Blockchain Papers

Esteban Ortiz‐Prado, María Paz Cadena, Jorge Vasconez-Gonzalez, Juan S. Izquierdo-Condoy

Latin America and the Caribbean are a global hotspot for emerging and re-emerging infectious diseases, yet regional One Health preparedness remains uneven and incompletely operationalized. This narrative Mini Review synthesizes evidence published mainly between 2015 and 2026 on One Health preparedness for emerging infectious diseases in the region, emphasizing how environmental disruption and climate change shape zoonotic and vector-borne spillover risk. Available regional surveys suggest broad professional familiarity with the One Health concept but limited operational implementation, with environmental health frequently identified as the least-integrated domain. We argue that spillover risk—and the failure to detect and contain spillover once it occurs—should be understood as a system-level outcome shaped by ecological disruption, socioeconomic vulnerability, surveillance capacity, and governance, rather than as an isolated biological event: deforestation, agricultural and extractive expansion—including illegal mining and logging—unplanned urbanization, and climate variability generate new human–animal–vector interfaces, while fragmented governance, uneven and poorly decentralized laboratory capacity, and limited reservoir and environmental surveillance leave these interfaces unmonitored. Environmental and climatic drivers are robustly linked to spillover, although the pathways are disease-specific rather than universal, and socioeconomic vulnerability concentrates the resulting burden in Indigenous, rural, and marginalized populations. We identify priority gaps in integrated surveillance, decentralized diagnostics, genomic capacity, reservoir ecology, governance, financing, and equity, and propose an agenda for anticipatory, climate-informed, and context-sensitive preparedness.

Virgil Kuassi Lokossou, Aishat Bukola Usman, Issiaka Sombie, Oluomachukwu Omeje · 34 authors

BACKGROUND: Lassa fever remains a major public health threat in West Africa, requiring coordinated scientific, policy, and financing responses. Regional scientific convenings are increasingly used to connect research evidence with policy action, yet their contribution to epidemic preparedness is not well documented. METHODS: We conducted a qualitative health systems and policy analysis of the 2nd ECOWAS Lassa Fever International Conference (ELFIC 2025) in Abidjan, Côte d'Ivoire. Data sources comprised 302 scientific abstracts, plenary and ministerial session records, and the official Ministerial Joint Communiqué. Using the conference's six thematic pillars as a deductive framework, we conducted a thematic content analysis and synthesized findings into four domains: scientific advances; surveillance and laboratory systems; policy and financing insights; and cross-cutting lessons for regional preparedness. RESULTS: Progress was noted in diagnostics, therapeutics, vaccine development, decentralized laboratory capacity, genomic surveillance, and digital reporting. Persistent gaps remain at sub-national and community levels, in surveillance coverage, workforce capacity, and operational readiness. A major outcome was the Ministerial Joint Communiqué endorsing regional co-financing for Lassa fever vaccine development. CONCLUSION: ELFIC 2025 demonstrates the role of regional scientific platforms in aligning evidence with policy commitments. Sustained impact will require institutionalized coordination, strengthened accountability, and targeted investments in frontline capacity.

Ezinne Victory Kanu, Charles Chibuisi Ehiemere, Ishaku Adamu Akyala, Eric Terkuma Chia · 5 authors

Despite global commitments under SDG-3, maternal mortality rates remain disproportionately high in Sub-Saharan Africa. This review examines how health policies have shaped outcomes between 2014 and 2024 in Nigeria, Rwanda, South Africa, and Gabon. A comparative narrative review was conducted using WHO, World Bank, UNFPA, DHS, and national policy documents. Guided by the Walt & Gilson Policy Triangle and the WHO Health System Building Blocks, policies were assessed for context, content, actors, process, and health system capacity. Data were synthesized thematically to compare implementation and outcomes. Rwanda achieved substantial declines through decentralized financing, performance-based funding, and community health worker integration. South Africa reduced deaths via integration of HIV and maternal services but still faces equity gaps. Gabon improved financial access but rural infrastructure and workforce limitations constrain outcomes. Nigeria’s fragmented governance and weak PHC financing explain stagnation despite multiple reforms. Implementation quality, not policy presence, drives progress. Strengthening governance, financing transparency, workforce readiness, and community engagement remains crucial for achieving SDG-3. This study highlights cross-country lessons transferable to similar contexts.

John Chinemerem Ogbete, AbuYusuf Aminu-Ibrahim, Obinna Chima Iwuanyanwu

Scaling molecular diagnostic facilities is essential for meeting growing demands for infectious disease surveillance, oncology, genetic screening, and precision medicine, particularly across resource-constrained and rapidly expanding health systems. This study examines how standardized infrastructure and operational design models can enable scalable, high-quality molecular diagnostics while ensuring biosafety, regulatory compliance, and cost efficiency. It synthesizes insights from laboratory engineering, health systems planning, and diagnostic network design to propose an integrated approach to molecular facility expansion. Standardized infrastructure models emphasize modular laboratory layouts, flexible cleanroom zoning, validated airflow and contamination control systems, and harmonized utilities for power, water, and waste management. These design principles enable rapid replication, phased expansion, and adaptability to evolving assay technologies without compromising analytical integrity. Operational design models complement physical standardization through optimized workflow sequencing, sample logistics, equipment utilization, and quality management systems aligned with international laboratory standards. Together, these models reduce setup time, minimize variability, and support consistent performance across decentralized molecular testing sites. The study further highlights the role of digital enablement in scaling molecular diagnostics, including laboratory information management systems, remote monitoring platforms, and standardized data architectures that support traceability, quality assurance, and network-level oversight. Workforce-aligned operational models, incorporating task differentiation, competency-based training, and remote supervision, are identified as critical to sustaining performance in settings with limited specialist capacity. Financing and governance mechanisms, including pooled procurement, regional laboratory networks, and public–private partnerships, are discussed as enablers of affordability and long-term sustainability. The study concludes that scalable molecular diagnostic capacity depends on the integration of standardized infrastructure with adaptive operational design. By embedding flexibility, quality assurance, and interoperability into facility and workflow models, health systems can rapidly expand molecular testing while maintaining safety, reliability, and regulatory alignment. Such approaches strengthen outbreak preparedness, support routine disease management, and advance equitable access to advanced diagnostics across diverse healthcare contexts. Importantly, standardization does not constrain innovation but provides a stable platform for continuous technological evolution, network optimization, and resilient diagnostic system growth in low-, middle-, and high-income settings globally. These frameworks also facilitate benchmarking, performance comparison, regulatory audits, and coordinated scale-up across national, regional, and cross-border diagnostic ecosystems worldwide.

Shinsuke Miyano, Ikuma Nozaki, Masahiko Hachiya, Tetsuya Miyamoto · 5 authors

The COVID-19 pandemic exposed critical gaps in regional health security mechanisms, prompting ASEAN to establish the ASEAN Centre for Public Health Emergencies and Emerging Diseases (ACPHEED), with functions distributed across Indonesia, Thailand, and Vietnam. This policy analysis examines strategic development approaches for ACPHEED through comprehensive benchmarking of the European Centre for Disease Prevention and Control (ECDC), Africa Centres for Disease Control and Prevention (Africa CDC), and Gulf CDC, supported by consultations in Indonesia (2024) and Sweden (2025) involving ASEAN member states and international partners. A comparative analysis reveals distinct organizational models: the ECDC operates within European Union (EU) institutional frameworks emphasizing functional specialization; the Africa CDC employs decentralized Regional Coordination Centers; and the Gulf CDC implements hybrid governance via Permanent Communication Networks. Each model offers valuable lessons for ACPHEED's development, particularly concerning governance structures that balance regional coordination with national sovereignty. ACPHEED faces unique challenges due to ASEAN's consensus-based, nonlegislative institutional nature and its tri-country operational structure. Critical success factors include phased surveillance emphasizing a defined scope and capacity building; inclusive governance mechanisms ensuring equitable member-state ownership; and operational frameworks applying subsidiarity principles to complement existing ASEAN mechanisms. Sustainable financing remains paramount given ASEAN's limited budgetary authority. Japan's strategic partnership should capitalize on its technical expertise in laboratory systems, digital surveillance, and disaster preparedness through comprehensive institutional support. ACPHEED's success depends on sustained political commitment, realistic financial arrangements, and effective integration into global health security architectures. This analysis provides a strategic roadmap for ACPHEED's preparatory phase so that it can serve as a regional health security leader while addressing ASEAN-specific institutional constraints.

Elizabeth Juma, Dorothy Achu, Abbie Barry, Abate Beshah · 23 authors

The 2025 Annual Meeting of National Neglected Tropical Disease (NTD) Programme Managers (2025 PMM) in the WHO African Region convened stakeholders in Lomé, Togo, under the theme "Innovating for Acceleration: Pathway to NTD Elimination." A key focus was the changing funding environment and the necessity for enhanced integration of NTD services within health systems to guarantee sustainable advancement toward the 2030 elimination goals. The conference was convened in the context of substantial disruptions stemming from the USAID funding pause, which interrupted essential mass drug administration (MDA) programmes and epidemiological monitoring activities across multiple nations. Country experiences highlighted the fragility of external funding dependence and underscored the importance of domestic resource mobilization, decentralized implementation, and programmatic integration. Strategic discussions highlighted opportunities to incorporate NTD services into national health financing mechanisms, and routine health campaigns, alongside leveraging digital tools and partnerships. Participants emphasized the urgency of political commitment, sustained investments, and integrated service delivery models to build resilience and close equity gaps. The meeting further underscored the need for bold, country-led responses and multisectoral collaboration to advance NTD elimination efforts in a rapidly evolving global health financing environment.

Hamidreza Khankeh, Samaneh Motalebi, naajmeh yazdanparast, Abbas Naboureh

Background: Over the past three decades, four international frameworks the Yokohama Strategy (1994), Hyogo Framework for Action (2005–2015), Sendai Framework (2015–2030), and WHO’s Health-EDRM Framework (2019) have shaped the disaster risk reduction (DRR) agenda. Despite advancing norms and principles, a persistent gap remains between policy commitments and implementation, particularly in integrating health systems.Methods: This study conducted a structured qualitative framework analysis of official UN and WHO documents, technical guidance, and monitoring reports. Frameworks were compared across four dimensions: governance, health system integration, monitoring and accountability, and financing/implementation guidance.Findings: Findings show a shift from state-centered governance toward multi-level, all-of-society approaches, although decision-making remains largely centralized. Health integration has progressed from minimal attention in Yokohama to explicit targets in Sendai and operational guidance in Health-EDRM; however, implementation remains fragmented. Monitoring systems have improved, particularly with Sendai’s 38 indicators, yet challenges in data quality and interoperability persist. Financing is consistently the weakest dimension, with limited guidance on sustainable funding.Conclusion: Overall, while DRR frameworks demonstrate normative and institutional progress, gaps in financing, decentralization, and alignment between Sendai monitoring and Health-EDRM implementation limit effectiveness. Future research should focus on translating global frameworks into local practice and their interaction with climate-related agreements.

David Olpengs, Jennifer Mamwa

Introduction Over the past two decades, Sub-Saharan Africa has achieved remarkable progress toward the UNAIDS 95-95-95 targets through sustained donor investment, community leadership, and political commitment. However, in early 2025, abrupt funding contractions including the suspension of PEPFAR disbursements by the United States and significant cuts by other major donors, threaten to reverse gains in HIV diagnosis, treatment initiation, and viral suppression. This study examines the potential impact of these funding shifts on the HIV response and explores strategies to sustain progress in a changing financing landscape. Methodology This review employed a structured narrative synthesis approach. A comprehensive search was conducted across peer-reviewed journals, grey literature, and institutional reports published between 2020 and 2025. Databases searched were PubMed, Google Scholar, and institutional repositories of UNAIDS, PEPFAR, USAID, and the Global Fund, using terms such as “HIV/AIDS,” “Sub-Saharan Africa,” “95-95-95 targets,” “donor funding cuts,” and “health system resilience.” Of 99 records identified, 15 articles and reports met inclusion criteria. Data were thematically analyzed along the three pillars of the 95-95-95 framework, emphasizing health system resilience, equity, and sustainability. Findings Funding cuts have led to immediate service delivery challenges. HIV testing programs in East and Southern Africa report supply chain interruptions, staff shortages, and reduced outreach, particularly in marginalized communities. ART initiation has slowed due to clinic budget constraints and inadequate safety nets, leading to declines in patient retention and treatment uptake. Viral load monitoring systems are increasingly strained, with insufficient resources for reagents, equipment, and logistics. These disruptions are projected to cause a sixfold increase in new infections and a surge in AIDS-related mortality by 2029 if unaddressed. Furthermore, funding disparities are exacerbating inequities, with countries like Botswana and Eswatini maintaining progress due to better ability to absorb shocks, while conflict-affected and resource-poor regions face greater setbacks. Discussion The donor funding shortfall presents both a crisis and an opportunity. Immediate mitigation requires tapping emergency funds, reprogramming health budgets, and negotiating bridge financing with bilateral and multilateral partners. Long-term sustainability hinges on strengthening domestic resource mobilization through health levies, sin taxes, and diaspora bonds, integrating HIV services into primary healthcare, and scaling digital and community-led service delivery platforms for decentralized adherence support. Geospatial targeting and real-time data systems can optimize resource allocation to emerging hotspots. By fostering regional solidarity and community-driven financing, Sub-Saharan Africa can convert this funding crisis into an opportunity for resilient, locally owned HIV responses that keep the path to ending AIDS within reach.

Marco Antônio Catussi Paschoalotto, Eduardo Alves Lazzari, Rudi Rocha, Adriano Massuda · 5 authors

Health system resilience (HSR) is essential to sustaining equitable essential functions under acute and chronic stressors in decentralized systems. We developed and validated a Brazil-tailored HSR framework that distinguishes steady-state performance from resilience-specific capacities and assigns responsibilities across federal, state, regional, and municipal levels. Using a three-phase qualitative deductive-inductive approach with 48 international and national experts, we identified nine dimensions, 18 subdimensions, and 65 indicators that prioritise governance coherence, surge workforce strategies, emergency regulation, real-time monitoring, and access to critical technologies. The framework clarifies boundaries between general health system performance and adaptive, absorptive, and transformative functions, and specifies how managers can apply it in practice through structured scoping, mapping, scoring, prioritisation, planning, and monitoring steps. Although designed for Brazil's Unified Health System (SUS), the development logic generalises to other decentralised contexts with appropriate re-allocation of responsibilities and calibration to national financing rules. This policy-facing tool supports actionable resilience strengthening in complex, multi-level systems.

Saadaq Adan Hussein, Marian Muse Osman, Mohamed Mohamoud Hassan, Mohamed Abdullahi Awale · 19 authors

INTRODUCTION: Somalia, the 44th largest country in the world by land area, struggles with a heavy burden of infectious diseases. Since 1991, populations have lacked essential health services, exacerbated by recurring infectious-disease outbreaks. Recurrent outbreaks of measles, cholera, and polio have devastated public health, generating significant morbidity and mortality. Despite improvements through new graduates, these issues remain unresolved. This study examines the impact of climate change on infectious-disease outbreaks in Somalia focusing on cholera, measles, and polio-to fill a gap in the literature by linking climate variability with outbreak dynamics and identifying weaknesses in Somalia's health system. The findings will inform targeted public-health strategies. METHOD: Following PRISMA guidelines, we undertook a narrative review of English-language literature (1990 - March 2025). Searches in PubMed, Scopus, Web of Science and Google Scholar combined terms for infectious-disease outbreaks, climate change and Somalia/Horn of Africa. Of 202 records identified, 74 met inclusion criteria. Two reviewers independently screened, extracted data and applied six-step inductive coding in NVivo 12, synthesizing findings into thematic domains. RESULTS: Four interlinked themes emerged. (1) Fragile health system: < 0.4 doctors, nurses and midwives per 10 000 population, poorly equipped facilities and patchy surveillance. (2) Control measures: routine immunization completeness ≈20%; limited oral-cholera-vaccine and WASH coverage sustain transmission. (3) Political instability and conflict: insecurity, decentralized coordination and ≥ 2.6 million IDPs hamper rapid response. (4) Impact of climate change: drought-induced water scarcity and flood-related latrine breaches create year-round face-oral exposure, while climate shocks divert resources and swell susceptibility pools. CONCLUSION: Outbreak control in Somalia now hinges on integrating climate adaptation with health-system strengthening. Climate-proofed WASH infrastructure, mobile vaccination and surveillance linked to hydro-meteorological alerts, a National Outbreak Operations Centre, and ring-fenced financing are urgent priorities. Without such measures each extreme-weather event will erase hard-won gains; with them, Somalia can break the climate-outbreak feedback loop.

Denis Okethwangu, Marit Johansen, Sherry Rita Ahirirwe, Mahima Venkateswaran · 16 authors

Abstract Stronger health systems are better equipped to withstand shocks and continue providing quality services as response measures are implemented. We conducted a systematic review to synthesize the understanding of the concept of health system resilience from various stakeholders in Africa, focusing on definitions and attributes of a resilient health system. We conducted a search for peer-reviewed articles and grey literature, filtered for Africa, from 1980 to 2023, using the SPIDER framework. We searched four databases: PubMed, the Bielefeld Academic Search Engine, the Cumulative Index to Nursing and Allied Health Literature, and Scopus, and reviewed the websites of the World Health Organization, Africa CDC, and Ministries of Health of African countries. Articles were selected based on set inclusion and exclusion criteria. Qualitative articles were appraised using the Critical Appraisal Skills Programme, and mixed-methods articles using the Mixed Methods Appraisal Tool. We mapped the distribution of included articles by country studied; categorized the articles based on reported shock, health system building block described; and identified the definition of health system resilience, and its attributes in each article. The search yielded 4,306 relevant records, fifty-five of which were included in the study. Studies were found from 48 of the 54 African countries. Up to 75% of the articles focused on COVID-19; others were on Ebola Virus Disease, cholera, and meningitis. Service delivery and health workforce were the most frequently studied health system building blocks. In defining or describing health system resilience, the adaptive capacity (39, 65%) was most frequently mentioned, followed by absorptive capacity (17, 28%), preparedness (3, 5%), and recovery (1, 2%). Identified attributes of a resilient health system were: community engagement and involvement; leadership and governance; collaborations and partnerships; human resources for health; health education and promotion; health information systems; health service delivery; decentralization and local governance; health infrastructure and logistics; preparedness; learning and adaptation; and innovation and financing. Our review reports four core capacities that define a resilient health system: preparedness, absorptive capacity, adaptive capacity, and recovery. Essential attributes encompass community engagement, health education and promotion, leadership and governance, surveillance and laboratory capacity, innovation, service delivery, and adaptability.

Vivian Nwechi, Yetunde Abioye, Fatima Saleh, Jibril Mayowa Alliyu · 6 authors

Introduction Lassa fever remains endemic in Nigeria, yet diagnostics, treatment, and hospitalization are excluded from the National Health Insurance Scheme (NHIS), leaving most patients to cover costs out-of-pocket. With NHIS coverage below 10%, both epidemic preparedness and financial protection are compromised. The 2022 National Health Insurance Authority Act offers a policy window to integrate Lassa fever services into NHIS and advance Universal Health Coverage (UHC). Methods A systematic desk review of national health policy, epidemic preparedness, and financing documents published between 2010 and 2024 was conducted using the PRISMA framework. Key sources included the NHIS Operational Guidelines (2012), National Health Policy (2016), NHIA Act (2022), Nigeria’s UHC Roadmap (2020–2030), and NCDC Lassa fever Incident Action Plans (2023–2024). Screening identified 62 unique records, 31 full texts were assessed, and 17 documents met inclusion criteria. Thematic analysis explored gaps in benefit design, financing barriers, and the roles of the Basic Health Care Provision Fund and the COVID-19 Preparedness and Response Project funds. Results The review revealed that NHIS benefit packages omit Lassa fever services and that primary health centers in endemic states lack accreditation. Analysis of the 2023 Incident Action Plan showed that only 6 of 38 (16%) priority activities were fully implemented, 7 of 38 (18%) were partially implemented, and 25 of 38 (66%) were largely not conducted. In 2024, flexible, decentralized financing markedly improved Emergency Operations Centre activation and case reporting. Conclusion Achieving resilient and equitable outbreak response in Nigeria requires more than emergency activation—it demands structural reform. Integrating Lassa fever services into NHIS benefit packages is not just a policy option; it is a public health imperative. Strategic actions such as expanding NHIS accreditation to endemic PHCs, institutionalizing flexible subnational financing, and operationalizing joint NHIA–NCDC accountability frameworks can transform underfunded response plans into sustainable national capacity. These reforms will not only improve the execution of IAPs but also serve as a model for embedding epidemic preparedness within UHC systems across West Africa.

AbuYusuf Aminu-Ibrahim, John Chinemerem Ogbete, Obinna Chima Iwuanyanwu

National diagnostic systems form the backbone of public health surveillance, outbreak response, and routine clinical decision-making, yet they are highly vulnerable to systemic shocks during public health stress conditions such as pandemics, natural disasters, and large-scale humanitarian emergencies. This study examines infrastructure resilience planning strategies for national diagnostic systems, focusing on how physical facilities, supply chains, digital platforms, and governance mechanisms can be designed to withstand, absorb, and rapidly recover from extreme stress. Drawing on resilience engineering, public health systems theory, and lessons from recent global health crises, the paper identifies critical resilience dimensions including redundancy, flexibility, surge capacity, interoperability, and decentralization. Particular emphasis is placed on diagnostic laboratory networks, specimen transport systems, data integration platforms, and workforce continuity planning. The analysis demonstrates that centralized systems without adaptive buffers are prone to cascading failures, whereas networked, modular infrastructures enhance continuity of diagnostic services under stress. Infrastructure resilience planning is shown to improve response time, testing coverage, and data reliability during emergencies while preserving routine diagnostic functions. The study also highlights the importance of governance coordination, scenario-based preparedness planning, and real-time performance monitoring to support rapid decision-making. Investment in resilient power supply, cold-chain logistics, digital connectivity, and cross-sector partnerships is identified as a critical enabler of national diagnostic stability. A conceptual resilience planning framework is proposed, integrating technical, organizational, and policy-level interventions across preparedness, response, and recovery phases. By positioning diagnostics as a strategic national asset rather than a passive service function, resilience planning strengthens health security, equity, and trust in public health systems. The paper provides practical insights for policymakers, health infrastructure planners, and emergency preparedness agencies seeking to future-proof diagnostic capacity against increasingly frequent and complex public health shocks. Future research should empirically assess resilience indicators across countries and quantify the relationship between diagnostic system resilience, mortality reduction, and socioeconomic recovery during prolonged public health emergencies. These findings underscore the urgency of embedding resilience metrics into national health investment decisions, enabling proactive planning, transparent accountability, adaptive financing mechanisms, coordinated intergovernmental action, and sustained diagnostic readiness that supports population health protection before, during, and after crises across diverse healthcare contexts.

Gislani Mateus Oliveira Aguilar, Luciana Freire de Carvalho, Caio Luiz Pereira Ribeiro, João Roberto Cavalcante · 8 authors

This article describes the trajectory of the city of Rio de Janeiro in facing public health emergencies between 2021 and 2024, based on three axes of action proposed by the World Health Organization (WHO): preparedness, surveillance, and response. Innovation in timely data analysis from non-conventional information sources has enabled an early detection of events, promoting reorientation in health surveillance practices. The construction of a strong institutional identity, as well as the coordination of response actions in Emergency Operations Centers, contributed to the consolidation of a culture of rapid response and networking. The integration of primary health care (PHC) and surveillance networks guaranteed a continuity of care and coordinated risk management, highlighting the importance of a decentralized health system that seeks intersectorality in responding to emergencies. The advances observed in combating the COVID-19 and dengue epidemics during this period in the city were driven by adequate investments in structure and human resources, emphasizing the importance of continuous financing and strategic planning aimed at this model of care.

Gislani Mateus Oliveira Aguilar, Luciana Freire de Carvalho, Caio Luiz Pereira Ribeiro, João Roberto Cavalcante · 8 authors

Abstract This article describes the trajectory of the city of Rio de Janeiro in facing public health emergencies between 2021 and 2024, based on three axes of action proposed by the World Health Organization (WHO): preparedness, surveillance, and response. Innovation in timely data analysis from non-conventional information sources has enabled an early detection of events, promoting reorientation in health surveillance practices. The construction of a strong institutional identity, as well as the coordination of response actions in Emergency Operations Centers, contributed to the consolidation of a culture of rapid response and networking. The integration of primary health care (PHC) and surveillance networks guaranteed a continuity of care and coordinated risk management, highlighting the importance of a decentralized health system that seeks intersectorality in responding to emergencies. The advances observed in combating the COVID-19 and dengue epidemics during this period in the city were driven by adequate investments in structure and human resources, emphasizing the importance of continuous financing and strategic planning aimed at this model of care.

Jacob Kazungu, Nancy Kagwanja, Huihui Wang, Jane Chuma · 5 authors

<title>Abstract</title> Background Healthcare workers (HCWs) face a high risk of infection during pandemics or public health emergencies as demonstrated in the ongoing COVID-19 pandemic. Understanding how governments respond can inform public health control measures and support health system functioning. An economic impact analysis examining HCW COVID-19 infections in Kenya and three other countries estimated that the total economic costs related to HCW COVID-19 infections costs and deaths in Kenya were US$113.2 million (range US$35.8-US$246.1). We examined the governance arrangements for and implementation of HCW protection during the COVID-19 pandemic in Kenya between March 2020 and March 2021. Methods We conducted a scoping review of 44 policy and legislative documents and reports on HCW protection and 22 media articles. We adopted the transparency, accountability, participation, integrity and capacity (TAPIC) governance framework to analyse and summarize our findings into policy gaps and implementation challenges. We followed the guidance of the Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews (PRSIMA-ScR). Results Policy design gaps included inadequate provisions for emerging threats, inconsistencies with the devolved context and inadequate structures to monitor, inform and respond to HCW COVID-19 infections. Implementation challenges were attributed to inadequate quantity and quality of PPE, difficulty in accessing medical care for HCWs, delays in HCW remuneration, insufficient infection prevention and control measures, the top-down application of plans, difficulties in working in a decentralized context, and pre-existing public finance management (PFM) bottlenecks. Conclusion Implementation of HCW protection during the COVID-19 pandemic and beyond could leverage the revamping of current legislation on labour relations to reflect devolved governance and develop a broader and long-term approach to occupational health and safety implementation that considers all HCWs. Improvements in PFM arrangements coupled with increased investment in the health sector and attention to efficient use of resources will also impact positively on HCW protection.

Maryam Tavakkoli, Aliya Karim, Fabienne B. Fischer, Laura Monzón Llamas · 11 authors

Objectives: With the application of a systems thinking lens, we aimed to assess the national COVID-19 response across health systems components in Switzerland, Spain, Iran, and Pakistan. Methods: We conducted four case studies on the policy response of national health systems to the early phase of the COVID-19 pandemic. Selected countries include different health system typologies. We collected data prospectively for the period of January–July 2020 on 17 measures of the COVID-19 response recommended by the WHO that encompassed all health systems domains (governance, financing, health workforce, information, medicine and technology and service delivery). We further monitored contextual factors influencing their adoption or deployment. Results: The policies enacted coincided with a decrease in the COVID-19 transmission. However, there was inadequate communication and a perception that the measures were adverse to the economy, weakening political support for their continuation and leading to a rapid resurgence in transmission. Conclusion: Social pressure, religious beliefs, governance structure and level of administrative decentralization or global economic sanctions played a major role in how countries’ health systems could respond to the pandemic.

Ayal Debie, Resham B. Khatri, Yibeltal Assefa

BACKGROUND: The shift in the global burden of disease from communicable to noncommunicable was a factor in mobilizing support for a broader post-Millennium Development Goals (MDGs) health agenda. To curb these and other global health problems, 193 Member States of the United Nations (UN) became signatories of the Sustainable Development Goals (SDGs) and committed to achieving universal health coverage (UHC) by 2030. In the context of the coronavirus disease 2019 (COVID-19) pandemic, the importance of health systems governance (HSG) is felt now more than ever for addressing the pandemic and continuing to provide essential health services. However, little is known about the successes and challenges of HSG with respect to UHC and health security. This study, therefore, aims to synthesize the evidence and identify successes and challenges of HSG towards UHC and health security. METHODS: We conducted a structured narrative review of studies published through 28 July 2021. We searched the existing literature using three databases: PubMed, Scopus and Web of Science. Search terms included three themes: HSG, UHC and health security. We synthesized the findings using the five core functions of HSG: policy formulation and strategic plans; intelligence; regulation; collaboration and coalition; and accountability. RESULTS: A total of 58 articles were included in the final review. We identified that context-specific health policy and health financing modalities helped to speed up the progress towards UHC and health security. Robust health intelligence, intersectoral collaboration and coalition were also essential to combat the pandemic and ensure the delivery of essential health services. On the contrary, execution of a one-size-fits-all HSG approach, lack of healthcare funding, corruption, inadequate health workforce, and weak regulatory and health government policies were major challenges to achieving UHC and health security. CONCLUSIONS: Countries, individually and collectively, need strong HSG to speed up the progress towards UHC and health security. Decentralization of health services to grass root levels, support of stakeholders, fair contribution and distribution of resources are essential to support the implementation of programmes towards UHC and health security. It is also vital to ensure independent regulatory accreditation of organizations in the health system and to integrate quality- and equity-related health service indicators into the national social protection monitoring and evaluation system; these will speed up the progress towards UHC and health security.

Amanda Marr Chung, Eliza Love, Julie Neidel, Idah Mendai · 15 authors

Leadership and management skills are critical for health programs to deliver high-quality interventions in complex systems. In malaria-eliminating countries, national and subnational health teams are reorienting strategies to address focal transmission while preventing new cases and adapting to decentralization and declines in external financing. A capacity-strengthening program in two regions in Namibia helped malaria program implementers identify and address key operational, political, and financial challenges. The program focused on developing skills and techniques in problem-solving and teamwork, engaging decision-makers, and using financial evidence to prioritize domestic resources for malaria through participatory approaches. Results of the program included an observed 40% increase in malaria case reporting, 32% increase in reporting and tracing of imported malaria cases, 10% increase in malaria case management, integration of malaria activities into local operational plans, and an increase in subnational resources for malaria teams. To promote program sustainability beyond the implementation period, key program aspects were institutionalized into existing health system structures, program staff were trained in change leadership, and participants integrated the skills and approaches into their professional roles. A capacity-strengthening program with joint focus on leadership, management, and advocacy has potential for application to other health issues and geographies.

Agnes Nanyonjo, Edmound Kertho, James Tibenderana, Karin Källander

INTRODUCTION: Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition. METHODS: We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas. FINDINGS: In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. CONCLUSION: Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.

Gyanendra Gongal

Rabies is one of the ancient diseases known to humanity. Dog-transmitted rabies accounts for about 99% of human rabies cases in rabies-endemic regions.[1] It is estimated that 59,000 people die from rabies every year.[2] Economic impact of rabies in livestock production is considered high, but surveillance data are missing. Elimination of human rabies is feasible and sustainable if rabies is controlled at the source, i.e., dog. Rabies elimination is a global public good as thousands of people are still dying due to this vaccine-preventable disease mostly in Africa and Asia! It is unacceptable to see premature deaths of young children due to rabies when proof of concept, technical knowledge, and tools are at our disposal. Unfortunately, rabies remains a neglected disease affecting poor-marginalized population in rabies-endemic countries of Asia and Africa due to competing priorities and lack of political will. Rabies elimination has a social, technical, organizational, and political dimension and demands multidisciplinary and multisectoral approaches. Considering that rabies control and subsequent elimination is a model for operationalization of One Health, the WHO in partnership with Food and Agriculture Organization of the United Nations, World Organization for Animal Health, and Global Alliance for Rabies Control came up with a vision of encouraging rabies-endemic countries to achieve zero human deaths from dog-mediated rabies by 2030 worldwide in line with the Sustainable Development Goals' target date of 2030. The rationale for the global strategy is to build on lessons learned, to align country and regional successes into a global strategy with a common goal of eliminating dog-mediated human rabies by 2030. India is a country of more than one billion population, and it has the highest burden of rabies in the world. Remarkable progress has been done in the last 12 years in phasing out of nerve–tissue rabies vaccine by both introducing cost-effective intradermal rabies vaccination and making accessible and available vaccine and rabies immunoglobulin for postexposure prophylaxis in public hospitals. A pan India survey was supported by the WHO to capture the programmatic experiences of rabies prevention and control with emphasis on human rabies, which provided a clear ground reality of accessibility, availability, and affordability of human rabies vaccine and rabies immunoglobulin in India with some recommendations for the improvement of surveillance, reporting, and policy advocacy. A multicenter study on burden of rabies was carried out with the WHO support in 2003, and it is appreciable that the National Centers for Disease Control and Indian Council of Medical Research have taken initiative to re-assess burden of human rabies in India which may show the impact of rabies control activities in human rabies incidence. All these assessments should lead to policy advocacy for operationalizing pan India rabies elimination campaign with goal of zero human rabies by 2030. Success stories have been generated for model dog rabies vaccination and animal birth control program in selected urban areas of India, but much needs to be done for surveillance and control of dog rabies under government leadership and ownership. The veterinary sector in India has a greater social responsibility in controlling dog rabies so that public fear of dog as a source of rabies is changed and livestock and people are no more victim of dog-mediated rabies. Investing in rabies control and elimination strengthens health systems, improves equity and access to healthcare, and contributes to sustainable development. There is a need for strong political commitment matched with equally robust activities, and India will have to play a proactive role to move South Asia Rabies Elimination campaign as it shares long border with rabies-endemic countries in South Asia.

John Grundy

BACKGROUND: In recent years there have been innovations in immunization financing and new technologies, and the scaling up of investment by the Global Alliance for Vaccines and Immunization (GAVI) in the Asia region. The main mechanism for coordination of this global health initiative (GHI) investment is country-level 'Inter-Agency Coordination Committees' (ICCs). AIM: The aim of the evaluation was to determine the utility and future perspectives of stakeholders regarding the role of ICCs in improving immunization services in the Asian Region. METHODS: A literature review, documentary analysis and semi-structured interviews (n = 65) were undertaken in five countries (India, Bangladesh, Nepal, Sri Lanka and Indonesia), with senior level members of Ministries of Health and the GAVI partnership. RESULTS: The evaluation has identified that there have been significant changes recently in the strategic environment for immunization, including developments in new vaccines, increasing GAVI investment, trends towards health system integration and decentralization, and institutional development of the non-government sector. This evaluation found that ICCs are functioning well in relation to information sharing and GAVI application processes. However, they are performing less well in the areas of evaluation, strategic gap analysis and coordination of immunization technical co-operation. CONCLUSIONS: There are high levels of institutional and contextual complexity at country level that require a more focused global response by GAVI to the governance challenges of institutions and partners implementing GHIs at the country level. ICCs should be maintained and strengthened in the more pluralistic context of an 'immunization coordination system' that is represented by the wider health sector, regulatory authorities, and civil society and private sector interests. Managing through systems, rather than being over-reliant on committees, will broaden participation in implementation and, in doing so, expand the reach of immunization and maternal and child health care services in developing countries.

Mamuka Djibuti, Natia Rukhadze, David R. Hotchkiss, Thomas P. Eisele · 5 authors

No abstract is available for this record.