Strengthening hospital resilience in the Eastern Mediterranean Region.

"Adaptation is surviving but resilience is for thriving."In recent years, the multiple threats of COVID-19 and other disease outbreaks, intensified climate change and severe weather events, and increasing conflicts and humanitarian emergencies have highlighted the need to strengthen resilience in the different sectors, including social, economic, environment, and health. Resilience is the ability of a system, community or society exposed to hazards to resist, absorb, accommodate, adapt to, transform, and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management.

Analysis of human resources for health in Afghanistan.

Background: Despite large-scale investment in health service delivery outsourcing, few studies have examined human resources for health (HRH) in Afghanistan. Aims: To review the HRH situation of outsourced healthcare services in Afghanistan and evaluate nongovernment organization (NGO) investments in the health workforce. Methods: Two questionnaires were used for data collection. One gathered information about the characteristics of HRH in 2020 and the other collected budgetary data for 2017-2020 to analyse budget allocation and expenditure by NGOs on the health workforce. Results: A total of 25 262 (65% male, 35% female) individuals were employed by NGOs in 31 provinces of Afghanistan. There was a critical shortage of personnel and a prevalence of gender imbalance across all provinces. Healthcare workers were mostly aged 26 to 30 years. Services were mostly provided by local NGOs and their scopes were not limited to outsourced projects. More than 75% of the budget of NGOs was allocated to the health workforce in 2017-2020, and more than 70% of allocations was spent on staff salaries, followed by other health workforce expenditure. Less than 5% was spent on capacity building. Conclusion: There is a gross shortage and large gender imbalance in the Afghanistan health workforce. It is essential to maintain and increase current financial and technical investments to ensure sustainability and enhance the fragile health system in Afghanistan.

Malnutrition and gender disparities in the Eastern Mediterranean Region: The need for action.

Malnutrition takes a heavy toll on the populations of the Eastern Mediterranean Region (EMR), with gender related socioeconomic risk factors impacting undernutrition and obesity in both women and men. This perspective article, a derivative of a report by the World Health Organization, reviews the scientific literature on the effect of gender on malnutrition related outcomes in the EMR. Results revealed that biological and gender-related socioeconomic risk factors play a role for undernutrition and obesity in both women and men. Malnutrition can be negatively influenced by gender-biased cultural standards, habits, structural determinants, differential exposures, and health system gaps. This can result, for example, in women tending to focus on familial and household related needs, at the expense of their own health and physical mobility and on suffering more food insecurity, undernutrition, micronutrient deficiencies and obesity compared to men in the EMR. Conflict and crisis situations negatively affect both genders, but generally put women at a higher risk of adverse. Women's socially limited autonomy in mobility is also an obstacle to access to health services in the EMR, including those related to nutrition. Multi-level approaches are needed to address gender issues to enable a more equitable distribution of resources and reduce the impact of malnutrition in the EMR.

Sustainable Healthcare Depends on Good Governance Practices.

Effective leadership and governance are at the heart of creating and maintaining resilient health systems. COVID-19 exposed a plethora of issues in its wake, most notably the need to plan for resilience. Facing threats that swirl around climate, fiscal solvency, and emerging infectious diseases, healthcare leaders are challenged to think broadly on issues that affect operational viability. The global healthcare community has offered numerous approaches, frameworks, and criteria to assist leaders in creating strategies for better health governance, security, and resilience. As the world exits the worst of the pandemic, now is the time to plan for the sustainability of those strategies. Based on guidance developed by the World Health Organization, good governance is one key to sustainability. Healthcare leaders who develop measures to assess and monitor progress toward strengthening resilience can achieve sustainable development goals.

What is "hospital resilience"? A scoping review on conceptualization, operationalization, and evaluation.

Background: COVID-19 underscored the importance of building resilient health systems and hospitals. Nevertheless, evidence on hospital resilience is limited without consensus on the concept, its application, or measurement, with practical guidance needed for action at the facility-level. Aim: This study establishes a baseline for understanding hospital resilience, exploring its 1) conceptualization, 2) operationalization, and 3) evaluation in the empirical literature. Methods: Following Arksey and O'Malley's model, a scoping review was conducted, and a total of 38 articles were included for final extraction. Findings and discussion: In this review, hospital resilience is conceptualized by its components, capacities, and outcomes. The interdependence of six components (1) space, 2) stuff, 3) staff, 4) systems, 5) strategies, and 6) services) influences hospital resilience. Resilient hospitals must absorb, adapt, transform, and learn, utilizing all these capacities, sometimes simultaneously, through prevention, preparedness, response, and recovery, within a risk-informed and all-hazard approach. These capacities are not static but rather are dynamic and should improve continuously occur over time. Strengthening hospital resilience requires both hard and soft resilience. Hard resilience encompasses the structural (or constructive) and non-structural (infrastructural) aspects, along with agility to rearrange the space while hospital's soft resilience requires resilient staff, finance, logistics, and supply chains (stuff), strategies and systems (leadership and coordination, community engagement, along with communication, information, and learning systems). This ultimately results in hospitals maintaining their function and providing quality and continuous critical, life-saving, and essential services, amidst crises, while leaving no one behind. Strengthening hospital resilience is interlinked with improving health systems and community resilience, and ultimately contributes to advancing universal health coverage, health equity, and global health security. The nuances and divergences in conceptualization impact how hospital resilience is applied and measured. Operationalization and evaluation strategies and frameworks must factor hospitals' evolving capacities and varying risks during both routine and emergency times, especially in resource-restrained and emergency-prone settings. Conclusion: Strengthening hospital resilience requires consensus regarding its conceptualization to inform a roadmap for operationalization and evaluation and guide meaningful and effective action at facility and country level. Further qualitative and quantitative research is needed for the operationalization and evaluation of hospital resilience comprehensively and pragmatically, especially in fragile and resource-restrained contexts.

Hospitals early challenges and interventions combatting COVID-19 in the Eastern Mediterranean Region.

BACKGROUND: During rapidly evolving outbreaks, health services and essential medical care are interrupted as facilities have become overwhelmed responding to COVID-19. In the Eastern Mediterranean Region (EMR), more than half of countries are affected by emergencies, hospitals face complex challenges as they respond to humanitarian crises, maintain essential services, and fight the pandemic. While hospitals in the EMR have adapted to combat COVID-19, evidence-based and context-specific recommendations are needed to guide policymakers and hospital managers on best practices to strengthen hospitals' readiness, limit the impact of the pandemic, and create lasting hospital sector improvements towards recovery and resilience. AIM: Guided by the WHO/EMR's "Hospital readiness checklist for COVID-19", this study presents the experiences of EMR hospitals in combatting COVID-19 across the 22 EMR countries, including their challenges and interventions across the checklist domains, to inform improvements to pandemic preparedness, response, policy, and practice. METHODS: To collect in-depth and comprehensive information on hospital experiences, qualitative and descriptive quantitative data was collected between May-October 2020. To increase breadth of responses, this comprehensive qualitative study triangulated findings from a regional literature review with the findings of an open-ended online survey (n = 139), and virtual in-depth key informant interviews with 46 policymakers and hospital managers from 18 out of 22 EMR countries. Purposeful sampling supported by snowballing was used and continued until reaching data saturation, measures were taken to increase the trustworthiness of the results. Led by the checklist domains, qualitative data was thematically analyzed using MAXQDA. FINDINGS: Hospitals faced continuously changing challenges and needed to adapt to maintain operations and provide essential services. This thematic analysis revealed major themes for the challenges and interventions utilized by hospitals for each of hospital readiness domains: Preparedness, Leadership, Operational support, logistics, supply management, Communications and Information, Human Resources, Continuity of Essential Services and Surge Capacity, Rapid Identification and Diagnosis, Isolation and Case Management, and Infection, Prevention and Control. CONCLUSION: Hospitals are the backbone of COVID-19 response, and their resilience is essential for achieving universal health coverage. Multi-pronged (across each of the hospitals readiness domains) and multi-level policies are required to strengthen hospitals resilience and prepare health systems for future outbreaks and shocks.

Building resilient hospitals in the Eastern Mediterranean Region: lessons from the COVID-19 pandemic.

Since the COVID-19 pandemic began, hospitals in the Eastern Mediterranean Region (EMR) have faced significant challenges in providing essential services, while simultaneously combatting this pandemic and responding to new and ongoing shocks and emergencies. Despite these challenges, policy-makers and hospital managers adapted their hospital responses to maintain operations and continue providing essential health services in resource-restraint and fragile and conflict affected, offering valuable insights to others in similar contexts. The aim of this paper is to share the lessons learnt from hospital responses to COVID-19 from the EMR. To do this, we triangulated findings from literature review, open-ended online surveys and 46 in-depth key informant interviews from 18 EMR countries. Qualitative findings from semistructured key informant interviews along with the open-ended survey responses resulted in nine major themes for lessons learnt in the EMR. These themes include Preparedness, Leadership and Coordination, Communication, Human Resources, Supplies and Logistics, Surge Capacity and Essential Services, Clinical Management (including Rapid Identification, Diagnosis and Isolation), Infection Prevention and Control, and Information and Research. Each of the nine themes (domains) included 4-6 major subthemes offering key insights into the regional hospital response to health emergencies. Resilient hospitals are those that can provide holistic, adaptable, primary-care-based health systems to deliver high-quality, effective and people-centred health services and respond to future outbreaks. Both bottom-up and top-down approaches are needed to strengthen collaboration between policy-makers, hospitals, front-line workers and communities to mitigate the continued spread of SARS CoV2, build resilient hospital systems and improve public health preparedness and emergency response.

Exposing Obstetric Violence in the Eastern Mediterranean Region: A Review of Women's Narratives of Disrespect and Abuse in Childbirth.

Background: Obstetric violence (OV) threatens the provision of dignified, rights-based, high-quality, and respectful maternal care (RMC). The dearth of evidence on OV in the Eastern Mediterranean Region poses a knowledge gap requiring research to improve rights-based and respectful health practice and policy. While efforts to improve the quality of maternal health have long-existed, women's experiences of childbirth and perceptions of dignity and respect are not adequately or systematically recorded, especially in the said region. Aim: This study centered on the experiences of women's mistreatment in childbirth to provide an overview of OV and offer recommendations to improve RMC. Methods: A scoping review was conducted, and a total of 38 articles met the inclusion criteria and were analyzed using Bowser and Hill's framework of the seven typologies of Disrespect and Abuse (D&A) in childbirth. D&A in childbirth (or violations to RMC) is a manifestation of OV and served as a proxy to analyze its prevalence in the EMR. Findings and Discussion: This study indicated that across the EMR, women experienced every type of D&A in childbirth. This happens regardless of health systems' strength or country's income, with 6 out of 7 types of D&A found in almost two-thirds of included countries. In the EMR, the most common types of D&A in childbirth are physical abuse (especially overused routine interventions) and non-dignified care (embedded in patriarchal socio-cultural norms). The intersections of these abuses enable the objectification of women's bodies and overuse of unconsented routine interventions in a hierarchical and patriarchal system that regards the power and autonomy of doctors above birthing women. If unchecked, the implications include acceptance, continuation, and underreporting of D&A in childbirth, as well as passivity toward human-rights violations, which all further cause the continuing the cycle of OV. Conclusion: In order to eliminate OV, a paradigm shift is required involving infrastructure changes, education, empowerment, advocacy, a women-centered and gender-sensitive approach to health system strengthening, and policy development. Recommendations are given at individual, community, health systems, and policy levels to ensure that every woman achieves her right to health and birth in a dignified, respectful, and empowered manner.

Proactive Innovation in a Prolonged Conflict Setting: Facing COVID-19 in a Specialized Cancer Hospital in Palestine.

The prolonged ongoing conflict in Palestine exacerbated socioeconomic conditions and weakened the health system, complicating the management of COVID-19 pandemic, especially for cancer patients who are doubly-at risk. Augusta Victoria Hospital (AVH) is Palestine's only specialized cancer hospital, receiving patients from the Gaza Strip and the West Bank for oncology, nephrology, hematology, and radiotherapy. AVH's preparedness measures enabled its agile response. These proactive and innovative preparedness measures included: implementing a facility-level preparedness and response plan; utilizing multidisciplinary team-based and evidence-informed approaches to decision making; prioritizing health workers' safety and education; establishing in-house PCR testing to scale up timely screenings; and accommodating health workers, patients, and their relatives at hospital hotels, to maintain daily, continuous and critical health care for cancer patients and limit the spread of infection. At the facility-level, the biggest challenge faced by AVH was continuing essential and daily care for immunocompromised patients while protecting them from potential infection from relatives, hospital staff and other suspected patients. At the national level, the lack of preparedness, inequalities in vaccine distribution, political instability, violence, delays in obtaining medical exit permits to reach Jerusalem, weakened AVH's response. AVH's flexible financing, hospital accreditation, and strong leadership and coordination enabled its agility and resilience. Despite compiling challenges, the hospital's proactive and innovative interventions minimized the risk of infection among two high-risk groups: the immunocompromised patients and their health workers, providing invaluable lessons for health facilities in other fragile-and-conflict-affected settings.

Role of hospitals in recovery from COVID-19: Reflections from hospital managers and frontliners in the Eastern Mediterranean Region on strengthening hospital resilience.

Background: COVID-19 highlighted the critical role that hospitals play throughout the prolonged response and continuous recovery stages of the pandemic. Yet, there is limited evidence related to hospitals in the recovery stage, particularly capturing the perspectives of hospital managers and frontliners in resource-restrained and humanitarian settings. Objective: This paper aims to capture the perspectives of hospital managers and frontliners across the Eastern Mediterranean Region on (1) the role of hospitals in recovering from COVID-19, (2) Hospitals' expectations from public health institutions to enable recovery from COVID-19, (3) the Evaluation of hospital resilience before and through COVID-19, and (4) lessons to strengthen hospital resilience throughout the COVID-19 recovery. Methods: A multi-methods approach, triangulating a scoping review with qualitative findings from 64 semi-structured key-informant interviews and survey responses (n = 252), was used to gain a deeper context-specific understanding. Purposeful sampling with maximum diversity supported by snowballing was used and continued until reaching data saturation. Thematic analysis was conducted using MAXQDA and simple descriptive analysis using Microsoft Excel. Findings: In recovering from COVID-19, hospital managers noted hospitals' role in health education, risk reduction, and services continuity and expected human resource management, financial and material resource mobilization, better leadership and coordination, and technical support through the provision of updated clinical evidence-based information from their public health institutions. Qualitative findings also indicated that hospital managers attributed considerable changes in hospitals' resilience capacities to the pandemic and suggested that strengthening hospitals' resilience required resilient staff, sustainable finance, and adaptive leadership and management. Conclusion: Hospitals are the backbone of health systems and a main point of contact for communities during emergencies; strengthening their resilience throughout the various stages of recovery is critical. Hospitals cannot be resilient in silos but rather require an integrated-whole-of-society-approach, inclusive of communities and other health systems actors.

Standing up for your birth rights: An intersectional comparison of obstetric violence and birth positions between Quichua and Egyptian women.

Obstetric violence is a pervasive phenomenon in reproductive health across the world. Denial of the choice in birth position is a common form of obstetric violence as horizontal positions are non-evidence based, yet routinely imposed. This contributes to the cultural barriers to access reproductive health care. The present study compares women's experiences in childbirth from the Quichua and Egyptian communities, exploring the intersectional factors that contribute to obstetric violence and the adoption of preferred birth positions to offer recommendations on implementing respectful and rights-based reproductive care. Two independent scoping reviews have been carried out and subsequently compared. The intersectional approach revealed how gender, race, and class have a multiplicative effect on the denial of choice in birth position as a form of obstetric violence. This phenomenon exacerbates the pre-existing health disparities that disproportionately affect women, indigenous and racialized groups, and people living in poverty. Culturally competent, multilevel, and multidisciplinary interventions, strengthening of health systems, and community participation are essential to combat discrimination and guarantee birth rights. Allowing women to choose their birth position is a low-hanging fruit to challenge the complex issue of obstetric violence and ensure a rights-based approach to reproductive health.

Recruitment and retention strategies, policies, and their barriers: A narrative review in the Eastern Mediterranean Region.

BACKGROUND: Understanding factors affecting recruitment and retention of health workers in rural and remote communities is necessary for proper policy development and the equitable achievement of Universal Health Coverage. AIM: Review and synthesize the literature on interventions used to retain health workforce in rural and remote areas by low- and middle-income countries (LMICs) in the Eastern Mediterranean Region (EMR). METHOD: We carried out a narrative review of literature (peer-reviewed and gray) on the distribution and retention of health workers in rural and remote areas in the LMICs of the EMR. Out of the 130 retrieved articles, 21 met the inclusion criteria and were studied using WHO's Global Recommendations For Increasing Access To Health Workers In Remote And Rural Areas Through Improved Retention (education, regulation, financial, and personal/professional) as the analytical framework for extractions. RESULTS: There is a dearth of literature on retention in rural areas in the EMR and a complete absence of evaluation studies for implemented intervention. Various LMICs in the EMR have implemented interventions across one or more of the WHO four categories, especially educational and regulatory interventions. Limitations in the number and quality of published studies, fragmented data, over-representation of certain cadres in research and policies, and poor governance were chief barriers to the design, implementation, and evaluation of health workforce retention policies in rural and remote areas. The main challenges for EMR countries are in policy implementation and evaluation. Strengthening data governance and health information systems would improve evidence-based policies and enhance retention in rural and remote areas. CONCLUSIONS: There is a need for a focused research agenda supported by regional collaboration to guide policymakers on factors, challenges, and best practices that need to be considered for improving the distribution and retention of the health workforce by cadre, gender, and region.

Addressing health workforce shortages and maldistribution in Afghanistan.

BACKGROUND: Afghanistan has the second lowest health workforce density and the highest level of rural residing population in the Eastern Mediterranean Region. Ongoing insecurity, cultural, socio-economic and regulatory barriers have also contributed to gender and geographic imbalances. Afghanistan has introduced a number of interventions to tackle its health worker shortage and maldistribution. AIMS: This review provides an overview of interventions introduced to address the critical shortage and maldistribution of health workers in rural and remote Afghanistan. METHODS: A review of literature (including published peer-reviewed, grey literature, and national and international technical reports and documents) was conducted. RESULTS: The attraction and retention of health workforce in rural and remote areas require using a bundle of interventions to overcome these complex multidimensional challenges. Afghanistan expanded training institutions in remote provinces and introduced new cadres of community-based health practitioners. Targeted recruitment and deployment to rural areas, financial incentives and family support were other cited approaches. These interventions have increased the availability of health workers in rural areas, resulting in improved service delivery and health outcomes. Despite these efforts, challenges still persist including: limited female health worker mobility, retention of volunteer community-based health workforce, competition from the private sector and challenges of expanding scopes of practice of new cadres. CONCLUSIONS: Afghanistan made notable progress but must continue its efforts in addressing its critical health worker shortage and maldistribution through the production, deployment and retention of a "fit-for-purpose" gender-balanced, rural workforce with adequate skill mix. Limited literature inhibits evaluating progress and further studies are needed.