernizing existing governance struc- Invest in digitalizing information and health care, tures to ensure the effective digitalization of health placing people at the center to reduce the digital systems. Therefore, a national digital health strat- divide. During the pandemic, innovation in service egy should be developed to guide efforts for the delivery revolved around using technology to ensure digitalization of health. The strategy should follow that people could access health care. As countries a person-centered approach to ensure people are move away from COVID-19, it is expected that ser- familiar with the technologies implemented in the vices like telemedicine will continue to be used as health sector and increase digital access, literacy, alternative modes of delivering care. While using and assimilation, preparing them to access health these delivery modes will alleviate the pressure on care during normal times and in times of crisis. health services, it could unintentionally increase inequalities in access to digital services (the digital divide) because of difficulties in internet access and digital literacy, particularly among vulnerable groups such as the elderly and minority groups.30 Following a person-centered approach in digitalizing informa- tion and health care will ensure that inequalities in digital access are not further widened. Investments in digitalization of health should follow a national digital strategy to avoid siloed Figure 9: Digital technologies drive the health and care paradigm Source: Based on EHTEL (2021) 30 Litchfield, Shukla and Greenfield, 2021 18 31 EHTEL, 2021 A way forward for building RESILIENT HEALTH SYSTEMS Conclusions COVID-19 has critically affected health systems and other sectors, allowing countries to implement changes at an unprecedented pace. Although the pandemic is not over, as new waves of cases con- tinue to test health systems around the globe, there have been important achievements that seemed distant prospects before the pandemic. For instance, countries expanded their health coverage, reorganized health system functions, and increased local production of medical equipment and phar- maceutics during a crisis. At the same time, the pandemic exposed areas that need urgent atten- tion, such as improving health workforce planning and strengthening the primary health care sector. The time to prepare for the next crisis is now. As countries overcome the acute impact of COVID-19, they will be faced with the long-term effects of the measures to control the spread of the virus during the last couple of years, including the forgone care of patients with chronic conditions and the impact on mental health, mainly among the health work- force. Although it is impossible to determine when the next crisis will occur, and its source, (re)emerging microorganisms and climate change are two lead- ing public health issues that require special atten- tion. The significant improvements made in recent years present a unique opportunity for countries to leverage these efforts to prepare for future crises. 19 A way forward for building RESILIENT HEALTH SYSTEMS References Arush Lal, et al., Fragmented health systems in European Commission (2022) State of Health in the COVID-19: rectifying the misalignment between EU: Companion Report 2021. Luxemburg. doi: global health security and universal health 10.2875/835293. coverage, The Lancet, Volume 397, Issue 10268, 2021, Pages 61-67, ISSN 0140-6736, https://doi. European Health Information Gateway (2022) Bed org/10.1016/S0140-6736(20)32228-5. (https:// occupancy rate and Total inpatient expendi- www.sciencedirect.com/science/article/pii/ ture as % of total health expenditure. Available S0140673620322285) at: https://gateway.euro.who.int/en/datasets/ (Accessed: 8 March 2022). Barış, E. et al. (2021) Reimagining Primary Health- care After COVID-19. Washington DC. Ghalechian N. (2021). 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Assessment of appropriateness of building resilient health systems. Available at hospitalisations in Ukraine: analytical framework, https://www.who.int/news/item/19-10-2021- method and findings. BMJ open. 2019 Dec who-s-7-policy-recommendations-on-build- 1;9(12):e030081. ing-resilient-health-systems (Accessed 20 March 2023) WHO (2020). WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Available at: https://www.who.int/ director-general/speeches/detail/who-direc- tor-general-s-opening-remarks-at-the-me- dia-briefing-on-covid-19---11-march-2020 (Acessed: 10 February 2023) WHO Country Office in Azerbaijan (2020). WHO Country Office in Azerbaijan supports the country in its COVID-19 response. 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Available at https://openknowledge.worldbank.org/ bitstream/handle/10986/35852/South-Cau- casus-GovTech-for-Armenia-A-Whole-of- Government-Approach-as-a-Key-Founda- tion-for-the-Digital-Economy-in-Armenia. pdf?sequence=1&isAllowed=y World Bank Data (2022) Physicians and Nurses and Midwives per 1,000. Available at: https://data. worldbank.org/indicator/SH.MED.PHYS.ZS?lo- cations=EU (Accessed: 8 March 2022). World Health Organization (no date) The 10 Essential Public Health Operations. Available at: https://www.euro.who.int/__data/assets/ pdf_file/0007/172762/Strengthening-pub- lic-health-services-and-capacity-an-ac- tion-plan-for-Europe-Eng.pdf (Accessed: 20 March 2023). 22 A way forward for building RESILIENT HEALTH SYSTEMS Annex: Summary of case studies Figure 10: Key public health indicators for Armenia Armenia Baseline characteristics and preparedness for shocks Substantial structural reforms were introduced fol- lowing the collapse of the Soviet Union in 1991. The reorganization towards a market economy led to economic growth, increasing gross domestic prod- uct (GDP) per capita in current USD from USD 623 in 2000 to USD 4,623 in 2019. A snapshot of key population health indicators is presented in Figure 10. Health expenditure as a share of GDP has more than doubled between 2000 (4.2 percent) and 2018 (10.03 percent); however, out- of-pocket (OOP) payments increased more than 20 percentage points in the same period to 84.79 Source: World Bank 2020 or latest percent of total health expenditure in 2019. The number of doctors has remained relatively constant the World Bank) facilitated the expansion of availa- over the past two decades (2.7 to 2.9 per 1,000 from ble resources and medical equipment. Lastly, Arme- 2000 to 2015), yet the number of nurses per 1,000 nia successfully introduced platforms for training and population decreased from 5.91 in 2000 to 4.85 in webinars, information exchange between doctors 2017. The number of hospital beds decreased by and patients, precise laboratory results, contact trac- over 60 percent between 1990 and 2019. Inpatient ing, tracking mobile data, as well as video-observed care expenditure also fell in recent years, from 44 treatment for tuberculosis patients. This demon- percent of government health expenditure in 2011 strated good use of the digitalization of both routine to 38 percent in 2019. and COVID-19 related health care services. Response to the shock Lessons learned and way forward Actions to reduce the spread of the virus included a Optimizing health system capacity and health nationwide lockdown, increased testing capacity, and workforce. As a post-Soviet country, Armenia does the availability of dedicated health facilities or hotels not lack health facilities and beds; however, the to quarantine non-severe COVID-19 cases. Hospital country still needs to build additional bed capacity capacity was enhanced by expanding the number of to respond adequately to the COVID-19 pandemic. beds and providing care for non-severe COVID-19 Therefore, preparedness for future shocks must cases in 16 hotels with 400 beds. All persons con- include hospitals having detailed disaster plans that firmed to have cases of COVID-19 were eligible for include the following: which areas of the hospital to hospital care free of charge. The health care workforce expand to and in what order (for example, recov- was increased by training local volunteers in health ery room first, ambulatory areas second), how to care professions and receiving medical doctors and increase ability to care for incoming patients (such nurses from other countries. Armenia established a as canceling routine surgery and appointments), Commandant Office with members from multiple and how to gain immediate access to additional sectors (including the Prime Minister; the ministers staff (such as reassignment of staff with appropriate of health, economy and finance; and the Head of training to affected areas).32 This approach would Police, among others), ensuring a whole-of-govern- benefit Armenia and prevent the need for urgent ment approach to the pandemic. Moreover, collabo- and speedy measures to cope with the increasing ration with international partners (such as WHO and demand for health care. Wei et al., 2021. 32 23 A way forward for building RESILIENT HEALTH SYSTEMS Improving skills in pandemic preparedness and response. In contrast to other sectors, simula- tion exercises to prepare for emergencies are not common in Armenia's health care system at the ministry/government, hospital, or community levels. In all developed health care systems, institutions such as departments of public health, hospitals, and emergency medical systems, routinely practice their responses to emergencies and have well-defined bodies coordinating such drills. The experience of combating this pandemic can and should serve as an essential foundation for developing long-term and institutionalized crisis management mecha- nisms. Collaboration with international partners (such as WHO and the World Bank) will provide the technical expertise and resources needed to achieve better pandemic preparedness and response. Ensuring a multisectoral approach. Timely iden- tification of the first imported case was critical for further mobilizing the national players. Armenia was quite successful in its quick response to the outbreak in mobilizing resources and undertaking measures to prevent its spread, such as the decla- ration of a State of Emergency, national lockdown, quarantine, contact tracing, regulatory changes, and risk communication. However, the delegation of the response to the Ministry of Health later in the pandemic highlights the need to implement coordi- nated national strategies rather than ad hoc deci- sions to respond to shocks and ensure a sustainable response to the crisis. Digitalizing health care and information services. Armenia has a long track record of digital gov- ernment transformation, including developing an e-government portal, implementing a digital signa- ture, smart ID, an interoperability platform, a G-cloud prototype, and cybersecurity.33 The COVID-19 pan- demic has made GovTech even more urgent, accel- erating the impetus to promote more effective, effi- cient, transparent, and accountable public services for citizens. Nevertheless, these activities need to be supported by legislation, and skills should be built for their use. World Bank, 2021 33 24 A way forward for building RESILIENT HEALTH SYSTEMS Azerbaijan Figure 11: Key public health indicators for Azerbaijan Baseline characteristics and preparedness for shocks The Republic of Azerbaijan (Azerbaijan) is an upper-middle-income country with a relatively young population (over 70 percent are under 65 years). Azerbaijan retained the centrally planned, governed, and financed health system inherited from the Soviet Union. However, in 2016, the coun- try experienced structural and financial reforms toward mandatory health insurance and universal access to essential healthcare. A snapshot of key population health indicators is presented in Figure 11. As a share of GDP, health expenditure is lower (4.04 percent) than neighboring Source: World Bank 2020 or latest countries. Public spending on health has increased in the country after the reforms, almost doubling Lessons learned and way forward to 1.9 percent of GDP in 2020. Despite increased public spending, OOP payments remain high, Optimizing the health infrastructure. The high making up over 57 percent of health expenditure. number of acute care hospital beds helped to swiftly Although the number of doctors per 1,000 popula- mobilize the required surge capacity and avert a tion has remained relatively stable since 2000, the major health system crisis. However, this should not number of nurses per 1,000 population has fallen dissuade Azerbaijan’s policymakers from gradually from 8.66 in 2000 to 6.43 in 2014. Hospital beds optimizing the health service delivery system and per 1,000 people fell from 8.69 in 2000 to 4.82 in reorientating it towards primary health care and 2014. In addition, hospital beds remain unevenly adjusting it to the changing public health needs distributed, creating a barrier to access to inpa- post-pandemic. Further optimization requires defi- tient care for those living in remote and rural areas. nition pof a new health facility masterplan with an “optimal” capacity, enabling efficient addressing of Response to the shock the population's health needs through a better-in- tegrated network of primary, secondary, and ter- Azerbaijan implemented strict measures to control tiary care facilities and, at the same time, being able the spread of the virus. In March 2020, a nation- to rapidly unfold surge capacity in case of pandem- wide lockdown was imposed, and businesses, air- ics and other public health emergencies. ports, and transportation hubs were closed. While these measures were relaxed in May 2020, mobil- Developing a resilient health workforce. Health ity restrictions were tightened in selected regions care workers proved to be the most critical element reporting outbreaks. Hospital capacity was gradu- of the global and national pandemic response. The ally expanded by increasing the number of hospital significant salary supplements and social support beds in existing and recently built hospitals and tem- provided to the health care workforce caring for porary modular hospitals. Two sports arenas were COVID-19 patients in Azerbaijan have most likely also reconfigured to treat COVID-19 patients. At the played an essential role in the sustained health same time, health care facilities providing COVID-19 system response efforts thus far. However, it is not care received financial compensation to cover the clear how long and to what scale these incentives losses, and health care workers received three- to can be retained in the post-pandemic period. A fivefold increases in their salaries. Governance was longer-term vision for human resource develop- improved by establishing the National Operational ment and retention must be in place to answer this Headquarters (OH), a dedicated task force to handle critical question for Azerbaijan's health system resil- the pandemic. The OH ensured horizontal and ver- ience and preparedness for future pandemics. tical national response coordination by integrating international organizations (the United Nations, the Enhancing universal health coverage. The COVID- World Bank, and WHO) with national, regional, and 19 pandemic once again demonstrated the need for local-level organizations. Lastly, the Government of and importance of UHC. Countries with universal or Azerbaijan expanded the population and services near-universal health coverage, particularly those covered through mandatory health insurance. with aligned pre-pandemic investments in UHC 25 A way forward for building RESILIENT HEALTH SYSTEMS and health security,34 revealed more health system resilience. Azerbaijan's experience of the nationwide scale-up of the Mandatory Health Insurance system also shows that UHC is an essential tool for ensur- ing the continuation of essential health services and a critical precondition for rebuilding more resil- ient health systems and societies less vulnerable to future pandemic shocks. Arush Lal, et al, 2021 34 26 A way forward for building RESILIENT HEALTH SYSTEMS Georgia Figure 12: Key public health indicators for Georgia Baseline characteristics and preparedness for shocks Since 1995, Georgia has experienced two major health system reforms. The first introduced a social insurance scheme with an arranged purchaser-pro- vider split. In 2012 this was changed to a tax-funded health care system. The introduction of the Univer- sal Health Coverage Program in 2012 expanded coverage, which reached 82 percent of the popula- tion in 2017. At the same time, private investments upgraded existing health care establishments, which led to the privatization of almost 85 percent of providers. Figure 12 presents a snapshot of key public health Source: World Bank 2020 or latest indicators. As a percentage of GDP, health expendi- ture fell from 9.84 percent in 2009 to 7.11 percent in module enabled all public and private providers to 2018. OOP payments declined by 21.24 percentage report into one system, increasing data availability points in the same period to 46.77 percent of total about tested and uncovered cases. health expenditure in 2019. Although Georgia has a higher proportion of doctors (7.1 per 1,000 popula- Lessons learned and way forward tion) than its peers, the proportion of nurses (5.2 per 1,000) is the lowest. Thus, Georgia has one of the Optimizing healthcare infrastructure. Spare surge lowest nurse-per-doctor ratios (0.62) in the WHO capacity within the health sector was a determin- European Region. The number of hospital beds per ing factor in Georgia's health system’s resilience 1,000 population is also among the lowest in the during the shockwave. The country is one of the top region; however, bed occupancy remains below 50 five countries in the WHO European Region by the percent. number of acute (short stay) hospital beds and doc- tors per 100,000 population, which helped to meet Response to the shock the demand for medical care during the response to the pandemic. However, maintaining this spare Transmission of the virus was reduced by measures capacity during normal times and spending on sus- to restrict social mobility, such as introducing a lock- taining surplus hospital beds and physicians are also down, closing air connections with other countries, root causes of Georgia's health sector inefficiencies, maintaining quarantine for travelers, and closing and should not be considered a plausible solution non-essential public places. However, restrictions for resilience. were loosened in the second half of 2020, increasing cases. Hotel rooms and “fever clinics” were available Ensuring multisectoral collaboration. The Govern- as quarantine facilities for contacts and suspected ment of Georgia demonstrated effective steward- cases. Health care system capacity was increased ship, coordination, and implementation abilities by by postponing all elective hospital admissions paid taking the “right actions at the right time while pri- from public funds, discharging eligible patients oritizing the right to health” in its decisions during within 48-96 hours, and treating non-severe the first wave of the pandemic. However, the par- COVID-19 cases at home. Although financial incen- liamentary elections held in October and Novem- tives were provided to hospitals treating COVID-19 ber 2020 redirected the government’s priorities, patients, focus group discussions revealed that this bringing a surge in COVID-19 cases and deaths. did not always translate into bonuses for health Nonetheless, with adequate governance arrange- care workers. Governance was improved by imple- ments, the health system withstood the shock and menting a whole-of-government approach and recovered in response to the second wave, which establishing the Interagency Coordination Council emerged in mid-March 2021. As expressed by a and the Operational Headquarters on the Man- senior health policymaker during one of the focus agement of the State of Emergency. Lastly, Geor- group interviews, the “coordination during COVID- gia enhanced its already existing health information 19 response was unprecedentedly good. This is an system for surveillance of COVID-19 cases.35 Spe- outstanding lesson of how effective the govern- cifically, the COVID-19 Lab diagnostic electronic ment can be because of the joint and synchronous National Center for Disease Control and Public Health, 2021 35 27 A way forward for building RESILIENT HEALTH SYSTEMS action and how many tangible results the govern- ment could achieve." Developing efficient information systems. Health information systems played a critical role in the response to the COVID-19 pandemic. These sys- tems, especially those related to disease surveil- lance and capable of capturing data from both public and private players, proved their value in ren- dering real-time information for evidence-informed decision-making. Preparedness for future shocks should involve the development of and improve- ments to information systems for facilitating evi- dence-based decision-making. 28 A way forward for building RESILIENT HEALTH SYSTEMS Figure 13: Key public health indicators for Moldova Moldova Baseline characteristics and preparedness for shocks The health system of the Republic of Moldova is based on the principle of universal access to essen- tial health services and is financed through manda- tory health insurance. Figure 13 presents a snapshot of key public health indicators. Health expenditure has almost halved as a percentage of GDP in the last decade, from 11.4 percent in 2009 to 6.6 percent in 2018. While mandatory health insurance exists, pharmaceutical expenses still rely on OOP payments. At the same time, informal payments remain prevalent. Human resources are scarce in the country, and over half Source: World Bank 2020 or latest of the health care workforce is over 50 years old or retired. Hospitals are unevenly distributed, as and decision-makers who have worked together around 50 percent are in the capital city, where less and committed to supporting the health system to than 25 percent of the population lives. sustain itself and adequately respond to COVID-19. The Commission for Exceptional Situations of the Response to the shock Republic of Moldova and the Extraordinary National Commission for Public Health have played an Measures were first introduced to control the spread essential role in coordinating and planning intersec- of COVID-19 in March 2020, when educational insti- toral measures to respond to the pandemic at the tutions and public venues were closed, and air and rail national level. Both commissions also played reg- traffic suspended. Testing sampling was expanded ulatory roles during the pandemic period. Despite through mobile teams visiting suspected cases’ complex political transformations and structural homes. Health capacity was increased by referring reorganizations in the Ministry of Health and sub- mild COVID-19 cases to primary health care workers, ordinated agencies, including the NAPH, these who provided care through telemedicine or home institutions – in collaboration with development visits. Similarly, real-time National Agency for Public partners and civil society – have made tremendous Health (NAPH) data were used to readjust hospital efforts not just to alleviate the increasing pandemic bed capacity. Intersectoral groups were established challenges avoiding imminent risks to the public at the national and local levels to ensure an ade- health system collapse, but also to adapt to unfold- quate public health response. Moreover, Moldova ing pandemic urgencies, build additional capaci- collaborated with international partners (WHO, the ties, and improve capacity to respond to COVID-19. World Bank, USAID, and the EU) to assess medical Maintaining a whole-of-government approach will institutions, acquire critical medical equipment, and be critical for ongoing pandemic preparedness. increase capacity to treat patients with COVID-19. Improving health care coverage. State policies Lessons learned and way forward must focus on improving access to medicines for outpatient treatment. The coverage (compensa- Implementing actions guided by scientific evi- tion) policy can be strengthened by: expanding the dence. The surveillance system developed in Mol- number of essential medicines compensated for by dova has been adjusted to comply with WHO rec- the NHIC in outpatient treatment and, at the same ommendations and to provide the information time introducing exemptions from co-payments needed to monitor the epidemiological situation in for specific categories of the population, introduc- the country and ensure the comparability of data ing an income-based ceiling for all co-payments; at the regional and international level, as well as to the gradual exclusion of percentage co-payments substantiate decisions taken. At the same time, lab- that expose people to inefficiencies arising from oratory testing capabilities for COVID-19 have been improper prescription and release, high or fluctuat- expanded to meet the growing demand. ing prices; and addressing inefficiencies in purchas- ing, pricing and delivering medicines for outpatient Ensuring multisectoral collaboration. Moldova has treatment, including increasing the use of generic taken advantage of a large pool of stakeholders alternatives. 29 A way forward for building RESILIENT HEALTH SYSTEMS Ukraine (pre-war) Figure 14: Key public health indicators for Ukraine Baseline characteristics and preparedness for shocks Ukraine was one of the last post-Soviet countries to introduce health system reforms. In 2015, the government began its reform of the public health system by focusing on managing non-commu- nicable diseases and decentralizing public health functions to regional public health centers under the umbrella of the Center of Public Health, also transferring some of the sanitary control responsi- bilities to the Food Safety and Consumer Protection Service. Between 2015 and 2020, major fiscal and structural reforms took place, including creation of a single-purchaser and an explicit benefit package. Source: World Bank 2020 or latest Figure 14 presents a snapshot of key public health indicators. Health expenditure as a proportion of reduced the speed and effectiveness of the govern- GDP has considerably increased from 5.5 percent ment’s pandemic response. No single multi-sector in 2008 to 7.72 percent in 2018. However, OOP coordinating structure was instituted to oversee payments as a proportion of health expenditure responses across the health, social and economic increased from 37.79 percent in 2008 to 49.35 per- fields, and the COVID-19 emergency committee cent in 2018. Despite recent reforms, care delivery focused strongly on limiting transmission. There remains fragmented and heavily hospital-oriented, was also no transparent whole-of-government evidenced by an average stay of three days longer response plan to the pandemic (beyond surveil- than the European Union-27 average.36 Human lance, control, and treatment). The government did resources remained constant from 2000 to 2008. not clearly communicate alternative response sce- In 2009, doctors and nurses increased by 0.4 and narios and the trade-offs it considered in making 0.9 per 1,000 population, respectively. However, response choices. This weakness was compounded the numbers declined after the 2013-2014 crisis, by political turbulence, including frequent leader- with doctors per 1,000 falling from 3.49 in 2009 ship changes in the Ministry of Health in the critical to 2.99 in 2014 and nurses per 1,000 from 7.54 in first months of the epidemic. Ukraine should invest 2009 to 6.66 in 2014. in developing solid and clear leadership throughout future pandemic responses to prevent public mis- Response to the shock trust of government and ensure coordination across the different sectors. Ukraine introduced school closures to control the spread of the virus. Although the first case was Reorganizing health system functions. The COVID- detected on March 3, 2020, only in April were 19 crisis has highlighted design weaknesses in measures tightened by banning access to public Ukraine's intended model for public health reform parks and making facemask-wearing compulsory that require considerable change. Decentralizing in public spaces. Hospital capacity was increased at surveillance capacities, which was in progress in the expense of restricting elective care. In addition, early 2020, was a barrier to systemic contact-trac- over 500 designated facilities were used to treat ing efforts that required a capable and accountable COVID-19 patients. The main limitation was lack of regional agency to implement tracking and control. oxygen supply. Lastly, the government set up the The rapid response actions related to the Chief San- operational headquarters of the Ministry of Health itary Doctor's office's reinstatement helped to intro- of Ukraine to coordinate the COVID-19 response.37 duce some control measures. However, designing Changes in the Ministry of Health leadership were and building new public health architecture with frequent, diminishing public trust in the govern- vertically accountable regional Centers for Disease ment’s actions to deal with the pandemic. Control and Prevention linked to the newly devel- oped contract tracing system took much longer. Lessons learned and way forward These changes indicate that an optimal public health organization would balance vertical account- Ensuring a fast and coordinated response. Weak ability with creating strong regional stakeholders for capacity for whole-of-government coordination disease surveillance and control. 36 Zhao F et al., 2019 30 37 See https://zakon.rada.gov.ua/rada/show/v1319282-19#n14 A way forward for building RESILIENT HEALTH SYSTEMS Implementing reforms towards primary health care and digitalization of care. Ukraine's young health financing reform, the launch of which mostly coin- cided with the onset of the epidemic, became both an asset and a challenge for the crisis response. The PHC reform, already established by 2020, has ena- bled a fast roll-out of COVID-related services (such as on-site COVID-19 testing using COVID-19 anti- gen tests) and rapid financial compensation adjust- ments through increased capitation payments to PHC providers through the National Health Service of Ukraine (NHSU). The e-Health system has been an important platform that has enabled surveillance and, later, vaccination campaigns. Implementing new purchasing models. The new strategic health care purchasing approach made it easier to allocate and adjust the financing of pro- viders quickly. In particular, data collected by the NHSU on specialized service provision, combined with the new flexible purchasing arrangements, helped to strengthen the rules for appointing and financing COVID-19 hospitals in mid-2021, con- tracting fewer facilities with a higher number of adequately equipped beds. However, challenges remain as hospitals are financially challenged during the transition to new purchasing models; thus, a sustainable longer-term transition plan is needed, including a likely future period of fiscal consolida- tion. Most of the financial support for the transition went into salary increases, which was unsustainable in the medium term and conflicted with the reform’s intention (a shift to output-based contracting of services). 31 © 2023 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org