From fragility to resilience

photographs of patients’ eyes and information about their symptoms to an Aravind doctor, who then assesses a patient’s need for hospital care via a real-time chat (Bhattacharyya et al. 2010).

Emergencies require health workers to take on tasks and competencies outside of their day-to-day routines; crises can also place enormous stress on health workers’ physical welfare and mental health. Appropriate training, planning, psychosocial assistance, and practical support can ease the burden of crises on the health workforce and help sustain continuity of care. Preparedness: Training and contingency planning

An adequate health workforce and appropriate training in outbreak prevention, detection, and response has been identified as a key characteristic of a health system prepared for emerging infectious diseases (Palagyi et al. 2019).

Even with the best planning, emergencies are by their nature unpredictable. Medical education—and training for nonphysician health workers—accordingly must emphasize agility and problem solving, helping prepare the health workforce to work confidently and capably in unusual conditions. This is consistent with the expectation that all health workers in PHC have a broad range of knowledge and skills as generalists within their disciplines, including technical capabilities and a range of nontechnical and leadership skills (Strasser et al. 2018).

Consequently, health workforce education and training should encompass mastering technical skills related to managing emergencies in the community, as well as nontechnical skills, including adaptive expertise and clinical courage. Adaptive expertise involves innovation in addressing uncertain, complex, and novel situations, balanced with efficiency that draws on routine knowledge (Croskerry 2018). Clinical courage balances probability and payoff to creatively manage problems in the moment at hand with whatever resources are available (McWhinney 1997). Leadership skills involve inspiring trust and respect, motivating action among team and community members, and allocating practical, achievable tasks (West et al. 1999). Learning in context through case-based learning (CBL) in the classroom and in community clinical settings is the most effective educational method for developing these generalist knowledge and skills (Strasser 2016b; Strasser et al. 2013). CBL encompasses learning the social and environmental determinants of health,

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including One Health (Rabinowitz et al. 2017) and integrating the individual and population health domains (Boelen and Berney 2000).

Immersive community-engaged education provides students and trainees with hands-on experience in interprofessional collaborative practice (Strasser et al. 2018). Integrated clinical learning (ICL) involves team teaching and team learning, whereby local health team members collaborate in teaching a mix of students of various health care disciplines (Pavelich and Berry 2009). ICL enriches the experience for all involved and embeds teamwork in the professional identity of future health workers. To consolidate their learning, it is important that students and trainees are involved in teams that undertake local contingency planning and practice exercises preparing for the management of crises, including infectious disease outbreaks.11

Agility, flexibility, and resilience in health emergencies

Some of the most effective workforce responses to the COVID-19 pandemic have required rapid task shifting, repurposing, or extraordinary deployment of existing health workers. The government of South Africa, for example, mobilized around 60,000 CHWs—half of whom were originally trained to trace/test for HIV—to support the COVID-19 response. In Bangladesh, Guinea-Bissau, Nigeria, and Senegal, CHWs and the PHC platform have been effectively deployed to conduct sample collection and case identification/isolation. In Guinea-Bissau, which has a strong community health workforce, CHWs work closely with dedicated contact tracing cadres, contributing their deep knowledge of community context. In Nigeria, over 30,000 PHC providers have been used to identify suspected COVID-19 cases, trace contacts, and conduct referrals.

Some countries (including the United Kingdom and the Netherlands) postponed re-registration and revalidation obligations for physicians. This measure reduced the administrative burden on practitioners and avoided potentially sidelining key professionals at the height of the crisis. Provisions have been made to recruit medical and nursing students to support health professionals, for example, by allowing final year students to graduate early and join the workforce or by offering them a gap semester to support practicing health professionals. Campaigns were launched in several countries (including Canada, Italy, and the United Kingdom) to bring retired or inactive health professionals and foreign-trained but unregistered professionals back into the workforce. Twinning individual facilities in hotspot areas with medical teams from other provinces also facilitated China’s response to COVID-19. In the United Kingdom,the government brokered an agreement to take over private hospitals and their staffs for the duration of the crisis, resulting in

tens of thousands of clinical staff provisionally moving to the public sector (Williams, Maier, and Scarpetti 2020).

The COVID-19 crisis has also led some countries to empower NPHWs with new responsibilities and authority. Pharmacists have received extraordinary authorization in several countries to assist in the COVID-19 response and relieve pressure on overburdened hospitals and physicians. Pharmacists have been allowed to issue and/or renew prescriptions (in Canada, France, and Poland); compound antiseptic solutions or hand sanitizers (in Belgium, the Czech Republic, Finland, Germany, and the Netherlands); and deliver prescriptions to patients’ homes, sometimes including controlled substances, hospital-only drugs, and even oxygen (Canada, Croatia, Italy, and Portugal) (Merks et al. 2021).

To avoid saturating hospital capacities during the crisis, the broader health workforce, including community-based practitioners, can contribute to emergency-related service provision. Previous outbreaks suggest that task shifting, supported by adequate training, is necessary to cope with emergency challenges (Lee and Chuh 2010; Opstelten et al. 2009). One of the lessons learned from the SARS outbreak in Hong Kong SAR, China, concerns the need for a wider involvement of general practitioners, who could contribute to the response as educators, triage decision-makers, and vaccine administrators (Lee and Wong 2003). Patient management and triage strategies need to be adapted; health workers need to be trained in the specifics of the response and appropriate patient care; and heightened safety precautions need to be implemented. Maintaining routine or essential health services (for example, chronic disease management and antenatal care), while delivering emergency-related services requires the availability of inputs, such as health workers, medicines, and safety supplies. Management systems must be adjusted to ensure input availability and smooth patient flow. Crucially, public authorities need to provide clear guidelines and adequate financing. Shortages of personal protective equipment (PPE), insufficient allocation of PPE to PHC systems, and in particular, CHWs, have reduced PHC platforms’ ability to sustain services during the COVID-19 pandemic (Nepomnyashchiy et al. 2020a; Nepomnyashchiy et al. 2020b).

Supplementary training during the crisis may also increase health workers’ capacity, confidence, and morale in handling the outbreak. During the Ebola outbreak in Sierra Leone, health workers showed lower levels of fear and became more confident in providing care after safety training; tentative evidence suggests the trainings also prevented further infections among health workers (Bemah et al. 2019). In a Canadian hospital setting, group resilience

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