Building resilience of the Ghanaian healthcare system: Lessons from a global health stage: Preparedness for the next pandemic: A scoping review

Review question

This scooping review sought to address the following research question: What are the critical gaps in Ghana’s health system resilience, as evidenced by its response to the COVID-19 pandemic, and how can global experiences inform strategies to strengthen its preparedness for future emergencies?

The concept of health system resilience

Health system resilience is a vital concept that encompasses the capacity of health actors, institutions, and populations to effectively prepare for, respond to, and recover from crises and shocks, while maintaining essential functions and services (Kruk et al., 2015). This concept has evolved to include strategies for minimizing exposure, managing risks, and addressing potential stressors, such as population aging (Paschoalotto et al., 2023). Recent definitions of health system resilience emphasize proactive elements, encompassing anticipation, absorption, and adaptation to sudden shocks and structural changes, extending beyond acute events to encompass continuity in health improvement and the ability to respond effectively to emerging health needs (Grimm et al., 2022; Karamagi et al. 2022; Sagan et al., 2021). Despite various definitions, resilience in health systems is understood as the collective ability to mitigate, respond, and recover from disruptions, maintain essential services, and learn for improvement.

Analytical framework

The study adopted the OECD Framework to explore how health systems responded to COVID-19 on a global stage and the lessons that can be drawn to guide Ghana’s efforts toward strengthening the resilience of its health system (OECD, 2022). The Framework focuses on three main policy responses corresponding to the different phases of the risk management cycle: pandemic preparedness, crisis management, and response and recovery (see Figure 1).

Figure 1. Framework for evaluating COVID-19 responses.

(Figure 1 has been reproduced with permission from [OECD (2022). First lessons from government evaluations of COVID-19 responses: A synthesis https://www.oecd.org/].

Pandemic preparedness involves anticipating and developing the capacity to respond to potential pandemics. It entails risk-anticipation capacities, critical sector preparedness, and pandemic management protocols. Crisis management refers to the policies and actions implemented during the COVID-19 pandemic. It involves risk-anticipation capacities, critical sector preparedness, and pandemic management protocols. Response and recovery are related to strategies to mitigate pandemic effects, support economic recovery, and protect vulnerable groups. These measures include lockdowns and restrictions to prevent the spread of the virus; financial assistance to households, companies, and markets to lessen the effects of the economic downturn; health initiatives to safeguard and treat the populace; and social initiatives to protect the most vulnerable groups.

Guided by the framework, this paper examined publications, reports, and policy documents related to the health system’s resilient response to COVID-19 in three main thematic areas: preparedness, crisis management, and response and recovery.

Design

A scoping review based on the synthesis of published journal articles and grey literature was used to gather relevant evidence to address the research question. This approach allowed us to explore the extensive literature on the global response to the COVID-19 pandemic. The scoping review process followed the methodological framework proposed by Arksey and O’Malley (2005). In reporting the outcomes of the scoping review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) checklist (Figure S2 attached as Extended Data) (Tricco et al., 2018).

Eligibility criteria

The primary inclusion criteria were papers that were published in English and focused on health system resilience related to COVID-19. Other inclusions were papers that discussed strategies for health emergencies or pandemic preparedness and response. The exclusion criteria included papers not marched with the research design, papers unrelated to healthcare system resilience (e.g., climate, environment, food security), those solely focused on the delivery of health services without considering the broader health system, clinical trials, or protocols as well as disease-specific conditions other than COVID-19. To ensure that the literature was contemporary with the emergence of the COVID-19 pandemic, papers published in English from 2020 onwards were considered.

Information sources

Online searches were conducted from May to June 2023 for relevant journal articles and gray literature related to health system preparedness and response to the COVID-19 pandemic. Journal articles were accessed from Medline, Scopus, Health Sources, and WHO databases. Websites of national and local organizations and Google Advanced Search were used to search for grey literature.

Search strategy

We used the Joana Briggs Institute (JBI) three-step search process to identify records for the review (Peters et al., 2015). The search strategy was developed in consultation with, and refined based on input from a librarian. First, we conducted a preliminary search using Medline and Google Scholar to gather background information and identify previous studies relevant to our topic. The analysis of these materials and their reference lists guided the authors in deciding to include journal articles, policy briefs, commentaries, editorials, and reports in the review process. In the second step, the first two authors searched across all four included databases using the search strategy, which had been refined based on all identified keywords and index terms from the first step. In the third step, the reference list of all the identified papers and reports was searched for additional sources.

The search queries were structured at three levels. Level 1 included terms related to health system resilience, such as “resilient,” “health system resilience,” “coping COVID-19,” “health system adaptation,” and “health system preparedness.” Level 2 terms focused on COVID-19, including “coronavirus,” “COVID,” “SARS-CoV-2,” “COVID-19,” “COVID-19 pandemic,” and “COVID-19 response strategies.” Level 3 terms denoted public health events, such as “health emergency,” “health emergency preparedness,” “health emergency response,” “shock,” and “health security.” During the search, we employed Boolean operators such as AND/OR to combine the search terms. The search strategy included the application of truncation and wild cards to broaden the search.

Screening and selection process

The screening involved reviewing the title and abstract of papers identified for inclusion in the study. The first two authors independently screened the titles and abstracts to identify potential articles for full-text assessment. They then assessed the selected full-text articles to confirm that the studies met the inclusion criteria. Where necessary, the authors sought additional clarity regarding article eligibility from the third author, who served as an impartial arbitrator. We used the PRISMA flow diagram (See Extended data; Ankomah et al., 2024) to show how the study progressed at each stage of the review process.

Data extraction

A Microsoft Excel, version 2403, spreadsheet was used to systematically capture the characteristics from the included studies. These characteristics included the source (author(s) and year of publication) document type (articles and reviews, editorials and commentaries, conference and meeting reports, policy briefs), focus areas, and intervention (response strategies). Retrieved references were managed using Mendeley Reference Manager, version 2.98.0. The elements in our analytical framework guided the process of data extraction. Given the exploratory nature of scoping reviews, we focused on mapping the existing literature. No critical evaluation of the quality of individual articles was done, as this is not part of the standard methodology of scoping reviews. All three authors independently charted the data to enhance reliability.

Data analysis and reporting

We adopted a thematic content analysis approach to analyze the data extracted from the literature review. We structured our data analysis and reporting using the OECD framework’s main policy response areas: pandemic preparedness, crisis management, and response and recovery (see Figure 1). Within this framework, we systematically analyzed each theme and its elements (sub-themes), identifying key areas of focus and synthesizing the strategies implemented. Additionally, we provided illustrative examples from various countries to showcase the diverse approaches adopted globally to address the COVID-19 pandemic. This approach allowed us to organize and present our findings in a structured and cohesive manner.

Global health systems response to COVID-19 pandemic

In the following paragraphs, we delve into the strategies implemented by various countries in addressing the challenges posed by the COVID-19 pandemic. These strategies are analyzed through the lens of the OCED’s comprehensive framework encompassing three main domains: preparedness for emergencies, crisis management, and response and recovery.

Emergency preparedness

Emergency preparedness encompasses three sub-themes: disaster risk anticipation and foresight, emergency protocols, and preparedness of critical sectors (Table 1).

Disaster risk anticipation and foresight

Disaster risk anticipation and foresight involve understanding hazards, developing risk-assessment capacities, and employing response strategies (OECD, 2022). Risk and vulnerability assessments were noted to be crucial for preparedness and response in Ethiopia and Malawi during the COVID-19 pandemic (Lanyero et al., 2021; Mghamba et al., 2023). Robust surveillance systems with early detection mechanisms were effectively implemented in South Korea, Vietnam, Singapore, China, and Australia, leading to the timely implementation of containment measures (Chua et al., 2020; Sundararaman et al., 2021; Wang et al., 2021; Williams, Fahy, et al., 2022). A comprehensive range of surveillance approaches, including case investigation, contact tracing, community-based initiatives, laboratory-based sentinel surveillance, serological studies, telephone hotlines, and genomic sequencing, also improved disease detection and response in Congo, Nigeria, Senegal, and Uganda (Okeke et al., 2022; Fawole et al., 2023).

Digital health tools such as Big Data in Singapore and Taiwan and the Surveillance Outbreaks Response Management and Analysis System (SORMAS) in Nigeria enhanced monitoring. China, Israel, India, South Korea, Singapore, Rwanda, and Tanzania employed GPS tracking, credit card records, surveillance videos, and mobile applications (Chang et al., 2020; Kuguyo et al., 2020; Mghamba et al., 2023; Okeke et al., 2022; Wang et al., 2021). European countries adapted digital health tools, such as France’s “TousAntiCovid” app. New Zealand, Sweden, and the US used syndromic surveillance, while China, Fiji, India, Japan, and Vietnam utilized real-time reporting systems for COVID-19 cases (Haldane et al., 2021; Williams, Fahy, et al., 2022).

Data governance was vital; South Africa used epidemiological data for interventions (Moonasar et al., 2021) and the Eastern Mediterranean region employed collaborative surveillance (Abubakar et al., 2022). Investment in research and development contributed to preparedness, as exemplified by Rwanda, while Indonesia’s health system foundations enabled proactive responses (Aisyah et al., 2022; Binagwaho et al., 2022). These examples emphasize the importance of risk assessment, surveillance, and digital technology in disaster response.

Emergency protocols

Emergency protocols provide a structured framework for coordinated responses during emergencies (OECD, 2022). Countries, including Rwanda, Trinidad and Tobago, Iran, and Sri Lanka, developed national policies and guidelines for COVID-19 prevention, clinical tools, and healthcare provider guidelines to ensure an effective response (Dzinamarira et al., 2020; Gouya et al., 2023; Hunte et al., 2020; Mghamba et al., 2023). Ethiopia also developed comprehensive standards, guides, and protocols to effectively respond to the COVID-19 pandemic. These documents covered various aspects, such as quarantine, infection prevention and control, border control, case management, and home-based care (Lanyero et al., 2021; Zikargae, 2020) and are vital for strenthening health system resilience by ensuring coordinated and effective responses to crisis.

Preparedness of critical sectors

The analysis revealed various strategies to enhance preparedness in critical sectors during the COVID-19 pandemic. These include maintaining strategic reserves of PPEs, ICU devices, consumables, and pharmaceuticals, optimizing supply chains and utilization protocols, and providing adequate healthcare professional training (Arabi et al., 2021; Williams, Fahy, et al., 2022). Public-private partnerships, research and development, and the continued use of digital health tools were also identified as crucial for building resilience and response capabilities during pandemics (Coccia, 2022). Additionally, improving the healthcare infrastructure, especially in the production and delivery of oxygen and therapeutics, was vital for better preparedness and management of future public health emergencies (Gebremeskel et al., 2021; Gouya et al., 2023). These measures are critical in preparing for and effectively managing future public health emergencies.

Management of crisis

Crisis management involves timely and coordinated policies and actions implemented by governments to effectively respond to and address crises (OECD, 2022). This encompasses crisis communication, government arrangements, and a whole-of-society response.

Crisis communication

Transparent communication with the public during the COVID-19 pandemic fostered trust and compliance with containment measures (Thomas et al., 2020). Countries such as Singapore, Trinidad, Tobago, and Vietnam utilized regular media briefings and transparent information sharing through official and social media (Chua et al., 2020; Ha et al., 2020; Hunte et al., 2020). Ecuador provided reliable information and practical hygiene measures (Alava & Guevara, 2021), whereas New York’s local health departments used various channels and trusted messengers to reach underserved communities and boost vaccination rates (Bloomstone et al., 2022).

Community engagement proved crucial for enhancing disease control and promoting health literacy during the pandemic, facilitating collaboration and adaptability in response strategies. The Eastern Mediterranean region emphasized active community engagement and transparent communication to promote public health measures and acceptance of COVID-19 vaccination (Abubakar et al., 2022). Oman used community participation through organizations, health committees, and volunteers, while Cambodia’s Ministry of Health implemented risk communication and engagement campaigns (Al Siyabi et al., 2021; Chhim et al., 2023). African countries like Rwanda, South Africa, Zimbabwe, Nigeria, and Malawi utilized diverse channels, including SMS, WhatsApp, radio, television, and hotlines, to disseminate verified information, debunk rumors, and raise awareness about COVID-19(Akande et al., 2023; Dzinamarira et al., 2020; Mghamba et al., 2023; Moonasar et al., 2021; Okeke et al., 2022; Talisuna et al., 2022). Community-based programs and capacity-building initiatives strengthened responses in Congo and Uganda (Corbin et al., 2021; Thu et al., 2022). CHWs in South Africa and Tanzania play a vital role in bridging communities and health systems, emphasizing community buy-in and addressing the social determinants of health (Gebremeskel et al., 2021). These examples underscore the importance of transparent communication and active community engagement in enhancing public trust, promoting health literacy, and facilitating adaptable and inclusive response efforts during crises.

Governance arrangements

Countries adopted various governance approaches during the pandemic, each with distinct outcomes. Germany’s decentralized approach empowered regional authorities, while Austria and Switzerland relied on centralized decision-making and effectively managed the health crisis. France’s centralized approach facilitated resource coordination but caused delays in testing policies. Canada’s decentralized setting resulted in varying success rates, and Belgium faced challenges due to the shared responsibilities between national and regional governments. Federated countries such as the US, Spain, and Australia witnessed governance variations, with states taking the lead. In Southeast Asia, responses were marked by controversies, power asymmetries, and political instability (Desson, Lambertz, et al., 2020; Desson, Weller, et al., 2020; Djalante et al., 2020; Ha et al., 2020; Kavanagh et al., 2021).

Strong high-level political leadership was crucial in coordinating stakeholders and strengthening health systems (Thomas et al., 2020). Ethiopia, Trinidad, and Tobago demonstrated strong leadership through coordination structures, such as the PHEOC and the COVID Plan (Hunte et al., 2020; Lanyero et al., 2021). Countries utilized multi-ministerial coordination platforms, such as task forces and committees, for a whole-of-nation response. Ethiopia, Singapore, Iran, Guyana, and Sri Lanka implemented such approaches (Chua et al., 2020; Gouya et al., 2023; Mghamba et al., 2023). Coordinated responses, including regional collaborations such as the Africa CDC and the European Union’s joint vaccine procurement, were crucial (Beesley et al., 2023; Lanyero et al., 2021). Effective governance involved transparency, accountability, and informed decision-making. Denmark, Switzerland, Italy, and Ethiopia exemplified these practices (Lanyero et al., 2021; Tille et al., 2022). Collaborative leadership and stakeholder involvement fostered trust (Assefa, Woldeyohannes, et al., 2022; Bigoni et al., 2022; Burke et al., 2021; Tille et al., 2022; Thu et al., 2022). Flexibility in decision-making, and addressing challenges such as misinformation was crucial (Djalante et al., 2020; Forsgren et al., 2022). These examples suggest that strong leadership, transparent governance, and multi-sectoral coordination are essential for strengthening future health system resilience.

Whole-of-society response

Whole-of-society response involved stakeholder engagement and partnerships among government agencies, communities, NGOs, and CSOs to collectively implement preventive measures, mobilize and manage resources to minimize the pandemic impact (Aisyah et al., 2022). Several strategies emerged from the analysis of this area. Rwanda, South Africa, Zimbabwe, and Nigeria successfully engaged stakeholders from various sectors in their COVID-19 response (Dzinamarira et al., 2021; Okeke et al., 2022). In Ethiopia, private partnerships expanded emergency response capacity through collaboration with university institutions, private hospitals, and laboratories (Lanyero et al., 2021). Strategic partnerships with international agencies and organizations enhanced COVID-19 response and management, such as the collaboration between the Pasteur Institute of Dakar and a UK-based biotech laboratory, leading to a rapid diagnostic test in Ethiopia (Dzinamarira et al., 2020). Community engagement through partnerships with local leaders and CHWs played a pivotal role in supporting non-pharmaceutical interventions, maintaining essential health services, and providing medication in countries such as Thailand, Singapore, Liberia, and the US (Haldane et al., 2021; Bloomstone et al., 2022).

Response and recovery

The response and recovery policies aimed at mitigating the impacts of the pandemic and economic crisis on citizens and businesses, supporting economic recovery, and reducing welfare losses (OECD, 2022). These policies encompassed lockdown and restriction measures, economic and financial support, social policies, and health measures.

Lockdown and restrictions

Many countries implemented various travel restrictions and bans. Germany, Australia, and Singapore enforced strict measures such as cruise line bans, quarantine requirements, and limited overseas travel (Kavanagh et al., 2021). Bulgaria, Croatia, and Romania initially imposed border closures, flight suspensions, and educational institution closures, which led to societal and economic consequences (Džakula et al., 2022). Estonia, Latvia, and Lithuania implemented early and effective lockdown measures, clear communication, and strengthened testing and contact tracing efforts (Webb, Winkelmann et al., 2022). Asian countries such as China, Singapore, Taiwan, Hong Kong, and South Korea successfully flattened their curves through lockdowns, testing, and rapid responses (Khanna et al., 2020; Tabish, 2020). Some European and American countries faced challenges owing to delayed containment measures, leading to devastating surges and lockdowns (Desson, Weller, et al., 2020; Khanna et al., 2020).

In Africa, most countries responded swiftly to strict lockdowns, providing PPE, testing, and isolating infected individuals (Talisuna et al., 2022; Dzinamarira et al., 2020, 2021; Emahi et al., 2021). Rwanda and Uganda demonstrated exemplary responses by prioritizing social distancing and travel restrictions even before registering their first cases (Binagwaho et al., 2020).

Countries also implemented strategies to scale up contact tracing during the COVID-19 pandemic, redirecting health workers, digitalizing tracing operations, and contracting with outsourcing corporations. Germany allocated €50 million to digitalization and hiring tracers, while Austria’s local health offices led contact tracing. Inadequate support for isolating individuals, especially those with low incomes or precarious jobs, led to continued normal activities (Tille et al., 2022).

Port of entries (PoEs)

Countries implemented various strategic responses to enhance preparedness at PoE in managing the COVID-19 pandemic, including enhanced health screening, information gathering, and contact tracing for arriving passengers. African countries adhered to WHO International Health Regulations (IHR) with measures such as mandatory negative COVID-19 PCR tests for travellers. Rwanda implemented repeat testing and 24-hour quarantine, whereas South Africa and Zimbabwe conducted pre-arrival testing. Stricter measures addressed the challenges of fake certificates (Dzinamarira et al., 2020, 2021). Ethiopian Airlines played a crucial role in training staff and transporting medical supplies (Lanyero et al., 2021). Taiwan and Hong Kong employed passenger screening, flight suspensions, and mandatory quarantine for travellers from Wuhan (Tabish, 2020). Singapore, Israel, and South Korea used mobile apps for contact tracing and enforced various travel restrictions (Chua et al., 2020; Kuguyo et al., 2020; Wang et al., 2020; Wang et al., 2021). Ecuador closed its borders to exposed countries and established testing and tracing capacities (Alava & Guevara, 2021). International collaboration addressed cross-border economic challenges (Binagwaho et al., 2022). These strategic responses highlight the importance of comprehensive screening, testing, and international collaboration at points of entry in strengthening health system resilience against future pandemics.

Economic and financial support

COVID-19 required sustained funding for outbreak response, and countries employed various strategies. Health financing policies were crucial in resource-constrained settings, with competing priorities (Bhatia & Abraham, 2022). Public funds were used for testing, treatment, vaccines, and supporting businesses and low-income households (Haldane et al., 2021). Countries tapped into reserves, reallocated budgets, and borrowed funds to manage increased health expenditure and economic impact (Sagan et al., 2022). In Europe, Germany, Austria, Switzerland, France, and Belgium introduced substantial support packages, with Germany allocating €156 billion to the MOH (Desson, Lambertz, et al., 2020; Desson, Weller, et al., 2020). Spain and Ireland utilized private-sector capacity (Thomas et al., 2020).

Canada implemented wage subsidies and financial aid (Alami et al., 2021; Desson, Weller, et al., 2020). In Asia, Singapore committed 60 billion SGD to support businesses and livelihoods, and Thailand implemented stimulus packages totalling 217 billion baht (Chua et al., 2020; Djalante et al., 2020). In Africa, Morocco, Algeria, Egypt, Libya, Mauritania, and Sudan implemented various measures, including a USD 3.3 billion COVID-19 Fund in Morocco and an IMF Rapid Credit Facility disbursement of $130 million in Mauritania (United Nations Economic Commission for Africa, 2020; Fakher & Abiari, 2020). Nigeria mobilized funds from the 2020 budget and special intervention funds, while South Africa allocated $10.6 million for aid and relief (Adebisi et al., 2021; Okeke et al., 2022; United Nations, 2021). Addressing corruption within governments was crucial, with Rwanda’s anti-corruption model serving as an exemplar (Dzinamarira et al., 2021). Flexibility in payment systems and incentivizing telemedicine were also observed (Sagan et al., 2022; Thomas et al., 2020). These strategies emphasize that sustained and flexible financing, alongside anti-corruption measures, is essential for strengthening health system resilience against future emergencies.

Social policies

The analysis identified several social protection measures implemented by various countries to address social disparities and mitigate the impact of the COVID-19 pandemic. African countries introduced several social protection measures, primarily focusing on non-contributory programs such as special allowances, food, nutrition protection, and health support. However, aspects such as access to education, sickness benefits, and family benefits received less attention. Women’s needs were also overlooked, with only 16% of interventions specifically targeting them (United Nations, 2021). Access to essential services such as water and sanitation posed challenges, hindering viral control, especially in vulnerable communities in South Africa and Zimbabwe (Banda Chitsamatanga & Malinga, 2021). European countries provided extensive job and enterprise protection, coupled with solidaristic policies to care for the most vulnerable, including strengthened minimum income schemes, but access remained challenging for non-standard workers. (Baptista et al., 2021). Arab countries used digital delivery methods for social protection targeting informal workers, foreign workers, persons with disabilities, and refugees (United Nations Development Programme, 2021). Canada and the US addressed housing, employment, and social assistance challenges with various measures (Béland et al., 2021). Several countries enhanced their health services to make them accessible to all, including non-nationals in Trinidad and Tobago, Estonia, Latvia, and Lithuania (Hunte et al., 2020; Webb, Winkelmann, et al., 2022). Singapore’s private insurers extended coverage for COVID-19 hospitalization, but noncompliance with travel advisories resulted in ineligible subsidies at public hospitals (Chua et al., 2020).

Health measures

Health measures encompass human resource strategies, maintenance of essential services, case management, facility-based infection prevention and control (IPC), logistics and operational support, laboratory diagnosis and management, and vaccine management.

Human resource

The COVID-19 pandemic exacerbated health workforce shortages in many countries, leading to the adoption of various HR response strategies to address the surge in demand, protect healthcare workers, and scale-up capacity (Assefa, Gilks, et al., 2022; Džakula et al., 2022; Fleming et al., 2022; Haldane et al., 2021; Hunte et al., 2020; Williams, Maier, et al., 2022; Williams, Scarpetti, et al., 2022).

Several countries, including Germany, Russia, Spain, the UK, Vietnam, the Netherlands, Austria, Portugal, and Trinidad and Tobago, increased recruitment quotas and enlisted medical and nursing students using emergency legislation (Assefa et al., 2022a; Burau et al., 2022; Džakula et al., 2022; Haldane et al., 2021; Hunte et al., 2020; Williams, Maier, et al., 2022, Williams, Scarpetti, et al., 2022). International collaborations facilitated the deployment of health professionals in regions with high COVID-19 cases (Williams, Maier, et al., 2022). Countries have simplified registration and hiring processes to include foreign-trained health professionals in their workforce. England extended visas for frontline workers from abroad, and France mobilized a “medical care reserve” consisting of various health professionals (Winkelmann, Panteli, et al., 2022). Iran utilized military staff, volunteers, and post-graduate students to support frontline healthcare providers (Gouya et al., 2023). Canadian Armed Forces and Canadian Red Cross reinforced CHSLDs (Alami et al., 2021).

Scaling up capacity involved extending work hours, modifying schedules, and redeploying primary care workers in emergency care wards and ICUs in countries like Croatia, Estonia, Lithuania, Malta, the Netherlands, Portugal, Romania, Italy, and Spain (Haldane et al., 2021; Tille et al., 2022; Williams, Maier, et al., 2022). Skill mix changes allowed various professionals to administer vaccinations, and non-health personnel were engaged to support the non-clinical aspects of testing and vaccination programs (Buchan et al., 2021; Williams, Maier, et al., 2022). Canada authorized private sector physicians to practice in the public sector alongside their private practice and engaged private clinics and physicians to address procedure delays caused by COVID-19 (Alami et al., 2021). Protecting health workers involved implementing hygiene protocols, providing sufficient PPEs, and offering remote consultation. Vaccination, infection control policies, and regular testing were also prioritized to safeguard healthcare workers (Chua et al., 2020; Džakula et al., 2022; Haldane et al., 2021; Hunte et al., 2020; Tille et al., 2022; Williams, Scarpetti, et al., 2022).

Maintaining essential health service delivery

Countries adopted diverse approaches to sustain essential healthcare amid COVID-19. For instance, Slovenia made a task shift from GPs to nurses to reduce the GP workload in primary care (Thomas et al., 2020). Sri Lanka ensured routine care for non-communicable diseases while managing COVID-19 through a whole-of-society approach (Mghamba et al., 2023). In some countries, the private sector was utilized to maintain essential health services. To mitigate disruptions in service delivery, triaging and alternative care models such as home-based care and telemedicine were adopted. Care pathways were adjusted within hospital facilities to segregate COVID-19 patients and ensure safe treatment. Telehealth and digital consultations were widely adopted to maintain essential care and minimize exposure risks (Assaye & Shimie, 2022; Assefa, Gilks, et al., 2022; Webb, Lenormand, et al., 2022; Williams, Fahy, et al., 2022). The pandemic emphasized the need to strengthen long-term resilience and capacity in the health sector, particularly in primary care and public health (Alami et al., 2021).

Case management

Prompt deployment of experts and guidelines to guide the clinical management of COVID-19 cases was observed in most countries (Talisuna et al., 2022; Okeke et al., 2022). Vietnam established a center for managing clinical support for COVID-19 patients, while Trinidad and Tobago increased their healthcare capacity by screening and isolating suspected cases (Ha et al., 2020; Hunte et al., 2020). Some countries adopted home-based and community case management models to reduce pressure on the health system, but challenges arose due to the lack of specialized hospitals and technical expertise for severe cases. Shortages of critical supplies strained case management, prompting countries like South Sudan and Ethiopia to establish specialized treatment facilities (Talisuna et al., 2022; Olu et al., 2022; Lanyero et al., 2021). Countries managed acute care and ICU capacity by postponing elective treatments, designating specific hospitals, and utilizing private ICUs and field hospitals, while hospital networks and cross-border cooperation were crucial for effective management (Khanna et al., 2020; Winkelmann, Panteli et al., 2022; Winkelmann, Webb, et al., 2022).

Facility-based IPC

Facility-based IPC measures were critical in managing the spread of COVID-19. The analysis identified several strategies implemented by various countries in this area. In Singapore, strict IPC measures were enforced, including temperature checks, mandatory PPE usage, and visitor controls. Innovative solutions like the ‘SG SAFE’ booth were implemented for large-scale screening (Chua et al., 2020). African countries focused on capacity building, guidelines, and environmental controls to reduce the spread of COVID-19 (Balde et al., 2022; Dzinamarira et al., 2021; Olu et al., 2022). Some countries faced challenges with poor adherence and enforcement of IPC measures, leading to shortages of PPEs and irrational use. Additionally, inadequate water supply in health facilities compromised IPC measures, and the indiscriminate disposal of surgical masks was observed (Abu & Elliott, 2022; Dzinamarira et al., 2021; Talisuna et al., 2022).

Operational support and logistics

Globally, countries employed diverse strategies to boost healthcare capacity during the COVID-19 pandemic. Some nations (Ireland, England, Italy, North Macedonia, Spain, and Russia) block-booked private hospitals, while others (Switzerland and Italy) enacted emergency legislation to acquire private facilities. Some countries also established field hospitals. Innovative procurement and international collaborations addressed equipment shortages (Khanna et al., 2020; Winkelmann, Webb et al., 2022). Japan, the UK, the US, South Korea, and Ecuador employed various approaches, including resource distribution and domestic production encouragement. Europe utilized digital tools for telemedicine, streamlined administrative procedures, and real-time monitoring through digital registries and dashboards (Džakula et al., 2022; Winkelmann, Webb, et al., 2022; Winkelmann, Panteli et al., 2022).

Several EU countries planned investments in digital infrastructure, (Bhaskar et al., 2021; Van Ginneken et al., 2022; Webb, Winkelmann, et al., 2022; Williams, Fahy, et al., 2022) and in the Asia-Pacific region, Taiwan regulated mask distribution and encouraged domestic production. Singapore’s National Center for Infectious Diseases coordinated outbreak management (Chang et al., 2020; Chua et al., 2020). African nations effectively utilized digital solutions; Uganda leveraged eELMIS to track and distribute COVID-19 supplies; and Rwanda used a national command post for surveillance and contact tracing. Ethiopia and South Sudan utilized global platforms for procurement, and Nigeria improved its healthcare infrastructure (Lanyero et al., 2021; Mghamba et al., 2023; Moonasar et al., 2021; Okeke et al., 2022; Wasswa et al., 2023). Trinidad and Tobago collaborated with regional partners for procurement and relied on local manufacturers for supplies (Hunte et al., 2020).

Laboratory diagnosis and management

The COVID-19 pandemic highlighted the critical importance of rapid and accurate laboratory diagnostic testing in various countries. The analysis identified various strategies implemented by countries in this area. Indonesia established 685 referral laboratories for COVID-19 testing, despite facing challenges with staff, reagent supply, and PPE shortages. South Korea’s large-scale testing program tested over 270,000 people (Aisyah et al., 2022; Tabish, 2020). In Europe, Germany used robust laboratory infrastructure to expand its testing. Denmark adapted its testing strategy over time, including milder symptoms and asymptomatic individuals. Smaller European nations utilized repurposed labs and sent samples abroad. Estonia, Latvia, and Lithuania established separate testing locations and flexible mobile sites (Tille et al., 2022; Webb, Winkelmann, et al., 2022). In the WHO African region, early testing faced challenges due to reagent shortages. However, progress was made with rapid antigen tests and the COVID-19 sequencing laboratory network. Community-based surveillance using Ag-RDT reached over 7 million people. African countries such as Nigeria, Rwanda, South Africa, and Ethiopia expanded testing centers through collaborations with the private sector, repurposing research facilities, and establishing networks of existing labs (Balde et al., 2022; Dzinamarira et al., 2021; Lanyero et al., 2021; Okeke et al., 2022; Talisuna et al., 2022; Tessema et al., 2021).

Vaccine management

Several countries, including Singapore and China, implemented effective COVID-19 vaccination plans through policy measures and transparent communication to build public trust (Zhang et al., 2022). Iran utilized its primary healthcare supply chain and mass vaccination centers, achieving a primary vaccination coverage rate of approximately 75% by January 2022. They developed local production capacity for domestic COVID-19 vaccines with WHO support (Gouya et al., 2023). Ecuador, the Central African Republic, and New York, USA, efficiently distributed vaccines through task shifting, community engagement, and partnerships with stakeholders. Digital health tools played a vital role in successful vaccine rollout (Alava & Guevara, 2021; Amani et al., 2023; Bloomstone et al., 2022; Williams, Fahy, et al., 2022). South Sudan utilized existing immunization systems for COVID-19 vaccination, straining health workers (Olu et al., 2022).

Whole-of-government engagement

The findings of this study suggest that decisive and committed political leadership, demonstrated in various countries (Hunte et al., 2020; Lanyero et al., 2021; Thomas et al., 2020; Haldane et al., 2021), is crucial for effective responses to health crises. This corresponds to the system awareness attribute, which underscores the importance of tracking health and mapping resources for effective response. Additionally, engaging multiple sectors beyond the health sector through whole-of-government efforts (Chua et al., 2020; Gouya et al., 2023; Mghamba et al., 2023) demonstrates integration, highlighting the need for coordinated efforts and societal engagement. Embracing pluralistic and adaptive leadership supported by an expanded governance framework (Alami et al., 2021; Assefa, Woldeyohannes, et al., 2022; Lanyero et al., 2021; Tille et al., 2022; Thu et al., 2022) also aligns with the adaptability attribute. It demonstrates the importance of flexible responses and evidence-based decision-making in different situations. Ghana can draw from these strategies to build a resilient health system, address the social determinants of health, and prepare for future health emergencies.

Financing for preparedness

The sustained funding strategies adopted by countries during the COVID-19 response highlight the critical role of health financing policies, especially in resource-constrained settings with competing priorities (Bhatia & Abraham, 2022). These efforts align with the self-regulation and adaptability attributes of health system resilience. Self-regulation was evident in the reallocation of budgets, tapping into reserves, and borrowing funds to manage increased health expenditure and economic impact. Adaptability was demonstrated by countries like Germany, Austria, Switzerland, France, and Belgium (Desson, Lambertz, et al., 2020; Desson, Weller, et al., 2020) introducing substantial support packages. This underscores the flexibility needed to address unforeseen challenges. Ghana can learn from these strategies to strengthen the financial capacity of its health system. This will allow it to self-regulate and adapt swiftly to changing circumstances, ultimately enhancing its ability to withstand and effectively manage health crises.

Robust surveillance system

The findings of this study underscore the importance of a robust surveillance system in enhancing health system and societal resilience. Effective surveillance systems, as seen in South Korea, Vietnam, Singapore, China, and Australia (Chua et al., 2020; Sundararaman et al., 2021; Wang et al., 2021; Williams, Fahy, et al., 2022) enabled timely containment measures. This reflects the significance of system awareness and integration attributes of health system resilience. The enhanced disease detection in Congo, Nigeria, Senegal, and Uganda through diverse surveillance approaches during the pandemic as noted in this study (Okeke et al., 2022; Fawole et al., 2023) underscores the critical role of diversity in fostering health system resilience. Integrating digital health tools like Big Data and Nigeria’s SORMAS enhances monitoring (Chang et al., 2020; Kuguyo et al., 2020; Mghamba et al., 2023; Okeke et al., 2022). The use of various tools such as GPS tracking, credit card records, surveillance videos, and mobile apps to enhance their surveillance system (Wang et al., 2021) aligns with adaptation attributes of the health system’s resilience. By incorporating these lessons, Ghana can reinforce its health system resilience against future health emergencies.

Emergency medical care

The diverse strategies employed in emergency care during the pandemic, as noted in this study, provide valuable lessons for Ghana’s health system resilience. Involving the private sector and alternative care models can enhance emergency capacity (Assefa, Gilks, et al., 2022; Thomas et al., 2020; Webb et al., 2022). This reflects diversity and integration in health system resilience. Effective case management, timely expert deployment, and cross-border collaboration for acute care and ICU surge capacity are crucial components in emergency preparedness, as highlighted by various studies (Khanna et al., 2020; Olu et al., 2022; Talisuna et al., 2022; Winkelmann, Panteli et al., 2022; Winkelmann, Webb, et al., 2022). These strategies align with system awareness and adaptation attributes of health system resilience. Again, improving laboratory testing capabilities, decentralizing testing through regional networks, and reinforcing infection prevention measures (Abu & Elliott 2022; Balde et al., 2022; Chua et al., 2020; Dzinamarira et al., 2021; Lanyero et al., 2021; Okeke et al., 2022; Talisuna et al., 2022; Tessema et al., 2021; Tille et al., 2022; Webb, Winkelmann et al., 2022) are crucial for system awareness, self-regulation, and adaptation. Ghana can strengthen its emergency medical care and health system resilience by applying these lessons.

Community engagement and trust

The vital role of community engagement and trust during the COVID-19 pandemic is underlined by the findings of this study. Involving communities and promoting transparent communication fosters collaboration and strengthens response adaptability and legitimacy (Al Siyabi et al., 2021; Chhim et al., 2023; Corbin et al., 2021; Thu et al., 2022). For future pandemics, Ghana should prioritize community involvement, leveraging trusted local messengers for risk communication. This approach fosters integration, strengthens adaptability, and ensures systems awareness, self-regulation, diversity, and legitimacy in responses, which are integral to a resilient health system.

Diverse workforce development

The COVID-19 pandemic, as noted in this review, intensified health workforce shortages globally, prompting the adoption of diverse human resources strategies to cope with increased demand and protect healthcare workers (Assefa, Gilks, et al., 2022; Džakula et al., 2022; Fleming et al., 2022; Haldane et al., 2021; Hunte et al., 2020; Williams, Maier, et al., 2022; Williams, Scarpetti, et al., 2022). Implementing emergency legislation by several countries to increase recruitment quotas and changing schedules, redeploying workers, and engaging a diverse workforce to scale up capacity demonstrated adaptability and integration while international collaborations and simplified registration processes showcased system awareness and diversity. Protection measures, including hygiene protocols and adequate PPE, illustrated self-regulation. To enhance its health system resilience, Ghana can learn from these lessons by strategically addressing workforce shortages, fostering international collaborations, adapting to changing demands, and prioritizing the well-being and protection of its healthcare workers.

Digital health integration

This review underscores the importance of digital health solutions in the pandemic response. Leveraging digital health technology such as big data, telemedicine, GPS tracking, credit card records, surveillance videos, mobile applications, syndromic surveillance, eELMIS for supply tracking, and SORMAS for real-time monitoring, were evident in managing COVID-19 impact and strengthening healthcare systems (Chang et al., 2020; Haldane et al., 2021; Kuguyo et al., 2020; Lanyero et al., 2021; Mghamba et al., 2023; Moonasar et al., 2021; Okeke et al., 2022; Wasswa et al., 2023; Williams, Fahy, et al., 2022). Using digital tools for standardized detection and response enhances system awareness, expanding access demonstrates diversity, and the integration of digital solutions with healthcare practices underscores integration. Ghana should prioritize investment in digital health solutions, expand access to underserved areas, and ensure robust training, supportive policies, and regulatory frameworks to enhance its preparedness to cope with future emergencies.

Critical health infrastructure

The need to enhance healthcare infrastructure, particularly maintaining critical ICU devices in strategic reserves for rapid response, outfitting emergency units, establishing robust laboratory networks to expand testing centers, establishing well-equipped infectious treatment centers, and oxygen and therapeutics production and delivery, emerged as a critical factor for future public health emergency preparedness and management (Gebremeskel et al., 2021; Gouya et al., 2023). A resilient health system entails diverse and well-equipped healthcare facilities. Continuous investment and improvement in critical healthcare infrastructure can enhance adaptability and allow the health system to transform its operations, respond flexibly to various situations, and strengthen its overall ability to withstand and manage health crises. Ghana can draw lessons from global insights to prioritize critical health infrastructure investments. Engaging the private sector through public-private partnerships can be beneficial in critical health infrastructure investment, but effective regulatory capacity is essential to ensure successful collaborations (Gebremeskel et al., 2021).

Well-planned commodities/products

Innovative procurement and international collaborations were crucial in addressing shortages of equipment, logistics, and vaccines during the COVID-19 response (Khanna et al., 2020; Winkelmann, Webb et al., 2022). Countries implemented diverse strategies, including resource distribution and encouragement of domestic production. Iran’s development of local production capacity for domestic COVID-19 vaccines with WHO support and their accomplishment of a 75% primary vaccination coverage (Gouya et al., 2023) demonstrated adaptability and self-regulation. Drawing lessons from these successful strategies, Ghana should vigorously pursue its aspiration to develop local pharmaceutical and vaccine production capacity. This will strengthen the country’s medical supplies capacity, enhance self-reliance, and support global health security.

Social capital

Social protection responses to the COVID-19 pandemic varied widely across the globe. African nations focused on non-contributory programs such as special allowances, food, nutrition protection, and health support, but gaps persisted in education and gender-specific interventions (United Nations, 2021). Some African countries also faced challenges in accessing essential services, particularly water and sanitation, hindering effective viral control in vulnerable communities. A key lesson for Ghana to improve healthcare for its citizens, particularly in vulnerable communities is the strategic use of social capital. Ghana can leverage social capital to activate networks across rural and urban areas. This approach allows for effective collaboration between individuals and organizations, addressing crisis-related needs, gender-specific concerns, and socio-cultural factors that influence health outcomes. Additionally, prioritizing sustainable financing for diverse social protection schemes and improving access to essential services like water, sanitation, and healthcare will further strengthen the health system's resilience against future. emergencies.

Limitations

This review is not without limitations. The review examined an extensive range of studies and grey literature. Although beneficial, exploring a wide array of studies in this review posed a challenge in synthesizing findings across various methodologies within the study framework. Besides, the study’s reliance solely on existing literature could restrict its ability to fully capture countries’ specific context. This could potentially limit the lessons that could be drawn to enhance Ghana’s health system resilience against future emergencies. Furthermore, the study’s exclusive focus on the COVID-19 pandemic might neglect other factors impacting Ghana’s readiness for future emergencies. Future research could broaden its focus beyond COVID-19 to include other health emergencies or crises. This will allow a more comprehensive analysis of Ghana’s resilience across various contexts. Despite the constraints highlighted above, the review offers valuable insights for informing health system resilience strategies in Ghana.

Underlying data

All underlying data are available as part of the article and no additional source data are required.

Extended data

Zenodo: Extended data for ‘Building resilience of the Ghanaian healthcare system: Lessons from a global health stage: Preparedness for the next pandemic: A scoping review’, https://doi.org/10.5281/zenodo.11154359 (Ankomah et al., 2024).

Reporting guidelines

Zenodo: PRISMA-ScR checklist for ‘Building resilience of the Ghanaian healthcare system: Lessons from a global health stage: Preparedness for the next pandemic’, https://doi.org/10.5281/zenodo.11154359 (Ankomah et al., 2024)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).