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What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review

  • Diane Meyer ORCID: orcid.org/0000-0003-4467-9169 ane,
  • Michael Snyder1,
  • Sanjana J. Raviane,
  • Ana Lapascu2,
  • Jon Souleles2,
  • Carolina I. Andradaone &
  • David Bishai2

BMC Public Wellness volume 19, Commodity number:1310 (2019) Cite this article

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Abstract

Background

The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economical, and political toll. Important work has been done to draw the general attributes of a wellness organisation resilient to these crises, and the next footstep will be to identify the specific capacities that wellness systems need to develop and maintain to achieve resiliency.

Methods

We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and whatsoever existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the Earth Health Organization's Articulation External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public wellness organizations.

Results

We identified sixteen themes of wellness organization resilience, including: the need to develop plans for altered standards of care during emergencies, the demand to develop plans for mail-upshot recovery, and a delivery to quality improvement. Most of the literature described the full general attributes of a resilient wellness arrangement; no implementation frameworks were identified that could translate these elements into specific capacities that wellness system actors can employ to ameliorate resilience to outbreaks and natural hazards in a variety of settings.

Conclusions

An implementation-oriented health system resilience framework could help translate the important components of a health arrangement identified in this review into specific capacities that actors in the health system could piece of work to develop to improve resilience to public health crises. However, there remains a need to farther refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and wellness service commitment every bit well every bit better their preparedness for emergencies.

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Background

Health organisation resilience has been previously divers as "the capacity of health actors, institutions, and populations to prepare for and finer reply to crises; maintain core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganize if conditions require it" [1, 2]. For many countries, the 2014–2016 Ebola outbreak in W Africa was a wake-upwardly phone call regarding the disquisitional importance of having resilient health systems. In each of the three countries most affected by Ebola, a fragile health arrangement was apace overwhelmed by the complexity of tracking cases, the need to create and disseminate communication strategies, and the challenges of safely caring for a surge of critically ill patients. Health workers were 21–32 times more likely to accept been infected with the virus than members of the general public [iii]. Sickened health workers could no longer care for Ebola patients, and poor infection control in healthcare facilities contributed to nosocomial Ebola manual. In turn, heightened risks of nosocomial Ebola infection increased public fright effectually hospitalization [4]. Rather than helping to contain Ebola, health systems became an amplifier of affliction, exacerbating the man, economic, and political toll of the outbreak.

Similarly, unprepared health systems beyond the earth inadvertently contributed to affliction transmission during recent epidemics of Severe Acute Respiratory Syndrome (SARS) and Centre Eastward Respiratory Syndrome (MERS) [v]. Wellness systems that were unprepared for disasters were also unable to provide essential services, even in highly adult countries (e.one thousand., Canada during SARS [6], Korea with MERS [7], and the The states post-obit Hurricane Sandy [8]). Many countries have committed resources and efforts toward health system strengthening based on these recent disasters, just actionable plans and approaches to build resilient wellness systems accept non even so achieved consensus.

Independent reviews of the global response to the 2014–2016 Ebola outbreak have stressed the importance of establishing metrics to assess and monitor progress towards improving countries' capacity to answer to public wellness emergencies [9,10,11]. In 2016, the World Health Organisation (WHO) created the International Health Regulations (IHR) Joint External Evaluation (JEE) tool—a framework and process designed to measure out countries' capacities to implement the requirements of the IHR, which include the ability to prevent, detect, and respond to public health emergencies of international concern [12]. Since its introduction, the JEE has go an important tool used by countries to assess their capacities for infectious disease outbreaks and other public health emergencies. To-date, more than 100 countries have conducted JEE assessments [13]. Some countries that accept undergone JEE assessments have also begun to develop action plans to address gaps found in their JEEs. Despite this progress, health facilities go on to be vulnerable to public health emergencies [xiv].

Important piece of work has been done to describe the general attributes of a resilient health system [1, 2, 15,16,17]. For case, Kruk et al. describe a resilient health organisation as one that is "integrated with existing efforts to strengthen health systems," able to "detect and interpret local warning signs and quickly call for support," able to provide treat a diverse population, able to "isolate threats and maintain core functions," and is able to "adapt to wellness shocks" [2]. However, as highlighted by Turenne et al., there continues to be a lack of clarity around the conceptualization of wellness systems resilience [eighteen].

The aim of this scoping review was to draw from existing literature to characterize specific capacities required to build resilient wellness systems in the face up of infectious disease emergencies and natural hazards, with an accent on highlighting potential efforts that wellness system actors (e.g. health facilities and health service delivery organizations that are not always well-integrated in government-led preparedness initiatives) could pursue to achieve desired health outcomes during health crises. We also sought to examine the extent to which capacities that are associated with resilient health systems are addressed by existing frameworks for measuring and motivating countries' health security, such as the JEE.

Methods

We searched the scholarly and grey-literature databases to place which capacities should be included in a framework for assessing and improving health organisation resilience to communicable diseases outbreaks and natural hazards. We besides sought to determine whether there were existing frameworks that highlighted these capacities that could be used in low-, eye-, and loftier-income settings. For the purposes of our inquiry, nosotros used the WHO definition of health systems, defined as "all the activities whose primary purpose is to promote, restore, or maintain health" [19]. Specifically, we integrated literature in the following three areas: health security, wellness systems strengthening, and quality improvement. The aims of this research were to narrate the impacts that infectious illness outbreaks and natural hazards have on health systems; to identify challenges in maintaining health service delivery during outbreaks and natural hazards; and to identify strategies for effecting sustainable alter in health systems-strengthening efforts.

Literature databases included PubMed, Web of Science, and OAIster. Key search terms were informed past, merely non inclusive of, Kruk et al.'s definition of a resilient wellness system, and included "wellness organisation," "health system strengthening," "resilience," "recover," "quality improvement," "infectious disease," "outbreak," "natural disaster," "global wellness security," "pandemic," "outbreak response," and "essential functions," every bit well every bit a variety of dissimilar pathogens responsible for recent infectious disease outbreaks (e.g., SARS, Ebola) and natural hazard types (e.thou., whirlwind, earthquake). Footnote 1 See Additional file ane: Table S1 for the full electronic search strategy. Additionally, we examined the websites of major relevant public wellness organizations (WHO, the Rockefeller Foundation, CDC Stacks) to identify articles and frameworks not indexed in the aforementioned databases.

All only one of the search results were filtered to include only those articles published during or after 2002, to capture literature emanating in the wake of the SARS epidemic, up until February 2018, the end of the study period. However, one search term did included articles published during or after 1990, to capture more broadly those resources that focused on essential health functions. Just English-language articles were considered. We included documents if they described health system capacities that could potentially strengthen health arrangement resilience to either infectious disease threats or natural hazards. Documents were excluded if they described health capacities that were outside the aims of this enquiry, as defined previously (i.e. articles that were purely most public health capacities that did non mention the relationship of these capacities to the healthcare system). For example, manufactures that described the importance of a trained epidemiologic workforce (a public health capacity) in outbreak identification and mitigation would be excluded. Articles almost the importance of engagement between Ministries of Health and the public would exist excluded; however, articles nigh the importance of engagement between healthcare facilities and Ministries of Health would be included. Documents were also excluded if the article described resilience in contexts exterior of natural hazards and infectious disease outbreaks (i.eastward. armed conflict situations).

Each of the research team members (seven in total) was assigned a set of articles to review. Each article title was reviewed by the assigned researcher for relevancy using the previously mentioned inclusion and exclusion criteria, followed past a review of the abstruse for those titles deemed relevant. All articles deemed relevant after title and abstract review were then read in their entirety past the assigned researcher, providing a concluding set of manufactures for analysis. Article references were also reviewed to identify important literature not located in the chief search. Articles were and then thematically coded by the assigned researcher using QRS International's NVivo 11 coding software [20] and a qualitative coding instrument developed from a priori themes previously identified in other resilience checklists [1, 2, 21, 22]. Additional topics of involvement that did not fit into the previously identified thematic rubric were coded equally "other" for further review during information assay. After completion of coding, through a process of anterior and deductive reasoning, the researchers identified a final list of themes and associated primal literature that described the disquisitional capacities necessary for health arrangement resilience to infectious disease outbreaks and natural hazards. We then sought to identify areas of overlap between the health arrangement resilience themes and capacities identified in our literature search, and the specific health security capacities that are the focus of the JEE.

Results

The search yielded a full of 1108 articles after the removal of duplicates (Additional file 3: Effigy S1). 1 hundred and fifty-eight articles were read in their entirety, of which 132 were deemed to be relevant and underwent thematic coding. After the completion of coding, we identified 77 cardinal documents that described 16 high-level themes of health system resilience, which are summarized in Boosted file one: Table S2 (see Additional file ii: Appendix A and Appendix B for a comprehensive breakdown of sources organized by theme and author). Thirty-nine papers focused primarily on infectious diseases, while another 12 addressed natural hazards. The remaining 26 papers were not threat-specific, merely rather articulated general principles for strengthening health systems and described baseline capacities required for wellness organisation functioning. While the themes institute in our search were consequent with the five elements of a resilient health system previously outlined by Kruk et al. [1, ii], we also identified iii additional themes not included in previous reviews, including the demand to:

  • Develop policies for determining what level of care will exist delivered when the level of need exceeds existing resources;

  • Programme for post-event recovery; and

  • Commitment to quality improvement that ensures integration of lessons learned.

For example, Mehta et al. described the demand to develop "altered standards of care" for responses to mass casualty events, which might include shifting resources to save as many lives equally possible (i.e., triaging patients differently during emergencies as compared to normal operating conditions) and allowing for group isolation of patients that would normally be boarded in unmarried rooms [23]. The literature identified a number of bug that must be addressed during the recovery phase of a public wellness emergency, including the demand for grief and psychological counseling [24], afterward-activity cess and revision of emergency response plans [25], and rebuilding of social cohesion and trust [26]. A delivery to continuous quality improvement was also identified as an important component of resilient wellness systems, including making hospital performance ratings mandatory and publicly bachelor to encourage peer competition with the primary goal being the overall improvement of hospital performance [27].

In integrating literature beyond subject areas, nosotros were able to identify multiple references to the capacities necessary to accomplish the 16 wellness system resilience attributes identified in our scoping review, which are summarized below (besides see Additional file 1: Tabular array S2).

  • Cadre Health Service Capabilities: A resilient health system sustains baseline levels of routine healthcare delivery during a public health emergency [28,29,30,31,32,33,34,35].

  • Barriers to Healthcare Admission: A resilient wellness organisation dismantles barriers to healthcare access so that the public accesses care during emergencies [36, 37].

  • Maintaining Disquisitional Infrastructure and Transportation: A resilient health organization develops plans to weather interruptions in critical infrastructure and transportation [24, 25, 38,39,40,41,42,43,44,45,46,47,48,49,50].

  • Timely and Flexible Access to Emergency/Crisis Financing: A resilient health system has timely, flexible access to financing so that it can better prepare for and respond to public wellness emergencies [24, 29, 36, 37, 39,twoscore,41, 51,52,53,54,55,56,57,58,59].

  • Leadership and Command Structure: A resilient health system has a articulate and flexible command structure that has been established prior to an event and is exercised ofttimes [24, 29, 57, sixty,61,62,63,64,65].

  • Collaboration, Coordination, and Partnerships: A resilient health system collaborates and coordinates with partners inside and exterior of the health arrangement [2, 29, 39, 45, 57, 66, 67].

  • Communication: A resilient health organization has clear channels of communication between health organization actors and other sectors, adventure communication protocols, and robust engagement with patient populations [60, 68].

  • Flexible Plans and Management Structures: A resilient health system has flexible plans and management structures to cope with rapidly evolving circumstances [ane, 69,70,71].

  • Legal Preparations: A resilient health system has made legal preparations to address challenges that may emerge during a crisis [i, 45, 49, 59, 62, 72, 73].

  • Surge Capacity: A resilient health organization is able to call on human and capital resource to "surge" the level of intendance during public health emergencies [36, 74].

  • Altered Standards of Care: A resilient wellness system has adjustable response plans to guide them in allocating scarce resources and healthcare services [23, 75].

  • Wellness Workforce: A resilient health organization has an acceptable, trained, and willing work force [4, 22, 36, forty, 45, 53, 54, 76, 77].

  • Medical Supplies and Equipment: A resilient health system has admission to medical supplies and equipment, including personal protective equipment, antivirals, and ventilators, during a crisis [40, 53, 78,79,80].

  • Infection Prevention and Command (IPC): A resilient wellness organization has implemented strong IPC measures, including staff preparation, standardized protocols, a defended IPC focal point, and dedicated treatment units [iv, 22, 39, 47, 51, 54, 81,82,83,84,85,86].

  • Delivery to Quality Improvement: A resilient health system requires a delivery to continuous quality improvement that promotes excellence and garners the trust of the community [xv, 27, 39, 54, 69, 87, 88].

  • Plans for Post-Upshot Recovery: Resilient health systems have plans for post-event recovery that address a broad range of problems [24,25,26, 34, xl, 59, 73, 89,90,91,92,93].

The capacities that nosotros identified are associated with different actors in health systems. Some of the capacities identified in our review could potentially be developed by private health facilities. For instance, Kim et al. discussed i health system'south plan to develop alternate care centers that could exist deployed during an influenza pandemic, including the infrastructure that needs to exist in place to ensure adequate functioning, such as send of patients to the middle [42]. Other capacities identified in the scoping review concerned the health system more broadly and would likely be addressed by national governmental regime. For case, Hanefeld et al. noted "the nature of the funding and financing mechanism as a core attribute enabling or hindering health systems' ability to reply to a stupor" [29].

No frameworks were identified in the search that translated these high-level themes into specific and actionable steps that health organization actors can use to better and support health arrangement resilience to both infectious diseases and natural hazards, and that tin can be undertaken in low-, centre-, and high-income settings akin. Frameworks that did articulate specific capacities were either 1) but applicative in the Us context [22] or 2) did not cohesively address both infectious diseases and natural disasters [fifty]. For instance, Meyer et al. created a checklist for wellness sector resilience to high-consequence infectious diseases [22], but the data for this checklist was informed by the US domestic response to the 2014–2016 West Africa Ebola outbreak. While some of the identified capacities may be generalizable to other countries, some are only pertinent in the The states context. Similarly, the Hospital Safety Index, a tool developed by WHO, does identify capacities that are relevant to some health facilities, but the tool is largely aimed at evaluating the vulnerability of infirmary infrastructure to natural hazards (an updated version includes limited consideration of the potential touch on of communicable diseases threats to hospitals) [50].

Merely two of the health system resilience themes and capacities identified in our literature search directly overlapped with the specific health security capacities that are the focus of the JEE—namely IPC and advice (See Boosted file ane: Table S3). Specifically, the JEE indicator on antimicrobial resistance does address IPC, but simply within the context of healthcare-associated infections and associated IPC programs [12]. Additionally, the literature nosotros collected emphasized the importance of communication between health organization actors, other sectors, and the community during outbreaks [threescore, 68]. The JEE contains a very detailed section on communication that specifically calls out for the need for communication and coordination betwixt stakeholders, including healthcare workers; for systems for rumor direction through healthcare workers; and for formal communication mechanisms with the hospital and healthcare sector [12].

Otherwise, health facilities are not directly addressed in the JEE framework. There are some indicators in the JEE that do accost the themes identified in the literature review, only only within the context of public health. For example, the literature suggests that health facilities need access to financing during emergencies to comprehend the added costs of preparing for and responding to emergencies [24, 29, 36, 37, 39,40,41, 51,52,53,54,55,56,57,58,59]. The JEE indicator on National, Legislation, Policy and Financing does address whether countries have the financing to fulfill their obligations under the IHR, which includes "regulations or administrative requirements, or other governmental instruments governing public health surveillance and response" [12]. However, it does non specifically accost financing within the context of health facilities, although countries could cull to include them in efforts to develop capacities in those areas.

Finally, some of the themes identified in our review could be leveraged through the evolution of other capacities that are the focus of the JEE. For example, the JEE does non explicitly appraise how healthcare facilities should accost barriers to healthcare access, such as long travel distances, the high cost of medical care, and public distrust. Notwithstanding, it does address the importance of run a risk communication and community engagement during an emergency. These relationships could potentially be leveraged by the healthcare system during an emergency to amend the public'southward trust in and subsequent use of the healthcare organization.

Discussion

To date, much of the literature that specifically references health organisation resilience has focused on high-level attributes, rather than identifying specific capacities that health systems need to be resilient to infectious disease outbreaks and natural hazards. For example, Kruk et al.'s 5 attributes of a resilient health organization include a system that is "self-regulating," with the ability to "apace identify and isolate a threat and target resource to it" [ane]. By integrating literature from beyond unlike disciplines, nosotros were able translate these high-level themes into actionable corresponding capacities that health systems need to respond to communicable diseases outbreaks and natural hazards. For example, the literature highlighted numerous IPC protocols and practices that are important for the control of communicable diseases threats, including the need for front-line healthcare workers to conduct travel histories [22] and the need to establish dedicated and multidisciplinary IPC committees to coordinate and guide healthcare staff on how to safely manage patients with infectious diseases [54, 84]. An article by Palagyi et al., published after this review was conducted, too highlights the importance of these capacities that nosotros identified [94].

Additionally, the literature highlighted 3 themes not previously identified every bit attributes of a resilient health system, which warrant consideration in time to come efforts to ascertain health system resilience. We present the capacities that we identified across the literature as merely the start of an attempt to ascertain capacities that health arrangement actors need to exist prepared for infectious disease outbreaks and natural hazards. Further scholarship in these areas could support efforts to interpret research findings into best practices in public wellness and healthcare practice and improve health outcomes following public health emergencies of all kinds.

Notably, the JEE does identify the capacities necessary to implement the IHRs to protect against public health emergencies of international business organisation, but lacks guidance for health facilities at the patient-provider interface [12]. Moreover, many of the capacities assessed in the JEE presume the beingness and operation of core health arrangement capacities, nevertheless these capacities themselves are not explicitly addressed in JEE assessments. For instance, while the presence of a national laboratory arrangement—a JEE indicator—is a disquisitional capacity to have during an outbreak, it requires that healthcare providers and the proper supplies exist available to collect patient samples (e.g., blood, sputum, etc.). Ideally, efforts to improve health organization resilience would complement and build upon those foundational capacities presumed by the JEE procedure.

The results of this literature review point to a need for increased integration of efforts to advance health security and health systems strengthening beyond the earth. Several high-priority elements for health systems resilience likely be at the nexus of health systems strengthening, health system resilience, and health security; further work is needed to decide the virtually effective co-investments in global wellness security and health organisation strengthening that enable more robust health organization responses at the local, national, regional, and global levels during emergent crises [95]. Identifying those areas of overlap can help to concretize the JEE's priority areas in health security, and also strengthen key components of national health systems such that their overall resilience is enhanced.

While nosotros strived to capture all relevant health systems literature, a potential limitation to our review is the lack of consistency and definitional clarity with which terms like "health system" and "resilience" are used throughout the medical and public health literature. Information technology is possible that we may have missed relevant articles that draw these concepts using different terms. We also found in the literature an overrepresentation of papers detailing health system impacts of certain events and, thus, our findings may not include considerations from other events not represented in the literature. Despite these limitations, we think our review serves to deepen the understanding of the specific capacities that health systems need to prepare for infectious diseases and natural hazards.

Conclusions

The themes and capacities identified in our literature review provide an initial pace in refining the concept of wellness system resilience to enable actors across the various sectors of the wellness system to take activity to be able to reply and recover from infectious disease outbreaks and natural hazards. In that location remains a need to farther define the concept of resilience then that health systems can simultaneously accomplish sustainable transformations in public wellness practice and wellness service delivery as well equally improve their preparedness for emergencies. In the same way that the JEE tool has helped motivate countries to appraise and improve their cadre public health capacities, an implementation-oriented health system resilience framework could assistance translate the of import components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public wellness crises. Moreover, such an endeavour may aid to integrate foundational health system capacities into national efforts to better core public wellness capacities.

Availability of information and materials

non applicative.

Notes

  1. Kruk et al.'s definition of a resilient wellness system was used to inform the search terms considering it was developed with broader expert input and because it addresses resilience within the context of infectious disease outbreaks and natural hazards.

Abbreviations

IPC:

Infection Prevention and Command

JEE:

Joint External Evaluation

MERS:

Middle East Respiratory Syndrome

SARS:

Severe Acute Respiratory Syndrome

US:

United States

WHO:

World Health System

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Acknowledgements

Not applicable.

Funding

This enquiry was supported past the Rockefeller Foundation. The Rockefeller Foundation had no role in the study blueprint, data drove, data analysis and interpretation, in the writing of the study, or the determination to submit it for publication.

Author information

Affiliations

  1. Johns Hopkins Center for Health Security, 621 Eastward Pratt Street, Suite 210, Baltimore, Physician, 21202, USA

    Jennifer B. Nuzzo, Diane Meyer, Michael Snyder, Sanjana J. Ravi & Carolina I. Andrada

  2. Johns Hopkins Bloomberg Schoolhouse of Public Health, 615 N. Wolfe Street, Baltimore, Physician, 21205, U.s.a.

    Ana Lapascu, Jon Souleles & David Bishai

Contributions

JBN and DB conceived of and led the study. DM led the scoping review process. JBN, DM, MS, SJR, AL, JS, and DB participated in data collection, coding, and analysis. JBN and DM drafted the initial manuscript, and JBN, DM, MS, SJR, AL, JS, CIA and DB participated in its revision and review. All authors read and approved the terminal manuscript.

Authors' information

Johns Hopkins Center for Health Security (JBN, DM, SR, MS, CIA), Johns Hopkins Bloomberg School of Public Wellness (JS, AL, DB).

Respective author

Correspondence to Diane Meyer.

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Consent for publication

not applicable.

Competing interests

The authors declare that they accept no competing interests.

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Supplementary data

Additional file ane:

Tabular array S1. Electronic search strategy. Tabular array S2. Summary of key themes and associated cardinal testify. Table S3. Overlap of scoping review themes with Articulation External Evaluation indicators.

Additional file ii:

Appendix A: Coding framework--the full coding framework is provided, along with definitions of each code, and the number and outset author/publication year of all sources that were coded into each theme. Appendix B: Citations are provided for all sources referenced in appendix A.

Boosted file 3:

Figure S1. Selection of Sources of Evidence.

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Nuzzo, J.B., Meyer, D., Snyder, 1000. et al. What makes wellness systems resilient against infectious affliction outbreaks and natural hazards? Results from a scoping review. BMC Public Health 19, 1310 (2019). https://doi.org/x.1186/s12889-019-7707-z

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  • DOI : https://doi.org/10.1186/s12889-019-7707-z

Keywords

  • Resilience
  • Health arrangement strengthening
  • Health organisation resilience
  • Quality improvement
  • Wellness security
  • Outbreak
  • Natural hazard

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