Lessons and long-term implications of the covid-19 response in Denmark from a resilience perspective

Abstract The paper focuses on crisis responses and resilience within hospitals. The study is based on structured expert interviews with medical directors in selected hospital departments in two of the five regions of Denmark and primary care physicians in the same regions. We investigate stage 3 (Shock impact and management) and stage 4 (Recovery and learning) within hospital organizations using Denmark as case country, and we pay particular attention to issues of “organisational learning”, “purchasing flexibility and reallocation of funding”, “distribution of human and physical resources” and “motivated and well-supported workforce”. Particular attention is paid to care for patients with chronic care needs and lessons for the long-term resilience building in the health system. The study highlights strategic choices and lessons for the long-term resilience within hospitals. It demonstrates, how the initial strategy of organizing specific COVID-19 response units was abandoned relatively early, as it appeared more efficient to integrate COVID-19 patients in the regular specialized department structure. Emergency wards experienced increasing pressure during the pandemic as primary care clinics were referring (too) many patients suspected of COVID-19. This raises questions about capacity and relations between primary and specialized care in crisis situations. Management of human resources is crucial. While the initial phases of the pandemic response were characterized by flexibility and “team-spirit”, there has been a negative long-term impact particularly among the nursing staff, where burnouts and attrition are major issues. Pandemic crises place significant strain on health systems and personnel. This raises issues about communication of strategies and principles for organizing efforts. The Danish health system managed the crisis adequately, but there are also lessons that should be learned regarding long-term implications and preparedness for future crises.

Health system resilience to shocks is perhaps the biggest global challenge facing health systems in the 21st Century. Health systems face an increasing prevalence and likelihood of a broad range of shocks (including economic crises, pandemics, climate-related events, political upheavals, mass migration, conflicts and cyberterrorism) that can each undermine the ability of a health system to function well. In particular, the twin processes of dealing with the legacy of a health system shock and preparing for the next shock are distinct but related challenges that face policy makers today. In this presentation the authors will present key findings on improving preparedness and building a constructive legacy drawing from: the results of a recent systematic review on how health system resilience has been measured in high income countries over the last twenty years; the results of a recent realist review exploring the legacy of the economic crisis for the resilience of the response of the health system to COVID-19, and analysis of interviews with Irish policy makers, managers and analysts as they reflect on the different shocks encountered by the Irish system over the last fourteen years. Triangulating these findings, the authors will reflect on the merits and challenges of measuring resilience and what the focus should be moving forward. Key strategies and approaches will be outlined to best prepare a system for a shock and to leave a positive legacy for the future.
The paper focuses on crisis responses and resilience within hospitals. The study is based on structured expert interviews with medical directors in selected hospital departments in two of the five regions of Denmark and primary care physicians in the same regions. We investigate stage 3 (Shock impact and management) and stage 4 (Recovery and learning) within hospital organizations using Denmark as case country, and we pay particular attention to issues of ''organisational learning'', ''purchasing flexibility and reallocation of funding'', ''distribution of human and physical resources'' and ''motivated and well-supported workforce''. Particular attention is paid to care for patients with chronic care needs and lessons for the longterm resilience building in the health system. The study highlights strategic choices and lessons for the long-term resilience within hospitals. It demonstrates, how the initial strategy of organizing specific COVID-19 response units was abandoned relatively early, as it appeared more efficient to integrate COVID-19 patients in the regular specialized department structure. Emergency wards experienced increasing pressure during the pandemic as primary care clinics were referring (too) many patients suspected of COVID-19. This raises questions about capacity and relations between primary and specialized care in crisis situations. Management of human resources is crucial. While the initial phases of the pandemic response were characterized by flexibility and ''team-spirit'', there has been a negative long-term impact particularly among the nursing staff, where burnouts and attrition are major issues. Pandemic crises place significant strain on health systems and personnel. This raises issues about communication of strategies and principles for organizing efforts. The Danish health system managed the crisis adequately, but there are also lessons that should be learned regarding long-term implications and preparedness for future crises. The pressure of COVID-19 on health system functioning has made policies to strengthen health system resilience a major theme of research. Accordingly, crises like COVID-19 can be seen as windows of opportunity for health system reforms to enhance health system resilience. In Finland, COVID-19 arrived on the eve of a major health system reform. In 2023 running health and social services will be transferred from 309 municipalities to 22 counties. While the reform was framed before the pandemic, we explore how lessons from COVID-19 matter for the future reform. Our results come from interviews of 53 top managers and civil servants in the year one of COVID-19, representing municipalities, municipal healthcare authorities and state agencies. The results offer a lookout to how national and local healthcare leaders view pandemic responses in connection to the future reform. Finland fared well in the pandemic compared to many countries e.g. in terms of excess deaths. However, our results reveal a tension between major issues in managing COVID-19 and implementing the reform. While the data suggest that dealing with a prolonged crisis proved challenging due to lack of trust, communication, and transparency between national and subnational actors in the health system, the dominant lessons learned and needs for reform among the interviewees build upon obvious fixes, such as ensuring supply of PPEs and ICU beds for the next pandemic. While being important in preparedness, these can build a legacy not tackling the root causes of lacking resilience and can be inconsistent with reform goals. The pandemic provides an opportunity to analyse the reformed system from a new viewpoint and may reveal weaknesses not considered in reform planning. Reforms can impact health system resilience in positive and negative ways. While different shocks may open new avenues for system transformation, they can also create path dependencies weakening the systems' ability to prepare for unknown threats.
The COVID-19 pandemic has stretched national health care systems to its limits, underscoring the importance of advance planning for health emergencies and the role of health data and evidence for informed policy interventions and actionable strategies. The experience with the pandemic has demonstrated the constraints of existing health information systems and the negative impacts that the lack of actionable and timely data can have on the implementation of rapid response measures during emergencies. This workshop aims to assist participants to become better prepared to deal with future health threats, such as pandemics, by exploring the role of trust in pandemic preparedness and response, effective communication strategies during a pandemic, and the use of qualitative research for evaluation of pandemic response. The specific objectives are to share and discuss: (a) results and conclusions derived from an online qualitative survey of experiences and lessons learned by member states across the WHO European Region; b) results and conclusions derived from an IHME study exploring the factors that contribute to / predict pandemic preparedness, and (c) lessons learned in the process of developing and disseminating scientifically valid, timely evidence across the globe, to assist policymaking during a pandemic. Together, these topics present and explore what countries and populations can do to effectively mitigate the negative effects of a pandemic or other health emergencies. These strategies and lessons learned include building trust, communicating clearly and succinctly, and using qualitative methods and data to evaluate pandemic response. Collectively, these are all geared at improving the capacity to address such threats and unexpected emergencies in the future. The panelists will also reflect on successful tools and strategies developed to aid policymakers and country governments in their response to the COVID-19 emergency. The workshop will be in the form of a 60-minute round table discussion with three panelists. Each panelist will make a brief presentation on their specific area of research, followed by a discussion between the panel members and audience.

Key messages:
Trust, transparent communication, and reliable and timely data are critical aspects of both pandemic preparedness and response. The importance of qualitative evaluation for exploring what worked during the pandemic and what innovations should become part of an enhanced health information system in the future is essential.

Speakers/Panellists: Maja Pasovic
Institute for Health Metrics and Evaluation, Seattle, USA

Elizabeth Serieux
Institute of Health Metrics and Evaluation, Seattle, USA