Health system response to health emergencies in low- and middle-income countries: a systematic review protocol

Abstract

Introduction

Health emergencies continue to stimulate greater interest in health systems and services, particularly their ability to respond to such shock. While studies have been done on health system response to health emergencies, there has been no attempt to synthesise this body of evidence to inform future emergency preparedness and response plan, particularly in low- and middle-income countries (LMICs) where health systems are deemed to be weak. This paper aims to provide a systematic review protocol for synthesising evidence on health system response to health emergencies in LMICs.

Methods and analysis

The WHO building blocks of health system functioning will be used as a conceptual framework for the review. The review will be conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Nine electronic databases will be searched: Medline, Embase, Ovid Emcare, Scopus, ScienceDirect, Academic Search Complete, HINARI, CINAHL and African Index Medicus. The search will be supplemented by citation searching, searching reference lists of included articles, search for grey literature in Google Scholar and relevant websites. Studies focusing on health system response to health emergencies in LMICs, published in English and between 2007 and 2025, will be eligible for inclusion. A narrative synthesis will be performed on all the included studies. Studies will be mapped and categorised into the WHO six building blocks of health system functioning, exploring relationships between and within studies, identifying the response mechanisms of the health system during health emergencies and their barriers and facilitators.

Ethics and dissemination

The data to be used do not include individual patient data, so ethical approval is not required. The results of the systematic review will be disseminated through a peer-reviewed journal publication, presentations at conferences and seminars.

PROSPERO registration number

CRD42024556271

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The review is conceptually grounded in the WHO building blocks of health system functioning, which will make it possible to provide a comprehensive understanding of how the various components of the health system responded to health emergencies and the areas that need critical attention.

• A systematic search will be conducted in nine electronic databases: Medline, Embase, Ovid Emcare, Scopus, ScienceDirect, Academic Search Complete, HINARI and African Index Medicus.

• The process of study selection, data extraction and quality assessment will be performed independently by two researchers, which will improve the internal validity of the review findings.

• A limitation of this review will be including only articles published in English, which may lead to exclusion of other articles published in other languages that could have passed for inclusion.

Introduction

The need to strengthen health systems to be more resilient to health emergencies continues to be high on the agenda of global health security experts and policymakers. The health system comprises all organisations, people and actions whose primary intent is to promote, restore and maintain health,¹ and all activities to prevent, mitigate and manage health threats by the health system are deemed as health system response. Health emergency has been defined by Morgans and Burgess² as ‘sudden or unexpected threat to physical health or well-being which requires an urgent assessment and alleviation of symptoms’ (p. 288). Nelson et al³ added that when an unpredictable health threat has the potential to overwhelm wider population, it becomes a public health emergency. These health emergencies could be disease outbreaks, environmental disasters and other humanitarian crises.⁴ The WHO strategic framework⁵ defines emergency preparedness as the knowledge, capacity and organisational systems that governments, response and recovery organisations, communities and individuals develop to anticipate, respond to or recover from emergencies. The 2019 Global Health Security Index (GHS) forecasted that health systems in high-income countries were the most prepared for a global health emergency.⁶ However, this assertion has been challenged in the wake of the COVID-19 health emergency as countries such as the UK and the USA, which received high GHS index scores, struggled to suppress the cases of COVID-19.^{7 8} This implies the need to study health systems and how they can prepare and respond to health emergencies. Recent studies have called for the need to critically examine the emergency preparedness and response of the health system to ensure that learning from the COVID-19 pandemic response is included in future pandemic preparedness and response domains.^{9 10} Similarly, understanding levels of preparedness in advance of a health emergency has been highlighted as an important knowledge gap.¹¹

Health emergencies continue to stimulate greater interest in health systems and services, particularly their ability to respond to such shocks.¹² Studies have found that the world economy was hit by COVID-19 and that most health systems struggled to bring the disease under containment.¹³ Other recent outbreaks—such as Zika, Ebola, H1N1 pandemic influenza and Marburg, among others—underscore the importance of studying the response of the health system in the face of shocks like health emergencies, particularly in low- and middle-income countries (LMICs) where health systems are deemed to be weak.^{14 15} Others have argued that the health systems in LMICs are not robust enough to handle shocks.¹⁶

Why is it important to do this review?

While studies have been done on health system response to health emergencies, there has been no attempt to synthesise this body of evidence to inform future emergency preparedness and response plan, particularly in LMICs. Fleming et al’s¹⁷ review on metrics and indicators used to assess health system resilience in response to shocks focused on high-income countries. While this review is useful, it did not focus on health system response to health emergencies per se. Further, the contextual differences in health system response to shocks between high-income countries and LMICs raise concerns about the applicability of the findings to LMICs.¹⁸ The available evidence syntheses so far are mainly scoping reviews focusing on emergency preparedness.919,21 For example, Lee et al⁹ conducted a scoping review of public health emergency preparedness of infectious diseases. Systematic reviews conducted so far have focused on the impact of health emergencies.²² Another systematic review which focused on understanding health system resilience in LMICs only included qualitative studies published during the Ebola outbreak in West Africa.¹⁴ Further, the metrics and measures used to assess health system response to health emergencies in LMICs are not known in the literature except for high-income countries when it comes to measuring health system resilience.¹⁷ There is therefore a gap in the literature on health system response to public health emergencies. The Lancet COVID-19 Commission’s report on ‘Lessons for the future from the COVID-19 pandemic’ also called for the need to strengthen the evidence base on health system response to health emergencies.²³ This systematic review fills these important gaps in knowledge by including all study approaches (qualitative, quantitative and mixed-method) focusing on health system response in the context of health emergencies in LMICs. The review is informed by the WHO building blocks of health system functioning to provide a comprehensive understanding of how the various components of the health system responded to health emergencies and the areas that need critical attention. The review will identify measures and metrics that have been used to examine health system response to health emergencies and any potential gaps to help improve future studies. The review findings will be useful for health policymaking by informing health systems’ preparedness and response to future health emergencies.

Review aim

This study aims to synthesise evidence on health system response to health emergencies in LMICs.

Review questions

• What has been the health system’s response to health emergencies in LMICs?

• What types of metrics and indicators have been used to assess and measure health system’s response to health emergencies in LMICs?

• What are the barriers and facilitators of health system’s response to health emergencies in LMICs?

Methods and analysis

Conceptual framework

Both et al²⁴ noted that systematic reviews that focus on complex and context issues need to make use of frameworks to guide the review. This review will be informed by the WHO building blocks for health system functioning²⁵ (see figure 1). In line with the WHO conceptual framework, a health system consists of all organisations, institutions, people and actions whose primary intent is to promote, restore or maintain health. The health system goal is to improve health and health equity, in ways that are responsive and financially fair and make the best or most efficient use of available resources.²⁵ The review will focus on identifying the specific response mechanisms of the various components of the health system to the COVID-19 health emergency to achieve the health system’s goals. It has been argued that investment in the building blocks aims to improve coverage of services through attaining desired access to interventions, without compromising quality and safety. The six components of the building blocks are service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance. To achieve the health system goal, the building blocks need to be functioning well for the health system to be resilient during shocks like the COVID-19 health emergency.

Figure 1. WHO health system building blocks.

Patient and public involvement

In line with the GRIPP2 reporting checklists,²⁶ this review will involve both patients and the public at various stages of the review. Public health managers and practitioners were engaged to provide input in refining the review questions. They will also be engaged to provide feedback on the search strategy. Both consumers and the public will be involved in the dissemination of the study results.

Design

This systematic review is a mixed-method review. A mixed method approach is suitable for this review as the initial scoping literature search revealed that there are quantitative, qualitative and mixed method studies that have been conducted to examine health system response to health emergencies. The review will be conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.²⁷ To improve the internal validity of the review, the methodology for conducting this review will follow Joana Briggs Institute Reviewers’ Manual²⁸ and the Enhancing Transparency in Reporting the synthesis of Qualitative Research guidelines.²⁹

Eligibility criteria

The SPIDER tool³⁰ will be used to provide a framework for study inclusion (see table 1).

Table 1. SPIDER framework.

SPIDER	Inclusion	Exclusion
S—sample	Low- and middle-income countries based on the World Bank’s classification	High-income countries based on the World Bank’s classification
PI—phenomenon of interest	Studies on health system response to health emergencies since the development of the WHO building blocks of health system functioning in 2007	Studies that do not focus on health system response to health emergencies and studies on health system response to health emergencies published before 2007
D—design	Both peer-reviewed published literature and grey literature of any research design	Studies that did not meet the inclusion criteria for design.
E—evaluation	Findings, lessons learnt, perceptions, lived experiences relating to health system responses to health emergencies across any domain of the WHO building blocks and barriers and facilitators of health system response to health emergencies	Findings not relating to health system response to health emergencies
R—research type	Qualitative studies, quantitative studies and mixed-method studies	Reviews, opinion papers and commentaries

Compared with the Population, Intervention, Comparison, and Outcome (PICO) framework, the Sample, Phenomenon of Interest, Design, Evaluation, and Resarch type (SPIDER) framework is useful for searching for qualitative and mixed-methods research studies.³¹

Sample

The sample to be examined includes a wide range of actors within the health system including policy makers, healthcare professionals (eg, doctors, nurses, midwives and public health and health promotion officers), health administrators and community members among others who may express views about health system response to health emergencies in studies.

Phenomenon of interest

The review will include studies published in English focusing on health system response to health emergencies in LMICs. Studies that focus on any aspect of the WHO health system building blocks will be included in the review. High-income countries based on the World Bank’s classification would be excluded. The WHO health system building blocks were published in 2007; therefore, only papers published between 2007 and 2025 will be eligible for inclusion.

Design

We anticipate that various designs and methods of data collection will be used in examining health system response to health emergencies. We will, therefore, consider all kinds of designs including experimental, quasi-experimental, cross-sectional, case studies, descriptive qualitative studies and other qualitative designs. For data collection methods, we will include questionnaires, interviews, focus groups, document analysis and observations. We will also pay attention to the use of conceptual frameworks and metrics and measures used to examine health system response to health emergencies.

Evaluation/outcome

Studies will be included in the review if they report on findings on health system’s response activities to health emergencies: lessons learnt, perceptions, lived experiences, barriers and facilitators, relating to health system responses to health emergencies across any domain of the WHO building blocks.

Research type

Studies that used qualitative, quantitative and mixed-method approaches would be eligible for inclusion. The quantitative approach is useful in assessing the level of preparedness ande response measures including metrics and indicators of the health system response to the health emergency. Qualitative approaches are also useful in exploring the barriers and facilitators of the health system response to the health emergency. All designs observational, interventional and quasi-experimental studies on health system response to health emergencies will be considered for inclusion. Commentaries and opinion papers will be excluded.

Search strategy

A systematic search will be performed in the following databases: Medline, Embase, Ovid Emcare, Scopus, ScienceDirect, Academic Search Complete, HINARI and African Index Medicus. Full-text search terms will be developed first for Medline and will be adapted for other databases, as necessary. The searches will be restricted to human subjects and to primary studies.

Electronic searches will be supplemented with citation searching, searching reference lists of included articles and a Google Scholar advanced search for grey literature. The websites of leading organisations such as the WHO, UNICEF and Center for Disease Control as well as The African Journals Online will be searched for papers.

The search terms will include ‘health system response,’ ‘health system resilience,’ ‘COVID-19,’ ‘Ebola,’ ‘H1N1 pandemic influenza,’ ‘Marburg,’ ‘health emergencies,’ ‘public health emergencies’ and ‘low- and lower middle-income countries.’ Both keywords and MeSH terms will be used. The search results will be exported to EndNote for data management and removal of duplicates. Online supplemental additional file 1 shows the initial search strategy for Medline.

Selection of studies

Two independent reviewers will carry out both the title and abstract screening and the full-text screening using the Covidence systematic review software. To ensure inter-rater reliability, a trial run of screening will be conducted for the first 10 papers by both reviewers at the same time, but independently. After that, the reviewers will discuss discrepancies (if any) and their reasons to make sure that both reviewers are all on the same page with the rules to include and exclude studies. Any disagreement will be resolved by discussion between the two reviewers and, if necessary, consultation with a third reviewer.

Data extraction

Data extraction form will be developed and adopted using the Joanna Briggs Institute data extraction form.³² Two independent reviewers will carry out the data extraction. To enhance validity, a standardised data extraction form will be developed and piloted on a sample of included reviews. The main components of the data extraction are as follows:

• Study authors and year of publication

• Study methodology: aim and research questions, study design, data collection methods and data analysis techniques

• Characteristics of included studies (participants, type of participants and study setting/ countries/regions)

• Main results/findings: aspects of the WHO health system building blocks covered by the study and strengths and weaknesses of the health system response to health emergencies;

• Framework/s used to inform the study

• Conclusions from the study on overall health system response

Critical appraisal of included studies

To assess the quality of the range of study designs included in this review, the most appropriate tool for each study design will be used including Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-1)³³ for non-randomised trials, Rob 2 for randomised controlled trials and the Joanna Briggs Institute’s³² Qualitative Assessment and Review Instrument for qualitative studies. The mixed-method appraisal tool³⁴ will be used for mixed-method studies. All eligible studies will be judged as ‘high,’ ‘moderate’ or ‘low’ quality, given an overall consideration of the risk of bias assessment/quality appraisal and the potential impact of the identified risks on the study results. As this is not an effectiveness review of an intervention, all studies will be included in the review regardless of the status of quality assessment. Two independent reviewers will perform the quality assessment using Covidence software. To enhance the level of agreement, five of the included studies will be piloted for critical appraisal.

Data synthesis

Considering the complexity of health system response to health emergencies, it is assumed that the data that will be generated will be heterogenous. Therefore, a narrative synthesis will be performed on all the included studies whether qualitative, quantitative or mixed-method studies.³⁵ This approach will entail undertaking a preliminary synthesis of the findings, exploring the relationships in the data and assessing the robustness of the synthesis. At the initial synthesis stage, the data extracted from the included studies will be used to provide a textual and a visual summary of the results using summary of findings tables as recommended by the Cochrane Handbook for Systematic Reviews.³⁶ This will help to explore the core themes across the studies in relation to the WHO health system building blocks. Studies will be mapped and categorised into the WHO framework of health system building blocks. A graphical and tabular representation of the data will be provided. The stage of exploring relationships between and within studies will involve identifying the response mechanisms of the health system during health emergencies and their barriers and facilitators.

Discussion

A number of scoping reviews have looked at how health emergencies have impacted the health system, but these studies have been in piecemeal, looking at different component parts of the health system such as workforce, laboratory, finance and information.37,39 However, it can be argued that the full health system response mechanism cannot be well appreciated from different components in piecemeal evidence.

Findings from this systematic review will bring forth evidence on health system response to health emergencies using the WHO health system building blocks. Some studies have critiqued the WHO health system building blocks and have called for their modification for better health system performance and resilience to health emergencies.^{40 41} Evidence from this review will be used to inform the WHO building blocks of health system functioning.

To better understand the performance and resilience of the health system, this review will also provide evidence on the barriers and facilitators of the health system’s response to health emergencies. Examining the barriers and facilitators of the health system response is crucial for effective performance because it will lead to effective implementation of evidence-based decision-making in health systems.⁴²

The major strength of this review is that it comes in at a time when the world is recovering from the COVID-19 pandemic, a major health emergency, and discussions are ongoing on how the health systems can better respond to future pandemics. Also, this systematic review will be the first to use the WHO building blocks to map evidence on health system response to health emergencies in LMICs.

This review has limitations. We acknowledge that the exclusion of studies in languages other than English is a limitation. Further, the concept of health system response is broad, transcending public health and crossing into many sectors. To overcome this, the search terms and the search strategy will be informed by the WHO health system building block to ensure a comprehensive literature search. Finally, due to the contextual differences in health system response to health emergencies between high-income and LMICs,¹⁸ the findings may not be applicable to high-income country settings.

Ethics and dissemination

Ethical approval will not be taken because the study is a systematic review, and ethical approval is not a compulsory requirement for conducting a systematic review. This systematic review will form a chapter of SBO-A’s PhD. The results will be disseminated through a peer-reviewed publication and a presentation at a conference. The results will also be disseminated to health systems’ stakeholders at the national and local levels in Ghana.