key: cord-0945863-hv29k30i authors: Akinyemi, Oluwaseun Oladapo; Popoola, Oluwafemi Akinyele; Fowotade, Adeola; Adekanmbi, Olukemi; Cadmus, Eniola O.; Adebayo, Adebusola title: Qualitative exploration of health system response to COVID-19 pandemic applying the WHO health systems framework: Case study of a Nigerian state date: 2021-08-20 journal: Sci Afr DOI: 10.1016/j.sciaf.2021.e00945 sha: 64f98698ebe2b0e472cbf377fcae588f6864a5ae doc_id: 945863 cord_uid: hv29k30i Pandemics can result in significantly high rates of morbidity and mortality with higher impact in Lower- and Middle-Income Countries like Nigeria. Health systems have an important role in a multi-sector response to pandemics, as there are already concerns that COVID-19 will significantly divert limited health care resources. This study appraised the readiness and resilience of the Nigerian health system to the COVID-19 pandemic, using Oyo State, southwest Nigeria, as a case study. This study was a cross-sectional qualitative study involving key informant and in-depth interviews. Purposive sampling was used in recruiting participants who were members of the Task Force on COVID-19 in the state and Emergency Operations Centre (EOC) members (physicians, nurses, laboratory scientists, “contact tracers”, logistic managers) and other partners. The state's health system response to COVID 19 was assessed using the WHO health systems framework. Audio recordings of the interviews done in English were transcribed and thematic analysis of these transcripts was carried out using NVIVO software. Results show that the state government responded promptly by putting in place measures to address the COVID-19 pandemic. However, the response was not adequate owing to the fact that the health system has already been weakened by various challenges like poor funding of the health system, shortage of human resources and inadequate infrastructure. These contributed to the health system's sub-optimal response to the pandemic. In order to arm the health system for adequate and appropriate response during major health disasters like pandemics, fundamental pillars of the health system - finance, human resources, information and technology, medical equipment and leadership - need to be addressed in order to have a resilient health system. A pandemic may be defined as -an epidemic happening over a wide region, crossing global boundaries, and typically influencing countless individuals‖ [1] . Pandemics are outbreaks of infectious diseases that occur on a large scale and can result in a high level of morbidity and mortality across countries causing a significant negative effect in economic, social and political [2] . The likelihood of pandemics is believed to have increased in the last century because of increased worldwide travel [3, 4] . SARS-CoV-2, a novel coronavirus, started a global pandemic of respiratory illness, named COVID-19 in December 2019 [5] . COVID-19 presents with a spectrum of symptoms ranging from a mild, self-limiting respiratory tract illness to severe progressive pneumonia, multiorgan failure, and death [6] . The vast majority of deaths from COVID-19 have occurred in Italy, China, Spain and United States of America-all countries with good health care resources [7] . The first case of COVID-19 in Nigeria was reported in February 2020 and since then the number of cases has gradually increased to more than 159,000 as at the time of putting together this paper [8] . Pandemics can result in significantly high rates of morbidity and mortality with the impacts being higher in lower-and middle-income Countries (LMIC) like Nigeria [2] . Health systems have an important role in a multisector response to pandemics, as there are already concerns that COVID-19 will severely divert limited health care resources [9, 10] . Responsiveness is a key objective of national health systems. Responsive health systems anticipate and adapt to existing and future health needs, thus contributing to better health outcomes [11] . This study assessed the health system's response to the global COVID-19 pandemic in a resource-limited context like Nigeria and provided lessons which may help ready the health system for future public health emergencies in a setting like this. Leadership is a necessary element of strong health systems. Leadership and governance of health systems, also referred to as stewardship, has been described as the most complex but critical building block of any health system [12, 13] . According to the WHO [12], leadership and governance are associated with the role of the government in health and its relation to other actors whose activities have an impact on health; this involves overseeing and guiding the whole health system in order to protect the public interest. Governance plays a critical role in creating an environment that facilitates productive partnerships for strengthening competencies within the health system and across sectors [14] . The lack of effective leadership and governance in the health sector is a major contributor to the failure of health systems in most LMICs, including Nigeria [15] . Nigeria's Federal Ministry of Health [16] observed that the lack of performance of the country's health system is attributable to the weakness in the leadership/stewardship role of government in health. Financing the health system is aimed at covering the health needs of the people both individually and collectively through the mobilization, accumulation and allocation of funds which will cover the health needs of the populace [17] . According to the WHO [12], a good health financing system raises funds that are adequate for health which ensures that people get access to the health services they need and are protected from impoverishment and incurring catastrophic expenditures associated with having to pay for health. A competent health workforce is a vital resource for health services delivery, dictating the extent to which services are capable of responding to health needs [18] . Human Resource for Health (HRH) development operations in Nigeria are sub-optimal, as in other LMICs [15] . Health systems can only function with health workers; improving health service coverage and realizing the right to the enjoyment of the highest attainable standard of health is dependent on their availability, accessibility, acceptability and quality. The health workforce has a vital role in building the resilience of communities and health systems to respond to disasters caused by natural or man-made hazards, as well as related environ-mental, technological and biological hazards and risks. A well-functioning health system ensures access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost effectiveness. According to the WHO framework for health systems [19] , this is one of the six building blocks of health systems and technology which is used in all types of health facilities, plays a major role in contemporary health care systems and contributes directly to the quality of patient care. Advances in information and communication technologies (ICTs) could play an important role in improving health systems in developing countries [20] . Information systems have great potential to reduce healthcare costs and improve outcomes [21] . Therefore, the aim of this study was to explore the health system response and resilience to the COVID-19 pandemic in Oyo State, Southwest Nigeria and to document lessons learnt for future public health emergencies. The study was carried out in Oyo state, south-west geopolitical zone of Nigeria. It covers 28, 454 km land area, with a population of 5,580,894. The state capital is Ibadan [22, 23]. HEALTH SYSTEM RESPONSE TO COVID-19 PANDEMIC 6 The study site is the Oyo State Ministry of Health, established in 1957 and one of the oldest in the southwest region. The ministry is saddled with the responsibility of policy initiation and implementation on issues relating to the health and wellbeing of the people of the State. Respondents in this study include Emergency Operating Centre (EOC) members (physicians, nurses, lab scientists, -contact tracers‖, logistic managers) officials from the Ministry of Health, WHO and other partners in Oyo State This study is a cross-sectional qualitative study. It involved key informant interviews, indepth interviews and desk review of documents. Interviews were conducted with 13 participants until saturation was reached, a point when similar responses are being collected with no new or additional information [24, 25] . Purposive sampling method was used to select participants, based on ability to provide required information to answer the study's research question: how did the COVID-19 pandemic affect the functioning of the health system? Participants were those who have been involved one way or the other in the COVID-19 response in Oyo state including health workers involved in the management of health facilities in the state. An interview guide containing questions and probe questions was used. The guide covered questions on the response of the leadership to the pandemic, availability of funds and medical equipment and adequacy of health workers. All intended participants are health workers with a minimum of a first degree done in English. The interviews were therefore conducted in English. All data collected from participants were treated with confidentiality and not shared with anyone except for the purpose of publications. Interviews were conducted by the last author assisted by two research assistants. All interviews were conducted in English, audio-recorded and then transcribed in full. All authors are medical doctors who practice in Oyo State. Interview transcripts were uploaded into the NVIVO software version 10 and then analysed iteratively based on the thematic framework earlier developed. Using a codebook, the first and last authors coded independently and later compared and matched the codes. Codes that emerged from reading the manuscripts were added to a priori themes. The Standards for Reporting Qualitative Research guidelines [26] for qualitative studies were used in the preparation of this manuscript. Ethical approval for this study was obtained from the Oyo State Ministry of Health Ethics Review Committee (Reference number: AD13/479/1796 A ). No known identifiers were used during the interviews and while transcribing so as to maintain the confidentiality of the participants. No part of this study caused any of the participants harm. The findings from this study provided recommendations on how to strengthen the health system especially during pandemics. Participation in the study was voluntary and participants were aware that they could decide at any point to opt out. Both verbal and written informed consent was taken from participants. From Table 1 , a total of 13 participants were interviewed for the study. Majority were male (76.9%), aged 40 years and above (61.5%) with a mean age of 45.1± 14.7 years. Based on their place of primary employment, more than half of the respondents (61.5%) work in the public sector. When asked about their view on how the leadership of the state addressed COVID-19 pandemic, some of respondents believed that the leadership had taken proactive steps to combat the pandemic. This was demonstrated by the creation of an EOC even before there was any case of COVID-19 in the state. They responded thus: The financing of the health system was also explored with respect to the adequacy, effectiveness and transparency of funds. Some believed that the impact of the pandemic has affected health financing globally but the state has made some progress through the provision of basic health services and awareness. "On that, I will say the government is doing her best even though the best may not be With regards to the availability and adequacy of the health workforce, the general consensus was that before the outbreak of the pandemic, Oyo state and Nigeria as a whole had a shortage of health workers. This shortage has however worsened due to the pandemic. " (female, nurse) The respondents were of the opinion that these medical products were already lacking before the pandemic and the inadequacy worsened with the pandemic. Some of the responses are quoted below " (male, doctor) On their views on the information dissemination system within the state, one of the respondents believed the dissemination did not reach rural areas, he responded thus: We asked the respondents on their thoughts on how the pandemic has affected service delivery in the health system in the state. The responses showed that the pandemic has had a major impact and affected service delivery negatively, especially through the disruption of the appointment system, emergency and routine services, as well as diversion of health resources to the control of the pandemic. In this study, the opinion about the response of the leadership and governance in addressing the pandemic was divided. While some believed the government's response was prompt, others thought there was a lag in response to the COVID-19 pandemic. Chukwuorji and Iorfa [27] from their study concluded that there was prompt response to the COVID-19 outbreak by the Nigerian government but the effectiveness of the response was undermined by a lack of preexisting social infrastructure. This is similar to our findings. The response of the Nigerian government to COVID-19 was also observed by Awofeso and Irabor [28] to be ineffective due to the ineffective coordination of lockdown across states and sustaining the economy. Unlike the initial health response to COVID-19, it has been reported that the South African government was slow in responding to economic concerns [29] . It was also observed that governments in Africa made noteworthy interventions to contain the virus but such interventions had to be relaxed as it may cause more deaths from hunger and other diseases asides Corona virus [30] . Respondents admitted that the state's health sector and that of the country as a whole did not have adequate funding prior to the onset of the pandemic and this worsened afterwards. However, the popular opinion was that the State government has been able to provide some of the required resources like facemask and PPE despite the lack of funds. This is corroborated by Ejiogu and colleagues [10] who observed from their study that Nigeria's health sector has faced decades of poor funding and mismanagement and was noted by the World Bank to have spent less on health than nearly every country in the world. Similarly, financial resources should be pooled from the government, non-governmental and private sources in order to shore up health systems' preparedness for future pandemics, particularly in LMICs [31, 32] . Furthermore, Bong et al. [9] predicted that the COVID-19 pandemic would have a negative effect on the health system of LMICs in the area of health care personnel due to the overwhelming shortage already experienced. Findings from this study support this prediction as respondents reported that there was already a shortage of health workers in the state which worsened due to the pandemic. Globally, the COVID-19 pandemic also decimated the number of health workers available to keep health systems running [32, 33] . This is also true for Nigeria as a country as previous studies have shown that there is a shortage of health workers in the country which has contributed to the challenges faced by the health system [34, 35] . Besides, availability of medical products is essential to the health system. The weak health system in Nigeria is also faced with inadequacy of medical products and technologies. In addition, there is a significant shortage of resources needed to care for patients with severe respiratory failure like oxygen, ventilators and infusions pumps asides from water and electricity supplies [9] . Apart from the usual facilities in place in the health system, the One of the limitations of this study is the subjectivity of self-reports, for some of the questions, participants had to assess how well their unit had performed in the course of the pandemic. To reduce this bias, concepts were properly explained and confidentiality of information shared was also assured. Another limitation was social desirability bias, some of the questions had to do with providing information on how the government has fared and most of the respondents were government employees. Participants may therefore respond in ways that put the government and leadership in good light. However, despite these limitations, this study provides important exploratory data on how the health systems responds to health emergencies in a LMIC setting. The COVID-19 pandemic has had a major effect on health systems across the globe. This effect has however been greatly multiplied in a LMIC like Nigeria and in Oyo state due to the weak health system characterized by shortage of health personnel, medical resources and technology and presence of health inequalities. Despite attempts made by the government to address the pandemic, the effect of these interventions has not been considered successful. In order to address the pandemic effectively government has to improve on the health system of the State based on the major building blocks. This will involve addressing the challenges with health personnel, medical resources and technologies and also health financing. 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