Table 2.

Perception on health systems response at the early phase of COVID-19.

Pillar 1: Country Level Coordination, Planning and Monitoring
Domains	Sub-Domains	Issues
Stakeholder	Stakeholders’ identification	1. Lack of assessment of capabilities/availabilities of all stakeholders including private agencies, industries, non-governmental organisations, experts, and community representatives
		2. Late involvement of key stakeholders
	Stakeholders’ cooperation	1. Lack of coordination across ministries and industries
		2. Lack of coordination between central and regional authorities
		3. Lack of involvement of experts for assessment, analysis and input generation for outbreak management
Process Implementation	Managerial approach	1. Lack of preparedness plan, policy and guideline
		2. Lack of evidence-based statement in information dissemination and action
		3. Timeliness of planning and activation
	Synchronised and coordinated instructions	Contradicting implementations between federal and regional authorities
	Monitoring, evaluation and documentation	1. Comprehensiveness and credibility in evaluation of policy/action/performance measures
		2. Need for lesson learned documentation
	Transparent planning, implementation and performance measure	Lack of transparency of action plan, assessment and performance measure towards public
Pillar 2: Risk Communication and Community Engagement
Domains	Sub-Domains	Issues
Dissemination of Information	Source of information	Lack of credibility in information dissemination to ensure information disseminated is accurate and evidence-based
	Content of information	1. Unclear information due to technical terms, language and incomplete information
		2. Inconsistent information
		3. Information disseminated is not tailored with community’s level of acceptance
	Relay of information	Inadequate channels and platforms to reach all population
Community Involvement	Extent of involvement of relevant parties	1. Lack of coordination with community representatives
		2. Untimely engagement
	Receptiveness on severity of outbreak	Not preparing the community prior to instruction dissemination
Pillar 3: Surveillance, Rapid Response Team and Case Investigation
Domains	Sub-Domains	Issues
Surveillance Structure	Legislation on data sharing	Incomprehensive legislation on sharing of surveillance data
	Extent of network and collaboration structure	1. Lack of networking and partnership with experts on data analysis
		2. Lack of coordination in data integration
Surveillance Functions	Case definition and guideline	1.Lack of clear case definition and strong team to detect all including isolated cases
		2. Lack of standardised guidelines
	Data collection and handling	1. Inaccurate data analysis and interpretation
		2. Inefficient centralised platform to communicate and disseminate data
		3. Inadequate training to improve competency
		4. Unoptimised resources for efficient tracing, data collection and data analysis
Surveillance Quality	Data quality	1. Lack of completeness and transparency
		2. Lack of representativeness and accuracy
Pillar 4: Point of Entry
Domains	Sub-Domains	Issues
Entry/Exit Control	Travel restriction	Lack of stringency in travel restrictions and country entry requirements
	Border closure	Untimely border closure
Screening measures	Stringency	Lack of stringency in screening measures and regulations at point of entries
	Competency	Incompetent health workers implementing and explaining needs for screening measure
	Consistency	Inconsistent method of screening measures at all entries including air, land and sea
Quarantine policy	Policy implementation	1. Untimely policy implementation
		2. Unclear instructions and advice for people instructed for quarantine upon entering the country
		3. Lack of tracking and follow up measures of people under quarantine
Information	Update on disease management and standard operating procedure (SOP)	Untimely and inefficient relay of information and update on SOP due to rapidly changing situation
Pillar 5: National Laboratories
Domains	Sub-Domains	Issues
Partnership and Networking	Co-ordination with universities, private laboratories and GPs	1. Lack of national level coordination with university and private laboratory for testing and research
		2. Inadequate information for management at general practitioner (GP) level
		3. Lack of collaboration in test kit development to increase diagnostic capacity
Laboratory Testing	Test criteria	Rigid test criteria affecting testing coverage
	Volume of testing	Inadequate testing for suspected case
	Sample transportation	Difficulty of transporting samples from East Malaysia
	Testing efficiency	Inefficient testing process causing delay of result
Surge phase preparation	Anticipation of surge phase	Lack of preparation leading to inability to cope with surge of cases
Financing	Cost and budget availability	1. More out of pocket money to do test in private sector
		2. Shortage of reagents and other inventories due to lack of fund
Monitoring and Evaluation	Monitoring screening process	Questionable quality of sample taken in private hospitals and clinics
Human Resources	Health workers mobilisation	Lack of and untimely mobilisation of human resources to busy centre
	Training	1. Inadequate training especially to private healthcare workers
		2. Need for GP empowerment
Procurement and Inventory Management	Supply	Inadequate supply of reagents/swab/personal protective equipment to cater for increase number of testings
	Evaluation of test method	Lack of evaluation on selection and usage of rapid testing
Pillar 6: Infection Prevention and Control
Domains	Sub-Domains	Issues
IPC programmes and policies	Facility lead team	Lack of dedicated and trained lead team to ensure infection prevention and control (IPC) programme at facilities run as planned
	Clear directives and policy	1.Unlear directives to help healthcare staffs adhere to IPC protocol
		2. Incomprehensive policy on public activities: mass gathering/punitive action/mask wearing/religious places
		3. Incomprehensive policy for workplace: shifts/numbers/protocols/SOP
		4.Incomprehensive policy on domestic travelling
	Enforcement	Weak enforcement of IPC protocol
	Risk stratification	Not utilising technology to risk stratify area and activities
	IPC training	1. Lack of allocation of time and budget for healthcare workers’ training
		2. Lack of empowerment of non-healthcare workers in healthcare facilities
	Public awareness creation	Need to increase awareness on basic measures such as proper handwash and wearing mask
Healthcare workers surveillance	Testing HCW testing	Healthcare workers should be given priority in doing testing
Monitoring and documentation	Monitoring and Analysis	Lack of monitoring and analysis of IPC programme. For example; healthcare workers adherence to IPC Protocol
	Documentation	Need for proper documentation of cases and lesson learnt
Built environment, materials and equipment	Infrastructure and engineering approach	Lack of proper isolation facility with good ventilation to quarantine positive cases
	Resources and stockpiling	Lack of resources and stockpiling
	Quarantine centre management	Inefficient organisation of quarantine centre
	Infrastructure and services	Inappropriate infrastructure and services to encourage public to adhere to IPC
Pillar 7: Case Management
Domains	Sub-Domains	Issues
Staff Training	Training and involvement of primary care providers	Lack of training and involvement of primary care providers in case management
Facilities	Capacity of treatment and quarantine centres	1. Inadequate intensive care units and tertiary care capacities
		2. Lack of quarantine centres
Treatment	Medical advancement	Incomprehensive utilisation of other COVID-19 treatment (example: plasma collection of convalescing COVID-19 patients)
Information and communication	Guidelines and information dissemination to public	Not using targeted approach (communication) in disseminating information
	Guidance and protocols for healthcare providers	1. Lack of guideline in managing patient transferred from MOH to private hospitals
		2. Unclear guidance on how to manage patient with mild symptoms
		3. Lack of single (centralised, key point) information source for both public and private healthcare workers
		4. Lack of guidance for general practitioner and primary care centres in patient screening and management
		5. Lack of protocol for private sector to support public health operationalisation
Pillar 8: Operational Support and Logistics
Domains	Sub-Domains	Issues
Supply chain	Landscape assessment	1. Inadequate review of emergency supply chain process
		2. Lack of preparedness in operational plan
		3. Party monopoly in supply provision
	Governance, financing and personnel	1.Lack of coordination on supply chain processes
		2. Unclear directive (hospital on their own)
		3. Lack of support to obtain equipment and set up
		4. Unclear fund release process
	Emergency protocol	Lack of protocol for emergency resources mobilisation
	Commodity planning and quantity forecasting	1. Not addressing shortage of PPE among general practitioners
		2. Poor resource forecasting
	Procurement and sourcing of emergency health commodities	1. Poor control on exports of materials
		2. Lack of planning and procurement process
		3. Not prioritising and supporting local suppliers
		4. Lack of centralised procurement effort
	Stockpiling and Warehousing	Not identifying reserve for basic field equipment
	Distribution of supply	1. Lack of coordination in distribution
		2. Lack of transparency in distribution
	Logistics Management Information Systems	No feedback of transparency
Human resources	Capacity	1. Need for more recruitment of contract and volunteer workers
		2. Inadequate identification of human resource requirement and deployment of resources
	Welfare	1. Need for supplementary vaccination
		2. Inadequate social and emotional support