Macro level influences on strategic responses to the COVID-19 pandemic - an international survey and tool for national assessments.

BACKGROUND: Variation in the approaches taken to contain the SARS-CoV-2 (COVID-19) pandemic at country level has been shaped by economic and political considerations, technical capacity, and assumptions about public behaviours. To address the limited application of learning from previous pandemics, this study aimed to analyse perceived facilitators and inhibitors during the pandemic and to inform the development of an assessment tool for pandemic response planning. METHODS: A cross-sectional electronic survey of health and non-health care professionals (5 May - 5 June 2020) in six languages, with respondents recruited via email, social media and website posting. Participants were asked to score inhibitors (-10 to 0) or facilitators (0 to +10) impacting country response to COVID-19 from the following domains - Political, Economic, Sociological, Technological, Ecological, Legislative, and wider Industry (the PESTELI framework). Participants were then asked to explain their responses using free text. Descriptive and thematic analysis was followed by triangulation with the literature and expert validation to develop the assessment tool, which was then compared with four existing pandemic planning frameworks. RESULTS: 928 respondents from 66 countries (57% health care professionals) participated. Political and economic influences were consistently perceived as powerful negative forces and technology as a facilitator across high- and low-income countries. The 103-item tool developed for guiding rapid situational assessment for pandemic planning is comprehensive when compared to existing tools and highlights the interconnectedness of the 7 domains. CONCLUSIONS: The tool developed and proposed addresses the problems associated with decision making in disciplinary silos and offers a means to refine future use of epidemic modelling.

Macro level factors influencing strategic responses to emergent pandemics: A scoping review.

BACKGROUND: Strategic planning is critical for successful pandemic management. This study aimed to identify and review the scope and analytic depth of situation analyses conducted to understand their utility, and capture the documented macro-level factors impacting pandemic management. METHODS: To synthesise this disparate body of literature, we adopted a two-step search and review process. A systematic search of the literature was conducted to identify all studies since 2000, that have 1) employed a situation analysis; and 2) examined contextual factors influencing pandemic management. The included studies are analysed using a seven-domain systems approach from the discipline of strategic management. RESULTS: Nineteen studies were included in the final review ranging from single country (6) to regional, multi-country studies (13). Fourteen studies had a single disease focus, with 5 studies evaluating responses to one or more of COVID-19, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), Influenza A (H1N1), Ebola virus disease, and Zika virus disease pandemics. Six studies examined a single domain from political, economic, sociological, technological, ecological or wider industry (PESTELI), 5 studies examined two to four domains, and 8 studies examined five or more domains. Methods employed were predominantly literature reviews. The recommendations focus predominantly on addressing inhibitors in the sociological and technological domains with few recommendations articulated in the political domain. Overall, the legislative domain is least represented. CONCLUSIONS: Ex-post analysis using the seven-domain strategic management framework provides further opportunities for a planned systematic response to pandemics which remains critical as the current COVID-19 pandemic evolves.

Using a decision support systems computer simulation model to examine HIV and tuberculosis: the Russian Federation.

The aim of this paper is to describe the development and use of a computer simulation model that can be used as a Decision Support System (DSS) to tackle the critical public health issues of HIV and HIV-related tuberculosis in the Russian Federation. This country has recently witnessed an explosion of HIV infections and a worrying spread of the Multi-Drug Resistant form of Tuberculosis (MDRTB). The conclusions drawn are that a high population coverage with Highly Active Anti-Retroviral Treatment (HAART) (75% or higher), allied with high MDRTB cure rates, reduces cumulative deaths by 60%, with limited impact below this level. This research offers a simulation model that can be applied as a DSS by public health officials to inform policy making. By doing so, ways of controlling the spread of HIV and MDRTB and reduce mortality from these serious public health threats is provided.

Encouraging innovation: ten research priorities for achieving universal access to HIV/AIDS prevention, treatment and care in Europe by 2010.

When the HIV epidemic officially hit western Europe in the early 1980s, central and eastern Europe were almost completely spared due to the isolation of the Soviet Union. However, in the mid-1990s, reported new cases of HIV in eastern European countries began to increase exponentially. While there have been many declarations and strategies addressing HIV/AIDS, today the goal is universal access to HIV/AIDS prevention, treatment, care and support services by 2010. The articles included in this thematic issue of the Central European Journal of Public Health on HIV/AIDS reflect this, while the ten priorities listed below are immediate and sometimes innovative research needs in the context of preventing HIV among the most-at-risk populations. While by no means exhaustive, they are intended to point out gaps in existing knowledge and thus serve as inspiration for future research efforts.

Health systems' responses to 25 years of HIV in Europe: inequities persist and challenges remain.

Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as commercial sex workers, prisoners, intravenous drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in eastern Europe, where civil society or NGO culture is weak as compared to western Europe. Scaling up of effective responses in many countries in eastern Europe will be challenging-where increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of the civil society in planning and delivery of client-focused services.

Когда в системах здравоохранения нужны вертикальные (автономные) программы?

Немного найдется еще таких вопросов, касающихся организации систем здравоохранения и предоставления услуг, которые привлекали бы к себе столько же внимания, сколько споры о том, что нужнее и лучше – вертикальные или интегрированные программы здравоохранения. С 60-х годовпрошлого столетия основной акцент в литературе делается на сравнительную эффективность вертикальных подходов (узко сориентированных на одно заболевание или на одну услугу) в противоположность болеесистемным подходам. За это время оба подхода были реализованы в широких масштабах как в странах с низким и средним уровнем доходов, так и в странах с высоким уровнем доходов. При вертикальных моделях(их также называют автономными, категориальными программами, программами ведения заболевания или борьбы с заболеванием) меры вмешательства осуществляются через системы предоставления услуг, у которых обычно имеются отдельные административные структуры и бюджеты и которые характеризуются разной степенью структурной, финансовой и оперативной интеграции с более широкой системой здравоохранения. При интегрированной модели (она также называется горизонтальными подходами или программами) у служб нет отдельных административных структур или бюджетов, и услуги обычно предоставляются через учреждения здравоохранения, предоставляющие стандартные или общие услуги здравоохранения. Перед данным аналитическим обзором, поставлены три цели, в соответствии с которыми и построено изложение: раскрыть, что означает противопоставление вертикальной и интегрированной программ; оценить имеющиеся фактические данные и выводы о том, когда именно в системах здравоохранения нужны вертикальные программы; показать, в каких обстоятельствах вертикальные программы нужны в системах здравоохранения, и отметить факторы, которые должны принимать во внимание лица, вырабатывающие политику, рассматриваявопрос о внедрении вертикальных программ.

Wann sind vertikale (eigenständige) Programme in Gesundheitssystemen sinnvoll?

Nur wenige Sachfragen hinsichtlich der Organisation der Gesundheitssysteme und der Gesundheitsversorgung erregen so viel Aufmerksamkeit wie die Diskussion über vertikale und integrierte Gesundheitsprogramme. In der Literatur wird seit den 1960er Jahren hauptsächlich die Effektivität von vertikalen (krankheits- oder leistungsspezifischen) Konzepten mit der systembezogener Konzepte verglichen, und beide Ansätze wurden seitdem sowohl in Ländern mit niedrigem und mittlerem als auch in Ländern mit hohem Einkommen auf breiter Ebene umgesetzt. Bei vertikalen Konzepten (die auch als eigenständige Programme oder als Krankheitsbewältigungs- oder Krankheitsbekämpfungsprogramme bezeichnet werden) werden Interventionen durch Leistungssysteme bereitgestellt, die meist über eine eigene Verwaltung und ein eigenes Budget verfügen und deren strukturelle, finanzielle und operative Verflechtung mit dem allgemeinen Gesundheitssystem unterschiedlich stark ausgeprägt sein kann. Beim integrierten Modell (auch als horizontale Konzepte oder Programme bezeichnet) dagegenwerden die Dienste nicht gesondert verwaltet oder finanziert; vielmehr werden die Leistungen meist durch Gesundheitseinrichtungen erbracht, die für routinemäßige oder allgemeine Gesundheitsleistungen zuständig sind. Dieses Grundsatzpapier verfolgt drei Ziele und ist dementsprechend gegliedert: Erläuterung der Begriffe „vertikale“ und „integrierte“ Programme; Bewertung der verfügbaren Erkenntnisse und Lehren darüber, wann vertikale Programme in einem Gesundheitssystem sinnvoll sind; und Erläuterung, unter welchen Umständen vertikale Programme in den Gesundheitssystemen empfehlenswert sind, und Hinweis auf die Faktoren, die die Politik bei der Prüfung der Einführung vertikaler Programme berücksichtigen muss.

Quand les programmes verticaux (indépendants) ont-ils une place dans les systèmes de santé ?

Peu de questions relatives à l’organisation des systèmes de santé et des prestations de services ont suscité autant d’intérêt que le débat sur lesprogrammes de santé verticaux, d’une part, et intégrés, d’autre part. La littérature a mis l’accent sur l’efficacité comparée des approches verticales(spécifiques à une maladie ou à un service) par rapport aux approches plus systémiques depuis les années 60, les deux approches ayant été largement mises en oeuvre dans les pays à bas et moyens revenus ainsi que dans les pays nantis. Dans le cadre de l’approche verticale (également appelée programme indépendant, programme catégorique, programme de prise en charge de la maladie ou encore programme de contrôle de la maladie), les interventions sont assurées par le biais de systèmes de prestations qui disposent généralement d’une administration et de budgets distincts, avec intégrationopérationnelle, structurelle et de financement variée dans le système de santé plus large. Au sein du modèle intégré (connu également sous le nom d’approche ou programme horizontal), les services ne disposent pas d’une administration ou de budgets séparés et sont généralement assurés par des centres de soins fournissant des services de santé généraux et de routine. Cette synthèse poursuit trois objectifs autour desquels elle s’articule, à savoir : décrypter ce que l’on entend par programme vertical et programme intégré ; évaluer les bases factuelles et leçons disponibles concernant le moment où les programmes verticaux ont un rôle à jouer dans les systèmes de santé ; préciser dans quelles circonstances les programmes verticaux ont un rôle à remplir dans les systèmes de santé et identifier les paramètres dont les décideurs doivent tenir compte lorsqu’ils envisagent de mettre en oeuvre des programmes verticaux.

When do vertical (stand-alone) programmes have a place in health systems?

Few issues related to the organization of health systems and service delivery have attracted as much attention as the debate on vertical versus integrated health programmes. The literature has focused on the comparative effectiveness of vertical (disease- or service-specific) versus more systemic approaches since the 1960s, and both approaches have been widely implemented in low- and middle-income countries and in high-income countries. In vertical approaches (also referred to as stand-alone, categorical, disease management or disease control programmes), interventions are provided through delivery systems that typically have separate administration and budgets, with varied structural, funding and operational integration with the wider health system. In the integrated model (also known as horizontal approaches or programmes), services do not have separate administration orbudgets and are typically delivered through health facilities that provide routine or general health services. This policy brief has three objectives and is structured accordingly: to unpack what is meant by a vertical programme versus an integrated one; to assess the available evidence and lessons on when vertical programmes have a role to play in health systems; and to indicate under what circumstances vertical programmes have a role to play in health systems and to note the factors policy-makers need to take into account when considering implementing vertical programmes.

Policy brief: when do vertical (stand-alone) programmes have a place in health systems?

The terms vertical and integrated are widely used in health service delivery, but each describes a range of phenomena. In practice, the dichotomy between them is not rigid, and the extent of verticality or integration varies between programmes ­ including (1) a vertically funded, managed, delivered and monitored programme; (2) one with integrated funding, organization and management but separate delivery; and (3) a fully integrated approach comprising comprehensive primary health care services. Most health services combine vertical and integrated elements, but the balance between programmes in these elements varies considerably. Hence, when vertical and horizontal and programme design are being discussed, clarity is needed on the programme element being referred to: (1) governance arrangements, (2) organization, (3) funding and (4) service delivery.

High coverage with HAART is required to substantially reduce the number of deaths from tuberculosis: system dynamics simulation.

We used a system dynamics simulation model of the transmission dynamics of drug-sensitive tuberculosis (DSTB), multidrug-resistant tuberculosis (MDRTB) and HIV to estimate the impact of coverage with highly active antiretroviral therapy (HAART) and different cure rates for MDRTB in settings of explosive HIV epidemics and high MDRTB levels. Population coverage levels at 0%, 25%, 50%, 75% and 100% for HAART, and 5% and 80% of MDRTB treatment cure rates were simulated over a 10-year period and cumulative deaths from tuberculosis and HIV-associated tuberculosis were estimated for populations with latent tuberculosis, DSTB, MDRTB, HIV and HIV-associated tuberculosis. Depending on levels of HAART population coverage, increasing MDRTB cure rates from 5% to 80% reduces cumulative tuberculosis deaths by 1% and 13%. High population coverage with HAART (75% or higher), allied with high MDRTB cure rates, reduces cumulative deaths by 60%, with limited impact below this level. High coverage with HAART is required to substantially reduce the number of deaths from tuberculosis.

Diffusion of complex health innovations--implementation of primary health care reforms in Bosnia and Herzegovina.

Most transition countries in Central and Eastern Europe and Central Asia are engaged in health reform initiatives aimed at introducing primary health care (PHC) centred on family medicine to enhance performance of their health systems. But, in these countries the introduction of PHC reforms has been particularly challenging; while some have managed to introduce pilots, many have failed to these scale up. Using an innovation lens, we examine the introduction and diffusion of family-medicine-centred PHC reforms in Bosnia and Herzegovina (BiH), which experienced bitter ethnic conflicts that destroyed much of the health systems infrastructure. The study was conducted in 2004-05 over a 18-month period and involved both qualitative and quantitative methods of inquiry. In this study we report the findings of the qualitative research, which involved in-depth interviews in three stages with key informants that were purposively sampled. In our research, we applied a proprietary analytical framework which enables simultaneous and holistic analysis of the context, the innovation, the adopters and the interactions between them over time. While many transition countries have struggled with the introduction of family-medicine-centred PHC reforms, in spite of considerable resource constraints and a challenging post-war context, within a few years, BiH has managed to scale up multifaceted reforms to cover over 25% of the country. Our analysis reveals a complex setting and bidirectional interaction between the innovation, adopters and the context, which have collectively influenced the diffusion process. Family-medicine-centred PHC reform is a complex innovation-involving organizational, financial, clinical and relational changes-within a complex adaptive system. An important factor influencing the adoption of this complex innovation in BiH was the perceived benefits of the innovation: benefits which accrue to the users, family physicians, nurses and policy makers. In the case of BiH, policies or the innovation are not simply disseminated, but rather assimilated into the health system. The assimilation and implementation of the new PHC model relied on the consensus of a diverse group of adopters; the changes brought by the reforms were aligned with the expectations of the adopters: this created a 'receptive context' for adoption and diffusion of the innovation. The new family-medicine-centred PHC service model had a major impact on professional identity, inter-professional relationships and organizational routines. The post-conflict context was perceived as an opportunity to introduce the new model and implement transformational change, while the complex government structure meant the process of diffusion was as important as the innovation itself. In BiH, a holistic approach-comprising multifaceted and simultaneous interventions at multiple levels of the health system-reduced 'policy resistance' and enhanced the adoption and diffusion of the PHC reforms.

Reform of tuberculosis control and DOTS within Russian public health systems: an ecological study.

OBJECTIVES: To investigate the association between clinical need and hospital bed supply and utilization in Russia; and, to investigate these associations in areas where traditional Russian tuberculosis health care systems exist and where the directly observed therapy-short course (DOTS) strategy has been implemented. DESIGN: Ecological study using 2002 routine data. MAIN OUTCOME MEASURES: Hospital bed utilization and hospital admissions for patients with tuberculosis in regions that adhere to the traditional Russian method of managing tuberculosis and those where the DOTS strategy has been implemented. RESULTS: The ratio of beds per newly notified case was 0.86. The mean duration of hospital stay per admission was 86 days for non-DOTS regions and 90 days for regions where the DOTS strategy had been implemented. The number of admissions in each region correlated closely with the number of newly registered cases and hospital beds were, on average, occupied for 325 days. In the regions where the DOTS strategy had been implemented bed occupancy was 324 days. CONCLUSIONS: Under the Russian tuberculosis control system, hospital utilization is predominantly determined by supply-side factors, namely the number of tuberculosis dedicated hospital beds, and this system extends across all regions. Implementation of the DOTS strategy in Russia has not led to fundamental structural changes in tuberculosis control systems.

Impact of joined-up HIV harm reduction and multidrug resistant tuberculosis control programmes in Estonia: System dynamics simulation model.

In Eastern Europe and Central Asia (ECA) the control of tuberculosis, multidrug resistant tuberculosis (MDRTB) and human immunodeficiency virus (HIV) poses important public health challenges. We used system dynamics simulation to determine impact on cumulative HIV/AIDS, tuberculosis and HIV-associated-tuberculosis deaths, over 20 years, of harm-reduction programmes to reduce needle-sharing and injection-frequency amongst injecting drug users (IDUs) and multidrug resistant tuberculosis (MDRTB) control in a population with an explosive HIV epidemic in IDUs and high MDRTB prevalence. We estimate that the number of HIV-associated-deaths will decline by 30% with effective harm-reduction programmes but double if these are ineffective. In our model, effective MDRTB and HIV control reduces cumulative tuberculosis deaths by 54%, cumulative MDRTB deaths 15-fold and cumulative HIV-associated-tuberculosis-deaths 2-fold. Effective MDRTB control, without effective harm-reduction programmes, only reduce tuberculosis deaths by 22%. However, effective harm-reduction programme with a poor MDRTB control reduce cumulative tuberculosis deaths by 34%, MDRTB by 14% and HIV-associated-tuberculosis by 56%. Even with good control programmes for drug sensitive TB, neglecting harm reduction and MDRTB control will result in 50% more tuberculosis-related deaths than if both are effectively addressed. Effective harm-reduction programmes reduces cumulative deaths from tuberculosis more substantively than effective MDRTB control. Our finding have important policy implications for communicable disease policies in post-Soviet countries, which need to substantially change if they are to effectively address the emerging HIV and MDRTB epidemics.

Teaching evidence-based medicine to undergraduate medical students: a course integrating ethics, audit, management and clinical epidemiology.

A six-week full time course for third-year undergraduate medical students at Imperial College uniquely links evidence-based medicine (EBM) with ethics and the management of change in health services. It is mounted jointly by the Medical and Business Schools and features an experiential approach. Small teams of students use a problem-based strategy to address practical issues identified from a range of clinical placements in primary and secondary care settings. The majority of these junior clinical students achieve important objectives for learning about teamwork, critical appraisal, applied ethics and health care organisations. Their work often influences the care received by patients in the host clinical units. We discuss the strengths of the course in relation to other accounts of programmes in EBM. We give examples of recurring experiences from successive cohorts and discuss assessment issues and how our multi-phasic evaluation informs evolution of the course and the potential for future developments.

Health-systems efficiency in the Russian Federation: tuberculosis control.

OBJECTIVE: To conduct a comprehensive assessment of the case-mix of patients admitted to tuberculosis hospitals and the reasons for their admission in four Russian regions: Ivanovo, Orel, Samara and Vladimir. We also sought to quantify the extent to which efficiency could be improved by reducing hospitalization rates and re-profiling hospital beds available in the tuberculosis-control system. METHODS: We used a standard questionnaire to determine how beds were being used and who was using the beds in tuberculosis facilities in four Russian regions. Data were collected to determine how 4306 tuberculosis beds were utilized as well as on the socioeconomic and demographic indicators, clinical parameters and reasons for hospitalization for 3352 patients. FINDINGS: Of the 3352 patients surveyed about 70% were male; the average age was 40; and rates of unemployment, disability and alcohol misuse were high. About one-third of beds were occupied by smear-positive or culture-positive tuberculosis patients; 20% were occupied by tuberculosis patients who were smear-negative and/or culture-negative; 20% were occupied by patients who no longer had tuberculosis; and 20% were unoccupied. If clinical and public health admission criteria were applied then < 50% of admissions would be justified and < 50% of the current number of beds would be required. Up to 85% of admissions and beds were deemed to be necessary when social problems and poor access to outpatient care were considered along with clinical and public health admission criteria. CONCLUSION: Much of the Russian Federation's large tuberculosis hospital infrastructure is unnecessary when clinical and public health criteria are used, but the large hospital infrastructure within the tuberculosis-control system has an important social support function. Improving the efficiency of the system will require the reform of health-system norms and regulations as they relate to resource allocation and clinical care and implementation of lower-cost approaches to case management for patients with social problems. Additionally, closer attention will need to be paid to the management of staff numbers in the tuberculosis system.

Analysis of how the health systems context shapes responses to the control of human immunodeficiency virus: case-studies from the Russian Federation.

OBJECTIVE: To develop a methodology and an instrument that allow the simultaneous rapid and systematic examination of the broad public health context, the health care systems, and the features of disease-specific programmes. METHODS: Drawing on methodologies used for rapid situational assessments of vertical programmes for tackling communicable disease, we analysed programmes for the control human of immunodeficiency virus (HIV) and their health systems context in three regions in the Russian Federation. The analysis was conducted in three phases: first, analysis of published literature, documents and routine data from the regions; second, interviews with key informants, and third, further data collection and analysis. Synthesis of findings through exploration of emergent themes, with iteration, resulted in the identification of the key systems issues that influenced programme delivery. FINDINGS: We observed a complex political economy within which efforts to control HIV sit, an intricate legal environment, and a high degree of decentralization of financing and operational responsibility. Although each region displays some commonalities arising from the Soviet traditions of public health control, there are considerable variations in the epidemiological trajectories, cultural responses, the political environment, financing, organization and service delivery, and the extent of multisectoral work in response to HIV epidemics. CONCLUSION: Within a centralized, post-Soviet health system, centrally directed measures to enhance HIV control may have varying degrees of impact at the regional level. Although the central tenets of effective vertical HIV programmes may be present, local imperatives substantially influence their interpretation, operationalization and effectiveness. Systematic analysis of the context within which vertical programmes are embedded is necessary to enhance understanding of how the relevant policies are prioritized and translated to action.