Integrated approaches to COVID-19 emergency response in fragile, conflict-affected and vulnerable settings: a public health policy brief

In the absence of fully effective measures to prevent and treat COVID-19, the limited access to and hesitancy about vaccines, the prolongation of the on-going pandemic is likely. This underscores the need to continue to respond and maintain preparedness, preferably using a more sustainable approach. A sustainable management is particularly important in fragile, conflict-affected and vulnerable countries of sub-Saharan Africa given several peculiar challenges. This Viewpoint proposes policy options to guide transitioning from current COVID-19 emergency response interventions to longer-term and more sustainable responses in such settings. In the long term, a shift in policy from a vertical to a more effective approach should integrate response coordination, surveillance, case management, risk communication and operational support, among other elements, for better results. We call on public health policymakers, partners and donors to support full implementation of these policy options in a holistic manner to encompass all emerging public health threats.


Introduction
The Corona Virus Disease 2019 (COVID-19) pandemic in sub-Saharan Africa defied all modelling projections of a massive and widespread epidemic on the continent [1]. Contrary to predictions, recent epidemiological and modelling data indicate lower COVID-19 death rates in sub-Saharan Africa than in the rest of the world [2]. Although recent epidemiological data point to a declining trend in the disease incidence in most parts of the world [3], this does not forestall possibility for another surge in cases [4]. In the absence of fully effective means to prevent and treat the disease and limited access to and hesitancy about COVID-19 vaccines on the continent, the long propagation of the current pandemic is likely [5]. This situation underscores the need to respond to outbreaks and maintain preparedness, albeit with a more integrated and sustainable approach. Initial stages of the pandemic justified the use of special measures such as establishment of vertical platforms for coordination of the response, surveillance, case management, risk communication and procurement of essential medicines, medical supplies and equipment to address an emerging crisis. But continuing this way is not sustainable due to the dearth of resources such as human resources and predictable funding in most sub-Saharan African countries. The developing countries of sub-Saharan Africa thus need different approaches to control the COVID-19 pandemic and other emerging and equally important public health threats [6].

Need for a longer-term, integrative approach to COVID-19 response in fragile, conflict-affected and vulnerable settings
The World Health Organization (WHO) defines fragile, conflict-affected and vulnerable (FCV) countries as those experiencing situations of crises due to protracted emergencies, disruption of governance structures and/or armed conflict [7]. While the WHO nomenclature is slightly different from that of the World Bank Group which uses "violence" instead of "vulnerable", the WHO classification of FCV countries largely depends on the World Bank Group list [8]. This list currently includes 37 countries out of which 18 are in sub-Saharan Africa. 1 In the context of this article, the term "fragile" refers to countries who are in unstable situations while "vulnerable" refers to countries who are at risk of multiple public health emergencies and both terms are viewed as distinct.
FCV countries of sub-Saharan Africa face peculiar challenges, such as pervasively weak health system, vulnerability to multiple public health emergencies, increased demand for healthcare services in the face of disrupted or weak routine healthcare delivery systems and inadequate health funding among others. The COVID-19 pandemic has further aggravated these challenges.
First, the COVID-19 pandemic overwhelmed already compromised health systems in these countries, rapidly depleting critical human, financial and material resources and adversely disrupting the delivery of essential health services. In South Sudan, a special survey estimated health workforce density (doctors, nurses and midwives) at 0.76 per 1000 population [unpublished data from the South Sudan Services Availability and Readiness Survey, 2018]-far below the Sustainable Development Goals (SDG) threshold of 4.45 per 1000 population for making progress towards Universal Health Coverage [9]. Within the countries of the WHO African Region, mainly in Sub-Saharan Africa, health workforce density is as low as 1.55 per 1000 population, with only four countries in the region (Mauritius, Seychelles, South Africa and Namibia) above the 4.45 threshold. FCV countries, such as Chad and Central African Republic, are among those with the lowest levels, fewer than 0.5 health workers per 1000 population [10]. For 2020, South Sudan's Humanitarian Response Plan estimated additional funding needed for COVID-19 at USD 150 million, or 8% of the original amount of $1.9 billion allocated for the overall humanitarian response for the year [11]. For the same year, the South Sudan Health Sector Strategic Plan listed the amount needed for the entire health sector routine programming at $457 million-largely designated for development interventions in the health care sector [unpublished data from the South Sudan Health Sector Strategic Plan 2017-2022]. Based on the 2020 Humanitarian Response Plan, the additional funds needed for COVID-19 response in 2020 alone, was 33% of the entire sector budget for the year.
Second, these countries continue to experience multiple and recurrent emergencies arising from conflicts, natural disasters such as droughts, floods and disease outbreaks, including of wild polio virus (and its vaccine derived variant), yellow fever, cholera, measles, meningitis, among others, due to prevailing poor living conditions and weak health systems. Third, the social, economic and cultural impacts of the pandemic have been particularly severe in these countries, including aggravation of poverty through disruption of livelihoods and of societal structures. Fourth, the current approach to COVID-19 epidemic response, which relies on vertical systems and structures is resource intensive and not sustainable.
We agree with Ali et al. on the need for longer-term, sustainable, cost-effective and integrated responses to the outbreaks in FCV settings [12]. The aims of such an approach are three: to enhance global health security, ensure health system recovery and strengthen health system resilience [13,14]. We propose policy options to guide transition from the initial emergency public health responses to the COVID-19 pandemic to humanitarian and development programming. We present a case study of South Sudan where health system challenges are enormous, and the complexity of its humanitarian crisis is among the most challenging in sub-Saharan Africa. We next summarize policy options and principles to guide implementation of more sustainable approaches. Then we discuss implications of the changes and summarize early lessons from implementation in South Sudan to inform the transition from emergency (vertical) COVID-19 responses to longer-term approaches integrating COVID -19 into routine care and structures in similar settings.

South Sudan as a case study: shifting from vertical to an integrated COVID-19 response
South Sudan, the world's youngest nation, grapples continuously with armed conflicts, natural disasters and chronic underdevelopment. Together these have decimated the country's health system, leaving inadequate availability of good quality, sustainable and affordable health services. The country reported its first case of COVID-19 on 5 April 2020 [15], and by 26 October 2022, it had reported 17,780 confirmed cases and 138 deaths [16]. As elsewhere in sub-Saharan Africa, the overall reported number of cases and deaths amounted to far fewer than anticipated. Limited surveillance and laboratory capacity could have contributed to the low counts.
At the onset of the outbreak in April 2020, the country, with the support of its partners such as United Nations agencies, national and international non-governmental organizations and the academia, established a vertical outbreak response system. It included a COVID-19 national incident management system and national taskforce, and a COVID-19 surveillance system with alerts, rapid response, case investigation, contact tracing, mortality surveillance and Points of Entry (PoE) components. The Ministry of Health rapidly adapted existing capacity for laboratory diagnosis of Ebola and other viral diseases for COVID-19 diagnosis while establishing case management centres in all the ten States of South Sudan. South Sudan also established structures for COVID-19 risk communication and community engagement and produced communication materials such as posters, billboards, television and radio messages among others. It also procured COVID-19 equipment, medicines and supplies through a dedicated global COVID-19 operational support and logistic platform. And, in the latter part of the response, the country introduced a COVID-19 vaccination strategy of campaigns.
These interventions proved effective, but not sustainable. Special measures to address the emergence of COVID-19 stressed South Sudan's pervasively weak health system as it struggled simultaneously to deal with other equally important needs, including outbreaks of cholera, measles, meningitis, yellow fever, among others, as well as perennial flooding. Establishing vertical incident management systems for each public health event proved impracticable and not cost-effective given the unpredictability of longer-term funding and dearth of human resources. Domestic resources remained grossly inadequate for meeting these needs. Thus, in the last quarter of 2020, the WHO COVID-19 response team worked with stakeholders in the country to develop the options to improve policies that we present below.

Policy options and key messages for integrating COVID-19 response into FCV countries' health and humanitarian systems
Our objective in presenting these options is to assist FCV countries to integrate on-going vertical COVID-19 response interventions into existing humanitarian response or health sector-wide development coordination systems' plans and programming. Table 1 presents in detail the policy shifts we propose. There, and below, we refer to "pillars" that signify the internationally proposed components of the COVID-19 response system [17].
In summary, we recommend that countries: • Move the coordination pillar of the response into the existing national coordination system, such as the health sector working group, the health cluster and intercluster coordination mechanisms. • Integrate the surveillance pillar of the COVID-19 response into existing, routine national public health surveillance systems such as the Integrated Disease Surveillance and Response (IDSR) and the Early Warning Alert and Response Network (EWARN). The IDSR is the WHO recommended routine system for collection and management of disease data at the country level; the EWARN is specifically used in humanitarian settings such as South Sudan. • Expand the current PoE pillar (comprising the COVID-19 surveillance at the land and air borders) to incorporate all aspects of the more robust port health services and integrate them into the National Action Plans for Health Security (NAPHS). The laboratory component of the pandemic requires a longer-term approach as part of a broader national laboratory strategic plan aimed at addressing the laboratory diagnosis of multiple pathogens. • Deliver the case triage, isolation, management, Infection Prevention and Control (IPC), and continuity of essential services pillars as an integrated package of on-going essential health services. That is, incorporate these pillars into existing  into the routine national health education and promotion interventions and communication materials. • Combine the operational support and logistics system with the national supply chain management system and the emergency core pipeline system which is managed by the health cluster. • Integrate the vaccine management pillar into the routine immunization system.
We also propose a few principles to guide implementation of the policy shifts: • Maintain government leadership through their ministries of health and continuing collaboration with relevant partners. Political commitment at the highest level of government is central to a smooth transition-particularly for effective coordination among stakeholders, to ensure buy-in, accountability and harmonization of the transition process with national health priorities and interventions. • Integrate all pillars of the COVID-19 national response plans into existing health sector plans to ensure comprehensive implementation and facilitate progress towards Universal Health Coverage. (These include the NAPHS, national health system recovery and stabilization plan, the humanitarian response plan and the health sector strategic plan.) • Establish a horizontal approach to emergency response for all emerging public health threats to prevent stretching the already limited resources. • Build health system resilience and global health security as fundamental elements for effective emergency preparedness and response. Emergency response should provide opportunities to strengthen the health system using existing funding, such as funds for the COVID-19 response, to fill critical gaps in the health system. This means adopting a health system strengthening approach during all phases of the COVID-19 response. • Emphasize continuity of all essential health services, those often disrupted during pandemics. • Maintain basic preparedness capacity to respond to resurgence in COVID-19 cases by maintaning minimum capacities for each of the pillars of the COVID-19 response within the broader framework of the NAPHS.

Implications of shifting policies and implementing the changes
Countries should anticipate and plan responses to actions, and to reactions, both negative and positive that such policy shifts may attract. Stakeholders often resist policy changes due to personal or organizational interests, competition for scarce resources or unwillingness to change traditional methods of operation. The resistance may deepen if communication of a new policy to the stakeholders is inadequate. Poor coordination may lead to duplication and gaps in emergency response efforts. However, integration of COVID-19 emergency response efforts with routine service delivery could improve cost-effectiveness, harmonization and alignment of humanitarian response interventions with national health priorities and strengthen health system resilience. We recommend a proactive and systematic approach to address these challenges, emphasizing • Strong advocacy and communication with all stakeholders to ensure common understanding and buy-in to the policy shifts. • Wide dissemination of documents explaining policy shifts to the relevant target audiences at national and sub-national levels. • Development of frameworks that will be necessary to effectively plan, supervise, monitor and evaluate the policy shifts process. This will require well-defined baselines and targets.
Furthermore, countries should watch for lessons from implementation of the policy shifts, document them systematically and use the observations as evidence to improve the overall process.

Lessons learned from early phase implementation in South Sudan and recommendations
South Sudan commenced pilot testing of these policy shifts in the first quarter of 2021. Lessons we report here for use in other FCV settings had emerged as of October 2022. We observed and recorded varied levels of success. We saw good progress in surveillance, case management and continuity of essential health services, IPC and vaccine management response efforts. We observed little progress, however, in coordination, risk communication and community engagement and in operation support and logistics. Anecdotal evidence indicated progress for those pillars with strong routine systems. For instance, South Sudan built on its fairly robust routine surveillance system (the IDSR and EWARN) to transition the surveillance component of the COVID-19 response. Similarly, the IPC pillar benefitted from recent development and on-going implementation of a national IPC strategic plan and large-scale training of healthcare workers on IPC. The little progress in coordination may be attributed to the weak capacity of the health sector working group, the main focal point for coordination for all health activities in the country. Activities in the operations support and logistic pillar improved little, likely due to the weak national supply chain management system. The vaccination systems, structures and human resources used for the pandemic relied heavily on the existing elements of routine immunization, including the cold chain equipment and vaccinators. However, delivery of COVID-19 vaccination as campaigns added stress to a weak system. It was the same health workers who provide routine immunization services who added COVID-19 vaccination campaigns to their responsibilities. We recommend addressing this challenge by using COVID-19 vaccination funds to strengthen routine immunization structures including cold chain equipment, supplies and staffing, and by revising the national routine immunization policy, strategy, schedule and mass campaigns to include COVID-19.
These lessons reinforce the importance of using emergency resources to strengthen routine health system elements where feasible and vice versa.

Conclusion
Although the COVID-19 pandemic trend has been declining recently in many parts of the world, emergence of new variants may result in resurgence if countries do not sustain effective preparedness and response capacities. The resource-intensive nature of responding to COVID-19 outbreaks and health system challenges in FCV settings both reinforce the importance of pursuing integrated and cost-effective COVID-19 outbreak responses. Early adoption and implementation of the approaches we recommend have several advantages: opportunities to strengthen the health system and global health security capacity to quell resurgence of the COVID-19 pandemic and other emerging public health threats, now including Monkeypox which has recently been renamed as mpox by WHO. We call on all public health policy makers, development and humanitarian partners, along with the donor community, to support full implementation of the proposed policy shifts in all FCV settings and to do so holistically, to encompass all emerging public health threats. For South Sudan, where implementation is underway, we recommend on-going supervision, monitoring, evaluation and systematic documentation of lessons from the process--to benefit South Sudan and all who can learn from their experience.

Development partners
These are partners who specifically focus on supporting national authorities to implement longerterm development interventions at the country level.

Tracer indicators
These are health indicators such as immunization coverage, antenatal and skilled birth attendance, outpatient services utilization etc. which are used as proxies to monitor the continuity of essential health services during a public health emergency. These indicators are being widely used during the COVID-19 pandemic to monitor health services Data Availability Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Conflict of interest The authors declare no conflict of interest
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