Abstract

This article maps the structural, nonstructural and functional vulnerabilities of healthcare facilities to the COVID-19 pandemic. It reports on a scoping review guided by JBI recommendations and structured by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The PubMed, CINAHL, LILACS, EMBASE, SciELO, Scopus and Web of Science Repositories and databases were consulted, as was the grey literature. The protocol was registered in the Open Science Framework. The 54 studies included summarised 36 vulnerabilities in three categories in 29 countries. Functional and non-structural vulnerabilities were the most recurrent. Limited material and human resources, service disruption, non-COVID procedures and inadequate training were the items with most impact. COVID-19 exposed nations to the need to strengthen health systems to ensure their resilience in future health crises. Prospective risk management and systematic analysis of health facility vulnerabilities are necessary to ensure greater safety, sustainability and improved standards of preparedness and response to events of this nature.

Key words:
Hospital; Health centre; Vulnerability analysis; COVID-19

Introduction

Disasters, regardless of their aetiology, tend to have different magnitudes of impact on different communities and their direct and indirect effects have repercussions on different institutions, sectors and governments. These events can change a region’s geographic configuration in seconds, disrupting years of development. Developed countries generally have more resources and are able to restructure more easily than those in the process of development¹1 World Health Organization (WHO), International Council of Nursing (ICN). ICN Framework of Disaster Nursing Competencies. Geneva: WHO/ICN; 2009.. One emblematic, contemporary example is the COVID-19 pandemic, which has been categorised by risk management experts as a disaster of natural origin and biological type²2 Silva RF, Siqueira AM, Silveira LTC, Oliveira AB. A redução de risco de desastres, a agenda dos Objetivos Sustentáveis e os princípios do SUS, no contexto da pandemia de COVID-19. Cien Saude Colet 2022; 28(6):1777-1788..

Given the complex, multifactorial and inter-/transdisciplinary nature of disaster situations, different concepts exist in the technical and scientific literature. This study emphasises the conception presented by the United Nations Office for Disaster Risk Reduction (UNDRR), which considers a disaster to be a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources³3 Secretaría Interinstitucional de la Estrategia Internacional para la Reducción de Desastres, Naciones Unidas (EIRD/ONU). Vivir con el riesgo: informe mundial sobre iniciativas para la reducción de desastres. Geneva: ONU; 2004..

A disaster, then, is a function of the risk process, which is socially constructed in a process related to the dynamics of development and combines hazards, degree of exposure, conditions of vulnerability and inadequate capacity or measures to reduce adverse outcomes and potential harm⁴4 Secretaría Interinstitucional de la Estrategia Internacional para la Reducción de Desastres, Naciones Unidas (EIRD/ONU). Terminología: términos básicos sobre la reducción del riesgo de desastres. Geneva: ONU; 2004.. In the light of the above, the COVID-19 pandemic is considered a global disaster, because it combines these elements and requires that strategic sectors focus and articulate various processes from the local to global levels⁵5 Freitas CM, Silva IVM, Cidade NC. COVID-19 as a global disaster: challenges to risk governance and social vulnerability in Brazil. Ambient Soc 2020; 23:e0115..

Commonly, these events alert authorities to activate and implement contingency plans to address such occurrences. The effects extend primarily to infrastructure, services, the local economy and society, which are the bases that underpin the conditions of life. In these emergency situations, the health sector at all levels of government is responsible for providing care to the population, and health services themselves may be prejudiced⁶6 Freitas CM, Silva DRX, Sena ARM, Silva EL, Sales, LBF, Carvalho ML. Desastres naturais e saúde: uma análise da situação do Brasil. Cien Saude Colet 2014; 19(9):3645-3656..

In this regard, disaster risk management extends across different kinds of intervention, from policy- and strategy-making to implementation of specific damage reduction and control measures and instruments⁷7 Narváez L, Lavell A, Ortega GP. La gestión del riesgo de desastres: un enfoque basado en procesos. San Isidro: Secretaría General de la Comunidad Andina; 2009..

Moreover, the uninterrupted operation of health facilities in response to events of this nature can determine the health and survival of large numbers of people. It is thus strategic that these facilities be planned and built in such a way that they resist the impacts of natural and technological phenomena, that their equipment not suffer damage and remain operational, that their lifelines continue to operate and that their personnel are able to continue providing care. In these usually complex and dramatic circumstances, this includes robust sizing and strategic planning of human resources⁸8 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). Indice de seguridade hospitalaria: guia del evaluador de hospitales seguros. Washington: OMS/OPAS; 2008..

Accordingly, an international pact “Hospitals Safe from Disasters” was agreed under the coordination of the Pan-American Health Organization. This policy characterises a ‘safe hospital’ as a health facility, whether large or small, whose services remain accessible and functioning at maximum capacity and within the same infrastructure immediately following a natural disaster. Under this pact, countries commit to ensuring that construction of all new health facilities will meet satisfactory levels of protection and implement appropriate measures to mitigate existing risks⁹9 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). ¿Su hospital es seguro? Preguntas y respuestas para el personal de salud. Quito: OMS/OPAS; 2007..

To guide this process, the Hospital Safety Index: Guide for Evaluators⁸8 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). Indice de seguridade hospitalaria: guia del evaluador de hospitales seguros. Washington: OMS/OPAS; 2008. established the Hospital Safety Index (HSI), an assessment measure that contemplates the structural, non-structural and functional conditions of health facilities’ vulnerability to disasters⁹9 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). ¿Su hospital es seguro? Preguntas y respuestas para el personal de salud. Quito: OMS/OPAS; 2007..

Structural vulnerability conditions relate to the supporting portions of the hospital building, such as walls, columns, beams and slabs, failure in one of which can compromise the structure of the building. Non-structural vulnerabilities involve components connected to the building structure, such as windows, ceilings, air conditioning, electrical network, water supply, furniture, equipment and inputs. These provide the basis for the dynamics of a healthcare establishment and relate to hospital infrastructure, working conditions, material resources and equipment. Functional vulnerabilities arise from the distribution of architectural spaces and the relationship between them and the clinical support services offered by the hospital unit. To summarise, proper zoning and correlation between areas of the building can assure effective management dynamics in normal conditions and also in emergency and disaster situations⁹9 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). ¿Su hospital es seguro? Preguntas y respuestas para el personal de salud. Quito: OMS/OPAS; 2007..

Following the identification of a new coronavirus in the city of Wuhan, Hubei province, China in 2019¹⁰10 Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395(10223):497-506., and the World Health Organization’s recognition of a pandemic¹¹11 World Health Organization (WHO). WHO Director-General's opening remarks at the media briefing on COVID-19 [Internet]. 2020. [cited 2023 fev 11]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/director-general/spe... , governments, institutions and communities began to mobilize to combat the direct and indirect effects of this disease. Countries of the Americas currently lead the global COVID-19 mortality ratings, with the United States of America (USA) and Brazil ranking highest¹²12 Johns Hopkins University & Medicine. Mortality Analyses [Internet]. 2022. [cited 2023 fev 11]. Available from: https://coronavirus.jhu.edu/data/mortality
https://coronavirus.jhu.edu/data/mortali... . Public health measures, however, were not restricted exclusively to severe cases; asymptomatic cases or mild symptoms represented around 80% of total cases¹³13 Medeiros GB, Iochims FS, Adams EM, Beling JC, Rezende B, Koepp J, Possuelo LG, Carneiro M, Gaedke MA, Schneider APH, Darsie C, Bertelli C. Prevalência de casos assintomáticos entre os infectados pelo SARS-CoV-2 em SCS: um estudo de base populacional. RJP 2021; 11(1):3-13.. These milder or moderate clinical cases needed to be managed appropriately, requiring that care models in place were consistent with the demands posed by the advancing pandemic¹⁴14 Fundação Oswaldo Cruz (Fiocruz), Universidade Federal do Rio de Janeiro (UFRJ), Universidade do Estado do Rio de Janeiro (Uerj). Organização emergencial da rede de atenção à saúde no estado do Rio de Janeiro para enfrentamento da pandemia do novo coronavírus (COVID-19): nota técnica conjunta de pesquisadores da UFRJ, UERJ e Fiocruz [Internet]. 2020. [acessado 2022 fev 8]. Disponível em: https://www.arca.fiocruz.br/handle/icict/40790
https://www.arca.fiocruz.br/handle/icict... .

COVID-19’s high transmissibility, health system overload from the large numbers of infected and the lack of medicines proven to be effective against the disease highlighted health facilities’ vulnerabilities and difficulties in managing this disaster, as shown by the partial collapse of many health systems. Until July 2022 (the study period), the Coronavirus Resource Center recorded 553,500,224 confirmed cases and 6,349,732 deaths from the disease worldwide¹⁵15 Johns Hopkins University & Medicine. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) [Internet]. [cited 2023 jun 11]. Available from: https://coronavirus.jhu.edu/map.html
https://coronavirus.jhu.edu/map.html... .

Overall, short- and long-term planning of actions based on good risk management practices was important in preventing the crisis from worsening¹⁵15 Johns Hopkins University & Medicine. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) [Internet]. [cited 2023 jun 11]. Available from: https://coronavirus.jhu.edu/map.html
https://coronavirus.jhu.edu/map.html... . Above all, a better standard of response entailed developing and implementing emergency response plans that considered healthcare facilities’ vulnerabilities in order to reduce risk conditions. In that respect, this scoping review mapped healthcare facilities’ structural, non-structural and functional vulnerabilities to the COVID-19 pandemic.

For that purpose, a preliminary search for reviews of similar scope to that objective was carried out in MEDLINE (via PubMed), JBI Database of Systematic Reviews and Implementation Reports and in the Cochrane Database of Systematic Reviews. No reviews with the same purposes were identified, making this study opportune.

Methods

This scoping review is structured according to JBI recommendations and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) as a matrix for preparing the study report¹⁶16 Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil, H. Chapter 11: Scoping Reviews (2020 version). In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020. p. 363-406. [cited 2023 jun 11]. Available from: https://doi.org/10.46658/JBIMES-20-12
https://doi.org/10.46658/JBIMES-20-12... ^-1717 Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE. PRISMA extension for scoping reviews (PRISMAScR): checklist and explanation. Ann Intern Med 2018; 169(7):467-473.. The research protocol was registered in the Open Science Framework (OSF) and can be consulted at: https://osf.io/3hkr6/.

Research question

The PCC mnemonic (P - Population/Participants, C - Concept and C - Context) was used to construct the following review question: “What structural, non-structural and functional vulnerabilities of health facilities were identified during the response to the COVID-19 pandemic?”

Eligibility criteria

Participants: all types of facilities that provided health services to the public during the COVID-19 pandemic were included.

Concept: the concept was based on the structural, non-structural and functional vulnerabilities that health services displayed. These posed challenges or problems that impaired and/or prevented health practices in response to the pandemic. Vulnerabilities were categorized by the items assessed in the Pan American Health Organization’s “Hospital Safety Index: Guide for Evaluators” (PAHO/WHO)⁸8 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). Indice de seguridade hospitalaria: guia del evaluador de hospitales seguros. Washington: OMS/OPAS; 2008..

Context: the context was limited to the COVID-19 pandemic, from March 2020 to July 2022. Studies outside the timeframe of the response to the pandemic, even if addressing similar biological disaster situations, were not considered.

Source types: this scoping review considered primary studies (original research) and secondary studies (systematic and non-systematic reviews) published, or not published, in national and international portals, repositories and databases. Duplicate studies, those without the full text and abstracts published in event annals were not considered.

Search strategy: initially, controlled (MeSH, DeCS and EMTREE) and uncontrolled descriptors, formulated from keywords of the research question and including “Health Services”, “Centros de Saúde”, “Hospitals”, “Vulnerability Analysis” and “COVID-19”, were identified and used to construct the initial search strategy. With the help of librarians, the search strategies were refined and adapted for each database/data repository searched.

The data sources searched were PubMed, CINAHL, LILACS (via VHL), EMBASE, SciELO, Scopus and Web of Science. For the grey literature, Epistemonikos (“Database of the best of Evidence-Based Health Care, Information Technologies and a Network of Experts”) was used, in conjunction with the academic search engine, Google Scholar.

Study selection and screening: selection took place in July 2022 and, after the searches, all records identified were grouped and imported into Rayyan (Qatar Computing Research Institute, Doha, Qatar)¹⁸18 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan - a web and mobile app for systematic reviews. Sys Rev 2016; 5(1):210.. First, duplicates were removed, then records were screened by title and abstract and, lastly, the full text and references of the selected articles were examined. Titles and abstracts, as well as studies from the reference lists, were selected by two independent, blinded reviewers, who evaluated the studies against the eligibility criteria. At all stages of screening, a third reviewer was consulted to resolve any conflicts by examining the studies and inclusion criteria.

The exclusion criteria were: studies off the topic addressed, either because for not addressing health services and/or impacts and vulnerabilities from the COVID-19 pandemic disaster; studies outside the time frame, that is, before 2020; duplicate studies or those lacking the full text; and abstracts published in event annals.

Data extraction: general data relating to identifying studies, and specific data on participants, concept and context, were collected from the articles included in this scoping review using a specific data extraction instrument developed in the form of a Microsoft Excel^® spreadsheet in line with the review objective. The extracted data included authors, year of publication, title, country, language, type of document, journal, research funding, method and concepts of interest to the study. The instrument for extracting vulnerabilities was modified by the authors in the course of the process by adding subcategories to adapt it to the information collected. It was unnecessary to request additional information or clarifications about the data from the authors of the articles included.

Data analysis and presentation: the extracted data were allocated and analysed by way of Excel^® spreadsheets, according to the previously defined extraction instruments. From the data analysis, illustrations were developed in Word, Lucidchart and Canva.

Results

Of a total of 3,226 studies selected for screening, only 127 articles were considered potentially relevant. Reading of the full texts found 51 to be off concept, 21 lay outside the specified population and full texts were not available for eight. In the end, 54 articles were included in this review, seven of them extracted from study reference lists. The results of the study screening and selection process are summarized in a PRISMA flowchart (Figure 1).

General characteristics of the studies

On examining the 54 studies included (Table 1), all were found to be produced by different authors and all were available in English. The year with most publications was 2021 (46.3%); and some had no funding of any kind (42.5%). By document type, 35 (64.8%) were original research articles, six (11.1%) were perspectives, while the other 13 studies took the form of comments (7.4%), pre-print (5.5%), point of view and brief communication (3.7%) and editorial, opinion and analysis (1.8%). Forty-two (77.7%) were published in different journals, of which PLoS ONE and Research Square, with three (5.5%) publications each, published the most on the subject.

The countries most mentioned were the USA (10.5% of studies), India (8.7%) and Brazil and Pakistan (7.0%). Three studies were not geographically delimited. However, countries from the five continents were reported in the studies selected. The table below summarises the main findings.

Most of the studies took a quantitative approach, were of an exploratory or descriptive type and used field research methodology (22.2%). Data was generally collected by way of observations, interviews or forms. The studies commonly focused on analysing and quantifying how services were affected by the COVID-19 pandemic. Meanwhile observational (case, cohort and cross-sectional) and qualitative studies accounted for 11.1% of the total. These publications recorded lived experiences or empirical opinions during the event and made risk management recommendations.

Vulnerabilities

For each type of structural, non-structural or functional vulnerability, subcategories were created by items assessed in the HSI (Chart 1). The 11 items established in this way were: condition of the building; condition and safety of healthcare personnel; condition and safety of medical and laboratory equipment and supplies; operation of lifelines; hospital capacity; condition of access roads to the hospital; services provision; health workforce; health information systems; health sector management; and management of COVID-19.

In total, 36 vulnerabilities were identified in structural, non-structural and functional components of health facilities/services. In the course of the review, there were 300 mentions, the most frequent being: limited material (13.3%) and human (8.6%) resources, interruption of non-COVID health services/procedures and inadequate training (7.6%), limited testing capacity (6.0%), inadequate personnel wellbeing strategies (5.3%), inadequate infection prevention and control (5.0%), insufficient beds (4.6%), inadequate facilities for COVID-19 patients (4.3%) and limited surge capacity (4%).

The vulnerabilities most mentioned were grouped in an Ishikawa diagram (Figure 2), representing the causes and effects of the main vulnerabilities to disasters that healthcare facilities faced in responding to the COVID-19 pandemic.

Discussion

This review of 54 studies involving 29 countries summarised a number of vulnerabilities displayed by hospital systems, departments, health services and other institutions in the context of the COVID-19 pandemic, which exposed how unprepared health systems were to respond to a biological disaster of this nature, even in more developed countries.

Structural vulnerabilities

Condition of the building

To be able to respond to a disaster, a healthcare facility needs to be in full working order and have resilient infrastructure. However, according to the 2021 Global Health Security Index, no country was prepared to manage a catastrophe effectively, including epidemics and pandemics. Its report recorded an overall average country score of 38.9 out of 100¹⁹19 Bell J, Nuzzo J. 2021 GHS Index: advancing collective action and accountability amid global crisis [Internet]. 2021. [cited 2023 jun 11]. Available from: https://www.ghsindex.org/wp-content/uploads/2021/12/2021_GHSindexFullReport_Final.pdf
https://www.ghsindex.org/wp-content/uplo... .

In this review, four studies reported deterioration of facilities in health services in Brazil, Ecuador, Colombia, Haiti, Jordan and Pakistan²⁰20 Haq W, Said F, Batool S, Awais HM. Experience of physicians during COVID-19 in a developing country: a qualitative study of Pakistan. J Infect Dev Ctries 2021; 15(2):191-197.

21 Martin-Delgado J, Viteri E, Mula A, Serpa P, Pacheco G, Prada D, Campos de Andrade Lourenção D, Campos Pavan Baptista P, Ramirez G, Mira JJ. Availability of personal protective equipment and diagnostic and treatment facilities for healthcare workers involved in COVID-19 care: a cross-sectional study in Brazil, Colombia, and Ecuador. PLoS One 2020; 15(11):e0242185.^-2222 Rajakaruna SJ, Liu WB, Ding YB, Cao GW. Strategy and technology to prevent hospital-acquired infections: lessons from SARS, Ebola, and MERS in Asia and West Africa. Military Med Res 2017; 4(1):32..

Historically, developing countries, because of their poor health infrastructure and undeveloped technologies for preventing epidemics, have greater difficulty in absorbing the impacts of public health emergencies²²22 Rajakaruna SJ, Liu WB, Ding YB, Cao GW. Strategy and technology to prevent hospital-acquired infections: lessons from SARS, Ebola, and MERS in Asia and West Africa. Military Med Res 2017; 4(1):32.. One study showed that most hospitals and healthcare facilities in Asia and Africa were not designed to deal with highly infectious diseases, as in the MERS, Ebola and SARS outbreaks²²22 Rajakaruna SJ, Liu WB, Ding YB, Cao GW. Strategy and technology to prevent hospital-acquired infections: lessons from SARS, Ebola, and MERS in Asia and West Africa. Military Med Res 2017; 4(1):32..

Non-structural vulnerabilities

Conditions and safety of healthcare staff and supplies

One of the biggest challenges posed by the COVID-19 pandemic was supply shortages, as demonstrated in several studies. Even the wealthiest countries suffered from shortages of personal protective equipment (PPE), supplies (medicines and disinfectants), as well as assisted ventilation equipment²³23 Livingston E, Desai A, Berkwits M. Sourcing personal protective equipment during the COVID-19 pandemic. JAMA 2020; 323(19):1912-1914.^,2424 Ranney ML, Griffeth V, Jha AK. Critical supply shortages - the need for ventilators and personal protective equipment during the COVID-19 pandemic. N Engl J Med. 2020; 382(18):e41.. In Italy, healthcare personnel experienced high rates of infection and death, connected in part with inadequate access to PPE²⁴24 Ranney ML, Griffeth V, Jha AK. Critical supply shortages - the need for ventilators and personal protective equipment during the COVID-19 pandemic. N Engl J Med. 2020; 382(18):e41.. In certain emergencies and disasters involving infectious diseases, these resources are essential to providing safe care and protecting frontline healthcare personnel.

Limited material resources, the most frequent COVID-19 impact, was reported in 40 studies. Lack of PPE was prevalent among services, especially during the first wave of the pandemic, when nations were practically fighting for this equipment on the global market²⁵25 McMahon DE, Peters GA, Ivers LC, Freeman EE. Global resource shortages during COVID-19: Bad news for low-income countries. PLoS Negl Trop Dis 2020;14(7):e0008412.. However, as pointed out in some studies, lack of PPE was already a chronic condition, especially in the poorest countries, such as in West Africa. This led to a critical scenario of rationing during the pandemic, demonstrating the extent to which the most vulnerable populations were exposed and lacked care²⁵25 McMahon DE, Peters GA, Ivers LC, Freeman EE. Global resource shortages during COVID-19: Bad news for low-income countries. PLoS Negl Trop Dis 2020;14(7):e0008412.^,2626 Fisher-Borne M, Isher-Witt J, Comstock S, Perkins RB. Understanding COVID-19 impact on cervical, breast, and colorectal cancer screening among federally qualified healthcare centers participating in "Back on track with screening" quality improvement projects. Prev Med 2021; 151:106681..

Health personnel were undeniably one of the crucial pillars in endeavours to combat a disease that was still unknown and whose progression was unpredictable; nonetheless, they still saved thousands of lives. Even though previous experience showed that this profession is among those that engage and suffer most during emergencies and disasters²⁷27 Jiménez-Giménez M, Sánchez-Escribano A, Figuero-Oltra MM, Bonilla-Rodríguez J, García-Sánchez B, Rojo-Tejero N, Sánchez-González MÁ, Muñoz-Lorenzo L. Taking care of those who care: attending psychological needs of health workers in a hospital in Madrid (Spain) during the COVID-19 pandemic. Curr Psychiatry Rep 2021 Jun 19;23(7):44.^,2828 Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018; 87:123-127., measures to ensure decent, safe working conditions are still largely unknown.

Sixteen studies reported inadequate strategies for health personnel’s wellbeing as a non-structural vulnerability. To a point, this indicates a poor supply of physical and material measures to alleviate job stress and discomfort. Environments with poor air-conditioning or lacking efficient ventilation, appropriate areas to rest or work and places for hygiene, donning or doffing, in addition to lack of PPE and necessary supplies for clinical patient management, were some of the challenges highlighted²¹21 Martin-Delgado J, Viteri E, Mula A, Serpa P, Pacheco G, Prada D, Campos de Andrade Lourenção D, Campos Pavan Baptista P, Ramirez G, Mira JJ. Availability of personal protective equipment and diagnostic and treatment facilities for healthcare workers involved in COVID-19 care: a cross-sectional study in Brazil, Colombia, and Ecuador. PLoS One 2020; 15(11):e0242185..

Hospital capacity

Another point emphasised among non-structural vulnerabilities was healthcare sectors’ inability to adjust to the increasing numbers of hospital admissions. In order to limit and control local transmission, rigorous detection, prevention and control measures were necessary, including rapid identification of suspected cases, isolation of patients and rapid diagnosis²⁹29 WHO Emergency Committee. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) [Internet]. 2020. [cited 2022 ago 19]. Available from: https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
https://www.who.int/news-room/detail/30-... . However, application of a vast framework of technical and operational interventions depends on each country’s infrastructure and laboratory and public health resources³⁰30 Gilbert M, Pullano G, Pinotti F, Valdano E, Poletto C, Boëlle PY, D'Ortenzio E, Yazdanpanah Y, Eholie SP, Altmann M, Gutierrez B, Kraemer MUG, Colizza V. Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study. Lancet 2020; 395(10227):871-877..

Problems involving inappropriate installations for COVID-19 patients were reported by 13 studies. This means that, in critical sectors of hospitals, such as intensive care units (ICUs), devices and/or technologies were absent or inadequate. Some studies reported that their sectors lacked a separate area for screening or that it was improvised³¹31 Shahid A, Zahra T, Mahwish R, Zaidi S. Preparedness of public hospitals for the coronavirus (COVID-19) pandemic in Lahore District, Pakistan. CUREUS 2022; 14(2):e22477.^,3232 Casalino E, Bouzid D, Ben Hammouda A, Wargon M, Curac S, Hellmann R, Choquet C, Ghazali DA. COVID-19 preparedness among emergency departments: a cross-sectional study in France. Disaster Med Public Health Prep 2022; 16(1):245-253. Areas for isolating COVID-19 patients were adaptations not architecturally designed to accommodate patients with diseases transmitted by droplets or aerosols³¹31 Shahid A, Zahra T, Mahwish R, Zaidi S. Preparedness of public hospitals for the coronavirus (COVID-19) pandemic in Lahore District, Pakistan. CUREUS 2022; 14(2):e22477.

32 Casalino E, Bouzid D, Ben Hammouda A, Wargon M, Curac S, Hellmann R, Choquet C, Ghazali DA. COVID-19 preparedness among emergency departments: a cross-sectional study in France. Disaster Med Public Health Prep 2022; 16(1):245-253

33 Tiruneh A, Yetneberk T, Eshetie D, Chekol B, Gellaw M. A cross-sectional survey of COVID-19 preparedness in governmental hospitals of North-West Ethiopia. SAGE Open Medicine 2021; 10:9:20503121 21993292.^-3434 Agência Nacional de Vigilância Sanitária (Anvisa). Segurança do paciente em serviços de saúde: higienização das mãos. Brasília: Anvisa; 2009.. Another important aspect was the absence of areas for hand hygiene³¹31 Shahid A, Zahra T, Mahwish R, Zaidi S. Preparedness of public hospitals for the coronavirus (COVID-19) pandemic in Lahore District, Pakistan. CUREUS 2022; 14(2):e22477., conduct that is crucial to avoiding cross-transmission in hospital environments³⁴34 Agência Nacional de Vigilância Sanitária (Anvisa). Segurança do paciente em serviços de saúde: higienização das mãos. Brasília: Anvisa; 2009..

“Surge capacity” was another challenge recorded in 12 studies, which explained that patient demand was much greater than health service supply could meet. The geographic distribution of healthcare facilities was also an important factor: areas further from urban centres tended to lack of healthcare facilities capable of serving their whole population³⁵35 Andini I, Djunaedi, A. Mapping of rural health services during COVID-19 pandemic in Central Java, Indonesia: rethinking remoteness IOP Sci 2021; 887:012032. https://doi.org/10.1088/1755-1315/887/1/012032
https://doi.org/10.1088/1755-1315/887/1/... .

Insufficient numbers of beds led health facilities to operate at maximum installed capacity, as recorded in 14 studies. Estimates indicate that, in Bangladesh, 0.7 ICU beds were available per 100,000 inhabitants, while the average in Asian countries is 3.6³⁶36 Molla MMA, Disha JA, Yeasmin M, Ghosh AK, Nafisa T. Decreasing transmission and initiation of countrywide vaccination: key challenges for future management of COVID-19 pandemic in Bangladesh. Int J Health Plann Mgmt 2021 36(4):1014-1029.. In any case, although bed numbers were an important parameter during the pandemic, the literature shows that care provision during the event was also affected by other factors, including scarcity of material resources and specialists²⁴24 Ranney ML, Griffeth V, Jha AK. Critical supply shortages - the need for ventilators and personal protective equipment during the COVID-19 pandemic. N Engl J Med. 2020; 382(18):e41.^,3737 Ma X, Vervoort D. Critical care capacity during the COVID-19 pandemic: global availability of intensive care beds. J Crit Care 2020; 58:96-97.^,3838 Centers for Disease Control and Prevention. Strategies to mitigate healthcare personnel staffing shortages [Internet]. 2020. [cited 2022 ago 3]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html
https://www.cdc.gov/coronavirus/2019-nco... .

Another aspect to be considered was limited testing capacity and inadequate laboratory services. Inadequate COVID-19 testing was the most common problem in this subcategory. This underlines the importance of testing in screening for, and diagnosing, suspected cases, as observed in studies in South Korea, Vietnam and China³⁹39 Her M. How Is COVID-19 affecting South Korea? What Is our current strategy? Disaster Med Public Health Prep 2020; 14(5):684-686.

40 Ha BTT, Ngoc Quang L, Mirzoev T, Tai NT, Thai PQ, Dinh PC. Combating the COVID-19 epidemic: experiences from Vietnam. IJERPH 2020; 17(9):3125.^-4141 National Health Commission of the People's Republic of China. Protocol on Prevention and Control of COVID-19 (Edition 6) [Internet]. 2020. [cited 2023 ago 3]. Available from: https://www.chinadaily.com.cn/pdf/2020/2.COVID19.Prevention.and.Control.Protocol.V6.pdf
https://www.chinadaily.com.cn/pdf/2020/2... .

Some studies revealed that the reasons for failures in the testing process included the limited number of laboratories, lack of kits or other supplies, delays in sample processing, underreporting, improper sample management and the people’s refusal or fear of testing. Moreover, some studies also reported challenges in sample handling, storage and transportation in services, as well as a lack of other laboratory services and technical competence for these purposes.

Functional vulnerabilities

Service provision and workforce in the health sector

With COVID-19 cases imminent, healthcare services were forced to reduce or interrupt non-essential procedures so as to allocate all their resources to combating the pandemic. Interruption of non-COVID services or procedures was recorded 23 times. This led to a decrease in elective surgery slots, screening procedures, triages, diagnoses and so on. Even two years after the start of the pandemic, the WHO reported healthcare facilities in 90% of countries surveyed were still suffering from continual disruptions to essential services⁴³43 Nações Unidas Brasil. Serviços essenciais de saúde enfrentam interrupções contínuas durante pandemia [internet]. 2022. [acessado 2023 jun 11]. Disponível em: https://brasil.un.org/pt-br/171278-servicos-essenciais-de-saude-enfrentam-interrupcoes-continuas-durante-pandemia
https://brasil.un.org/pt-br/171278-servi... . In Italy, the pandemic caused interruptions, delays, reductions and cancellations of maternity and neonatal consultations in 70% of mother and child health institutions⁴⁴44 Cena L, Rota M, Calza S, Massardi B, Trainini A, Stefana A. Estimating the impact of the COVID-19 pandemic on maternal and perinatal health care services in Italy: results of a self-administered survey. Front Public Health 2021; 9:701638..

The root causes of most of these interruptions recorded in the studies were “limited human resources”, “inadequate training”, “inadequate staff management” and “psychological impacts”. These health workforce vulnerabilities also impaired service provision, so much so that services finding difficulty in managing work teams and in receiving support sufficient to meet the large demands were described in most of the studies cited. The difficulty most mentioned was limited human resources, meaning the shortage of qualified health personnel in health services and the need for strategic planning and plausible scaling of human resources.

Notably, one study of healthcare working conditions during COVID-19 in Brazil found that 43.3% of personnel felt unprotected against COVID-19 and that the main reason was limited access to PPE⁴⁵45 Leonel F. Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2023 ago 8]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude#:~:text=Os%20dados%20indicam%20que%2043,a%20necessidade%20de%20improvisar%20equipamentos
https://portal.fiocruz.br/noticia/pesqui... .

These factors connect with the psychological impacts caused by high workload and ineffective management, resulting in high levels of stress and exhaustion from the chaotic situation never before experienced in ICUs. Publications list high rates of burnout, depressive symptoms, sleep disorders and anxiety among these staffs. PAHO recommended that facilities’ contingency plans provide necessary psychological support measures for health personnel⁸8 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). Indice de seguridade hospitalaria: guia del evaluador de hospitales seguros. Washington: OMS/OPAS; 2008..

Many records noted that healthcare personnel also lacked sufficient technical knowledge to deal with critically ill patients. Unpreparedness was a common situation in most countries affected, such as Spain, where around 54% of primary care personnel did not receive appropriate training in donning and doffing⁴⁶46 Cebrián-Cuenca A, Mira JJ, Caride-Miana E, Fernández-Jiménez A, Orozco-Beltrán D. Sources of psychological distress among primary care physicians during the COVID-19 pandemic's first wave in Spain: a cross-sectional study. Prim Health Care Res Dev 2021; 22:e55.^,4747 Kamerow D. COVID-19: the crisis of personal protective equipment in the US. BMJ 2020; 369:m1367..

Health sector management and managing COVID-19

According to PAHO, hospitals need to have a guaranteed, budgeted financial reserve for emergencies⁸8 Organización Mundial de la Salud (OMS), Organización Pan-Americana de la Salud (OPAS). Indice de seguridade hospitalaria: guia del evaluador de hospitales seguros. Washington: OMS/OPAS; 2008.. However, seven studies in low- to high-income countries reported limited funding as among the challenges to health management. Research has attributed this difficulty to both the reduction in clinical care and non-COVID services and to pre-existing chronic underfunding internationally.

Another difficulty highlighted was the need to prepare the health sector to face future biological disasters, as attested in publications that exposed inadequate levels of preparedness and inter-sector coordination to address the pandemic.

In short, research has demonstrated that hospitals lacked contingency plans, rapid response teams, crisis offices and multi-sector risk communication. It was recommended that Pakistan, for example, develop an outbreak detection and control system, as it scored zero in emergency preparedness and response planning on the 2019 Global Health Security Index⁴⁸48 Atif M, Malik I. Why is Pakistan vulnerable to COVID-19 associated morbidity and mortality? A scoping review. Int J Health Plann Mgmt 2020; 35(5):1041-1054..

As regards infection prevention and control, studies summarized the main problems as resulting from suboptimal working conditions, including lack of hospital supplies and equipment and knowledge gaps among frontline workers with little or no ICU experience. Among the first cases of COVID-19 in Wuhan, China, 29% of patients were members of the hospital workforce, showing that infection prevention protocols in force at the time were insufficient to contain the spread of the virus⁴⁹49 Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y, Li Y, Wang X, Peng Z. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; 323(11):1061-1069.. Others issues included reuse and inappropriate use of PPE, when this was available.

Added to this was staffs’ lack of knowledge or unpreparedness regarding COVID-19 clinical management protocols. As this was a new disease, clinical treatment and diagnosis guidelines changed frequently with new research findings. Meanwhile, implementation of protocols was also hampered by technical, logistical and stock constraints.

Two studies reported the use of scientifically unproven medicines, such as hydroxychloroquine and antiretrovirals. Despite the lack of scientific support, political leaders in American countries, such as Brazil and the USA, produced, stockpiled and encouraged the use of these drugs to treat COVID-19⁴²42 Narwal S, Jain S. Building resilient health systems: patient safety during COVID-19 and lessons for the future. J Health Manag 2021; 23(1):166-181., raising serious human safety concerns in the scientific community. This also limited stocks for patients making recommended use of the medicines to treat other clinical conditions⁵⁰50 Tripathy JP. Does pandemic justify the use of hydroxychloroquine for treatment and prevention of COVID-19 in India? J Med Virol 2020; 92(9):1391-1393..

Conclusion

The COVID-19 pandemic exposed nations’ need to strengthen health systems to ensure their resilience, especially against similar health crises in the future. In the throes of this global disaster, the constraints imposed by resource scarcity accentuated existing problems, such as deficient health infrastructure in both high- and low-income communities, which further hampered attempts to respond to this disaster and the unprecedented challenges it raised. Prevalent functional vulnerabilities significantly affected service provision, underscoring the importance of engaging qualified health personnel, providing continued professional development for those already working in health facilities and ensuring appropriate working conditions so that clinical practices can operated safely and with appropriate quality, all of which is guaranteed by sound strategic human resource planning to respond to disasters.

It is recommended that recommendations for the construction of disaster-resilient buildings of whatever type be considered within the scope of projects for new healthcare facilities. Moreover, existing facilities need to implement systematic vulnerability analysis processes, with a view to prospective risk management and adaptation to current security standards.

More research is needed into the HIS’s applicability in different types of healthcare facilities besides hospitals, because the list of vulnerabilities contemplated in the document is limited and does not include all existing models of healthcare facility, with a view to strengthening local resilience and developing a culture of hospitals safe from disasters.

Acknowledgements

To the librarians at the Instituto de Estudos de Saúde Coletiva and the Escola de Enfermagem Anna Nery, at Universidade Federal do Rio de Janeiro, for their invaluable help in refining the information source search strategies.

References

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History