Nature Medicine 2021

FOCUS | Review Article
FOCUS | Review Article https://doi.org/10.1038/s41591-021-01381-y
Health systems resilience in managing the

COVID-19 pandemic: lessons from 28 countries
Victoria Haldane 1,9, Chuan De Foo 2,9, Salma M. Abdalla3,4,9, Anne-Sophie Jung5,9, Melisa Tan2,
Shishi Wu2, Alvin Chua2, Monica Verma2, Pami Shrestha2, Sudhvir Singh4,6, Tristana Perez5,
See Mieng Tan2, Michael Bartos4,7, Shunsuke Mabuchi4, Mathias Bonk4,8, Christine McNab4,
George K. Werner4, Raj Panjabi4, Anders Nordström4 and Helena Legido-Quigley2,4,5 ✉
Health systems resilience is key to learning lessons from country responses to crises such as coronavirus disease 2019
(COVID-19). In this perspective, we review COVID-19 responses in 28 countries using a new health systems resilience frame-
work. Through a combination of literature review, national government submissions and interviews with experts, we conducted
a comparative analysis of national responses. We report on domains addressing governance and financing, health workforce,
medical products and technologies, public health functions, health service delivery and community engagement to prevent and
mitigate the spread of COVID-19. We then synthesize four salient elements that underlie highly effective national responses
and offer recommendations toward strengthening health systems resilience globally.
C
OVID-19 has caused an unprecedented global crisis, includ- Health systems resilience literature stresses that efforts should
ing millions of lives lost, public health systems in shock and focus not only on absorbing unforeseen shocks precipitated by
economic and social disruption, disproportionately affecting emerging health needs, but also on ensuring continuity in health
the most vulnerable. As of April 2021, there are over 140 million improvement, sustaining gains in systems functioning and foster-
confirmed cases and over three million COVID-19 deaths globally1. ing people centeredness, while delivering high-quality care9,10. As
While vaccination has commenced in numerous countries, new COVID-19 has overwhelmed health systems worldwide, debates
outbreaks and variants continue to emerge. At the same time, the around resilience have become more urgent, and there is a need
global distribution of vaccines is marred by challenges of equity on to better understand the elements of national responses through
top of logistical complications. Millions more are therefore still at a resilience lens11,12. Thus, in this perspective, we use an expanded
risk of dying, facing significant morbidity or losing their livelihoods health systems resilience framework centered on community
given the uncertain economic outlook. engagement to examine 28 national responses to COVID-19. This
The pandemic has challenged local, national, regional and global analysis provides insights into the policies countries implemented
capacities to prepare and respond. The various national strategies and how these were implemented to tackle the pandemic.
taken to control viral transmission are widely debated2,3. However,
the relative success of these strategies depends largely on how an Conceptual framework. Our conceptual framework (Fig. 1) is
existing health system is organized, governed and financed across grounded in the World Health Organization’s (WHO) health sys-
all levels in a coordinated manner4. The pandemic has exposed tems framework13. We develop the framework elements by adding
the limitations of many health systems, including some that have public health functions, including testing, contact tracing, dis-
been previously classified as high performing and resilient5. A ease surveillance and non-pharmaceutical public health interven-
comprehensive analysis of the resilience of health systems during tions, which often operate separately from health service delivery.
the pandemic can therefore pinpoint important lessons and help Yet, they are critical both to pandemic responses and to ongoing
strengthen countries’ preparedness, response and approach to future population health. Similarly, health information systems are vital
health challenges. functions for both public health and health systems as, ideally, they
While resilience is a core concept in disaster risk reduction, its should be integrated to capture data at individual, health system and
application to health systems is relatively new. It has been defined population levels.
broadly as institutions’ and health actors’ capacities to prepare for, We centered our analysis on community engagement as core
recover from and absorb shocks, while maintaining core functions to all elements of health systems resilience (see Box 1 for more
and serving the ongoing and acute care needs of their communi- information on the analytical approach). To serve communities
ties6,7. During a crisis, a resilient health system is able to effectively in a more equitable manner and promote healthy societies, resil-
adapt in response to dynamic situations and reduce vulnerability ience must be developed with these communities and according
across and beyond the system. Experience from previous epidem- to their needs. There can be no health systems resilience without
ics, such as Ebola, severe acute respiratory syndrome (SARS) and community engagement across domains14. We also acknowledge
Middle East respiratory syndrome, emphasized the links between the critical role of coordination with non-health sectors as essential
resilience and thwarting new outbreak transmission8. to providing necessary supports to address the social determinants
1
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. 2Saw Swee Hock School of Public Health,
Singapore, Singapore. 3School of Public Health, Boston University, Boston, MA, USA. 4The Independent Panel for Pandemic Preparedness and
Response Secretariat, Geneva, Switzerland. 5London School of Hygiene and Tropical Medicine, London, UK. 6Faculty of Medical and Health Sciences,
University of Auckland, Auckland, New Zealand. 7School of Sociology, Australian National University, Canberra, New South Wales, Australia. 8Berlin
Institute of Global Health, Berlin, Germany. 9These authors contributed equally: Victoria Haldane, Chuan De Foo, Salma M. Abdalla, Anne-Sophie Jung.
✉e-mail: [email protected]
Nature Medicine | www.nature.com/naturemedicine

Review Article | FOCUS NaTure MeDICIne
uity and outco Box 1 | Analytical approach

lth eq mes
Hea
ration across se
Col
labo cto
rs
The analysis presented in this review is based on a purposive se-
lection of countries including positive and negative outliers in
relation to reported COVID-19 deaths per capita among high-
Governance
and financing
ly populous countries, as well as a selection of countries in the
middle ground from different regions and with widely varying
health systems and economic status. Figure 2 provides an over-
view of countries in our review. Countries were selected accord-
Health service Health
ing to the recorded number of deaths attributed to COVID-19
delivery Community workforce per 100,000 inhabitants on 6 November 2020. Given the dynamic
engagement and continuously changing situation, the ranking of positive and
negative outliers in terms of death per capita may have changed
during the pandemic. The analysis is thus limited to this specific
time period.
Public health Medical products
functions and technologies
Five complementary methods were adopted to analyze
national responses to COVID-19:
1. Literature review: using standardized methods, we identi-
fied peer-reviewed papers and public reports that examined
national and subnational policy responses and extracted
data for each country on five dimensions comprising 62
items. The dimensions and items were identified through a
review of 14 existent frameworks.
Fig. 1 | Determinants of health systems resilience framework. The scheme 2. Semi-structured interviews and national government
illustrates the components of the resilient health systems framework we submissions: to supplement the literature review, we asked
developed based on the WHO’s health systems building blocks framework. the selected countries and country experts a set of questions
The five elements of resilient health systems are centered around related to the measures implemented to contain COVID-19
community engagement as core to all elements of health systems resilience. in their respective countries. A total of 45 interviews and
written submissions were provided. Semi-structured inter-
views with COVID-19 national experts at the policy, opera-
of health. Underpinning these elements are health equity and out- tional and academic levels were recorded and transcribed
comes. Resilient health systems should aim to generate positive in full. All interviews were coded through an inductive ap-
physical and mental health outcomes for all, including vulnerable proach and thematic analysis, using QSR NVivo 12 software,
and marginalized groups. In many countries, COVID-19 mortality drawing on techniques of the constant comparison method.
rates have been disproportionately higher among older populations, 3. In-depth case studies of 6 countries to validate the data
minority ethnic groups, socioeconomically deprived populations from the 28 countries.
and low-wage and migrant workers, emphasizing the interconnect- 4. Expert validation of country-specific data with country
edness between equity and health outcomes15. experts. Experts in countries were provided with the spe-
cific data for each of their respective countries to validate the
COVID-19 responses in 28 countries data.
Using our framework, we organized our results beginning with 5. Expert validation through roundtable discussions with
domains often viewed as external to health, which are neverthe- country experts. A total of 35 national and international ex-
less central determinants of health systems resilience—governance, perts in COVID-19 policies participated in two roundtable
finance, collaboration across sectors and community engagement— discussions.
before exploring domains more closely associated with traditional
views of health and health systems—health service delivery, health
workforce, medical products and technologies and public health universal health coverage (UHC) and strengthened or impover-
functions. We offer illustrative examples of selected countries for ished social safety nets that underpin health and well-being.
each domain in Tables 1–6. We analyzed 28 countries based on a Overall, COVID-19 responses saw health policy moving beyond
purposive selection, including positive and negative outliers in the remit of Ministries of Health and in doing so, draw on exper-
relation to reported COVID-19 deaths per capita among highly tise from other ministries, particularly during the early response.
populous countries, as well as a selection of countries in the middle Countries took whole-of-government approaches to strengthen
ground (as of 6 November 2020). Figure 2 provides an overview of health systems in response to COVID-19, particularly those
countries in our review. with experience of other health-related disasters, such as Ebola.
These decisions were, in most countries, made by translating
Governance, finance and collaboration across sectors. COVID-19 evidence-based research into policies that preserve health system
has made policymakers and the wider public acutely aware of the capacity, while protecting both public health and livelihoods. As
relationship between health systems, domestic economies and gov- such, most countries established temporary COVID-19 advisory
ernance. Government decisions determine healthcare infrastruc- groups to inform government decisions. However, in the majority of
tures, regulations and guidelines, defining access to medication countries, the views represented on these committees were largely
and treatment, the provision of health coverage and the financing biomedical. More information on national responses from a gover-
of these. Government responses to COVID-19, in the immediate nance and leadership perspective is available (V.H., A.-S.J., R. Neill,
term, have meant the difference between lockdown or business as S.W. and M. Jamieson, unpublished data).
usual, and have eroded or increased public trust. In the longer term, The COVID-19 response requires testing, treatment and vac-
they have shaped national choices regarding private healthcare or cines to be financed with either a portion or all of these costs

NaTure MeDICIne FOCUS | Review Article
Africa:
Liberia, Mozambique,
Niger, Nigeria, Uganda
Asia Pacific:
China, Fiji, India, Japan,
New Zealand, Pakistan,
Singapore, South Korea, Sri
Lanka, Thailand, Vietnam
Europe:
Germany, Russia, Spain,
Sweden, United Kingdom
Middle East:
Egypt
North America:
United States of America
South/Latin America:
Argentina, Brazil, Mexico,
Peru, Uruguay
Fig. 2 | Countries included in the review. The map presents an overview of countries selected according to the recorded number of deaths attributed to
COVID-19 per 100,000 inhabitants on 6 November 2020. Countries are listed according to region and in alphabetical order.
coming from public funds, and depends on healthcare infrastruc- volunteers to educate seniors and help distribute daily necessities.
tures, workforce and supplies to provide much-needed surge capac- Liberia further empowered community leaders by providing orien-
ity within health systems. Additionally, fiscal support measures, tation on COVID-19 epidemiology to support containment efforts.
including relief packages aiming at helping businesses stay viable, However, many of these efforts depended on volunteers.
protect jobs or provide financial aid to low-income households and During early response efforts, a few countries conducted surveys
the unemployed have been taken by many countries. These policies to understand public sentiment regarding evolving measures. Japan
support people to adhere to public health guidance, with the aim conducted a survey in April 2020 to understand compliance with
of preventing infections, in turn mitigating the strain on the health social distancing measures, using the results to inform response
system resulting from the need to deliver high-intensity COVID-19 strategies. Governments also started multilingual hotlines to ensure
care. To further enhance the reach of health services, many coun- comprehensive access to COVID-19 information. Other countries
tries reviewed took specific actions to mitigate potential financial used social media platforms to engage communities. For example,
and physical barriers to care, such as covering part or all of the costs the #TakeResponsibility campaign in Nigeria called on citizens to
of COVID-19 care, and funding the establishment of testing and join forces and be proactive in taking greater individual and collec-
treatment centers in communities16. Importantly, the outcomes tive responsibility in controlling the spread of COVID-1920.
resulting from financial expenditures on health and well-being are
only as good as the structures that support them. Thus, they require Health service delivery. Health systems globally have employed
governance expertise across levels, sectors and domains and depend three common approaches to rapidly scale up health system infra-
on a system’s ability to reach (vulnerable) populations. structure, namely by constructing new treatment facilities, convert-
ing public venues and reconfiguring existing medical facilities to
Community engagement. Deep engagement with local communi- provide care for patients with COVID-19. Thus, some of the health
ties is central to resilient health systems as a way to inform service systems reviewed invested significant resources into rapidly creating
delivery, decision-making and governance and to meet the needs of dedicated field facilities. For example, in early 2020, China estab-
communities before, during and after crises. Community engage- lished two specialty field hospitals in under 2 weeks21. Where field
ment strategies, such as building partnerships with local leaders hospitals were set up to house patients with COVID-19, countries
and working alongside community members to tailor messages often drew on their armed forces and military field hospital mod-
and campaigns are crucial during public health emergencies17. The els, or adapted existing large public facilities. However, most health
range of non-pharmaceutical public health interventions employed systems relied on a less resource-intensive approach that modified
in response to COVID-19, such as mask wearing and social distanc- traditional healthcare facilities into dedicated COVID-19 care cen-
ing, rely on shared values and a sense of social responsibility within ters22. Other health systems relied on home care for patients with
communities to break chains of viral transmission18. mild to moderate COVID-19, with facilities available if patients
Several countries reviewed engaged networks of community were unable to safely self-isolate within their homes. Additionally,
health workers (CHWs) to encourage active community partici- the majority of reviewed countries canceled elective surgeries in an
pation in COVID-19 responses. Their roles range from creating effort to ensure system capacity for COVID-19 care.
awareness through door-to-door visits, supporting contact trac- In many health systems, primary-care providers are the front-
ing efforts, maintaining essential health services, providing nec- line of the health system providing continuous, coordinated
essary medication to patients without COVID-19, surveillance and people-centered care. Primary care is an important point of
or monitoring adherence to quarantine measures and assessing COVID-19 triage, as well as the point at which most routine and
mental well-being19. They are also key to identifying and refer- acute care services are provided within communities23. In many of
ring patients who face barriers to accessing healthcare services. For the countries reviewed, primary-care providers rapidly adopted and
example, Thailand deployed over 1 million CHWs to disseminate scaled up digital technology or telehealth services to provide ongo-
and amplify messages widely in communities. Singapore deployed ing and acute care while also triaging and referring persons with

Table 1 | Examples of governance and financing approaches
Subdomain Snapshot of health systems resilience measures in reviewed countries
Countries with the least deaths per 100,0000, with a population of over Countries with the most deaths per 100,0000, with a Countries in the middle category in terms of deaths per 100,000 population
20 million population of over 20 million
Governance China: established top-down Mozambique: opted for a Peru: despite political instability, Mexico: the Ministry of Germany: a whole-of-government Japan: set up the coronavirus task force, consisting
approach governance structures to multi-sectoral, whole-of-government there was an emphasis on Health initiated a national approach was adopted. At the of diverse medical experts (virology, infectious
reach across all levels within approach. The Ministry of Health multi-sectoral action in the meeting of state governors national level, the central government disease, molecular genetics, genomic medicine
the government and created a established an Emergency pandemic response. In the early and health authorities convenes weekly as the ‘Small Corona and computational science) and includes 36
whole-of-government approach. Commission to ensure effective stages (end of March 2020), to coordinate efforts to Cabinet’. It consists of the Chancellor high-ranking bureaucrats from several ministries.
The State Council established coordination of COVID-19 prevention the president convened a respond to COVID-19. and various ministries. Additionally, The headquarters acts as the site of the prime
a Joint Prevention and Control and response through the efforts teleconference between regional During the meeting, the government convenes on a minister’s decision-making process on the
Mechanism. It is a platform for of nine Technical Working Groups health governors together with state authorities agreed weekly basis in the ‘Large Corona country’s virus countermeasures.
communication, collaboration co-led by Ministry of Health staff the Minister of the Interior, to participate in working Cabinet’. Besides the members of the
and mobilization of resources and development partners. The the Minister of Health and the groups to learn firsthand the small cabinet, ministers from specific
between 32 different ministries Government’s disaster agency Minister of Agriculture, who national situation, updates ministries, depending on issues
and departments. It consists of (INGC) and the Ministry of Economy each presented the plans of and the decisions made to discussed, are invited to join.
workgroups responsible for COVID- and Finance are currently working their sectors and the measures address each step of the
19 control, medical treatment, with line ministries to identify the that were adopted to guarantee pandemic. It was also agreed
research, education, logistics and needs and priority measures to be security and food supply. that local and municipal
frontline workers. At local levels, implemented. Aligned with this, governments will be
Review Article | FOCUS
emergency response leading the Humanitarian Country Team, involved and will collaborate
groups, headed by local government led by the resident coordinator and on communicating cases,
leaders, were established in composed of UN agencies, NGOs, incidents and necessary
provinces, cities and counties Red Cross and donor representatives, actions.
across the country. The local is developing a response plan to
emergency response leading groups COVID-19, focusing on sector-specific
are responsible for implementing impacts of COVID-19.
the central government’s policies
and control strategies, thus forming
a top-down system.
Coordination Uruguay: in June, an Honorary Uganda: CDC Uganda provides Argentina: the government Spain: the government has New Zealand: epidemiologists, South Korea: the Korea Disease Control and
with scientific Scientific Advisory Group (GACH) technical input to the Uganda created a special government appointed highly recognized immunologists and public health Prevention Agency has the leading role in the
advice was formed, which included a Ministry of Health. For example, unit to respond to the COVID-19 clinical experts and experts advised on the risk the virus country’s response to COVID-19. The COVID-
broader and more diverse group of with CDC Uganda input, the pandemic. The unit’s main task epidemiological scientists posed to the country and helped 19 Response Strategy Consultation Committee
expertise, including socioeconomic, Emergency Operations Center set is to advise the Presidency and as members of the COVID- communicate the threat to the convenes on a regular basis to discuss government
than the previous committee up a national task force to prepare the Ministry of Health on matters 19 Scientific and Technical public and the government officials response strategies and areas for improvement.
formed in March. As of June 2020, for the COVID-19 pandemic before regarding available human Committee to provide in charge of the response. The The Korean government supports Korean
this group comprised 55 members the first cases were detected. CDC resources and infrastructure. advice to the government Ministry of Health brought some researchers by providing data that were used
and holds weekly meetings with support for influenza surveillance In addition, The Ministry of and inform policymaking. of these experts into a Technical for forecasting the spread of COVID-19 and the
subgroups, makes biweekly reports at the Uganda Virus Research Health of Argentina has jointly The Ministry of Health, Advisory Group, established as part effectiveness of response measures, which aided
to the Transition group, holds Institute is proving critical in the coordinated the pandemic through the Centre for the of the Ministry of Health’s response in decision-making for infection control. The Korea
special meetings with the president COVID-19 response. The Ugandan response together with provincial Coordination of Health to COVID-19, which is chaired by Institute of Science and Technology (KIST) used
and has daily contact with the government drafted researchers into ministries of health within the Alerts and Emergencies the chief science advisor, Ministry a supercomputer and Individual Simulation for
government; all the announced a COVID-19 scientific committee to Federal Health Council (COFESA) (CCAES, in Spanish), of Health and comprises various Transfer Phenomena, KIST’s own modeling method,
measures have the support of inform the country’s prevention and and the following groups of activated the COVID-19 health professionals (epidemiologist, to analyze the effectiveness of disease control
scientists on the GACH. treatment strategy for the pandemic experts: National Immunization protocol and coordinates pathologist, virologist, infectious measures taken by the Korean government.
after cases were reported in East Commission, National Advisory the response with the disease physician, microbiologist,
Africa. This committee has been at Committee on Research Ethics departments of health in medical officer of health, coordinator
the center of Uganda’s COVID-19 and National Commission on Spain’s 17 autonomous and public health officer). The group
response, drafting local measures Vaccine Safety, among others. communities. To design the met twice weekly to provide updated
and guidelines for the prevention and exit strategy plan and the advice to the Director-General of
treatment. vaccination strategy, a group Health.
of multidisciplinary experts
were appointed to produce
the reports.
Continued

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Table 1 | Examples of governance and financing approaches (continued)

Countries with the least deaths per 100,0000, with a population of over Countries with the most deaths per 100,0000, with a Countries in the middle category in terms of deaths per 100,000 population
20 million population of over 20 million
Cost of COVID- Thailand: the government covers China: the government covers all United Kingdom: residents of the Peru: cost of COVID-19 Singapore: the government covers the Russia: the entire amount of medical care, including
19 treatment the cost of seeking COVID- COVID-19 costs for all patients, United Kingdom need not pay treatment was reduced to costs of hospitalization bills incurred testing and treatment, is covered by the state
services 19-related treatment services at all including domestic migrants, a for COVID-19-related treatment make it more accessible by patients with COVID-19 in public insurance system. All assistance is provided to the
NaTure MeDICIne
levels of care. payment structure that is part of its services. The free services for the general public after hospitals, which applies to Singapore population free of charge.
‘wartime’ governance. are also extended to certain the government had struck citizens, permanent residents and
exemption categories of people an agreement with private long-term pass holders.
such as those covered by the healthcare providers to
immigration health surcharge. charge a lower fee for
COVID-19-related services.

Cost of Sri Lanka: testing is provided free Uganda: cross-border cargo truck United States: the federal Peru: after reports of South Korea: free testing for all; New Zealand: COVID-19 tests are free of charge.
diagnostic of charge at designated public drivers, Ugandans returning from government enacted The Families private clinics charging initially, however, asymptomatic This applies whether you have symptoms
testing hospitals. abroad, visitors arriving in the country First Coronavirus Response Act, for COVID-19 tests, the persons wishing to receive a COVID- of COVID-19 or not, and regardless of your
and individuals and employers who which provides funding for free National Institute of Health 19 diagnostic test on their own had to citizenship, immigration status, nationality or level
want their staff tested are required to coronavirus testing, 14-d paid of the Ministry of Health pay about 160,000 KRW/133 USD if of medical insurance coverage.
pay a fee for testing. leave for American workers reaffirmed that this service their test results came back negative.
affected by the pandemic and is totally free, public and
increased funding for food indispensable in the context
stamps. of the pandemic.
Financial relief Niger: an updated crisis response Vietnam: the government introduced United Kingdom: financial support Brazil: a series of fiscal Germany: the clause for exceptional Pakistan: the federal government announced a relief
packages to plan has been presented to donors a fiscal support package valued at includes: (1) additional funding measures adding up to 12% circumstances in the debt break package worth PKR 1.2 trillion/USD 7.5 billion in
individuals/ with an estimated cost of 18.4% VND 291.7 trillion/USD 12.5 billion or for the NHS, public services of GDP, of which the direct was triggered on 25 March 2020. March 2020. Key measures include cash transfers
households/ of GDP, divided into an immediate 3.6% of GDP to support the economy. and charities (GBP 48.5 billion/ impact in the 2020 primary This allows debt financing of a to 6.2 million daily-wage workers (PKR 75 billion/
businesses health response and broader Measures include deferring payment USD 66.6 billion); (2) measures deficit is estimated at 8.4% supplementary budget of EUR 156 USD 4.9 million); cash transfers to more than 12
economic and social mitigation. Key of rent and taxes. The government also to support businesses (GBP 29 of GDP. Congress declared billion/USD 185 billion or 4.5% of million low-income families (PKR 150 billion/USD
elements include food distribution, approved a cash transfer package for billion GBP/USD 39.8 billion), a state of ‘public calamity’ GDP to cover response measures. On 981 million); support to SMEs and the agriculture
free utilities to vulnerable affected workers and households with including property tax holidays, on 20 March 2020, lifting 3 June 2020, an additional recovery sector (PKR 100 billion/USD 654 million) in the
households and temporary tax relief monthly cash transfers provided for no direct grants for small firms and the government’s obligation package was agreed on of roughly EUR form of power bill deferment, bank lending, as well
for hard-hit sectors. The Finance more than 3 months, among others. firms in the most-affected sectors to comply with the primary 130 billion/USD 154 billion or 3.8% as subsidies and tax incentives, among others.
Ministry also announced credit and compensation for sick pay balance target in 2020. The of GDP for 2020 and 2021. Economic
support to the private sector in the leave; and (3) strengthening fiscal measures included support for businesses and individuals
form of loan guarantees. The revised the social safety net to support the expansion of health during the second lockdown was also
cost includes large-scale support vulnerable people (by GBP 8 spending and temporary provided. Emergency loans were made
for agricultural production, revenue billion/USD 10.9 billion) by income support to vulnerable available for self-employed workers
shortfalls and the building of liquidity increasing payments under the households, among others. and businesses, among others.
buffers. An additional supplementary Universal Credit scheme, as well
budget with 1.3% of GDP was also as expanding other benefits.
approved. The government has launched
three separate loans schemes to
facilitate business access to credit.
Self-employed and furloughed
employees also received financial
support to cover loss of wages,
among others.
Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. CDC, Centers for Disease Control and Prevention; GDP, gross domestic product; NGO, nongovernmental organization; NHS, National
Health Service; SME, small and medium-sized enterprise; UN, United Nations.
Table 2 | Examples of community engagement approaches

Countries with the least deaths per 100,0000, with a Countries with the most deaths per 100,0000, with a population Countries in the middle category in terms of
population of over 20 million of over 20 million deaths per 100,000 population
Involvement in providing Thailand: VHVs assess mental China: WeChat app was Brazil: in some Spain: Red de Cuidados (Care Liberia: the government South Korea: Central
essential services well-being of people in the used to find volunteer communities, primary- Network) was set up for volunteers worked with Last Mile Disaster and Safety
community and refer to care if drivers to assist people care providers work to link up with the most vulnerable Health to augment the Countermeasure
needed. They also undertake working in vital roles, with CHWs to conduct groups to help out with everyday National Community Headquarters
health surveys, collect data and like doctors and other home visits, promote tasks such as buying and delivering Health Assistant recommended
maintain family health records healthcare workers. social distancing and medicines from pharmacies to their Program by providing assigning a community
to support the public health continuity of health homes. training to CHWs to member as a local
authorities during the pandemic. services for patients with ensure continuity of quarantine manager to
chronic conditions in the primary-care services coordinate with local
community. and reduce transmission officials.
from known cases.
Risk communication Uganda: the government Thailand: the Mexico: utilized an Peru: ‘El covid no mata solo. No Russia: on social Egypt: the government
strategies for the engaged community members government deployed innovative way of seamos cómplices.’ (‘Covid does not media, the Russian has set up a
community in COVID-19 hot spots to over 1 million VHVs to storytelling by using kill alone. Let’s not be accomplices’) Ministry of Health communication center
warn the public about the disseminate and amplify characters from Sesame is a campaign launched to promote launched a flash mob (website) where
consequences of negative messages widely in Street to explain how the adherence to public health measures; #Оборона О
т К
ороны COVID-19 information
behaviors, given that fewer communities. virus spreads and teach incorporates advertising on television, (#DefenceFromCorona), is publicly available,
deaths and a lack of knowledge prevention measures radio, public roads, social networks, which was supported by including infographics
about asymptomatic cases like practicing good activations and urban interventions, celebrities. The essence on how to stop the
led to reports of public hand hygiene and cough among other forms of communication; of the flash mob was to spread of the virus
complacency in adhering to etiquette. incorporates regional and local appeal to the citizens of and protect people.
public health measures. governments, various actors from civil the Russian Federation The government also
society and private companies. to adhere to the personal provided a hotline
hygiene rules and to for COVID-19 and a
observe preventive WhatsApp number to
measures during the answer questions.
spread of COVID-19.
Government providing a Thailand: online survey to Sri Lanka: in April United States: in Mexico: in April 2020, researchers Japan: conducted an New Zealand: conducted
channel for feedback on monitor perception toward 2020, the government collaboration with from the National Institute of Public online survey in April the COVID-19 Health
national strategies information, misinformation introduced a hotline multiple federal Health (INSP), the Government 2020 to understand and Wellbeing Survey to
and knowledge, attitude and for the public to submit agencies, the Census of Mexico City and mobile phone compliance with social provide the government
behavior of residents regarding complaints on difficulties Bureau is undertaking a operators Movistar and Telcel, joined distancing measures. with information on
misinformation on COVID-19 in receiving essential Household Pulse Survey forces to carry out a study on how Results were used how New Zealanders
and assessing communication services due to strict to understand citizens’ much the inhabitants of Mexico to inform response are coping, financial
capacity. The survey showed that public health measures. experiences regarding City adhere to measures of physical strategies. impacts and the level
82% of participants identified The Operation Centre was employment status, food distancing and isolation; up to of understanding
misinformation regarding tasked with following up security, housing, physical 200,000 mobile phone users will be and compliance with
COVID-19 in social media and on complaints and taking and mental health, invited weekly to answer a survey via regulations.
that the Thai population had necessary action. access to healthcare and text messages (SMS) on the behaviors
high trust in health agencies educational disruption. observed in their homes.
disseminating information.
Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. VHV, village health volunteer.

NaTure MeDICIne
Table 3 | Examples of health service delivery approaches
Countries with the least deaths per 100,0000, with a population of Countries with the most deaths per 100,0000, with a population of over Countries in the middle category in terms of deaths per 100,000
over 20 million 20 million population
Construction of new China: large specialty field Niger: Médecins Sans Frontières Argentina: in May 2020, the United States: in New York, a Nigeria: The United States Russia: prefabricated modular infectious
treatment facilities hospitals (for example, constructed a 50-bed treatment government built 12 modular faith-based organization built an Department of Defense disease centers were built across the
Leishenshan and Huoshenshan) center at the Amirou Boubacar hospitals in 20 d, mostly in the emergency field hospital in Central Africa command donated country, for example, the Ministry of
were rapidly constructed Diallo National Hospital in Buenos Aires suburbs; hospitals Park with a respiratory unit and ICU four field hospital tents that Defence of the Russian Federation built
to deliver respiratory care Niamey, with the potential to have 76 beds, of which 24 are for capability. have negative-pressure 29 multifunctional medical centers
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services. accommodate up to 100 beds intensive care and are provided isolation facilities and using prefabricated modular structures
should case numbers increase. with respirators, and the rest of the can house up to 40 in 23 constituent entities of the Russian
beds have oxygen. They are also patients. The facilities Federation with a total capacity of more
equipped with primary-care rooms, were assembled by an than 3,000 beds.
guardrooms, shock rooms, clinical all-Nigerian team.
analysis laboratories, consulting
rooms and diagnostic imaging areas.

Converting public venues into Vietnam: anticipating high China: converted large public Brazil: worked with football clubs Peru: Villa Panamericana de Lima, the Pakistan: designated Germany: the first specialized treatment
treatment facilities demand following the Danang venues into specialty hospitals to transform stadiums into field residential complex used for athletes COVID-19 hospitals centers for patients with COVID-19 and
outbreak in July 2020, Vietnam (for example, Fangcang) to deliver hospitals. of 2019 Pan American Games, was across the country with patients with respiratory symptoms
converted a sport stadium into respiratory care services. converted into a 3,000-bed hospital the necessary equipment, were set up by the Regional Association
a 1000-bed field hospital. facility, with the Armed Forces including PPE, and of Statutory Health Insurance (SHI)
responsible for the conversion and nominated a focal person to Physicians in North-Rhine Westphalia.
allocation of medical equipment. manage IPC at all times. Some diagnostic centers have been
converted into specialized centers and are
designated for suspected and confirmed
cases.
Reconfiguring existing Thailand: reconfigured Mozambique: private sector United States: some tertiary United Kingdom: hospital trusts Liberia: the Incident South Korea: reconfigured designated
medical facilities many tertiary hospitals company Total LNG refurbished hospitals augmented COVID- were directed to optimize their Management System tertiary hospitals into respiratory split
to increase the number of a 50-bed hospital to manage 19-related services and built more infrastructure by redesigning existing established a dedicated hospitals that effectively segregate
negative-pressure rooms and patients with COVID-19. negative-pressure rooms and space for clinical use and converting treatment unit and suspect and positive cases from
equipment to deliver respiratory integrated a separate heating, existing wards to make them precautionary observation non-respiratory disease so that these
care services. ventilation and air-conditioning suitable for patients with COVID-19. centers using renovated facilities can continue to provide essential
channeling system. Critical-care capacity increased from public buildings and the 14 tertiary-care services.
around 4,000 to 7,000 beds. military hospitals.
Postponement of elective Mozambique: yes. Uganda: yes. United Kingdom: yes. Spain: yes. Uruguay: yes. New Zealand: yes.
medical procedures
Increased usage of digital Vietnam: Hanoi Medical Thailand: promoted the use of United States: the government Argentina: The Ministry of Health South Korea: initially, Singapore: actively expanded
health technologies for University Hospital introduced teleconsultation services for developed a new website for authorized doctors to make online telemedicine was not telemedicine services following an
regular consultations the ‘digital hospital’ to nonurgent and stable chronic telehealth guidance during prescriptions for certain medications approved in South Korea increased demand that came with
provide services remotely, cases, with drug delivery services COVID-19 for patients and to help people comply with the for clinical care. In 2020, implementing social distancing measures.
and the ‘remote health and provided. providers. The website was mandatory self-isolation period. the Korean government
examination. project was also developed in collaboration with Chronic and non-transmissible temporarily allowed
approved to trial and promote the Health Resources and Services diseases may be prescribed through telemedicine only for
similar digital initiatives. Administration, an agency working this system. WhatsApp, email and established patients.
on programs that provide healthcare fax are some of the platforms that
to people who are geographically may be used.
isolated and economically or
medically vulnerable.
Primary-care providers as the Vietnam: local commune Uganda: CHWs are the first contact United Kingdom: clinical Brazil: the COVID-19 Service Singapore: PHPCs were Japan: Public health centers began to
first point of contact before centers provide primary-care point for the community. They commissioning groups work with Centers for Coping, available to all set up with general systematically allocate patients to a wider
triaging to onward care services to the community. They provide education, detect cases general practitioners in primary-care municipalities, act as a reference point practitioners trained in IPC, network of hospitals, including privately
help provide information on and perform referral to higher levels networks to implement a total triage for primary care within the service with necessary equipment owned facilities, matching patients to
prevention and identify potential of care. and remote consultation model network of the Unified Health System and PPE provided. PHPCs appropriate designated or non-designated
cases and cases for triaging to during the pandemic to ensure that (SUS). It is a strategy that seeks to are used to forward triage hospitals by symptom severity and
other care facilities. every patient is triaged before an expand diagnoses and care for people suspected cases to other resource availability while urging mild and
appointment is made. with influenza, while providing greater levels of care. asymptomatic patients to stay at home or
resolution of care to people with mild in converted hotels without a mandatory
symptoms related to COVID-19. hospitalization.
Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. IPC, infection prevention and control; PHPC, public health preparedness clinic.
Table 4 | Examples of health workforce approaches
Countries with the least deaths per 100,0000, with a population of over 20 Countries with the most deaths per 100,0000, with a population Countries in the middle category in terms of deaths per 100,000 population
million of over 20 million
Strategies to rapidly Uganda: additional healthcare Thailand: The Ministry of Public Health Mexico: a national call was made Brazil: The Brazilian Health New Zealand: a nationally India: the government had called on
expand health manpower including contracted 150,000 temporary medical to recruit specialized personnel Ministry hired more health coordinated online system was retired doctors, armed forces medical
workforce capacity epidemiologists, doctors, workers to respond to the pandemic, in intensive care, emergency, workers, including reinstating set up for retired or nonpracticing staff and private sector medical
anesthetists, nurses, laboratory 40,000 of whom were approved to be internal medicine, pneumology, medical licenses for Cuban health workers to register to rejoin professionals to join the public health
technologists, psychiatric clinical converted into permanent civil servants infectiology and anesthesiology medical professionals who the workforce to assist in outbreak facilities. Over 30,000 responded to the
officers, ambulance assistants, due to their invaluable contributions to to address the pandemic. The remained in Brazil from the management. More than 2500 government’s appeal. Final-year medical
drivers, emergency care assistance, the healthcare system. government also considered Mais Medicos (More Doctors) doctors, nurses, midwives and students and paramedical students were
among others, were contracted for 6 contracting foreign health program and to permit final-year laboratory scientists came out of also deployed to conduct screenings,
months and deployed to COVID-19 workers as necessary to augment medical students to bolster the retirement or parental leave. A contact tracing and vaccination.
treatment centers and to support domestic health workforce existing medical workforce. system was put in place to match
districts and points of entry for capacity. returning health workers with
surveillance purposes. suitable positions.
Reallocation China: in the initial stages of the Vietnam: after receiving training, 97 United States: with its Spain: medical doctors from Uruguay: to alleviate the lack of South Korea: government employees
of healthcare pandemic, medical workers from all senior medical students volunteered predominately private healthcare other specialties such as internal intensive care physicians, the from non-healthcare sectors were
professionals parts of China were reallocated to with the Hanoi Center for Disease system and federal states, the medicine, anesthesiology, Uruguayan Society of Intensive reassigned. Contact tracing was
provide medical care for the people control to conduct epidemiological United States implemented pneumology and geriatrics, as Medicine (SUMI) and the Society performed by repurposed low-level to
of the Hubei province. investigation of cases; duties include measures to increase staff in hot well as trained nurses, teamed of Anesthesiology announced middle-level government employees
providing counseling to people over spots. Many states developed up with intensive care specialists an agreement that anesthetists or those who were underemployed.
the phone, collecting samples from guidelines to allow recent to increase care capacity for can assist in critical-care tasks to It expanded its usual workforce of
suspected community groups, importing medical graduates and health people with severe or critical augment intensive care manpower. Epidemic Intelligence Service officers
data into computers and cleaning and workers from other states to COVID-19. by quickly training these staff at
disinfection of congregate settings. practice in hot spots. This was approximately 250 local public health
needed as different states in centers.
the United States have different
licensure for practice.
Pandemic-related China: in Wuhan in January 2020, Sri Lanka: WHO worked with the Argentina: online training was Peru: military and civilian health Russia: almost 1.6 million medical Singapore: increased training of nurses
training for onsite training for infection control Ministry of Health and Indigenous provided to health workers on professionals were trained specialists were trained (remotely) for intensive care to bolster existing
healthcare and patient management was Medical Services and the Sri Lankan critical COVID-19 treatments through a Ministry of Defense to provide medical care to patients intensive unit staffing. Former and
professionals provided to all health workers based College of Microbiologists to design involving ventilators, intubations initiative. The course is a 16-h with COVID-19. current professionals and personnel
on the ‘guideline for COVID-19 a set of training modules for health and extubations, among other theoretical and hands-on session with no qualifications were trained
management and control’ and the workers on IPC guidelines related to relevant skills for treatment of to orient students to care for for support and testing, while medical
‘guideline for hospital infection COVID-19 in Sri Lanka. patients with COVID-19. Both patients with severe COVID-19. students and nurses were trained for
of COVID-19’ before they started entry-level and advanced training The initiative started in May specific tasks to augment the existing
working in COVID-19 units. were available. 2020, with service member-only health workforce.
classes that expanded to include
civilians from June 2020.
Mental health China: several measures were Sri Lanka: hospitals arranged special United States: the CDC advised United Kingdom: free New Zealand: Health Care New Sweden: the government proposed
support for health implemented to ensure the care of meals to boost health worker morale; that healthcare facilities establish one-on-one support sessions Zealand provides free counseling funds to support staff in regional and
workforce medical personnel and their families, food sellers brought staple foods to a plan for providing additional with accredited psychologists or services for frontline healthcare municipal healthcare and elderly care
such as regulations on shifts hospitals so that staff did not have to support for health workers, mental health experts available workers and staff who seek mental in its autumn budget amendment for
and leave arrangement to relieve visit markets or supermarkets to get considering aspects such as to NHS staff. A tool kit was health and well-being support. 2020. This provides additional funding
frontline medical workers. groceries; a hotel chain offered 1,000 mental health, parenting, meals also developed by the NHS to Help will be rendered through an for crisis support, counseling and trauma
complimentary full-board holiday and nonpunitive sick policies. encourage conversation in the appointment-based system with an support during the pandemic.
packages for frontline health workers. workplace and talk about mental experienced therapist, which will be
and emotional health. kept confidential.
Financial support for Thailand: offered financial support Vietnam: incentives were provided for Argentina: financial incentives Spain: COVID-19 infection is Russia: since the beginning of the Germany: care workers can claim tax
health workforce to health workers in case of adverse field workers engaged in surveillance granted to healthcare workers deemed a workplace accident pandemic, incentive payments benefits of up to EUR 1,000/USD 1,200.
events: for death or permanent activities. who managed and were exposed for healthcare workers managing to health workers for special The federal government announced
disability: THB 240,000–400,000 / to patients with COVID-19 infected patients. working conditions and additional it would expand the bonus payments
USD 7,684–12,807; for organ loss or included four bonuses, in both the workloads have been introduced given to nurses and care professionals in
disability. Incentives offered to health public and private sectors. or increased on a federal level; the hospitals fighting COVID-19 to all hospital
workers were THB 1,500/USD 48 government allocated more than staff during the pandemic. Bavaria was
per shift for doctors and THB 1,000/ USD 64,900,000 to pay medical the first state to announce a reward for
USD 32 per shift for nurses and other workers increased vacation pay or all nursing and care staff in healthcare,
paramedical staff. compensation for vacation, which long-term care, rehabilitation, emergency
they had to give up due to the services and institutions for disabled
situation with the coronavirus. people of a EUR 500/USD 600 bonus.
Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020.

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Table 5 | Examples of approaches using medical products and technologies
Countries with the least deaths per 100,0000, with a Countries with the most deaths per 100,0000, with a population of over 20 million Countries in the middle category in terms of deaths per 100,000
population of over 20 million population
Preexisting national China: the central and local Thailand: the government United States: the Department of Health and United Kingdom: the Department Singapore: drew on lessons South Korea: Seoul had maintained
stockpiles government’s emergency rapidly built up a national Human Services mobilized the Strategic National of Health and Social Care activated from previous the SARS the largest amount of PPE stockpiles
stockpile of commodities, stockpile over the first few Stockpile to provide medical essentials to combat the nation’s emergency stockpile to outbreak, and the government (around 16,000 Level D coveralls,
necessities and medical months of the pandemic the pandemic. augment existing supplies at NHS ensured adequate national 5,200 Level C coveralls and 2,000
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supplies was activated to while also sourcing external facilities. stockpiles of PPE and essential powered air-purifying respirator
meet the immediate demand alternatives and domestic medicines for up to 6 months. hoods).
during the earlier stages of production alternatives.
the pandemic.
Measures to increase Thailand: Board of Vietnam: promoted United Kingdom: several brewers contributed to United States: The Defense Production Singapore: a Japan: Ministry of Trade Economy
in domestic production Investment (BOI) approved inter-industry transfers of the production of hand sanitizers by taking the Act allowed the president to direct government-affiliated and Industry, through the Subsidy

volume 12 ventures in March 2020 technology to produce more alcohol from their production lines to bolster the private companies to prioritize orders engineering company was Project for Supporting Businesses in
to produce face masks, innovative and portable local and regional supply of hand sanitizers. from the federal government during tasked to start a production Introducing Facilities for Producing Face
adding to the already 13 ventilators at a faster rate national emergencies. An example line for face masks by securing Masks, had encouraged manufacturers
BOI-approved garment and to bolster overall production was the federal government requesting equipment, training manpower to supply 100 million face masks per
textile companies that are volume in the country. automakers to manufacturer ventilators and protecting supplies of raw week by introducing new and enhanced
producing medical masks to increase overall domestic production materials for the manufacturing equipment in manufacturing lines for
and gowns. volume. processes. face masks.
Measures to facilitate China: temporary decrease Sri Lanka: elimination of Peru: temporary implementation of export Argentina: the government established Fiji: elimination of import duties Nigeria: federal government approved
the import of medical in import tariffs for medical import duties and taxes on authorization requirements on face masks, gloves a zero-percent rate to import taxes, and VAT on medical supplies to a waiver for import duties and VAT on
products devices to stabilize domestic masks and disinfectants to and other PPE to regulate outwards movement of applied to alcohol, laboratory and promote movement of medical all medical equipment and supplies into
supplies especially during facilitate movement of these essential medical resources. pharmacy equipment, gloves, products necessary to combat the country from May 2020 onwards.
the start of the pandemic. products into the country. disinfectants and sanitary supplies. the pandemic.
Measures to restrict Vietnam: Drug China: initial prohibition United Kingdom: banned the export of Argentina: released a decree that Pakistan: authorities imposed Russia: executive order signed in
the export of medical Administration of Vietnam on exporting test kits essential medicines such as insulin and prohibits the export of critical medical restrictions that prohibit the March 2020 imposed a temporary
products initially prevented the export and medical supplies hydroxychloroquine over fears of domestic merchandise such as oxygen therapy exports of antimalarial drugs ban on exports of some medical goods
of 37 drugs to be reserved manufactured by uncertified shortages. devices, their parts and accessories. and other essential medicines. and equipment, including antiviral
for domestic healthcare companies was downgraded drugs, with the exception of goods for
facilities. to export restriction upon humanitarian relief to foreign states.
authorization.
Receiving donations of Uganda: the WHO, with Thailand: medical supplies Peru: Germany gave over USD 1 million worth Fiji: Japan together with the Asian Pakistan: China donated 1,000 Nigeria: the United States donated
medical products funding from the Irish including face masks, face of oxygen concentrators, digital thermometers, Development Bank and UNICEF ventilators to Pakistan in 200 ventilators to Nigeria, which
Government, delivered shields and protective suits oximeters and more than 32,000 coronavirus provided USD 11 million worth of August 2020. Other donations contributed to its membership in the
USD 250,000 worth of for frontline workers were tests for health professionals with the aim to help medical equipment to Fiji. included PPE, test kits and face Every Breath Counts Coalition, which
equipment to the Ugandan donated by the Jack Ma 90,000 people from underserved communities in masks. aims to combat pneumonia, hypoxemia
Ministry of Health, which Foundation and Alibaba the indigenous and rural areas of Peru’s Amazon. and COVID-19.
included 60 handheld Foundation to Thailand’s
pulse oximeters, 49 oxygen Ministry of Public Health.
concentrators and 31
high-flow nasal cannulas.
Securing grants or Sri Lanka: China provided a Uganda: the UK government Argentina: The World Bank provided emergency Mexico: the United States donated Liberia: The World Bank Pakistan: the COVID-19 Active
loans for procuring USD 90 million grant to Sri released GBP 1.322 million/ cash transfers and loans under its COVID-19 Fast more than USD 1.8 million in Migration approved a USD 3.75 million Response and Expenditure Support
medical products Lanka in October 2020 for USD 1.84 million to support Track Facility to Argentina. and Refugee Assistance funds to grant and USD 3.75 million program secured USD 500 million from
an array of uses including various aspects of Uganda’s Mexico to assist the country’s most concessional International the Asian Development Bank to import
medical care. fight against COVID-19. vulnerable populations. Development Association equipment and medical supplies.
Activities funded by the UK credit for Liberia to strengthen
grant are being implemented immediate healthcare capacity
by the WHO and the and longer-term outbreak
International Organization response.
for Migration.
Continued
Table 5 | Examples of approaches using medical products and technologies (continued)
Countries with the least deaths per 100,0000, with a Countries with the most deaths per 100,0000, with a population of over 20 million Countries in the middle category in terms of deaths per 100,000
population of over 20 million population
Guidance principles Uganda: rational-use Mozambique: released United States: CDC and Occupational Safety and Brazil: guidelines used as South Korea: during the India: in the initial months of
released for the guidance documents rational-use guidance Health Administration released guidelines on the recommendations so that the earlier stages of the pandemic the pandemic, PPE and masks
rational use of medical released by heath authorities integrated into its proper use of PPE for frontline workers, which unnecessary use of equipment is in South Korea, when PPE were procured centrally due to
products accompanied by videos on Environmental and Social includes donning, repairing, washing, storing and reduced and contingency is established supplies were insufficient, import challenges. Once domestic
how to properly don PPE. Management Framework disposing of PPE. in case of shortages. Hand and hospitals changed Level D manufacturers were developed and
for COVID-19 Response to respiratory hygiene are emphasized coveralls to disposable plastic standards defined, vendors were
maximize existing supplies strongly in the guidelines. gowns and N95 respirators to onboarded to the Central Government
of PPE and ensure safe and KF94 masks. Although KF94 e-Marketplace and states encouraged
effective usage. masks cannot ensure airtight to buy standard and fair price essential
seals due to the ear-loop commodities from this platform.
structure, their filtration
capacity is similar to the N95,
and the KCDC recommended
the KF94 or KF99 for health
workers.
Advance-purchase Vietnam: the government Thailand: purchase Spain: secured multiple agreements through Mexico: signed an advance-purchase Japan: made multiple India: as the largest buyer of vaccines,
agreements with had engagements with arrangements secured the European Commission’s Advance-Purchase agreement for 35 million doses of investments in many potential India has already purchased 196 million
pharmaceutical Russia to buy 150 million to obtain 2 million doses Agreements with vaccine producers Chinese firm CanSino Biologics’ vaccine candidates. In August doses of domestically manufactured
companies doses of Russian vaccine of Sinovac vaccine including Pfizer- BioNTechArn, AstraZeneca, COVID-19 vaccine while solidifying 2020, the health ministry vaccines from Serum Institute and
(Sputnik V) and 30 million and 61 million doses ModernaARNm, Johnson & Johnson, Sanofi and arrangements in January 2021 to started negotiations with Bharat Biotech of India. It has also
doses from AstraZeneca. from AstraZeneca to GSK and CureVac to ensure sufficient access to procure 24 million doses of Russia’s Moderna to secure enough supported R&D efforts of local
be manufactured in approved vaccines. Sputnik COVID-19 vaccine. vaccines from the drug firm to manufacturers. It is in talks to secure
collaboration with Siam cover 20 million people within 1.6 billion doses of other vaccines once
Bioscience. the first half of 2021, with Pfizer Indian trials conclude (Sputnik V and
to cover 60 million people Novavax).
and with AstraZeneca for 120
million doses.
Participation in the Mozambique: part of the Thailand: did not pledge to United Kingdom: helped raise USD 1 billion for Peru: to receive approved COVID-19 Sweden: pledged SEK 100 Singapore: co-chaired the Friends
COVAX facility COVAX Advance Market the COVAX facility opting COVAX AMC through match-funding other vaccine from the COVAX AMC in early million/USD 119 million to the of the COVAX Facility initiative with
Commitment and will to acquire directly from donors, which was added on to the initial amount 2021. COVAX facility and will receive Switzerland to promote vaccine
receive vaccines to cover manufacturers. the United Kingdom had pledged. a predetermined number of multilateralism and contributed USD
an average of 20% of the vaccine doses. 5 million to the facility in return for
population. a predetermined number of vaccine
doses.
Platforms to monitor China: the Ministry of Uganda: The Emergency Brazil: regarding price monitoring, the Health United Kingdom: a parallel supply India: in the state of Japan: medical facilities reported
supply chains Industry and Information Logistics Management Price Bank (BPS) system and the Material Catalog chain distribution mechanism set up to Odisha, the supply chain is information on their operating status,
Technology established System (Eelmis) provided (CATMAT) for public health managers and control augment the NHS supply chain system normally managed using the bed occupancy rates in general wards,
a platform for mobilizing real-time feedback on bodies helps the government procure reasonably for the rapid and organized distribution Government e-Marketplace. infectious disease wards, ICUs and
resources nationwide. This medical resource availability priced drugs and other medical supplies from of medical essentials guided by the During the pandemic, special utilization rates of ventilators and ECMO
platform aims to ensure the at national and subnational credible suppliers after price comparisons. principles of plan, source, make, order interdepartmental committees support, to the Gathering Medical
production and allocation of levels. The digital system and deliver. were set up to rapidly Information System. This platform helps
sufficient medical supplies to rapidly collects, shares finalize purchase indents, allocate and coordinate the movement
regions in need. and analyzes information audit documents and track of medical resources nationwide.
on supplies to guide a movements of medical products.
coordinated response to
allocate medical resources.
Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. ECMO, extracorporeal membrane oxygenation.

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Table 6 | Examples of public health functions
Countries with the least deaths per 100,0000, with a population of over 20 Countries with the most deaths per 100,0000, with a population of over 20 Countries in the middle category in terms of deaths per 100,000 population
million million
Diagnostic China: in Wuhan, two rounds Vietnam: the country had performed Spain: to mitigate spread in Peru: used mass antigen rapid New Zealand: testing was performed Uruguay: tests were randomly conducted
testing of community-based mass targeted testing. Initially, those with a the long-term care sector, the testing to find COVID-19 cases for all symptomatic individuals or on construction workers covering the
strategies screening were carried out travel history, who were close contacts Interterritorial Council expanded among the national police force, people who were identified as being entire country to identify any potential
with tests administered free of of confirmed cases and those who the frequency and coverage of PCR urban transport and food market in close contact with a positive case. clusters during reopening measures;
charge, resulting in 4.21 million showed symptoms were tested. This was testing in long-term care facilities. workers. Border testing was also mandatory. The active case finding was also conducted
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households receiving the test later expanded to mass testing in entire government ensured access to testing in senior’s homes across the country.
to rule out potential sources of hot spots or high-risk areas. was effective and equitable for all Additionally, Uruguay had also
infection. groups, in particular Māori and Pacific implemented an open testing policy at its
islanders. borders regardless of symptoms.
Increasing Vietnam: increased the Mozambique: national testing capacity Peru: decentralized test processing Argentina: in March, the Ministry Pakistan: the National Disaster Uruguay: rapidly developed a network of
laboratory number of testing laboratories from public laboratories increased from throughout the national territory of Health started the delivery of Management Authority worked with 24 laboratories known as the ‘COVID-19
capacity nationwide from 3 in January around 60 tests per day in April 2020 to by equipping and training staff of 35,000 reagents to expand testing the National Institute of Health to diagnostic lab network,’ which increased

2020 to 112 by April 2020. 3,186 tests per day across the country in Regional Reference laboratories. to 21 laboratories for diagnosis in increase the number of laboratories diagnostic capacity from 200 tests per
November 2020. Expanded laboratory all 24 jurisdictions in an effort to from 15 to 144 as of November 2020, day in March to nearly 1,000 per day by
capacity to seven of eleven provinces decentralize test processing. thus increasing the number of tests the end of May.
either through open PCR platforms or conducted per day.
through existing platforms in clinical
laboratories.
Contact tracing China: all cases undergo Vietnam: ‘Four Tier’ contact tracing United Kingdom: implemented Argentina: the Detectar program, Japan: conducted retrospective contact Sweden: infected individuals are
policies contact tracing; county/ process based on the degree of contact NHS Test and Trace to ensure that launched in May 2020, is a unified tracing (14 d before symptom onset) to themselves responsible for contacting
district level CDC staff should from the infected individual (F0), to the people who develop COVID-19 national protocol for proactive identify the source of the infection and people who they may have infected.
complete contact tracing person who had close contact (F1), to symptoms can quickly be tested, case detection and contact tracing break up clusters.
within 24 h after receiving the person who had close contact with which includes asymptomatic in communities, with an emphasis
the reports of suspected or F1 (F2+), all the way to F5. testing of NHS, social care staff on vulnerable communities.
confirmed cases. and nursing home residents. If
positive, the NHS will ask for
details of close contacts to be
shared via a secured website or
through a call with contact tracers.
Contact tracing Mozambique: contact tracing Sri Lanka: contact tracing is carried United States: some states Argentina: contact tracing is Germany: public employees from Liberia: contact tracers were recruited
teams is carried out by staff at the out by community physicians, regional have increased their number of conducted by teams of volunteers, other areas of the bureaucracy were from communities and trained on their
National Institute of Health epidemiologists and nearly 900 medical employees and volunteers to meet or reassigned personnel, as well as transferred to help identify and control roles and responsibilities.
with assistance from medical officers of health from 357 Ministry of the demand for contact tracing by primary-care teams, or through COVID-19 outbreaks. In areas that have
residents, and students from Health areas in late January 2020. staff, while others have reassigned specific field operations. been particularly affected, soldiers and
the master program on Field state and county staff to contract officials of the armed forces were called
Epidemiology and Laboratory tracing responsibilities. to support contact tracing efforts.
Training, supported by the
Centre for Disease Control.
Quarantine Thailand: close contacts Uganda: implemented auto-monitoring Spain: contacts are not actively United States: policies to provide New Zealand: people who have been Nigeria: the International Organization
strategies or those suspected to be of case contacts for 14 d. The person followed up or tested, but they are facilities for close contacts have in close contact with a person who has for Migration will construct, manage
infected are mandated to be under auto-monitoring measures his or instructed to quarantine at home focused on workers who are confirmed or probable COVID-19 need and maintain self-quarantine shelters to
quarantined either at home her temperature twice a day and makes for 10 d. The health authorities expected to be in close proximity to self-isolate for 14 d from the last date quarantine internally displaced persons
or in a state facility, under the sure there are no breathing problems may assess individual situations to infected individuals such as first of contact with the infected individual and host community members with
close supervision of health or coughing. During auto-monitoring, that require other types of responders and health workers, not while they were considered infectious; travel and contact history, as well as new
workers. They are tested normal activities can be continued. recommendations if needed. family or other contacts exposed in some cases, they may be able to arrivals from other towns.
twice—on 7th day and 14th to people with COVID-19. quarantine in a facility (for example, if a
day. dependent has confirmed COVID-19).
Self-isolation Mozambique: institutional Uganda: auto-isolation applies to people Brazil: symptomatic individuals Spain: phone hotlines are offered Nigeria: offers home care management Egypt: once diagnosed, those with mild
strategies isolation in a health who have symptoms of COVID-19 are asked to stay home for 14 d for nonhospitalized patients with for patients with mild to moderate cases symptoms go home, while those with
(home-based) establishment if therapeutic but whose infection is not confirmed. and to be hospitalized if condition COVID-19 who are required to of COVID-19. medium to serious symptoms remain in
criteria are met. If the They are required to stay home for 7 d worsens. self-isolate at home. the hospital.
symptoms are mild, they from the onset of symptoms and avoid
will be isolated at home for contact with other people if possible.
recovery. Once the symptoms have resolved, they
must stay at home for another 24 h.
Continued
Table 6 | Examples of public health functions (continued)
Countries with the least deaths per 100,0000, with a population of over 20 Countries with the most deaths per 100,0000, with a population of over 20 Countries in the middle category in terms of deaths per 100,000 population
million million
Self-isolation China: all confirmed cases Thailand: government-subsidized hotels, United States: isolation strategies Peru: persons considered to Fiji: community isolation centers Japan: asymptomatic cases and patients
strategies will be isolated and treated public or private dorms were modified to vary by state. In New York, officials have suspected, probable or are used to isolate people with mild with mild symptoms who do not require
(designated at COVID-19 designated isolate asymptomatic cases. collaborated with hotels to provide confirmed COVID-19 who do not symptoms and who were determined hospitalization can recuperate at
facilities) hospitals and treatment shelter for people not ill enough to require hospitalization but do not as low risk for developing severe designated lodging facilities.
facilities. be admitted at the hospital and for have domestic conditions that COVID-19.
patients who had been discharged guarantee isolation in a room with
but not quite recovered. adequate ventilation and hygienic
services will be offered housing in
a temporary isolation center for
follow-up.
Social and Sri Lanka: the Presidential Niger: implemented price controls for Argentina: the government United Kingdom: over 1 million Uruguay: subsidy of up to 50% of Russia: citizens with a mortgage or
economic Task Force collaborated with essential goods for food distributions prohibited basic public service food boxes have now been rent for individuals enrolled in the consumer loan could take advantage of
support for the cooperative societies and and 2 months of free utilities to companies, such as those providing delivered to those most at risk unemployment insurance. Flexible debt standstill for the period of up to
general public supermarket chains to offer vulnerable households. The Council of electrical energy, water, gas, from coronavirus through the agreements on mortgage payments 6 months in the event of a decrease in
to aid adherence home delivery of food to Ministers declared the implementation mobile telephones, internet and shielding program. either with a discount or with deferral of income by 30% or more; citizens of the
to public health prevent uncontrolled gathering of state support for electricity and water TV cable, from suspending their installments, with further deferrals for Russian Federation who lost their jobs
interventions of people at marketplaces. bills for the months of April and May services due to lack of payment pensioners or retirees. due to the COVID-19 pandemic had
2020. by certain people, for up to three the maximum unemployment benefit,
periods of payment. regardless of the length of service and
level of earnings.
Surveillance Sri Lanka: the Ministry of Mozambique: multiple surveillance United States: the CDC deploys Mexico: case reporting by New Zealand: multisource surveillance Japan: multiple surveillance strategies,
strategies Health requests mandatory strategies, involving sentinel multiple surveillance systems, 475 Viral Respiratory Disease systems, involving mandatory case including case reporting by healthcare
case reporting by all surveillance, serological surveillance, including case reporting, Monitoring Units and medical reporting, sentinel surveillance, providers, active surveillance of
healthcare institutions. Active active surveillance at entry points and syndromic surveillance and units, which reported cases to syndromic surveillance, serological suspected cases, and monitoring the use
surveillance in communities through contact tracing. surveillance systems for influenza a centralized system called the surveillance and scenario modeling. of medical consultation hotlines among
is conducted through contact and respiratory diseases. Epidemiological Surveillance the public. Additionally, LINE Corporation
tracing. System for Viral Respiratory also implemented its own COVID-19
Diseases of the Mexican Ministry syndromic surveillance system that
of Health. collects demographic information and
reported symptoms.
Contact tracing Vietnam: NCOVI mobile app Thailand: Thai Chana online platform Spain: Radar COVID app is based United Kingdom: NHS COVID-19 Russia: ‘Stopcoronavirus. My Contacts,’ Singapore: TraceTogether, a mobile app
technologies creates a ‘neighborhood watch launched to facilitate monitoring of on the DP-3T protocol and uses contact tracing app allows users scans the user’s surroundings in a 10-m or token-based proximity tracing tool
system’ for citizens. It includes customers at shops; those who come in the Apple/Google API for contact to scan official NHS QR code radius and measures how close and (non-location based) using Bluetooth
a map of positive cases and close contact with infected people are tracing. posters at businesses, venues and for how long they interact with other technology to identify contacts of people
clusters, enables users to notified and called for testing. transport hubs for contact tracing users. Users who become infected will with confirmed COVID-19.
declare their health status and purposes. voluntarily notify the app, which then
report suspected cases. sends alerts to all others who were in
close proximity to them.
Online or Niger: the Urgent Medical Aid Mozambique: online risk assessment Spain: mobile app for citizens to Mexico: coronavirus information Pakistan: Ministry of Health launched Russia: implemented a hotline for
phone-based Services have set up a green for exposure and risk factors, with self-assess their health status, hotline, mobile app and text the Corona Helpline on WhatsApp COVID-19-related information and also
case line. All callers with symptoms toll-free hotlines to direct people who provide recommendations and services are made available for which provides up-to-date information a source of triaging potential cases. At
management of COVID-19 will be redirected are eligible for testing at National Health direct to onwards care. questions and self-assessment of about COVID-19 using an automated the request of the Rospotrebnadzor,
tools for the to the center, examined and Institute public laboratories or private COVID-19. ‘chatbot’ service to obtain information all regions have established their own
public tested. laboratories in the different provinces. 24 h a day. hotline.
Surveillance Vietnam: an online COVID- China: the China CDC launched a United States: data on COVID- Brazil: a new surveillance tool for Japan: the Ministry of Health, Labour Fiji: The SORMAS (Surveillance, Outbreak
databases 19 reporting system was web-based surveillance system that 19 cases is sent to the National COVID-19 case reporting was and Welfare launched the COVID-19 Response Management and Analysis
developed, which allows the allows real-time reporting of COVID-19 Notifiable Disease Surveillance developed based on the existing Surveillance and Management System System) is deployed for real-time digital
Ministry of Health to access cases by healthcare providers. System managed by the CDC. surveillance system for flu-like (HER-SYS), which is an online reporting surveillance and early detection of
and analyze epidemiological symptoms. system. outbreaks.
developments across the
country in real time.
Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. API, application programming interface.

NaTure MeDICIne
symptoms of COVID-19 to onward care24. Additionally, some coun- masks, gloves, face shields and gowns, which were used as a buffer
tries complemented digital technology with proactive deployment of while awaiting imported supplies or scale up of domestic produc-
existing and new community health resources25. Community-based tion. Singapore, for example, drew from experience responding to
approaches developed with deep knowledge of local contexts are SARS and preserved a national stockpile of medical products for
crucial to pandemic response and health systems resilience, par- up to 6 months30. To replenish stockpiles in Japan, medical product
ticularly given the disproportionate impact of the pandemic on vul- manufacturers were urged to boost production output, resulting in
nerable groups15,26. While outside the reach of the health system in the tripling of production volume as factories operated 24 h a day31.
many countries, there have been extensive outbreaks in long-term Governments also worked beyond the typical health sectors
care homes with devastating impacts on the health and well-being and developed guidelines and specifications for non-health sectors
of high-risk older adults, long-term care patients and their fami- to supplement the existing medical product manufacturing lines.
lies27. In response, most countries reviewed prioritized long-term In India, automotive manufacturers were repurposed to produce
care facilities and older adults for testing, surveillance and vaccine low-cost ventilators and PPE32. Beyond industry, communities
distribution, although often not until there had been high rates of in some countries mobilized to bolster medical product supplies.
mortality in these settings. Several countries had also relied on purchasing consortia, like the
UN COVID-19 Supply Chain System and Africa Medical Supplies
Health workforce. Resilient health systems manage crises by having Platform, donations from development partners or grants and loans
an adequate, trained and willing workforce. Yet, in many countries, from other countries and international financial entities (that is, The
COVID-19 has spread quickly among health workers as they have World Bank and Asian Development Bank) to secure medical sup-
been the most exposed to the virus, with data indicating that they plies33–37. Vaccine procurement is also an essential part of the medi-
have been disproportionately affected by the pandemic28. Health cal supply chain, and countries have either made advance-purchase
workforce challenges during COVID-19 include low staffing levels agreements or participated in the COVAX facility to ensure prompt
(particularly among nurses) and uneven geographical distribution, access to the vaccine for their populations, although concerns
shortages of adequate personal protective equipment (PPE), lim- remain about equitable access to vaccines in short supply.
ited testing capacity, insufficient training, social discrimination and In response to increased demand driven by widespread commu-
attacks and poor mental health29. nity transmission, countries enacted laws to prevent hoarding and
As cases surged globally, most reviewed countries reallocated exploitative pricing, as well as policies prohibiting export of medical
healthcare professionals, including primary-care workers, to emer- supplies, while relaxing import licensing requirements and tariffs38.
gency care wards, intensive care units (ICUs) and diagnosis and Within health facilities, measures including rational-use guidelines,
surveillance activities. Several recruitment strategies were imple- per WHO recommendations, and postponement of nonemergency
mented to increase the healthcare workforce. Retired, student or medical procedures helped stretch existing medical inventories39.
nonpracticing medical and paramedical professionals were asked to Although supply chains began to stabilize during 2020, many points
volunteer for healthcare tasks. For example, medical and nursing of care globally faced uncertain stocks and reports of counterfeit
students were recruited and allowed to perform supervised work medical essentials highlighting the need for secure supply pipelines.
in different COVID-19 response capacities in countries such as Platforms that assist in monitoring logistics networks are integral
Germany, Russia, Spain, the United Kingdom and Vietnam. Given in ensuring a steady and rapid flow of medical products and tech-
these new roles or expanded job scopes, there was an immediate nologies, promoting transparency and ensuring better management
need for rapid and high-quality pandemic-related training of front- of supply chains.
line healthcare workers, which was accomplished through virtual
training courses in many countries. Public health functions. Public health interventions embedded
Further measures were taken by countries to maintain, protect within communities, such as testing, contact tracing, quarantine or
and support their healthcare workers in light of the physical and psy- self-isolation, and surveillance are crucial functions to break chains
chological strain of the pandemic. In some countries (for example, of transmission40. However, in many health systems, public health
Japan, Mozambique, Singapore and South Korea), healthcare profes- and health service delivery systems are siloed: their coordination
sionals were supported by measures such as organization of shifts to is limited or ineffective, and they have separate referral processes
avoid extended hours without rest, leaves from duty for mental and and reporting systems, all of which serve to undermine health sys-
physical recovery, accommodation near their workplaces to protect tems resilience41. Testing and contact tracing are a case in point that
their families, and childcare. Additionally, most countries reported clearly illustrates why public health and health systems must act
giving some form of financial support to their health workers, such together in a coordinated manner.
as monetary incentives, bonuses, insurance, tax benefits, overtime Diagnostic tests to identify whether a person is, or has been,
pay, meal allowances, classification of their infections as an occupa- infected are foundational to infectious disease responses to pin-
tional disease or injury and declaring cause of death as work related. point locations of spread, and provide care and treatment if it exists.
Several countries reported making psychological support available Testing strategies are broadly classified as passive or proactive.
for health workers, such as counseling or trauma support, to main- Many of the countries reviewed relied on passive testing strategies,
tain well-being and morale. Frontline staff and their families were where symptomatic individuals self-present to a healthcare facility
especially vulnerable and were targeted for psychological interven- for testing after meeting certain criteria. However, some countries
tions. Moreover, some countries launched social media campaigns adopted proactive testing strategies characterized by programs tai-
that encourage people to show their pride, admiration and gratitude lored to the unique needs of specific populations as an important
for healthcare workers to promote solidarity. tool toward breaking chains of transmission and offering a clearer
epidemiological picture42,43. Additionally, many countries rapidly
Medical products and technologies. High-quality prevention, diag- decentralized testing capacity by strengthening or developing new
nosis and management of COVID-19 require the ongoing develop- laboratory networks.
ment, production and sustained distribution of mass quantities of Proactive testing must be accompanied by comprehensive con-
medical products and technologies. However, overreliance on a few tact tracing in partnership with communities. Contact tracing is
countries for production, competition among countries and supply the systematic process of following up with individuals who may
chain disruptions have caused global supply shortages. Some coun- have been exposed to COVID-1944. It can be characterized as either
tries reviewed had national or regional stockpiles of PPE, including forward, aiming to find ‘downstream’ individuals who have been in

Activate comprehensive responses

• Multi-ministry task forces or committees and whole-of-government approach
• Training on COVID-19 including infection prevention and control for all health workers
• Advance purchase agreements and participation for novel medical products (e.g., participa-
tion in COVAX)
• Active surveillance, testing and contact tracing mechanisms supported by networks of
laboratories
oration across se • Quarantine and isolation facilities, routine press briefings and regular updates on the situation
llab cto
Co rs
Adapt health system capacity
Governance • Public–private approaches that are cost-effective, accountable and transparent
and financing • Financial and social supports for health workers
• Reallocation and recruitment of health workers, including retired or foreign-trained health
workers and trainees
• Access and use of digital technologies
Learn and adjust

• Creation of temporary healthcare facilities or adaptation of existing civic facilities
Health service Health • Postponing elective procedures
delivery Community workforce
engagement Preserve health system functions and resources
• Cost-effective procurement through purchasing consortia participation
• Rational-use guidelines to maximize and preserve medical resources
• Domestic research, development and production of PPE, test kits and other medical
Public health Medical products equipment
functions and technologies • Support CHWs so that public health can reach local populations
• Support primary care for response activities and ongoing routine and acute care
• Engage the community in the planning of health services
Reduce vulnerability
• Financing mechanisms to provide relief for businesses, individuals and families
• Leverage the skills and knowledge of CHWs or other community leaders (e.g., youth groups
and religious groups) to reach the general population and at-risk subpopulations
• Manufacturing and supply chain strengthening
• Proactive testing and contact tracing strategies
• Communication strategies that reach people where they are, e.g., social media, WhatsApp
and public campaigns
Fig. 3 | Four resilience elements of highly effective country responses. The framework presented expands upon and applies the determinants of health
systems resilience framework to identify four resilience elements characteristic of highly effective country responses to COVID-19.
contact with a person with COVID-19, or backwards, aiming to find comprehensive to provide accurate depictions of disease burden and
an ‘upstream’ source of infection45. While most countries reviewed epidemiology to prevent and mitigate community transmission53–55.
conducted forward contact tracing, Japan conducted backwards As recommended by WHO guidelines, nearly all countries have
contact tracing measures aimed at identifying and ‘busting’ clusters adapted existing surveillance system infrastructure to collect infor-
by working with individuals to trace 14 d before symptom onset46. mation on COVID-19 cases55. However, surveillance based on case
Contact tracing, particularly backwards tracing, is labor and time reporting may underestimate the epidemiological characteristics of
intensive and may be stigmatizing if not done with community COVID-19, given that stigma or other barriers may limit healthcare
engagement and consideration of at-risk and vulnerable groups47. seeking, particularly in vulnerable populations56,57. Therefore, New
The majority of countries reviewed introduced digital contact trac- Zealand, Sweden and the United States have additionally deployed
ing tools. Even when fully operational, they may not be accessible, syndromic surveillance, which monitors cases that meet the clinical
acceptable or feasible for use among those with limited access to, or definition of COVID-19 without confirmation by testing. By imple-
concerns in using, adequate technology such as migrants, refugees menting active surveillance approaches, countries have expanded
or those experiencing homelessness, among others48. surveillance coverage from healthcare settings into communities,
Once cases and contacts are identified, self-isolation and quar- such as through primary care, thereby strengthening epidemiologi-
antine measures are crucial to prevent onwards transmission and cal surveillance among vulnerable populations.
identify emergent cases. All countries reported on quarantine and Timely sharing of case-based data between public health and
isolation protocols. While necessary to outbreak management, healthcare sectors is key to early detection of outbreaks, identifica-
unless done in coordination with communities, quarantine mea- tion of changes in epidemiological trends and planning of health
sures can have negative impacts on mental health and well-being, services58. This was facilitated by the use of innovative digital tech-
become a source of stigma and be deployed at the significant cost of nology. For example, the China CDC launched a web-based infec-
human rights49. Some countries have implemented policies to pro- tious disease reporting system that allows real-time reporting of
vide social and economic assistance to those who must self-isolate confirmed and suspected COVID-19 cases by healthcare provid-
or quarantine. Social supports range from services that ensure food ers59,60. Similar real-time surveillance and information systems are
and necessities during quarantine to dedicated quarantine or iso- also used in Fiji, India, Japan and Vietnam.
lation facilities (for example, converted hotels, public facilities or
purpose-built quarantine hospitals). Such self-isolation supports Discussion
are recognized as integral to mitigating transmission, particu- Assessing health systems resilience is vital in helping policymak-
larly among younger people and those working in high-exposure ers plan for sustainable recovery and strengthen systems to better
occupations, living in overcrowded housing or without a home50. prepare and respond to current and future crises. Using an adapted
However, to avoid negative unintended consequences, such facili- and improved resilience framework, our review highlights many
ties must be operationalized with a human rights focus51. parallels in the measures implemented by countries in response
These efforts are enhanced by surveillance, including testing in to COVID-19. The similarities across countries with divergent
areas or settings with outbreaks, to rapidly limit community circu- health outcomes makes clear that there is no one silver bullet
lation52. Given the high transmissibility of severe acute respiratory toward a resilient health system. Nevertheless, there are a number
syndrome coronavirus 2, surveillance needs to be geographically of characteristics of well-performing countries across the resilience

determinants that stand out. These are summarized as four elements local authorities, and is based on strong and clear coordination
of resilience that are featured in highly effective country responses. that extends beyond early-stage emergency management61. Crucial
These elements draw on the concept that resilient health systems to health systems resilience is that governance must consider the
are systems that: (1) activate comprehensive responses, which are intersections of gender, racialization and human rights, and their
responses that consider and address health and well-being as inter- impact on health and well-being before, during and after crises62–64.
twined with social and economic considerations; (2) adapt capacity Urging governments to adopt such an approach, which COVID-19
within and beyond the health system to meet the needs of com- has made clear is essential, is not a new proposal. Yet, our review
munities; (3) preserve functions and resources within and beyond highlights a lack of uniform appreciation or adoption of such an
the health system to maintain pandemic-related and non-related approach by countries.
routine and acute care; and (4) reduce vulnerability to catastrophic Second, health systems need appropriate financing, not only to
losses in communities, both in terms of health and well-being, as prepare for new pandemics, but also to ensure that at all times, all
well as individual or household finances; all while continually learn- people have access to the health services they need, when and where
ing, monitoring and adjusting in light of emerging evidence or the they need them, without financial hardship, regardless of ability
evolving epidemiological situation (Fig. 3). to pay65. This is the foundation of UHC. While many countries
have provided subsidized COVID-19 testing and treatment, more
High-performing countries. High-performing countries activated must be done to ensure people are not pushed into poverty due to
comprehensive responses across the determinants’ domains, includ- out-of-pocket spending on health. Investing in UHC not only pro-
ing through whole-of-government approaches and the creation of tects people from health threats but also mitigates the social and
multi-ministry task forces, to ensure adequate translation of evi- economic burdens that have characterized COVID-19. Countries
dence into policy and practices that preserve health system capacity, will have to revisit the thresholds of health expenditure that they are
while protecting public health and livelihoods. Specific measures willing to invest to build resilient health systems, promote popula-
taken include training health workers, bolstering public health func- tion health and protect communities against financial risk.
tions (including offering designated isolation facilities, either for all Third, while country capacities varied, the pandemic has demon-
or for those unable to safely self-isolate at home) and preparing for strated a need to invest in improving both the quantity and quality
new technologies and medicines through purchase agreements, of health workers to better prepare for and respond to future pan-
while also engaging communities through routine communications demics. Our review highlights that resilient health systems are those
on the epidemiological situation and emergent policies. that not only invest in pandemic-related planning and training of
These countries also learned from emerging evidence and health workers, but also ensure their physical, mental and economic
adapted the capacity of their health system in response to the evolv- protection in the workplace and beyond. Emphasis should also be
ing epidemiological situation. This was achieved by increasing placed on community mobilization where adequately trained and
capacity in hospitals, through construction of makeshift hospitals or supported CHWs are equipped to play substantial roles in outbreak
repurposing of existing health facilities or civic spaces. The health response and community engagement, much as they have played a
workforce in high-performing countries was expanded through crucial role in tuberculosis and HIV/AIDS response efforts globally
reallocation and recruitment and supported through financial and for decades66.
social supports. Fourth, in terms of access to medicines and products, the pan-
These countries took action to preserve health system func- demic has made visible, yet again, the clearly identified and thor-
tions and resources through purchasing consortia and rational-use oughly debated challenges to global supply chains for medicines
guidelines to maximize available material resources such as PPE, as and products. These challenges range from limited manufacturing
well as investing in domestic research, development and produc- capacities to financing to equity in access. The early experience of
tion of medical supplies, test kits and vaccines. Additionally, these COVAX, with some high-income countries bypassing the initiative,
countries protected health and well-being more broadly by ensur- has demonstrated the glaring limitations in the current system.
ing health system functioning for non-COVID-19-related health Fifth, health service delivery, including non-COVID-19-related
services. High-performing countries supported primary care and health services, has been directly threatened, and often compro-
CHWs to conduct COVID-19 screening, assessment and/or refer- mised, at all levels by the demands of the pandemic, even in tra-
ral, while providing ongoing routine and acute care in communities. ditionally high-performing health systems. Our review emphasizes
High-performing countries also sought to reduce vulnerability that bolstering system capacity requires strong and well-funded pri-
across the resilience determinants by providing financial relief and mary care, with a skilled and protected workforce, to ensure that
social supports to complement proactive and robust testing and high-quality care is delivered in communities, with strengthened
contact tracing in partnership with communities to ensure public linkages to public health systems. Similarly, the long-term care sec-
health measures and safety net supports reached all groups. tor, and care for older adults, must be prioritized and better inte-
grated into health service delivery and public health functions. This
Building resilient health systems. While some countries have must be underpinned by a renewed commitment to UHC to ensure
demonstrated elements of resilience, as we highlight above, progress high-quality care for all.
is limited in developing resilient health systems overall. Our review Finally, public health functions, such as testing and contact trac-
highlights six areas requiring urgent action to build resilient health ing, that are delivered in coordination with the health service sys-
systems globally. tem, are cornerstones for successful COVID-19 responses. These
First, COVID-19 responses provide a clear illustration of the approaches often depend on innovative digital technologies, which
importance of governance supported by scientific evidence and bear their own challenges, including the potential to exacerbate
leadership willing to learn and adjust course for successful health inequalities and be the vehicle for human rights violations67–70. As
systems that protect health and well-being. Enhancing resilience such, future investments in these technologies requires a more
to future disease outbreaks requires longer-term work to cre- holistic approach—one that engages communities, particularly the
ate high-quality healthcare systems and build community trust. most vulnerable—that takes into account the potential risks and
Our review emphasizes that governments are well advised to considers how health systems can minimize harms from their use71.
address COVID-19, and any future disease outbreak, through Importantly, our analysis of country responses points toward
a whole-of-government approach that incorporates all sectors, foundational debates on how we understand and think about resil-
engages relevant actors across all levels, including community and ient health systems. Health system resilience as a concept must

expand beyond technical and biomedical knowledge and actions, 12. Haldane, V. & Morgan, G. T. From resilient to transilient health systems: the
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