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In December 2019, a new coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and associated disease, coronavirus disease 2019 (COVID-19), was identified in China. This virus spread quickly and in March, 2020, it was declared a pandemic. Scientists predicted the worst scenario to occur in Africa since it was the least developed of the continents in terms of human development index, lagged behind others in achievement of the United Nations sustainable development goals (SDGs), has inadequate resources for provision of social services, and has many fragile states. In addition, there were relatively few research reporting findings on COVID-19 in Africa. On the contrary, the more developed countries reported higher disease incidences and mortality rates. However, for Africa, the earlier predictions and modelling into COVID-19 incidence and mortality did not fit into the reality. Therefore, the main objective of this forum is to bring together infectious diseases and public health experts to give an overview of COVID-19 in Africa and share their thoughts and opinions on why Africa behaved the way it did. Furthermore, the experts highlight what needs to be done to support Africa to consolidate the status quo and overcome the negative effects of COVID-19 so as to accelerate attainment of the SDGs.

Background Community health workers (CHWs) play a critical role in grassroots healthcare and are essential for achieving the health-related Sustainable Development Goals. While there is a critical shortage of essential health workers in low- and middle-income countries, WHO and international partners have reached a consensus on the need to expand and strengthen CHW programmes as a key element in achieving Universal Health Coverage (UHC). The COVID-19 pandemic has further revealed that emerging health challenges require quick local responses such as those utilizing CHWs. This is the second paper of our 11-paper supplement, “Community health workers at the dawn of a new era”. Our objective here is to highlight questions, challenges, and strategies for stakeholders to consider while planning the introduction, expansion, or strengthening of a large-scale CHW programme and the complex array of coordination and partnerships that need to be considered. Methods The authors draw on the outcomes of discussions during key consultations with various government leaders and experts from across policy, implementation, research, and development organizations in which the authors have engaged in the past decade. These include global consultations on CHWs and global forums on human resources for health (HRH) conferences between 2010 and 2014 (Montreux, Bangkok, Recife, Washington DC). They also build on the authors’ direct involvement with the Global Health Workforce Alliance. Results Weak health systems, poor planning, lack of coordination, and failed partnerships have produced lacklustre CHW programmes in countries. This paper highlights the three issues that are generally agreed as being critical to the long-term effectiveness of national CHW programmes—planning, coordination, and partnerships. Mechanisms are available in many countries such as the UHC2030 (formerly International Health Partnership), country coordinating mechanisms (CCMs), and those focusing on the health workforce such as the national Human Resources for Health Observatory and the Country Coordination and Facilitation (CCF) initiatives introduced by the Global Health Workforce Alliance. Conclusion It is imperative to integrate CHW initiatives into formal health systems. Multidimensional interventions and multisectoral partnerships are required to holistically address the challenges at national and local levels, thereby ensuring synergy among the actions of partners and stakeholders. In order to establish robust and institutionalized processes, coordination is required to provide a workable platform and conducive environment, engaging all partners and stakeholders to yield tangible results.

Background The COVID-19 pandemic control strategies disrupted the smooth delivery of essential health services (EHS) globally. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS during the COVID-19 pandemic. This study aimed to identify the health system challenges encountered and document the mitigation strategies and adaptations made across geopolitical zones (GPZs) in Nigeria. Methods The national qualitative survey of key actors across the six GPZs in Nigeria involved ten states and the Federal Capital Territory (FCT) which were selected based on resilience, COVID-19 burden and security considerations. A pre-tested key informant guide was used to collect data on service utilization, changes in service utilization, reasons for changes in primary health centres’ (PHCs) service volumes, challenges experienced by health facilities in maintaining EHS, mitigation strategies implemented and adaptations to service delivery. Emerging sub-themes were categorized under the appropriate pillars of the health system. Results A total of 22 respondents were interviewed. The challenges experienced in maintaining EHS cut across the pillars of the health systems including: Human resources shortage, shortages in the supply of personal protective equipments, fear of contracting COVID-19 among health workers misconception, ignorance, socio-cultural issues, lockdown/transportation and lack of equipment/waiting area (. The mitigation strategies included improved political will to fund health service projects, leading to improved accessibility, affordability, and supply of consumables. The health workforce was motivated by employing, redeploying, training, and incentivizing. Service delivery was reorganized by rescheduling appointments and prioritizing some EHS such as maternal and childcare. Sustainable systems adaptations included IPC and telehealth infrastructure, training and capacity building, virtual meetings and community groups set up for sensitization and engagement. Conclusion The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

Background The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on health systems worldwide, resulting in disruptions to essential health service delivery, such as routine immunizations, maternal and child health, and treatment for communicable and noncommunicable diseases. These services have been disrupted due to the diversion of resources towards the COVID-19 response. Therefore, the objective of this scoping review was to identify the strategies and challenges associated with maintaining the continuity of essential health services during a pandemic. Methods This scoping review study was conducted in 2023 using the proposed Arksey and O’Malley framework. We conducted searches on PubMed, Scopus, ProQuest, and Web of Science using relevant keywords. Additionally, we searched Google Scholar, hand-searched reference lists of included studies, and reviewed organizational reports, websites, and other sources of information. Content analysis was employed to summarize the themes from the selected articles. Results Our search of major databases yielded 3,732 results. After the screening process, 47 articles were included in the scoping review. The extracted interventions were classified into six groups based on the building blocks of the World Health Organization health system: leadership and governance, access to essential medicines, health systems financing, the health workforce, health service delivery, and health information systems. Conclusions The implementation of effective strategies and interventions can help ensure the provision of essential health services during a pandemic. These strategies include leveraging technology for remote care, ensuring the safety of healthcare workers and patients, strengthening supply chains, and establishing flexible and adaptive healthcare systems.

Introduction Community health workers (CHWs) played a vital role in providing diverse essential health services to their communities during the pandemic. Using CHWs perspective, this study investigates barriers to seeking and delivery of essential health services in the nine Afghan communities during the COVID-19 pandemic. Method In this cross-sectional study, 107 primary health care clinics from 9 provinces were selected, in which around 45% of the total country population reside. We used the validated questionnaire “Community Needs, Perceptions and Demand, Community Assessment Tool” which was contextualized by WHO headquarters and the WHO Afghanistan office. Data was exported into Excel, cleaned, and then exported into and analyzed using STATA version 17. Result Most CHWs were men (80.9%), from rural areas (87.2%), and volunteers (58.1%). About 66.3% reported that lack of information about available services was a main barrier. Other reported barriers were a lack of transportation to health facilities (47.2%), their home were too far from health facilities (40.9%), and a perceived lack of medicines at facilities (23.6%). More than half of CHWs reported that they received some training on how COVID-19 spreads (67.2%), COVID-19 vaccine (65.4%), and how to use a mask properly while working (56.3%), while 27.2% said that they had not enough mask available to use. Conclusion Our research demonstrated that most barriers and concerns related to using critical services during a pandemic may be addressed by providing information about available services, providing transportation to facilities, and providing masks to personnel and individuals. CHWs could play critical role in managing and responding to emergencies and pandemics if the government invest on their capacity and motivation. Revision of training curriculum for CHWs and their job description to include the emergency and pandemic management at community level, and providing them monetary incentives are highly recommended.

Background The level of trust in health systems is often in flux during public health emergencies and presents challenges in providing adequate health services and preventing the spread of disease. Experiences during previous epidemics has shown that lack of trust can impact the continuity of essential health services and response efforts. Guinea and Sierra Leone were greatly challenged by a lack of trust in the system during the Ebola epidemic. We thus sought to investigate what was perceived to influence public and community trust in the health system during the COVID-19 pandemic, and what strategies were employed by national level stakeholders in order to maintain or restore trust in the health system in Guinea and Sierra Leone. Methods This qualitative study was conducted through a document review and key informant interviews with actors involved in COVID-19 and/or in malaria control efforts in Guinea and Sierra Leone. Key informants were selected based on their role and level of engagement in the national level response. Thirty Six semi-structured interviews (16 in Guinea, 20 in Sierra Leone) were recorded, transcribed, and analyzed using an inductive and deductive framework approach to thematic analysis. Results Key informants described three overarching themes related to changes in trust and health seeking behavior due to COVID-19: (1) reignited fear and uncertainty among the population, (2) adaptations to sensitization and community engagement efforts, and (3) building on the legacy of Ebola as a continuous process. Communication, community engagement, and on-going support to health workers were reiterated as crucial factors for maintaining trust in the health system. Conclusion Lessons from the Ebola epidemic enabled response actors to consider maintaining and rebuilding trust as a core aim of the pandemic response which helped to ensure continuity of care and mitigate secondary impacts of the pandemic. Monitoring and maintaining trust in health systems is a key consideration for health systems resilience during public health emergencies.

Background The COVID-19 pandemic strained health systems worldwide, diverting resources and disrupting routine healthcare services. These disruptions may lead to health risks from delayed or reduced care. Health system resilience (HSR) – a critical factor in maintaining health services during crises – refers to a system’s ability to anticipate, prepare for, absorb, respond to, recover from, and adapt to disruptions. To be effective, HSR must also be equitable, ensuring that all socioeconomic groups have access to healthcare services during crises. Sweden’s approach, which relied on public adherence to government recommendations rather than enforcing restrictions, presents a unique case for studying HSR. Aim This study aims to evaluate aspects of HSR in Sweden during the COVID-19 pandemic by analysing changes in essential health service utilisation across different phases of the pandemic, and by examining sociodemographic differences in utilisation by education and sex. Method This study utilises interrupted time series analysis to evaluate changes in healthcare service utilisation across various levels of the Swedish health system with stratification by education and sex. Primary care was measured through diabetes diagnoses, emergency care through appendicitis cases, inpatient care through hospital admission for inflammatory bowel disease (IBD), and cancer diagnostics through diagnosis rates. Data were obtained from various population based Swedish health registries through the SWECOV project. Results The findings highlight varying degrees of disruptions and resilience across different sectors. Emergency care, primary care, and symptom-based cancer diagnosis showed signs of recovery after an initial drop, whereas cancer screening, was more affected. In the case of inpatient care for IBD, the number of admissions declined, though the length of hospital stays remained unchanged. Education level did not impact healthcare utilisation for most indicators, and differences between men and women were generally small. Conclusion The Swedish HSR during the COVID-19 pandemic was challenged but remained intact in most healthcare sectors. The health system on different levels also managed to a large degree cater for the diagnoses covered in this study, largely independent of educational level and sex. As data availability increases with time further research will help gain a deeper understanding of the outcomes of the pandemic on health services unrelated to COVID-19, including the role of education in influencing healthcare utilisation.

Background In Nigeria, COVID-19 vaccines were delivered through outreach activities, as well as integrated within routine immunisation. However, evaluations of integrated approaches for novel vaccines are scarce. We aimed to understand the perceived benefits and challenges of integrating the COVID-19 vaccine within routine immunisation in Nigeria, and identify ways to strengthen this approach. Methods We conducted 30 semi-structured interviews with community members and healthcare workers in primary healthcare facilities (PHCs) in Jigawa ( n  = 16) and Oyo ( n  = 14) states, Nigeria from 08 August to 13 September 2022. Participants were selected purposively from PHCs. We obtained information on participants’ perception about routine immunisation, and perceived benefits and challenges associated with integrated COVID-19 vaccine delivery. Healthcare worker and community interviews were analysed separately following a thematic analysis approach. Results We identified four themes that describe the community and healthcare workers’ responses, perceived impact, and the health system adaptions to the challenges associated with the integrated vaccine delivery approach. Community members expressed concern that children might be given COVID-19 vaccines instead of routine immunisations, while others appreciated the integrated approach due to their trust in the efficacy of COVID-19 vaccines, government, and healthcare providers. Healthcare providers perceived the integrated approach as improving vaccination coverage and awareness but noted additional problems of increased workload, vaccine scarcity, and prolonged clinic visits. Insufficient resources were subsisting barriers to effective integration in both states, but the provider’s gender was also a challenge in Jigawa state. Additionally, the use of incentives to generate demand had ambiguous effects in Jigawa state. Conclusion Taking an integrated approach to deliver COVID-19 vaccines was acceptable by healthcare providers but community members expressed concerns. Given existing vaccination programmes have persistent challenges, it is pertinent to address these barriers to enhance effectiveness of an integrated approach.

Background Health systems around the world are being challenged by an on-going COVID-19 pandemic. The COVID-19 pandemic and associated response can have a significant downstream effect on access to routine health care services, and indirectly cause morbidity and mortality from causes other than the disease itself, especially in resource-poor countries such as Ethiopia. This study aimed to explore the impact of the pandemic on these services and measures taken to combat the effect. Methods The study was conducted at St. Paul’s hospital millennium medical college (SPHMMC) from December 15, 2020 to January 15, 2021 using a comparative cross-sectional study design. We collected data on the number of clients getting different essential health care services from May to October 2019 (Pre COVID) and the same period in 2020 (during a COVID-19 pandemic) from the patient registry book. The analysis was done with SPSS version 24 software. Result Overall, the essential services of SPHMMC were affected by the COVID-19 pandemic. The most affected service is inpatient admission, which showed a 73.3% (2044 to 682) reduction from the pre-COVID period and the least affected is maternal service, which only decreased by 13% (3671 to 3177). During the 6 months after the COVID-19 pandemic, there was a progressive increment in the number of clients getting essential health services. Conclusion and recommendation The establishment of a triple setup for fighting against COVID-19, which encompasses non-COVID services, an isolation center and a COVID-19 treatment center, played a vital role in preserving essential health services.

Background The COVID-19 disrupted the provision of essential health services in numerous countries, potentially leading to outbreaks of deadly diseases. This study aims to investigate the effect of the COVID-19 pandemic on the utilization of essential health services in Iran. Methods An analytical cross-sectional study was conducted using interrupted time series (ITS) analysis. Data about five indicators, including 'childhood vaccination, infant care, hypertension screening, diabetes screening, and breast cancer screening,' were obtained from the electronic health record System in two-time intervals: 15 months before (November 2018 to January 2020) and 15 months after (January 2020 to May 2021) the onset of the COVID-19 pandemic. The data were analyzed by utilizing ITS. In addition, a Poisson model was employed due to the usage of count data. The Durbin-Watson (DW) test was used to identify the presence of lag-1 autocorrelation in the time series data. All statistical analysis was performed using R 4.3.1 software, considering a 5% significance level. Results The ITS analysis showed that the COVID-19 pandemic significantly affected the utilization of all essential health services ( P  <  0.0001 ). The utilization of hypertension screening (RR = 0.51, p  < 0.001), diabetes screening (RR = 0.884, p  < 0.001), breast cancer screening (RR = 0.435, p  < 0.001), childhood vaccination (IRR = 0.947, p  < 0.001), and infant care (RR = 1.666, p  < 0.001), exhibited a significant decrease in the short term following the pandemic ( P  <  0.0001 ). However, the long-term trend for all service utilization, except breast cancer screening (IRR = 0.952, p  < 0.001), demonstrated a significant increase. Conclusions The COVID-19 pandemic affected utilization of essential health care in Iran. It is imperative to utilize this evidence to develop policies that will be translated into targeted planning and implementation to sustain provision and utilization of essential health services during public health emergencies. It is also vital to raise awareness and public knowledge regarding the consequences of interruptions in essential health services. In addition, it is important to identify the supply- and demand-side factors contributing to these disruptions.