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      Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage

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      , MSc a , b , * , , PhD c , d , , MD e , , MD f , g , , MBA d
      Lancet (London, England)
      Elsevier Ltd.

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          Abstract

          The COVID-19 pandemic has placed enormous strain on countries around the world, exposing long-standing gaps in public health and exacerbating chronic inequities. Although research and analyses have attempted to draw important lessons on how to strengthen pandemic preparedness and response, few have examined the effect that fragmented governance for health has had on effectively mitigating the crisis. By assessing the ability of health systems to manage COVID-19 from the perspective of two key approaches to global health policy—global health security and universal health coverage—important lessons can be drawn for how to align varied priorities and objectives in strengthening health systems. This Health Policy paper compares three types of health systems (ie, with stronger investments in global health security, stronger investments in universal health coverage, and integrated investments in global health security and universal health coverage) in their response to the ongoing COVID-19 pandemic and synthesises four essential recommendations (ie, integration, financing, resilience, and equity) to reimagine governance, policies, and investments for better health towards a more sustainable future.

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          Most cited references36

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          The Italian health system and the COVID-19 challenge

          Italy is facing a massive burden from the coronavirus disease 2019 (COVID-19) pandemic. Since Feb 21, 2020, when the first case of COVID-19 was recorded in Italy, the National Healthcare Service, which offers universal access to health care, has faced increasing pressure, with 41 035 total cases of COVID-19 and 3405 deaths as of March 19, 2020. 1 In the most affected regions, the National Healthcare Service is close to collapse—the results of years of fragmentation and decades of finance cuts, privatisation, and deprivation of human and technical resources. The National Healthcare Service is regionally based, with local authorities responsible for the organisation and delivery of health services, leaving the Italian Government with a weak strategic leadership. Over the period 2010–19, the National Healthcare Service suffered financial cuts of more than €37 billion, a progressive privatisation of health-care services. Public health expenditure as a proportion of gross domestic product was 6·6% for the years 2018–20 and is forecast to fall to 6·4% in 2022. 2 The Lombardy region has the heaviest burden of the COVID-19 pandemic, with (as of March 19, 2020) 19 884 total cases of the disease, 2168 deaths, and 1006 patients requiring advanced respiratory support. At its standard operational level, Lombardy has a capacity of 724 intensive care beds. 3 To tackle the medical equipment shortage, Italian Civil Protection undertook a fast-track public procurement to secure 3800 respiratory ventilators, an additional 30 million protective masks, and 67 000 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests. 4 To avert the shortage of health workers produced by decades of inadequate recruitment practices, the Italian Government authorised regions to recruit 20 000 health workers, allocating €660 million for the purpose. 5 There are lessons to be learned from the current COVID-19 pandemic. First, the Italian decentralisation and fragmentation of health services seems to have restricted timely interventions and effectiveness, and stronger national coordination should be in place. Second, health-care systems capacity and financing need to be more flexible to take into account exceptional emergencies. Third, in response to emergencies, solid partnerships between the private and public sector should be institutionalised. Finally, recruitment of human resources must be planned and financed with a long-term vision. Consistent management choices and a strong political commitment are needed to create a more sustainable system for the long run.
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            Are high-performing health systems resilient against the COVID-19 epidemic?

            As of March 5, 2020, there has been sustained local transmission of coronavirus disease 2019 (COVID-19) in Hong Kong, Singapore, and Japan. 1 Containment strategies seem to have prevented smaller transmission chains from amplifying into widespread community transmission. The health systems in these locations have generally been able to adapt,2, 3 but their resilience could be affected if the COVID-19 epidemic continues for many more months and increasing numbers of people require services. We outline some of the core dimensions of these resilient health systems 4 and their responses to the COVID-19 epidemic. First, after variable periods of adaptation, the three locations took actions to manage the outbreak of a new pathogen. Surveillance systems were readjusted to identify potential cases while public health staff identified their contacts. National laboratory networks developed diagnostic tests once the COVID-19 genetic sequences were published 5 and laboratory testing capacity was increased in all three locations, although expansion of the diagnostic capacity to university and large private laboratories in Japan is still ongoing. In Hong Kong, initially, only pneumonia patients without a microbiological diagnosis were tested, but surveillance has been broadened to include all inpatients with pneumonia and a purposively sampled proportion of outpatients and emergency attendees totalling about 1500 per day (Leung GM, unpublished). Japan's testing strategy has also evolved with diagnostic tests now offered to all suspected cases irrespective of their travel history; however, there are reports of cases that should have been tested but were not. Different strategies were used to selectively control travellers entering these locations. In Singapore, there was a stepwise series of decisions to restrict entry for anyone from mainland China and, more recently, from northern Italy, Iran, and South Korea. Hong Kong has imposed mandatory 14-day quarantine for everyone who enters from the mainland, and denies entry to non-local visitors from South Korea and Iran as well as the most affected parts of Italy. In Japan, there were travel restrictions on citizens from Hubei and Zhejiang provinces, and cruise ships with cases of COVID-19 were quarantined. Second, intragovernmental coordination was improved because health authorities drew on their experiences of severe acute respiratory syndrome during 2002–03 in Hong Kong and Singapore, H5N1 avian influenza in 1997 in Hong Kong, and the 2009 influenza H1N1 pandemic in all three locations. Hong Kong and Singapore began interministerial coordination within the first week, whereas Japan did this in early February when the operation to quarantine passengers on the Diamond Princess cruise ship was heavily criticised as inadequate, resulting in the widespread infections among crew and passengers. Third, all locations adapted financing measures so that all direct costs for treating patients are borne by the governments. In Singapore, the government pays the cost of hospitalisation, irrespective of whether the patient is from Singapore or abroad. In Japan, funding has been provided through routine financing and contingency funds. Meanwhile, Hong Kong is using routine financing that already pays for all such care. Fourth, the three health systems developed plans to sustain routine health-care services, but the integration of services has been problematic. In Japan, as the capacity at designated hospitals becomes overstretched, the coordination between hospitals and local government will be a major challenge. In Singapore, at the beginning of the outbreak, there were difficulties with disseminating information to the private sector. In all locations, intensive-care unit bed capacity is limited. © 2020 Roslan Rahman/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Fifth, in all locations, critical care treatment and medicines have been available for patients with COVID-19, but adequate supplies of personal protective equipment in hospitals and face masks in the community are a key concern. In Japan and Hong Kong, hospital supplies are running low but have not yet impacted clinical management. In all locations, pressure on critical care treatment is likely if there is a sustained increase in cases of COVID-19. Sixth, in all three locations training and adherence to infection prevention and control measures in hospitals have largely been appropriate, but Japan could face a shortage of infectious disease specialists. Health-care staff are stretched in all localities, especially in selected designated hospitals. Long-term escalation in the need for health services will place pressures on health-care workers, and could at some point compromise the clinical management of people with COVID-19 and other patients. Seventh, management of information systems is comprehensive in all locations. In Singapore, there are almost daily meetings between Regional Health System managers, hospital leaders, and the Ministry of Health. However, in Japan information sharing across prefectures could be improved. The interoperability of systems between the government health department and public hospitals in Hong Kong is not optimal. Timely, accurate, and transparent risk communication is essential and challenging in emergencies because it determines whether the public will trust authorities more than rumours and misinformation. 6 Singapore health authorities provide daily information on mainstream media, the Ministry of Health has Telegram and WhatsApp groups set up with doctors in the public and private sectors where more detailed clinical and logistics information is shared, and authorities use websites to debunk circulating misinformation. Risk communications to establish trust in authorities has been less successful in Japan and Hong Kong. Finally, the political environment and differences in communities and their moods and values are important. The ongoing social unrest in Hong Kong has led to a breakdown of public trust with the government 7 and affected front-line health-care staff and the reception and acceptance of government information. 8 In Hong Kong and Singapore, rumours led to panic purchasing to the extent that shops ran out of some food and supplies. 9 In Japan, concerns related to the Diamond Princess cruise ship and the sudden announcement of school closures fuelled increased public anxiety. The three locations introduced appropriate containment measures and governance structures; took steps to support health-care delivery and financing; and developed and implemented plans and management structures. However, their response is vulnerable to shortcomings in the coordination of services; access to adequate medical supplies and equipment; adequacy of risk communication; and public trust in government. Moreover, it is uncertain whether these systems will continue to function if the requirement for services surges. Three important lessons have emerged. The first is that integration of services in the health system and across other sectors amplifies the ability to absorb and adapt to shock. 2 The second is that the spread of fake news and misinformation constitutes a major unresolved challenge. Finally, the trust of patients, health-care professionals, and society as a whole in government is of paramount importance for meeting health crises.
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              What is a resilient health system? Lessons from Ebola.

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                Author and article information

                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier Ltd.
                0140-6736
                1474-547X
                1 December 2020
                2-8 January 2021
                1 December 2020
                : 397
                : 10268
                : 61-67
                Affiliations
                [a ]Department of Health Policy, London School of Economics and Political Science, London, UK
                [b ]Women in Global Health, Washington, DC, USA
                [c ]O'Neill Institute, Georgetown University, Washington, DC, USA
                [d ]Centre for Universal Health, Chatham House, London, UK
                [e ]Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
                [f ]UHC2030, Nairobi, Kenya
                [g ]Amref Health Africa, Nairobi, Kenya
                Author notes
                [* ]Correspondence to: Mr Arush Lal, Department of Health Policy, London School of Economics and Political Science, London WC2N 5BY, UK
                Article
                S0140-6736(20)32228-5
                10.1016/S0140-6736(20)32228-5
                7834479
                33275906
                ae48d31e-89d9-4dec-903a-4fc821b2e4cd
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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