From fragility to resilience

data can also be posted on bulletin boards or in other public spaces. In China, such reporting has been shown to help reduce antibiotic prescriptions (Yang etal. 2014) and improve the rational use of medicines (Wang et al. 2014).

Community scorecards and citizen report cards are variants on public reporting that directly engage citizens to hold health organizations accountable for the services they provide. In Afghanistan, a community scorecard initiative based on stakeholders’ discussions about performance scores and participatory action planscontributed to improvements in structural capacity indicators, such as water and power supply, availability of essential medicines and equipment, and number and cadres of service providers (Edward et al. 2015). In Uganda, report cards were shared with citizens and PHC staff through village meetings; PHC staff and citizen representatives worked together to identify strategies for improvement (PHCPI n.d.). The intervention led to a 13-percentage point reduction in absentee rates, 12-minute shorter waiting times, and a statistically significant reduction in the under-five mortality rates (Björkman and Svensson 2009). However, other evaluations on citizen report cards found partial or no results,7 suggesting that the impact of this social accountability strategy depends on its implementation.

Finally, financial accountability mechanisms connect provider funding and remuneration to their performance. These mechanisms are considered in detail in Priority Reform 3.

Preparedness, resilience, and the multidisciplinary platform

Integrated, multidisciplinary team-based PHC platforms also offer important benefits for preparedness, response, and resilience in emergencies—most recently, the COVID-19 pandemic. These benefits can be broadly segmented into three categories.

First, integrated and team-based PHC platforms can and should include explicit data collection, public health, and surveillance functions, integrated with national systems. Syndromic surveillance and close coordination with national public health authorities can help identify and contain nascent outbreaks before they spread more widely. Experiences from the severe acute respiratory syndrome (SARS) in east and southeast Asia, Zika in the Caribbean, and Ebola in West Africa, all showed that delayed detection and reporting of cases due to poor surveillance contributed to the escalation of these epidemics.8 Many

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countries have relied on PHC for effective surveillance and contact tracing during the COVID-19 pandemic, especially coupled with CHWs; an integrated surveillance system appears to be the most important enabling factor. For example, Colombia, North Macedonia, and Vietnam have mobilized their information systems and integrated their COVID-19 surveillance systems with national information systems, with COVID-19 modules included and utilized for surveillance and in contact tracing in certain instances.

Second, established relationships and trust between the PHC team and community can enable effective communication and behavior change during an emergency. In Liberia, community education on preventive measures was among the most effective interventions to fight Ebola (Kirsch et al. 2017). During the Ebola and Zika epidemics, CHWs served as community-level communicators and educators, contributing to community health literacy in personal hygiene and other precautionary measures (Boyce and Katz 2019; CHIC 2020). Resilient PHC platforms can quickly adapt to increase the frequency of communication, ensuring clarity on emergency status and prevention and treatment recommendations. In partnership with central public health authorities, PHC teams’ deep knowledge of their catchment communities can help tailor communication strategies and messaging to the population’s specific concerns and preferences, building trust, for example, by highlighting facility and health worker adherence to safety standards and people-centered approaches to care. In Bangladesh, Colombia, Guinea-Bissau, Senegal, and Vietnam, PHC platforms, including CHWs, have helped inform communities about COVID-19 symptoms, transmission, and vulnerabilities; they have also helped to counteract social stigma. In Nigeria, 230,000 CHWs have been mobilized to deliver messaging and outreach. In Vietnam, community health stations and village health workers have played a crucial role in improving community awareness and enhancing trust. During an emergency recovery phase, resilient PHC facilities can progressively scale back communication efforts while ensuring continued clarity and transparency in communication about service procedures as the emergency subsides.

Third, team-based organizations may be better equipped than other organizational models to maintain essential services and prevent health system breakdowns during a crisis. Team-based approaches may more effectively sustain continuity of care; demonstrate greater agility in task shifting and alternative service delivery; and offer a first triage point to take stress off overburdened hospitals. Building on the strong foundation of a community-centric health system model to mount an effective response, Italy’s Veneto region was able to prevent overcrowding in hospitals for COVID-19. Authorities required effective and proactive public health