Introduction
For the first time in many years, a health crisis such as the coronavirus disease 2019 (COVID-19) pandemic has become a global crisis. Governance at all levels has faced an unprecedented need to interconnect the various complex aspects of society and health systems to manage reactions.Reference Nitzan, Perehinets, Meyer and Smallwood1 Health responses to these complex challenges are usually not met with a unified crisis approach. Studying and managing responses to different types of disasters and crises, with a strong focus on health as requested by the Sendai Framework for Disaster Risk Reduction, will be of paramount importance during the next years.2 Applying the principles of disaster medicine to the current pandemic means ensuring a systematic approach that helps to improve the response, focusing efforts on disaster mitigation and preparedness.
Throughout the pandemic, scientific advice and expertise have been essential to guide policy decisions. Countries and European institutions have relied on existing authorities such as the European Centre for Disease Prevention and Control (ECDC; Stockholm, Sweden) and the European Medicines Agency (EMA; Amsterdam, The Netherlands) to collect and translate emerging evidence into action. In addition, temporary ad hoc COVID-19 advisory groups, task forces, and panels of experts to inform decision making have been established.Reference Heymann and Legido-Quigley3 Collective action should progress incrementally, with the necessary input from all levels (ie, international organizations, individual Member States [MS], and local health institutions).Reference Sagan, Greer and Webb4 These issues were discussed in depth in a workshop in the European Parliament (EP) in Brussels, Belgium.5 The event was requested by the Panel for the Future of Science and Technology (STOA), which supports members of the EP in evidence-based policymaking by providing independent research on a wide range of scientific and technological topics.6 The event was organized in collaboration with the Medical Preparedness and Crisis Management Unit (MPCMU) - a recently created EP unit as part of its response to the COVID-19 crisis. The MPCMU works on medical crisis management response and crisis preparedness.
Report
The workshop presented experiences in managing the pandemic at three different levels: international level, national level, and local level.
International Level
At international level, the workshop discussed the pandemic at the European Union (EU) level. During the last two years, the EU put in place various instruments to strengthen and improve health systems at MS level. The situation was challenging, because all MS were affected at the same time, all needing equipment, medicines, and support. Action from the EU spanned across many fields such as economics, social, regional, and research and innovation, all with implications for health and health system organization.Reference Mauer, Panteli, Fahy and De La Mata7
The Recovery Assistance for Cohesion and the Territories of Europe (ReactEU) instrument has received an increased budget, becoming one of the largest programs under Next Generation EU. By financing health entities directly, it will allow MS greater flexibility in responding to the on-going health crisis.8 Horizon 2020, the former EU research program, had pledged over one billion euro for projects responding to COVID-19. The current EU framework program for research, Horizon Europe, will continue to fund basic and public health research.9 The Pharmaceutical Strategy for Europe aims to modernize the regulatory framework and to support pharmaceutical research and technology.10 The new health program, EU4Health, seeks to improve public health and bring innovation to EU health systems.11 The European Health Union concept touches upon competences at different levels. For example, a new Regulation on Cross-Border Health Threats is nearly approved, which provides a more comprehensive framework for EU action on preparedness, early warning, and response. The mandates of ECDC and EMA have also been expanded. Furthermore, a new Health Emergency Preparedness and Response Authority (HERA) has been established, aimed at improving the EU response to cross-border health threats.12
National Level
At national level, the workshop discussed in more detail how two EU MS, Romania and Belgium, managed the pandemic and health crises in general. In Romania, under the authority of the Department of Emergency Situations, a national coordination center was set up in March 2020. The same department was responsible for overall coordination of the operational and logistical aspects of the health sector, whilst the Ministry of Defense took the responsibility for vaccination. Both worked in cooperation with the Ministry of Health and the National Institute of Public Health.
Many decisions were needed to create the legal framework that allowed further financial decisions, acquisitions, mitigation measures, and hiring and dispatching of health personnel to ensure the needed workforce, flexible services, and stable supply chains. The Romanian government promoted multi-sectoral, whole-of-government decision making, which included many actors and stakeholders, especially from civil society, military, and health services. The strategic decisional level was managed by the National Committee of Emergency Situations, headed by the Prime Minister, with all ministers and institutions involved being members of the committee at the highest level.
In Belgium, as in many MS, governance with effective leadership has been a challenge throughout the past two years. The challenges were even enlarged by the complicated state structure, with one federal ministry of health, three regional ministries of health (Flanders, Wallonia, and Brussels), and three official languages (plus English). Even so, the establishment of a COVID-19-Commissariat in October 2020 to build bridges between health managers, policy makers, and scientists brought about substantial improvements in decision making, coordination, and implementation.13,14 A lesson learnt is that this model of collaboration should be maintained not only during the acute phase of a crisis, but at all times.
Hospital and Occupational Health Responses
In addition to general public health measures at international and national level, hospital and occupational health responses have been needed during the pandemic. The workshop discussed the experience of the Colmar hospital in France and the institutional response of the EP medical service. During the crisis, the governance of the Colmar hospital was simplified, with a less bureaucratic and more patient-oriented approach. The hospital implemented and facilitated an increased mobility in beds and health workers. The organization was completely revised to meet the needs of the large number of COVID-19 patients, transforming the hospital into a single massive emergency department. The stocks of protective equipment were quickly depleted, and other solutions had to be found, creating partnerships with fire and rescue services, local companies, and local authorities.
Decisions and actions were driven by pragmatics rather than bureaucracy. Because the hospital closely borders other MS, cross-border transfer of critically ill patients was undertaken by the Franco-German local authorities. This was crucial in alleviating pressure on the hospital. The management of health personnel required great care, given the issues of anxiety, fatigue, and stress. Additionally, staff were themselves often infected, or otherwise personally affected when friends or relatives fell sick.
The workshop also debated how the internal EP medical service, primarily an occupational health service, faced the crisis. In normal times, the EP medical service focusses on occupational health, preventive medicine, emergency medicine, travel advice, psychosocial support, and medico-administrative aspects. As response to the pandemic, the EP medical service switched “overnight” to COVID-19 crisis mode. New activities were implemented, including COVID-19 case management and contact tracing, e-medicine, increased mental health support, and management of essential employees and teams for business continuity, with direct reporting and medical advice to top management on COVID-19 risk assessment, internal surveillance, and risk mitigation. At the institutional level, the EP Secretary General headed the Crisis Management Team, bringing all directors general and the head of the legal service around one (virtual) table. An internal medical advisor was involved in direct line. The approach aimed at keeping members and staff safe and safeguarding business continuity of the EP in order for it to be able to fulfill all its legal obligations,Reference Valenza, Dea Hrelja and Celotti15 whilst also showing solidarity with the host cities.16 Governance was characterized by strong leadership at the highest political and administrative level and it adopted the principles of medical disaster management, with a clear command and control structure, coordination of all key disciplines including safety, medical, security, logistics, and communication,17 and close involvement of key stakeholders. The health workforce was rearranged and increased, and a large internal network of Mental Health First Aid (MHFA) volunteers was involved across the organization.Reference Bovopoulos, LaMontagne, Martin and Jorm18 An internal PCR test center was put in place. A COVID-19 vaccination center was organized in close collaboration with the Brussels public health authorities and operated by EP doctors and nurses, interim reinforcements, and volunteers for administrative and logistical functions. Involving a large number of volunteers contributed to a strong sense of solidarity.
Discussion
The crisis exposed many structural weaknesses and vulnerabilities at international, national, and local level, including chronic under-investment, workforce shortages, and vulnerabilities of information systems.Reference Quaglio19 The workshop discussed a number of key strategies for enhancing health system resilience, namely: (1) governance; (2) financial stability within health systems; (3) health workforce stability, and; (4) flexibility in delivering health care services.Reference Thomas, Sagan, Larkin, Cylus, Figueras and Karanikolos20
Governance
Some speakers reported a general feeling of lack of urgency among policy makers. Responses were often too slow, with a lack of worst-case scenario thinking, and a fear of taking bold and drastic decisions. During a health crisis, robust global, regional, national, and local governance is necessary. At international and national levels, health governance needs to move out of a paradigm narrowly confined to health care, into a wider economic, social, and political framework which better reflects health as a public priority and focuses on health as an investment, rather than a cost. The need to move from a cost-efficiency concept in the health sector to a resiliency concept was considered indispensable by many speakers. Essential health services must be financed based on preparedness and resilience concepts rather than looking at paying for services provided. Governance can no longer be solely administrative - it must be more medically and clinically oriented. During the crisis, the governance of hospitals has been simplified and this method must be kept in the future, with an approach more patient-oriented and less bureaucratic. It has been also recommended that workplaces should include medical experts in their top-level crisis management teams when dealing with a health crisis to make sure that medical disaster management principles are implemented by design.
Financial Stability within Health Systems
Financial stability within health systems is largely dependent on the specific health care financing mechanisms. The share of health expenditure has declined in many EU MS in recent years,Reference Masters, Anwar, Collins, Cookson and Capewell21,Reference Rechel22 with consequences evident during the pandemic. Both in and out of health crises, it is necessary to ensure that financing within health systems is appropriate, and that service delivery operates as intended. This pandemic has affected all social and economic sectors. In May 2020, 350 organizations representing 40 million health workers from 90 countries urged policy makers to put public health at the center of their economic recovery packages. Together, the letter’s signatories represent more than one-half of the world’s health and medical workforce.23
Ensuring a Stable Health Workforce
During the pandemic, several EU countries reported difficulties in retaining and recruiting health staff.Reference Hung, Mashino and Chan24 The demand for health care professionals in Europe is continually increasing, one reason being the growing number of patients with chronic conditions.Reference Barriball, Bremner and Buchan25 Health care workforce needs to be protected, both physically (eg, vaccination and availability of good quality personal protective material) and mentally (eg, ensuring sufficient rest and explicitly communicating societal and political appreciation.) Proper remuneration and working conditions are essential. Limiting the impact of new pandemic waves through measures in society (eg, non-pharmaceutical interventions and vaccination) is equally important. Also necessary is constant investment in attracting and training new generations of health care workers. In order to keep the strain on the health care system bearable, studies on a revision of the indications for ICU-care as well as on the diversification in levels of critical care needs to be done in “peace time.” A special mention was made for the specialist in public health. Public health professionals are at the frontline when it comes to the implementation of protective behaviors and surveillance tools.Reference Czabanowska and Kuhlmann26 Public health managers are actively engaged in adapting the health workforce to the new demands in a health crisis.Reference Azzopardi-Muscat27,Reference van Schalkwyk, Bourek and Kringos28 Public health work should be adapted centrally, regionally, and locally, and the organizations involved should differ from country to country, depending on the context and circumstances. Public health needs to be an attractive career option: in many MS, training for public health personnel should be revised with better support from national public health institutes and universities.Reference Mainor, Decosimo and Escoffrey29
Flexibility in Delivering Health Care Services
In delivering health care services during health crises, surge-strategies need to be developed for all lines of the health care system, including temporary task shifting. In the hospital setting, a more wide-spread “crisis management culture” should be developed and become part of everyone’s business. A more pragmatic organization of health systems is needed, allowing the organization to develop by adapting, becoming more reactive and efficient in response to health crises and unpredictable situations. One aspect that needs further analysis is that during disasters, standards of care should be adapted to patient management: this should be well-understood and incorporated by all health workers.
Elements to be Implemented to Better Deal with New Health Crises
The debate raised a number of elements to be implemented to better deal with new health crises.
Preparedness—In the COVID-19 pandemic, a lack of preparedness was evident in hospitals, and more so in nursing homes and primary care.Reference Quaglio30 The weakness of the primary care system has been a crucial issue throughout the pandemic. Regularly updated and upgraded contingency plans, drawn up by multi-disciplinary teams, are needed. They should include better legal tools to facilitate not only response, but all phases of the disaster management cycle, increasing the flexibility and adaptability of all key strategies, and extending stockpiling capabilities. A large-scale emergency cannot be faced with ordinary tools and a legal framework that is either lacking or leads to blockades when swift response is crucial. Collaboration between health managers and scientists was a gradual process, taking time for people to learn each other’s ways of working, and how to work as complementary as possible. Collaborations between health scientists and decision makers have now been established at different levels, and these must be maintained and further developed.
Surveillance—In many EU MS, the essential contact tracing operations were done with inadequate and inefficient systems. Surveillance and data gathering strategies should be in place at all times, not only during emergencies. All MS should agree on common criteria for case identification and continuously collect and share reliable and timely data. Contact tracing and quarantining of close contacts should be facilitated via an IT tool or linked to alert apps, taking into account all legal, privacy, and data protection regulations. Occupational health services should also have compliant IT tools and procedures in place to enable in-house contact tracing.
Health Personnel—Strategies need to be in place to ensure that a multi-sectoral workforce is available throughout the health system, flexible enough to adapt to new and emerging needs. On-going investment in the maintaining an adequate health workforce is necessary. In addition, during health crises, it is clear that it is crucial to have an adequate centralized management of human resources to guarantee coordination and integration of health care workers.
Training and Education—The pandemic has shown that health crisis managers with competencies for performing disaster and global health crisis-related management, research, and development are needed. Health must be included in the disaster risk management processes at all levels for all disasters. A unified disaster/crisis approach should take into consideration the health consequences and impacts on health systems and the health workforce. More investment is needed in the global dimension of health to understand that human health is also connected to animal health, environment, and climate.
International Guidelines—The initial lack of consistent and clear international guidelines and risk assessments was a problem. The unclear and sometimes contradictory information regarding issues such the efficacy of mask wearing and the ways in which the virus spread created confusion among health workers and the public in general. For future crises, an early consensus between ECDC and World Health Organization-Europe (WHO-Europe; Copenhagen, Denmark) guidelines is needed. The COVID-19 crisis affected the very elderly and entailed the ethical debate on end-of-life care. This matter must be discussed extensively and respectfully with the health care sector, the age group, and in society as a whole.
Disinformation and Misinformation—The public needs clearly presented guidelines and information, preferably with infographics. Disinformation and misinformation negatively influence public opinion. It lowers public trust in medical science. In causing delays in vaccine uptake, disinformation and misinformation has led to avoidable deaths. It has also undermined confidence in measures intended to keep people and business safe in the midst of viral surges, such as social distancing and mask wearing. To prevent disinformation and misinformation from gaining ground, investment in communication with the general public is needed, along with further studies on the origin of these problems and how to best respond to them.
Limitations
This article has a number of limitations common to this type of report: although the event discussed the pandemic internationally and locally, several aspects of the crisis were not discussed. The meeting essentially focused on the management of the COVID-19 pandemic at a European level, so the conclusions cannot be automatically applicable everywhere.
Conclusion
In health, responses to crises have formerly been mostly reactive. A switch to proactive behavior is needed. It is difficult to convince health authorities to invest in crisis preparedness when there is no immediate, obvious threat. Even though it is widely held that prevention is better than cure, far more tends to be spent on cure than prevention. Now is the time to change this. Perhaps the most important lesson to be learned is that crisis management is a joint effort. Synergies must be created so that responses can be coordinated effectively. Joint frameworks of cooperation need to be developed between all sectors, identifying and mapping the complex technical and operational roles and capabilities involved in health crises.
Conflicts of interest
The authors declare none.
