ABSTRACT

Objective.

To identify and describe innovative initiatives implemented as a response to the interruption of health services during the COVID-19 pandemic in Latin America and the Caribbean (LAC).

Methods.

This was a descriptive study that reviewed 34 initiatives implemented during the COVID-19 pandemic in LAC to address health services needs among deprioritized groups. The review of initiatives included four phases: a call for submissions of innovative initiatives from LAC countries; a selection of initiatives that had the ability to address health services gaps and that were innovative and effective; systematization and cataloging of the selected initiatives; and a content analysis of the information collected. Data were analyzed from September to October 2021.

Results.

The 34 initiatives show important variations regarding the target populations, the stakeholders involved, level of implementation, strategies, scope, and relevance of the innovative initiative. There was also evidence of the emergence of a bottom-up set of actions in the absence of top-down actions.

Conclusion.

The findings of this descriptive review of 34 initiatives implemented during the COVID-19 pandemic in LAC suggest that systematizing the strategies and lessons learned has the potential to expand learning for re-establishing and improving post-pandemic health services.

Keywords
Community health services; community health planning; vulnerable populations; Latin America; Caribbean Region

RESUMEN

Objetivo.

Detectar y describir iniciativas innovadoras instrumentadas como respuesta a la interrupción de los servicios de salud durante la pandemia de COVID-19 en América Latina y el Caribe (ALC).

Métodos.

Se trata de un estudio descriptivo en el que se examinaron 34 iniciativas instrumentadas durante la pandemia de COVID-19 en ALC para hacer frente a las necesidades de servicios de salud en grupos poblacionales desatendidos. La revisión constó de cuatro fases: convocatoria para la presentación de iniciativas innovadoras por parte de los países de la Región; selección de iniciativas capaces de abordar las deficiencias en los servicios de salud y que fueran innovadoras y eficaces; sistematización y clasificación de las iniciativas seleccionadas; y análisis del contenido de la información recopilada. Los datos se analizaron entre septiembre y octubre del 2021.

Resultados.

Las 34 iniciativas presentan importantes diferencias en cuanto a los grupos poblacionales destinatarios, las partes interesadas implicadas, el grado de aplicación, las estrategias, el alcance y la pertinencia de la iniciativa innovadora. También se constató el surgimiento de un conjunto de acciones generadas desde la base como respuesta a la ausencia de medidas aplicadas de forma descendente.

Conclusión.

Los resultados de esta revisión descriptiva de 34 iniciativas aplicadas en ALC durante la pandemia de COVID-19 sugieren que la sistematización de las estrategias y las enseñanzas extraídas podría ser útil para ampliar el aprendizaje con vistas al restablecimiento y la mejora de los servicios de salud pospandémicos.

Palabras clave
Servicios de salud comunitaria; planificación en salud comunitaria; poblaciones vulnerables; América Latina; Región del Caribe

RESUMO

Objetivo.

Identificar e descrever iniciativas inovadoras implementadas em resposta à interrupção dos serviços de saúde durante a pandemia de COVID-19 na América Latina e no Caribe (ALC).

Métodos.

Este estudo descritivo analisou 34 iniciativas implementadas durante a pandemia de COVID-19 na ALC para atender às necessidades de serviços de saúde entre grupos que haviam perdido prioridade. A análise das iniciativas incluiu quatro fases: chamada pública para a apresentação de iniciativas inovadoras de países da ALC; seleção de iniciativas inovadoras e efetivas capazes de abordar lacunas nos serviços de saúde; sistematização e catalogação das iniciativas selecionadas; e análise de conteúdo das informações coletadas. Os dados foram analisados de setembro a outubro de 2021.

Resultados.

As 34 iniciativas apresentam variações importantes com relação às populações-alvo, partes interessadas envolvidas, nível de implementação, estratégias, escopo e relevância da iniciativa inovadora. Também houve evidências do surgimento de um conjunto de ações de baixo para cima (bottom-up) na ausência de ações de cima para baixo (top-down).

Conclusão.

Os resultados desta análise descritiva de 34 iniciativas implementadas durante a pandemia de COVID-19 nos países da ALC sugerem que a sistematização das estratégias e das lições aprendidas tem o potencial de ampliar as oportunidades de aprendizado para reestabelecer e aprimorar os serviços de saúde pós-pandemia.

Palavras-chave
Serviços de saúde comunitária, planejamento em saúde comunitária; populações vulneráveis; América Latina; Região do Caribe

Latin America and the Caribbean (LAC) was among the subregions most affected by the COVID-19 pandemic. By January 13, 2022, more than 50 million cases and 1 568 000 deaths had been reported from LAC (¹1. World Health Organization [Internet]. WHO Coronavirus (COVID-19) Dashboard [cited 2022 Jan 13]. Available from: https://covid19.who.int/
https://covid19.who.int/... , ²2. Reuters [Internet]. Reuters COVID-19 tracker: Latin America and the Caribbean [cited 2022 Jan 13]. Available from: https://graphics.reuters.com/world-coronavirus-tracker-and-maps/regions/latin-america-and-the-caribbean/
https://graphics.reuters.com/world-coron... ). In response to this crisis, health systems prioritized COVID-19 by reallocating resources, which interrupted and/or delayed other health services (³3. World Health Organization. Second round of the national pulse survey on continuity of essential health services during the COVID-19 pandemic: January-March 2021. Interim report. Geneva: WHO; 21 April 2021., ⁴4. The Lancet. COVID-19 in Latin America-emergency and opportunity. Lancet. 2021;398(10295):93. doi:10.1016/S0140-6736(21)01551-8
https://doi.org/10.1016/S0140-6736(21)01... ).

Moreover, COVID-19 was assumed to be proportionally worse for older people given that most deaths came from this age group (⁵5. Organization for Economic Cooperation and Development [Internet]. OECD Health at a Glance, 2021 [cited 2021 Dec 26]. Available from: https://www.oecd-ilibrary.org/sites/b0118fae-en/index.html?itemId=/content/component/b0118fae-en#section-d1e14794
https://www.oecd-ilibrary.org/sites/b011... ); consequently, health services to other populations—children, adolescents, and women—were expected to be affected by the COVID-19 situation (⁶6. Hackett K, Proulx K, Zonji S. COVID-19 and early childhood development in low- and middle-income countries: a research roundup. Washington, DC: ECDAN; 2021. https://ecdan.org/assets/ecdan_covid-19-ecd-research-roundup_dec2021.pdf
https://ecdan.org/assets/ecdan_covid-19-...

7. Hennis AJM, Coates A, Del Pino S, Ghidinelli M, Gomez Ponce de Leon R, Bolastig E, et al. COVID-19 and inequities in the Americas: lessons learned and implications for essential health services. Rev Panam Salud Publica. 2021;45:e130. https://doi.org/10.26633/RPSP.2021.130
https://doi.org/10.26633/RPSP.2021.130...

8. Villalobos Dintrans P, Maddaleno M, Granizo Román Y, Valenzuela Delpiano P, Castro A, Vance C, Castillo CA. Interrupción de servicios de salud para embarazadas, recién nacidos, niños y niñas, adolescentes y mujeres durante la pandemia de COVID-19: proyecto ISLAC 2020. Rev Panam Salud Publica. 2021;45:e140. https://doi.org/10.26633/RPSP.2021.140
https://doi.org/10.26633/RPSP.2021.140... -⁹9. Comisión Económica para América Latina y el Caribe. Desastres y desigualdad en una crisis prolongada: hacia sistemas de protección social universales, integrales, resilientes y sostenibles en América Latina y el Caribe. Santiago: CEPAL; 2021.). Considering the uncertainty during the first months of the pandemic, this response appears to have been justifiable; however, the extended duration of the crisis and its ongoing effects during 2021 have substantially affected the health status of deprioritized populations, both in the short and the long terms (¹⁰10. Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, et al. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health. 2020;110:1774-1779. https://doi.org/10.2105/AJPH.2020.305890
https://doi.org/10.2105/AJPH.2020.305890...

11. The Lancet Child & Adolescent Health. Pandemic school closures: risks and opportunities. The Lancet Child & Adolescent Health. 2020;4(5):341. https://doi.org/10.1016/S2352-4642(20)30105-X
https://doi.org/10.1016/S2352-4642(20)30... -¹²12. Osendarp S, Akuoku JK, Black RE, Headey H, Ruel M, Scott N, et al. The COVID-19 crisis will exacerbate maternal and child undernutrition and child mortality in low- and middle-income countries. Nature Food. 2021;2:476-484. https://doi.org/10.1038/s43016-021-00319-4
https://doi.org/10.1038/s43016-021-00319... ).

Anticipating potential issues, the ISLAC project (Impacto en los Servicios de Salud de la Mujer, de la Niñez y de la Adolescencia) was initiated in April 2020. Its aim was to engage in real-time operational, quantitative, and qualitative research on the COVID-19 pandemic in 25 LAC countries, specifically addressing child, adolescent, and women’s health to inform public policies and resource allocation. The project was justified by the deprioritization of the delivery of child, adolescent, and maternal health services—because these population groups were at lower risk of dying from COVID-19—and because of the lack of information on the indirect effects of COVID-19 in most countries (¹³13. ISLAC project [Internet]. COVID-19 in Latin America and the Caribbean: impact on health services for women, children, and adolescents [cited 2021 Dec 15]. Available from: https://en.islaccovid.org/proyecto
https://en.islaccovid.org/proyecto... ).

During 2020, several activities were carried out to understand the impact of the pandemic on child, adolescent, and maternal health services, including a multi-country survey and in-depth interviews with relevant stakeholders in LAC (¹³13. ISLAC project [Internet]. COVID-19 in Latin America and the Caribbean: impact on health services for women, children, and adolescents [cited 2021 Dec 15]. Available from: https://en.islaccovid.org/proyecto
https://en.islaccovid.org/proyecto... ). The findings showed that stakeholders’ perceptions in every country were that health services coverage had decreased and that these setbacks would not recover within 12 months. A positive relationship between the perception of health services coverage before and after the pandemic was found, showing that countries with lower coverage by and quality of health services before the pandemic were the most affected by the COVID-19 pandemic in terms of interruption of health services (⁸8. Villalobos Dintrans P, Maddaleno M, Granizo Román Y, Valenzuela Delpiano P, Castro A, Vance C, Castillo CA. Interrupción de servicios de salud para embarazadas, recién nacidos, niños y niñas, adolescentes y mujeres durante la pandemia de COVID-19: proyecto ISLAC 2020. Rev Panam Salud Publica. 2021;45:e140. https://doi.org/10.26633/RPSP.2021.140
https://doi.org/10.26633/RPSP.2021.140... ).

These findings served as a diagnosis of the situation in LAC. Once the problem was identified, solutions were needed. Based on the experience of the first year, as well as recommendations from several stakeholders, the project moved to identify responses to deal with the pandemic among deprioritized populations, that is, infants, children, adolescents, and women.

In 2021, a call to identify and synthesize innovative initiatives to mitigate the effects of the pandemic in LAC was launched. This article aims to describe the process used for identifying and selecting innovative initiatives, as well to acknowledge the strategies that best dealt with the challenges of continuing health services delivery to deprioritized groups in a COVID-19 pandemic environment.

MATERIALS AND METHODS

This study was reviewed and approved by the institutional review board of Universidad de Santiago (Santiago, Chile) and Tulane University (New Orleans, Louisiana, United States). This descriptive study was carried out in four phases: a call for innovative initiatives; selection of initiatives; systematization and documentation; and analysis.

Call for Innovative Initiatives

During the first half of 2021, the ISLAC project made a call inviting public and private actors, cooperation, academia, civil society, and community organizations to present initiatives that had been implemented since March 2020. The call highlighted the need for the initiatives to be innovative, i.e., new strategies and actions to mitigate the negative health repercussions of the COVID-19 pandemic and the well-being of infants, children, adolescents, women, and pregnant women in any area in LAC. The definition was based on a model of community participation and promotion of social cohesion at the local level (¹⁴14. Hernández-Ascanio J, Tirado Valencia P, Arizamontes A. El concepto de innovación social: ambitos, definiciones y alcances teóricos. Revista de Economía Pública, Social y Cooperativa. 2016;88:165-199. https://www.redalyc.org/pdf/174/17449696006.pdf
https://www.redalyc.org/pdf/174/17449696... ). An electronic submission form was made available through the project’s website and social networks (¹³13. ISLAC project [Internet]. COVID-19 in Latin America and the Caribbean: impact on health services for women, children, and adolescents [cited 2021 Dec 15]. Available from: https://en.islaccovid.org/proyecto
https://en.islaccovid.org/proyecto... ). Additionally, the call for submissions was sent to all 2020 ISLAC COVID-19 survey participants who had agreed to be recontacted. The call was available from 1 April to 30 June 2021. In all, 43 initiatives were received from 15 countries in LAC.

Selection of initiatives

The process of selecting the initiatives to be included in the analysis was performed in three stages: verification of information and eligibility for inclusion; assessment of the initiative’s (technical) features; and an assessment of each initiative’s innovativeness and potential effectiveness/impact. In the first stage, the experiences and activities were reviewed to properly categorize each initiative; the supporting information was verified; and the background of each institution affiliated with the initiative was researched. This stage was intended to complement the information sent by the institutions as well as to detect inconsistencies. After this process, 9 applications were declared inadmissible.

In the second stage, a rubric of seven criteria was applied to the 34 admissible initiatives: (i) identification of the problem that justified the initiative; (ii) the target population; (iii) the solution and/or initiative implemented; (iv) the strategy; (v) its replicability; (vi) its scalability; and (vii) its sustainability. Each criterion was evaluated against the information provided and/or collected using a 4-point scale: no information (0 point), could be improved (1 point), adequate (2 points), and outstanding (3 points). Each initiative was assessed by two different evaluators (PVD, PV, CC, YG, MM) who reached a consensus score.

In the third stage, a cut-off score was established based on a previous assessment to identify the initiatives with the best prospects. Of the 34 initiatives, 28 had a score greater than the predefined threshold. These were evaluated by the ISLAC project team using three criteria: creativity; potential effectiveness/impact; potential applicability and/or sustainability. A 4-point scale was used in this assessment (Table 1).

Lastly, the selection of initiatives included a criterion of representativeness to ensure that initiatives for diverse populations implemented in different countries were included in the review. Of the 34 initiatives, 15 were classified as outstanding and 19 as adequate/promising.

Systematization and Documentation

The selected initiatives were systematized and documented for the construction of a catalog that would allow them to be shared with other actors in the LAC subregion. Contact was made with the individuals who referred the outstanding initiatives to verify and complement the information submitted. In-depth interviews were conducted and any additional documentation was reviewed and verified. Finally, the all of the information was standardized and cataloged according to data fields such as country of implementation, coverage, target population, and justification for and description of the strategy. This catalog was made available at the project’s website (https://www.islaccovid.org/participa?lang=en) to the public for horizontal learning.

Analysis

Content analysis of the selected initiatives was based on established and emerging categories: target populations to whom they were directed, type of implementers and level of implementation, strategies utilized, as well as scope and relevance of the innovations. Data were analyzed from September to October 2021, and results were systematized using Microsoft Excel™ (Microsoft Corp., Redmond, Washington, United States).

RESULTS

The 15 initiatives categorized as outstanding are summarized in Table 2 (additional details on each initiative are available on the project’s website (https://www.islaccovid.org/participa). The actions—implemented in 11 LAC—included programs targeted to different deprioritized populations (newborns and infants, early childhood, children, adolescents, and women and pregnant women); by several implementers, including public sector actors (central and local governments, health sector), civil society and international organizations, and the private sector during the COVID-19 pandemic. The initiatives differed in strategies and goals, although they all shared some common features given that they all emerged as a response by a local actor to a local problem and all implemented innovative solutions within the COVID-19 context.

In terms of the implementers, the initiatives were classified as bottom-up responses, with most designed and implemented by community-level organizations with low-scale coverage. Examples of these are COVID Storytelling (Cuba), We Are With You (Chile), and Contraceptive Methods Delivery (Paraguay).

Regarding innovations, these arose either as a solution to new problems generated or aggravated by the pandemic (e.g., mental health issues, violence) or as a way to continue providing health services in a context of stringent limitations (e.g., mobility) and scarcity of resources. In the first group, 2 programs stood out: the Amazonian Indigenous Health Route (Brazil), which sought to improve access to COVID-19 prevention and protection services for the indigenous population, and the Methodology for the Progressive Eradication of Physical Punishment and Humiliating Treatment in Early Childhood (Honduras), which addressed the problem of violence against children. In the second group, there were also two initiatives that should be highlighted: Youth Social Approach in Times of Pandemic (Chile) and Telerehabilitation for Children and Adolescents with Cancer (Chile).

These study findings indicate that technology has been key to solving many of the problems encountered in the COVID-19 environment: radio programs, telephone calls, SMS, chat groups, online platforms, and electronic material. The implementers in different countries tried to find a way to provide still-needed health services to their existing and new beneficiaries, as shown by the initiatives: Grow Up Playing (Chile), Radio Programs for the Strengthening of the Community Protection Committee (Honduras) and Accompanying Your Development (Peru).

The outstanding initiatives differ in terms of consolidation (how long they have been implemented) and potential for replicability; however, all contain elements that can serve as inspiration and learning for the implementation of responses to COVID-19 in other contexts. An example is the initiative, Recipe Book Love of the Jungle (Peru).

Systematizing the strategies and lessons from different initiatives was helpful information for expanding and recovering health services during the COVID-19 pandemic. For example, remote services, online education, and the creation of online support groups arose as alternatives to traditional health care and enriched the delivery of services for specific population groups or became complementary options for health services already in place. Much of LAC is highly exposed to natural disasters and other conflicts that affect health services delivery. Therefore, these innovations together with the experience gained by the health teams in emergency response skills can be leveraged to better implement effective responses to future crises.

DISCUSSION

The selected initiatives show bottom-up responses to the COVID-19 pandemic in the Region of the Americas. From these we can extract important lessons. The experiences highlight how these actions—most of which were generated organically to address the emergency—quickly identified problems, access barriers, and community needs to quickly generate mitigation actions tailored to specific needs and contexts (opportunity and relevance).

Another common feature present in all the selected initiatives was the importance of collaboration among various actors and at different levels, showing a virtuous circle of collaboration to create context-adapted solutions that can be implemented in a timely manner in a specific population. Central to the innovative response was its flexibility and user-centered strategies, which allowed for adaptation to specific circumstances and the global context, maximizing available resources creatively.

It is also important to emphasize the generation of small-scale strategies that were refined and expanded in a short time as adjustments were made to their implementation through human-centered design schemes (with prototypes that can be improved based on the opinions of implementers and beneficiaries) in a process that collected feedback from the actors involved in more or less formal ways (¹⁵15. Barker PM, Reid A. Schall MW. A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Sci. 2015;11:12. https://doi.org/10.1186/s13012-016-0374-x
https://doi.org/10.1186/s13012-016-0374-... ,¹⁶16. Milat AJ, Newson R, King L, Rissel C, Wolfenden L, Bauman A, et al. A guide to scaling up population health interventions. Public Health Research & Practice. 2016; 26(1):e2611604. doi: http://dx.doi.org/10.17061/phrp2611604
http://dx.doi.org/10.17061/phrp2611604... ).

The pandemic had an unexpected and radical influence on the institutions. Institutional systems with the greatest weaknesses saw a wider space in which to innovate because their needs became more evident and relevant. For example, previous analysis of the ISLAC data show that the perception of the negative effects of COVID-19 on the provision of services for deprioritized populations were greater in countries with lower perceived health services coverage and quality before the pandemic (¹³13. ISLAC project [Internet]. COVID-19 in Latin America and the Caribbean: impact on health services for women, children, and adolescents [cited 2021 Dec 15]. Available from: https://en.islaccovid.org/proyecto
https://en.islaccovid.org/proyecto... ). In this context, recognizing innovation as a learning process that feeds the system itself implies that after the emergency period from which responses emanated, the challenge is to identify and evaluate the innovations carried out, clearly delimiting their scope, benefits, and limitations, and using their best elements for regular health care services. During the emergency period, especially in institutions where the greatest formal response gaps occurred, the teams learned new tools and created effective responses among population groups that can benefit from them beyond the context of a pandemic. In this sense, many innovations are here to stay because they were positive learnings for health systems (e.g., telehealth and increased technology use) and other innovation may be relevant in responding to new emergencies (¹⁷17. Woolliscroft JO. Innovation in response to the COVID-19 pandemic crisis. Acad Med. 2020;95(8):1140-1142. https://doi.org/10.1097/ACM.0000000000003402
https://doi.org/10.1097/ACM.000000000000... ).

A future challenge is to ensure that innovative responses in the context of routine health care are sustainable and scalable. Although not as relevant in an emergency context where a rapid response may be in regular times and with routine care, we should expect innovations to be scalable and sustainable, particularly in low- and middle-income settings (¹⁸18. Yamey G. What are the barriers to scaling up health interventions in low- and middle-income countries? A qualitative study of academic leaders in implementation science. Global Health. 2012;8:11. https://doi.org/10.1186/1744-8603-8-11
https://doi.org/10.1186/1744-8603-8-11... ,¹⁹19. Nowell B, Foster-Fishman P. Examining multi-sector community collaboratives as vehicles for building organizational capacity. Am J Commun Psychol. 2010;48(3-4): 193-207. doi:10.1007/s10464-010-9364-3
https://doi.org/10.1007/s10464-010-9364-... ). Of course, this implies a rigorous evaluation of the results of these interventions, not only in terms of maintaining and increasing service coverage, but also in terms of improving health outcomes.

Another interesting element of the identified innovations was that many of them were created by community organizations, many of which had scarce experience, resources, and capacity for systematizing, analyzing, and assessing their results. In this scenario, the role of academia, international cooperation, or government institutions takes center stage in the establishment of alliances that facilitate the monitoring, evaluation, and development of innovative responses with relevant potential.

On the other hand, collecting the learnings from these innovations, measuring their results, and identifying any limitations in other contexts are tasks that require will and resources. It is probable that given the urgency of the pandemic, several processes and their lessons will be lost. The systematization of these successful, innovative, small-scale, bottom-up experiences along with how they were designed from existing and emerging theories and frameworks (e.g., behavior theory, implementation sciences) is key to improving health systems and responding to future crises (²⁰20. Gilson L, Marchal B, Ayepong I, Barasa E, Dossou J-P, George A, et al. What role can health policy and systems research play in supporting responses to COVID-19 that strengthen socially just health systems? Health Policy and Planning. 2020;35(9):1231-1236. https://doi.org/10.1093/heapol/czaa112
https://doi.org/10.1093/heapol/czaa112... ).

Limitations

This study had some limitations that should be acknowledged. Although a total of 43 initiatives were received from 15 countries, the sample of highlighted initiatives is not representative of the LAC subregion. Given this, it is highly probable that there are many other similar initiatives that would be useful to know about and to highlight. Consequently, the presented initiatives should be seen as an example and not as the full picture of the COVID-19 actions in LAC. Despite representativeness and scale issues, the information presented is relevant to understanding the bottom-up responses to the pandemic and serve as lessons for any organization looking for strategies that address the disruption of health services in the community.

Conclusions

The COVID-19 pandemic has not only exposed inequities in health, but has also generated inequities by deprioritizing key health actions for highly excluded population groups, such as women and children. Faced with the formal institutional response gaps, a relevant space opened for community-based and local action where bottom-up initiatives filled the void. Thus, community responses constituted a basis for developing pertinent responses to complex problems and promoting greater community resilience. These innovative solutions, especially when they arose in low-resourced settings, became feasible low-cost and efficient strategies for providing health services to their beneficiaries.

Lastly, for other countries in LAC and in other regions, we underscore that the current situation is complex and acknowledge that the challenges associated with recovery of health services are substantial. However, these initiatives show that innovation can help to expand the responses to crises, from the development of new strategies to the involvement of more actors. It is a challenge to create the conditions that encourage development of innovative community-based responses. It is also challenging to incorporate successful emergency actions into routine actions that improve health services delivery in general. However, doing so will likely increase social and institutional resilience, not only in the context of an unexpected global crisis, but in the everyday health needs of the entire population.

This article describes the process for identifying and selecting innovative initiatives to maintain and to recover health services delivery to deprioritized groups in a COVID-19 pandemic environment in LAC. The findings show the importance of local initiatives for implementing quick changes and flexible solutions to be adapted in an emergency context. The experiences presented are relevant for countries in the LAC subregion to improve the delivery of health care to underserved populations and to design and implement responses to future emergencies.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or the Pan American Health Organization (PAHO).

Acknowledgements.

The authors thank all the people who answered the call for proposals and provided the information on the innovative initiatives. We also appreciate the comments from two anonymous reviewers as well as an editor of the journal.

REFERENCES

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