Health systems in the world and COVID-19

Health systems in the world and COVID-19 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health systems in the world and COVID-19 Ligia Maria Vieira-da-Silva, Jairnilson Silva Paim, Monique Azevedo Esperidião, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8952346/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Understanding how different Health Systems respond to pandemics is essential to identify vulnerabilities and inform preparedness for future events. This article analyzes national response to the covid-19 pandemic in 15 selected countries, investigating the relationship between health systems and the control measures adopted. A logical model was developed based on a goal oriented Framework, defined through a consensus technique, providing an analytical reference for cross-country comparison. Multiple correspondence analysis was applied to classify countries according to their alignment with the goal oriented Framework. The resulting typology enabled the identification of shared patterns and divergences in national responses, further explored through in-depth case studies. National responses were diverse, with many specificities related to historical and social characteristics, as well as government and pandemic management. Successful experiences included New Zealand’s rapid transmission-interruption strategy; Vietnam’s four-tier surveillance model; the coordinated actions of political authorities, health agencies, and scientific communities in Germany and Portugal; Canada’s genomic surveillance; and Cuba’s strong primary care response. The comparative analysis point to the absence of a relationship between the type of health system and the more or less successful response. Instead, more adequate responses, reflected in better alignment with the framework and lower excess mortality, were related to the strategy adopted and the management of the crisis with regard to coordination, risk communication and timeliness of the measures adopted. Health systems covid-19 pandemics cross country comparisons* Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Highlights 1. Type of strategy adopted shaped pandemic outcomes more than health system design 2. Coordination, timely measures and risk communication drove better performance 3. Cross-country cases exposed structural gaps and preparedness needs 4. The comparative framework enabled robust cross-country comparison Introduction Before the COVID-19 pandemic, knowledge about the social determinants of health and the need for global coordination of intersectoral actions in cases of health emergencies was already consolidated. However, the responses showed little preparation for crises of this type and were fundamentally implemented by national states that developed differentiated control strategies with sometimes different outcomes[ 1 ] The various institutional arrangements corresponding to health systems were strained to the maximum during the successive epidemic waves between 2020 and 2022. Several cross-country comparative analyses have been carried out to understand the similarities and differences between responses to the pandemic, identifying the most successful approaches[ 2 – 10 ] The period analysed, the scope of the comparison, the countries involved, and the methodologies used are varied, which makes it difficult to synthesise these studies. To develop hypotheses about the main processes related to the success or failure of control strategies, a certain systematisation is necessary, given the inaccuracy and inability of previous estimates to gauge countries' preparation. This was the case with the Global Health Security Index (GHSI), published in 2019. The comparison between the countries' GHSI scores and their performance in the pandemic, measured using standardised mortality indicators, among others, revealed discrepancies[ 11 ] The comparative analysis of health systems implies a choice between theoretical depth and the number of countries included[ 12 ]. The number of countries evaluated in the reviewed studies varied between 3 and 43 (Table 1 ). The authors used several criteria to select countries that would be part of each investigation. Some authors selected countries based on the number of cases and deaths[ 13 ] and testing and vaccination coverage[ 14 ]. Others included, in addition to deaths, economic characteristics and health systems[ 15 ]. Other selection criteria involved the geographic location of countries [ 8 , 10 ], available information[ 16 ], characteristics of government, health systems, and their responses to the pandemic[ 17 ], population density [ 6 ], and income levels[ 7 ]. Table 1 Characterization of comparative studies on health system responses to the COVID-19 pandemic, according to objectives, methods, theoretical frameworks, countries analyzed, and selection criteria. Authors Year Article Title Objective Methodological aspects Theoretical Reference N countries Selection criteria Abbey and Khalifa 2020 The Global Health Security Index is not predictive of coronavirus pandemic responses among Organization for Economic Cooperation and Development countries To evaluate the utility of the GHS index in predicting the current responses of 36/37 OECD countries, for which data are available, to the COVID-19 pandemic This is a comparative study with a quantitative approach with OECD countries, except France. It was not explicitly mentioned in the text 36 OECD countries with data on covid-19 available, such as tests/thousand people. Burau et al. 2022 Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries To analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January‐May/June 2020), and to assess how health systems prerequisites influence these capacities. Comparative study of countries with different types of health systems and pandemic burdens. The analysis was based on case studies of the countries, using written secondary and primary sources and expert information. Health workforce, profession studies, and comparative health systems, governance, and policy studies Bal et al., 2020; Thomas, Sagan, Lakin, 2020; Blank, Burau, Kuhlmann, 2018; Burau, 2018; Hulmann, Batenburg, Wismar, 2018. Also cited are the literature on health system resilience Van Schalkwyk, Bourek, Kringos, 2020; Chamberland-Rowe, Chiocchio, Bourgeault, 2019; Hanefeld et al., 2018; European Commission, 2021; Sagan et al., 2021. 6 Different types of health systems, which in turn influence the capabilities of the health workforce Desson et al. 2020 An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada The paper presents an overview and comparative analysis of the epidemiological situation and the policy responses in France, Belgium, and Canada during the early stages of the 2020 Covid-19 pandemic (Feb.-Aug. 2020). Rapid review with government, international database, and local media data sources. It was not explicitly mentioned in the text 3 OECD countries with different governance structures. Desson et al. 2020 Europe’s Covid-19 outliers: German, Austrian and Swiss policy responses during the early stages of the 2020 pandemic The paper presents an overview of the policy responses in Germany, Austria and Switzerland (the DACH region) during the early stages of the 2020 Covid-19 pandemic (Feb.-June 2020), which provides the context for a comparative policy analysis. Comparative analysis of available data on covid-19 from the countries of the DACH region. Theoretical works focused on federalism, social policy and health systems during a crisis (Federalism - Erk, 2008; Study of critical conjunctures - Capoccia, Kelemen, 2007) 3 Three neighbouring countries (DACH Region - Germany, Austria, Switzerland) with systems with two COVID-19 responses that prevented the virus from spreading rapidly Djalante et al. 2020 COVID-19 and ASEAN responses: Comparative policy analysis To document and analyze individual and collective responses to COVID-19 by ASEAN member states in the period from January 2020 through to August 2020. Case studies, based on content analysis of ASEAN and member countries' statements and policies. It was not explicitly mentioned in the text 10 ASEAN member countries Dos Santos et al. 2023 COVID-19 in Latin America: inequalities and response capacity of health systems to health emergencies To identify correlations between COVID-19, demographic and socioeconomic characteristics, and the capacity of Latin American health systems to respond to health emergencies. Ecological study, using secondary data from 20 Latin American countries regarding incidence, mortality, testing, and vaccination coverage for COVID-19 in the period from 2020 to 2021, as well as demographic and socioeconomic information It was not explicitly mentioned in the text 20 Latin American Countries Haldane et al. 2021 Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries To analyze 28 national responses to COVID-19 using a new conceptual framework for resilience in health systems Comparative study with triangulation of literature review, semi-structured interviews and written responses, in-depth case studies, validation of country data by experts, and validation in expert roundtables Expanded health systems resilience framework , World Health Organization’s (WHO) health systems framewor. 28 Intentional selection of 28 countries including positive and negative outliers in relation to COVID deaths per capita recorded among populous countries, as well as a selection of intermediate countries (as of November 6, 2020) Hernandez-Pineda et al. 2024 Covid-19 vaccination: a mixed methods analysis of health system resilience in Latin America To capture the impact of the stages of health system resilience (HSR) and the factors underlying differences in HSR during the covid-19 pandemic, especially in vaccination, and identify potential improvements for future crises and for vaccination programs in general. Mixed methods study, consisting of a quantitative and a qualitative phase. The background on health system resilience (HSR) consists of the largely system-wide culture, economics, politics, and system characteristics (Mirzoev et al., 2017) that can condition causal mechanisms to hinder or drive certain outcomes (Pawson & Tilley, 1997). This background was represented by the “Sustainable Economic Development Assessment” (SEDA) index (Boston Consulting Group, 2023), and the HSR was measured through the proxy of vaccination performance indexes. 21 (quantitative phase) 7 (qualitative phase) Latin American countries. The selection for the second phase was guided by the quantitative stage, with the countries with the highest Sustainable Economic Development Assessment - SEDA - and performance in vaccination coverage (Uruguay and Chile) and those in group 5 being selected, according to the interest of the researchers, since any of the other groups did not show a relationship between vaccination coverage and SEDA. Irfan et al. 2022 Coronavirus pandemic in the Nordic countries: Health policy and economy trade-off To determine how the Nordic countries have balanced this trade-off between the restrictive COVID-19 health policy and response measures and their impact on the economy Comparative analysis of the health policies of the Nordic countries in the response to COVID-19 using public databases such as WHO, European CDC, OECD, for the period between January 2020 and January 2021 It was not explicitly mentioned in the text 5 Nordic countries with similar health systems, but different policy responses. Keleş and Keles 2021 A comparative analysis of world health systems and COVID-19 To assess the adequacy of global health systems in the face of this pandemic Comparative study of 12 countries with a quantitative approach. Information on health systems and COVID-19 was obtained from data from the Organization for Economic Cooperation and Development 2018, World Health Organization 2020, and Deep Knowledge Group It was not explicitly mentioned in the text 12 Number of COVID-19 cases and deaths Ko et al. 2023 Lessons from health insurance responses in counteracting COVID-19: a qualitative comparative analysis of South Korea and three influential countries To present the directions for health insurance support by comparing countries in terms of the domains and contents of COVID-19 health insurance support to ensure timely support in case of future pandemics Comparative qualitative analysis, considering an analysis framework that compared health insurance interventions for COVID-19 and non-COVID patients, considering space, personnel, and supplies as subdimensions. Considering that insurance should create conditions for the care of people with COVID-19 and maintain care for non-COVID patients. The authors developed an analytical framework for the analysis of domains in which financial support (in the form of health insurance) was provided in response to COVID-19m based on WHO (2020) 4 South Korea and countries that influenced its health insurance model Lupu et al. 2022 Covid-19 and the efficiency of health systems in Europe To analyze the efficiency of the health systems of 31 European countries in the treatment of COVID-19, for the period from January 1, 2020 to January 1, 2021, incorporating some factors from a multidimensional perspective analysis. The study used data envelopment analysis, a qualitative method to analyze the efficiency of the health systems of 31 European countries in responding to covid-19. It was not explicitly mentioned in the text 31 Member countries of the European Union, Iceland, Norway, Switzerland and the United Kingdom Machado et al. 2024 The response to COVID-19 in Argentina, Brazil, and Mexico: challenges to federative coordination of health policies To identify the main characteristics, constraints, positive elements, and limits in the responses to the COVID-19 pandemic in these Latin American nations Multiple case study with comparative perspective. Literature review, documentary analysis and secondary data. Historical-comparative approach to the Social Sciences and literature on health systems. 3 Latin American countries with different health systems and similar federative challenges. Moola and Hiilamo 2023 Health system characteristics and COVID-19 performance in high-income countries To analyze how characteristics of health systems influenced COVID-19 mortality rates. Comparative study of 43 OECD countries and selected economies, with data from the WHO and OECD, considering their financing models, service provision and public health characteristics. It was not explicitly mentioned in the text 43 OECD countries and selected economies. The countries were selected because they represent distinct health systems from different geographic regions and because they are OECD members or selected non-member economies (Brazil, China, Costa Rica, Indonesia, Russia, and South Africa), which are strategic partners of the OECD and some of the world's largest economies. Rafieepour, Masoumi, Dehghani 2021 Health responses during the COVID-19 pandemic: an international strategy and experience analysis To review the measures taken in selected countries to combat the COVID-19 and analyze international policies and experiences to develop appropriate health guidelines to deal with the inevitable health threats of the future This is a comparative study, following 10 effective indicators in the response to covid-19, based on literature review, government reports, interviews with professors and epidemiologists, through a content analysis matrix. It was not explicitly mentioned in the text 6 Canada, Japan, Germany, Korea, Turkey, and Iran, which are not only among the leading countries in the fight against COVID-19, but have also been significantly affected by this disease. In the selection of these countries, we sought to include at least one country from each continent. Saunes et al. 2024 Nordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic To explore and compare the Nordic health systems responses to the COVID-19 pandemic in the context of governance features and provide insight into differences and similarities in terms of policy responses to the epidemiological situation Comparative analysis of 5 countries based on Covid-19 Health System Response Monitor and public sources. It was not explicitly mentioned in the text 5 Nordic countries with similar health systems, but different policy responses to the covid-19 pandemic. Tan et al. 2023 Mitigating the impacts of the COVID-19 pandemic on vulnerable populations: Lessons for improving health and social equity To analyze mitigation strategies adopted by governments to support vulnerable populations during the pandemic. This was a comparative study of 15 countries, with a systematic review of the literature and interviews with key informants. The authors adopted a vulnerability framework by Li et al. (2023) while simultaneously incorporating established vulnerability definitions by the National Bioethics Advisory Commission of the United States (NBAC (National Bioethics Advisory Commission of the United States), 2001). 15 Countries representing all WHO regions, with different income levels and health arrangements. Tsalampouni 2022 Health systems in the European Union and policy responses to Covid-19: A comparative analysis between Germany, Sweden, and Greece To analyze the characteristics of the health care systems in three EU countries-Germany, Sweden, and Greece-that represent three different health care system types in Europe as well as their health policy response, to the COVID-19 pandemic Comparative study of 3 countries on population coverage, degree of decentralization, ownership and management of health structures, sources of financing, private sector participation and employment status of physicians, using data from the European Observatory on Health Systems and Policies, as well as from the OECD Health System Characteristics Database and national health legislation Social welfare systems (Esping-Andersen, 1990); Welfare state and the case of health care (Moran, 2000); Types of health systems: a conceptual framework for comparison (Wendt, Frisina, Rothgang, 2009); Theory and method for the transnational study of health systems (Elling, 1994) 3 Three different types of health systems in Europe, as well as their health policy response to the COVID-19 pandemic Van De Pas et al. 2022 COVID-19 vaccine equity: a health systems and policy perspective To analyze equity in the distribution of COVID-19 vaccines and the impact of health systems. Comparative analysis of vaccination policies in countries of different continents. Tanahashi health systems framework (1978). 5 Availability of data on vaccination and equitable access. Waitzberg et al. 2024 Early health system responses to the COVID-19 pandemic in Mediterranean countries : A tale of successes and challenges To compare initial health systems responses to COVID-19 in Mediterranean countries. Comparative analysis of 7 countries based on the Covid-19 Health System Response Monitor. It was not explicitly mentioned in the text 7 Mediterranean countries with similar health systems. Source: integrative review ( Web of Science, Science Direct, Scopus and PubMed Central (PMC)) There is also great theoretical-methodological diversity in analysing health systems, and there is no canon to follow[ 12 ]. By elaborating a theoretical framework and systematizing what emerges from the cases, it becomes possible to "open a range of hypotheses and possible conclusions" and to obtain inferences based on the comparative method [ 18 ]. Although they did not specifically analysed the COVID-19 pandemicClique ou toque aqui para inserir o texto., Immergut et al., updated the situation of European health systems between 1989 and 2019, supported by neo-institutionalism [ 19 ]. The most commonly used approaches in the reviewed studies included: a) Adaptation of the WHO framework for health systems assessment [ 15 ]; b) Articulation between extensive indicator analyses and in-depth case studies [ 15 ]; c) Case studies guided by a common framework[ 20 , 21 ]. The use of typologies to classify health systems and the type of welfare state, found to be less frequent, has encountered difficulties related to the dynamics of the evolution of institutional arrangements that characterise health systems, leading to generic conclusions regarding their influence on responses[ 22 ]. However, in most studies reviewed, the theoretical references are not made explicit, except in Machado et al. (2024) [ 20 ], which were based on a historical-comparative approach from the Social Sciences. In addition to initiatives such as the Delphi panel involving 386 academics and experts on COVID-19 from 112 countries [ 1 ], comparative studies are necessary to aggregate theoretical-methodological approaches and different perspectives of analysis capable of filling gaps that consensus panels of experts leave, such as the use of theoretical references and more consistent and detailed logical models. This study aims to identify possible relationships between national responses to the COVID-19 pandemic and characteristics of health surveillance systems, seeking to determine the most successful strategies. [Insert Table 1 here] Reference Framework Health systems have been considered instruments to achieve the coordination of resources and can be defined as "(...) all organisations, people and actions whose primary intent is to promote, restore or maintain health"[ 23 ]. From another perspective, health systems are historical constructions and constitute one of the forms of organised social response to the population's health problems and needs. Each society engenders its health system based on historical and structural determinants, although it is subject to constraints derived from international relations[ 24 ]. Considering the adoption of pro-market reforms of health systems in the last 40 years, with limitations in coverage and increased inequalities[ 24 ], it would be understandable to be cautious about the real possibilities of health systems presenting an adequate response to control this pandemic. Several opinions disseminated in the international media and statements by experts suggested that there could be a revival of the recognition of universal and public health systems, as they would have better conditions to face COVID-19. Some investigations have also highlighted the types of health systems [ 7 ] and their efficiency[ 5 ] in the effort to explain the results in facing the pandemic. Concerning health systems, except for Cuba, most countries have some segmentation, either differentiated models of social security for public servants or the military, or for the population defined as vulnerable, or through complementary private insurance for workers and higher-income strata. Funding ranged from predominantly public to fundamentally private, with sources including taxes, employee and employer contributions, and/or direct disbursement. The provision of services also involves a public-private articulation that varies in proportion between the countries studied [ 25 ]. The comparative study intentionally included 15 countries from five continents (Canada, China, Cuba, France, Germany, Italy, Mozambique, New Zealand, Portugal, South Korea, Sweden, the United States (US), the United Kingdom (UK), Uruguay and Vietnam), based on their health systems, geographic location, and state characteristics. The research strategy consisted of four steps: in-depth case studies, construction of logical models and analysis matrices, multiple correspondence analysis (MCA), and graphical analysis, detailed more elsewhere [ 25 ]. Case studies were carried out for each country, supported by an integrative literature review (adapted from the proposal by Whittemore and Knafl, 2005)[ 26 ]. Searches were carried out between May 2020 and December 2022 in Web of Science, Science Direct, Scopus and PubMed Central (PMC) databases, using combinations of the descriptors "Country name" and "COVID-19" with "health system", "national response" and "surveillance", applying advanced search engines. Data from the WHO's COVID-19 monitoring database, the Our World in Data portal and WHO reports from the European Observatory on Health Systems and Policies were also used. Information on mobility in different locations and types of establishments was also used, obtained from the Google Mobility database. The preliminary establishment of a logical framework, based on a theoretical model of health surveillance [ 27 ], with a goal-oriented framework defined through a consensus technique, enabled the construction of a reference framework for comparative analysis of the responses of various countries. Three logical models were then constructed: a macro model of the waves (Fig. 1), a causal model (Fig. 2) and an intervention model (Fig. 3). The logical models guided the selection of dimensions and criteria, resulting in a second matrix for comparing countries containing five dimensions and twenty-two evaluation criteria. These dimensions included management, measures adopted, structures and agents mobilised, and civil society action and effects. [Insert Fig. 1 here]Clique ou toque aqui para inserir o texto. [Insert Fig. 2 here]Clique ou toque aqui para inserir o texto. [Insert Fig. 3 here]Clique ou toque aqui para inserir o texto. Secondary data from Our World in Data and the WHO were used for mortality, vaccination coverage, tracking, and testing indicators, with distribution by quartiles. After constructing and validating the matrices for each country in 2020 and 2021, based on the criteria for analysing responses to COVID-19, the Multiple Correspondence Analysis (MCA was conducted. The study used the MCA to examine the relationship between the matrices over the years, identifying homogeneities and heterogeneities and defining subgroups close to or far from the most appropriate pandemic response. The active variables in the MCA in 2020 were coordination, strategy, mobility, Stringency Index (SI), surveillance, and excess mortality. In 2021, these variables were maintained, with the addition of complete vaccination coverage against COVID-19 in December. The other variables were considered supplementary. Statistical analysis was performed with the R software. After defining the groups and subgroups, radar charts were created for each subgroup and year, covering all the matrix criteria to understand the response patterns better. The scores related to the responses to each criterion in the matrices were categorised based on the proximity of the goal oriented framework, classifying the countries as most adequate (MA), adequate (A), least adequate (LA) and an intermediate classification (INT) for those located among the other categories. Each criterion or variable received a score within these categories: Least Adequate (LA): 0 and ≤ 3.3; Intermediate (INT): > 3.3 and ≤ 6.6; Adequate (A): > 6.6 and ≤ 9.5; Most Adequate (MA): > 9.5 and ≤ 10.0. The final stage of the study involved graphical analysis to compare the criteria and indicators of the matrix across countries, also considering the groups/subgroups established by the ACM. The answers were classified into three categories: most adequate (lines closer to the end of the graphs, with high scores), less adequate (more central lines, with low scores), and intermediate (with more significant variation). The conformation of groups and subgroups based on the classification made it possible to compare and better understand the characteristics of the responses to COVID-19 that influenced the course of the pandemic in each country. The in-depth case studies of the 15 countries brought possible explanations for these identified proximities and distances, resulting from the multiple correspondence analysis supported by the evaluation matrix score. Results and discussion Although there are no specific response patterns in the proposed classification, especially for those countries with an intermediate response, the results of the ACM suggest the constitution of groups and subgroups with similarities and approximations. In 2020, Asian countries (China, Vietnam, and South Korea), island countries (New Zealand and Cuba), and Canada were those with the most adequate responses. Among the least suitable were the US, the UK and Sweden, the latter as an outlier . Portugal and Germany were the intermediaries closest to the appropriate group. In the intermediate range, France, Italy, Mozambique and Uruguay presented responses closer to the least adequate (Fig. 4). [Insert Fig. 4 here]Clique ou toque aqui para inserir o texto. Among countries with most adequate responses, in 2020, we have some capitalist (South Korea, New Zealand and Canada), socialist (Cuba and Vietnam) and state capitalist (China) countries with a variety of health systems: National Health Service, universal public with predominant financing of tax resources and predominantly public service provision (New Zealand); segmented system with greater weight of public funding, financed by general taxes (Canada); a universal health system with a state monopoly (Cuba); segmented social insurance with a greater weight of public financing (China and Vietnam) and segmented social insurance with a greater weight of private (South Korea). The Socialist Republic of Vietnam has universal public insurance, but with the presence of the private sector, especially at specialised and hospital level, unlike Cuba, whose health system is entirely state-owned Clique ou toque aqui para inserir o texto.. The countries with the least adequate responses are all capitalist and have different segmented health and social protection systems. The US has a market-bound healthcare system with no comprehensive social insurance. Sweden was one of the precursors of the social-democratic welfare state, with a universal social protection system and a national health service, which has undergone pro-market modifications in recent decades. The UK has a universal social protection system and a paradigmatic health system – public and universal (NHS), but which has been making its public character more flexible since the 1980s, carrying out pro-market reforms in this century [ 28 ]. This diversity of health and social protection systems is also present in countries classified as intermediate. Thus, we can mention Portugal with a National Health Service of a public and universal nature, France and Germany with a broad social insurance system and universal health system, Uruguay with the social insurance model and segmented health system, with public and private sectors coexisting, and Mozambique with a similar model, but having a National Health Service (SNS) with more limited coverage. In the group of intermediaries closest to the inadequate, Italy enacted a Health Reform in 1978, implementing a National Health Service (SSN), a Beveridgian model, of a public, universal and decentralised nature (Berlinguer, Fleury Teixeira and Campos, 1988), despite adopting incremental pro-market reforms in recent years, with a reduction in public infrastructure [ 29 ]. In 2021, only China, South Korea, and New Zealand remained as countries with an adequate response. In the intermediate responses, closer to the adequate subgroup, are Germany, Canada, Cuba, Mozambique, Portugal, Uruguay and Vietnam. In the subgroup of countries with an intermediate response closer to inadequate, France and Italy remained, while the US, the UK, and Sweden continued in the group with inadequate response. (Fig. 5). [Insert Fig. 5 here]Clique ou toque aqui para inserir o texto. To the extent that the types of society, social protection and health systems were not expressed in the most appropriate responses, it would be relevant to discuss some differences concerning the second level of the logical model of intervention: pre-existing and emergency social policies, crisis management, structures and agents mobilised exceptionally (Fig. 1). These elements, especially crisis management/response, stand out in the comparative analysis mainly due to their consequences in terms of coordination, risk communication, degree of adherence to the main measures adopted, relevance and adequacy of actions and main strategy (epidemiological surveillance, medical and hospital care, herd immunity, vaccination and exceptional measures) (Figs. 6 and 7). In the two years analysed, the countries classified as more adequate (Figs. 6 and 7) had their lines demarcated more at the end of the radar graphs, representing a higher score for the criteria, close to the defined goal oriented framework. The opposite was observed in countries with an inadequate response, with graphic representation closer to the centre. On the other hand, for the countries with an intermediate response, the closer to the adequate, the higher the score, approaching the ends of the graph. The opposite, with some points closer to the centre, was also confirmed in the intermediate countries closest to the least adequate (Figs. 6 and 7). [Insert Figs. 6 and 7 here]Clique ou toque aqui para inserir o texto. Countries with more adequate responses showed precise national coordination with science-based decision-making, a rapid response strategy based on careful surveillance of cases and contacts, widespread testing, isolation of cases, and quarantine of contacts with articulation in different spheres of government, which reflected positively on the reduction of mobility. These countries presented a preparedness plan elaborated before the crisis and widely discussed lessons learned from previous epidemics. China and South Korea had great learnings, especially with SARS and H1N1, and South Korea with MERS [ 30 ]. New Zealand's learning from previous communicable diseases is cited [ 31 ]. Although there are not many reports of significant epidemics in Cuba, the lessons learned from the Ebola epidemic in 2013 stand out (Vasco et al., 2023). In 2020, it is noteworthy that these countries had lower investments in income support, especially Cuba and Vietnam (Fig. 6 ). This can be attributed to the effectiveness of the response to the pandemic, which is based on strict surveillance measures, which have had less impact on the economies of these countries. In Cuba, the economic crisis worsened after the pandemic and had repercussions on tourism, a mechanism adopted in the face of the embargo maintained by the US for decades [ 32 ]. In this more appropriate responses group, South Korea, China, New Zealand, and Canada implemented compensatory policies for different target audiences at various times, ensuring aid in the minimum wage (MW) amount throughout the period or above 50% of the MW in different periods. There was a slight variation in the healthcare offered, and the risk communication was clear, consistent, and grounded in scientific evidence. In the group with adequate response, in 2021, China, South Korea, and New Zealand had vaccination coverage above 74% in December 2021 (Fig. 7). Among the intermediaries, there was a more significant variation in the responses in the two years. Generating subgroups in the intermediate classification after the MCA analysis was helpful for a better understanding of the differences and proximities (Fig. 7). France and Italy, countries with an intermediate response closer to the least adequate, showed, especially in 2020, a graphic representation with closer proximity to the centre of the radar graphs, while others, such as Germany and Portugal, remained closer to the drawn goal oriented framework, being the closest intermediate to the appropriate ones (Fig. 6 ). Canada and Cuba showed higher excess mortality than countries with an adequate response in 2021, as well as changes in testing, SI rates, and collapse structure. Mozambique, in the intermediate response group, presents variations in response to criteria such as mobility, SI rates, testing, and emergency aid, mainly related to the country's economic and social structure. For 2021, there is a certain relaxation of non-pharmacological measures, reflected in lower SI than those observed in 2020, with the main difference in strategies being the start of vaccination (Fig. 7). In 2021, vaccination coverage for the group classified as intermediate also varies, with Portugal, Canada, and Cuba showing the best results. The closer they are to the not adequately group, the lower the vaccination coverage, as in Uruguay, Germany, Italy, France and Mozambique. In general, there is a relaxation of non-pharmacological measures and greater regularity in the supply of tests in 2021. Among the least adequate countries, all had the maximum score in the income benefit in 2020 (Fig. 6 ). They did not perform adequately in the response, despite having respected and internationally recognised public health institutions such as the CDC (US) and the NHS (UK). The scores of these countries for the criteria analysed are mostly below 6.0, approaching the centre, denoting that these institutions could not guarantee an adequate response to COVID-19 despite their technical capacity. Although the UK and the US started vaccination against COVID-19 in December 2020, its coverage did not reach high percentages, possibly due to the anti-vaccine movements and vaccine hesitancy. Vaccination made it possible for economic activities to resume safely so that these countries' investment in emergency aid was reduced in 2021. The graph shows an improvement in some of the categories evaluated in the UK and the US, in the latter more markedly, representing the improvement in coordination, strategy, risk communication, as well as a higher supply of tests with the beginning of the Biden-Harris administration [ 33 , 34 ] Two poles of conceptions and attitudes incorporated, implicitly or explicitly by the governments of the different countries analysed in facing the pandemic were identified, influencing the strategies adopted. On the one hand, there was the anti-science position, ostensibly disseminated at the beginning of the pandemic by heads of State, as was the case in the US in 2020 [ 35 , 36 ].This position initially denied the very existence of the pandemic and then its severity. There were also disagreements and disputes regarding control strategies. Some countries have advocated the herd immunity thesis, defended by some doctors in the US and the UK [ 37 ]. Sweden has radicalised this point of view in 2020, not approving restrictive measures, closing schools, discouraging the use of masks, and defending the thesis of respect for individual freedoms by adopting these positions [ 38 ]. At the opposite pole were heads of government who took the lead in managing the fight against the pandemic and articulated not only with parliament but also with the leaders of health institutions, and incorporated points of view defended by broad segments of the scientific community and by international organisations, such as the WHO, like New Zealand, Germany, Canada, Cuba, China and South Korea. We can identify nuances and variations between these two poles depending on national specificities concerning the interfaces between health institutions and other social spheres. It is possible to verify common characteristics of the various answers and specificities that help to understand their dynamics better. As common characteristics that acted favourably in those cases classified as more adequate, it is worth considering the coordination, the strategy adopted, the surveillance, and the relationship between the prioritised measures and the population's adherence in 2020, as well as vaccination coverage in 2021. The participation of society in favour of the measures, as opposed to the denialist and anti-vaccine movements that opposed the control policies, was also facilitating aspects. The main strategy of countries with more adequate responses was focused on containment ("Covid-zero"), seeking to reduce community transmission and, therefore, suppress the circulation of the virus, thereby "flattening the curve" of cases. The lockdown (New Zealand, China, and South Korea) was the preferred measure along with surveillance, extensive testing and tracing of cases and contacts, before the availability of immunisation. South Korea has successfully controlled risks and damage, in addition to taking significant action on social determinants and previous experience with other respiratory epidemics. Cuba and Vietnam had substantial participation and adherence of the population in the control measures, activating revolutionary referents and the "collective spirit" to the point that the SI reached 100% on the Caribbean island in June 2020. In New Zealand, good performance was associated with the Prime Minister's leadership alongside the Public Health General Director, a career official at the Ministry of Health since 2004. Clear and consistent messages would have inspired confidence and security, obtaining greater adherence from the population. There was significant national coordination and relevant governance in these countries with more adequate responses. Countries with less adequate responses had mitigation as their main strategy, emphasising medical and hospital care, while neglecting epidemiological surveillance and physical distancing. The UK and the US, although having health systems with opposite characteristics, saw their health services pressured, if not collapsed, due to the lack of control of the pandemic at various times in 2020, placing it in the quartile with the highest mortality rates and excess mortality in both 2020 and 2021. The explanation for the inadequate performance of these two countries, technically classified as the most prepared to face pandemics by the 2019 Global Health Security Index (GHSI), involves several factors [ 39 ]. In the UK, in December 2021, an Independent Commission of Inquiry was established to examine the country's response and the impact of the COVID-19 pandemic and learn lessons for the future (UK Covid inquiry. Available at https://covid19.public-inquiry.uk/ . Accessed on 10.08.2023). Numerous testimonies highlighted the unpreparedness of the NHS and the social care system to face the pandemic, mainly due to a decade of budget cuts (OPENING STATEMENT OF THE TRADES UNION CONGRESS MODULE 1. Available at https://www.covid19.public-inquiry.uk/documents/opening-statement-of-trades-union-congress-dated-12-june-2023/Accessed on 08/10/2023). In the US, in addition to a health system favouring the market and decentralisation, in the first year of the pandemic, they faced problems such as the politicisation against the use of masks recommended by the CDC and conflicts in health communication, with misinformation attributed to the Trump administration. Even the CDC changed some of its published guidelines, despite the objections of its experts [ 34 ] Sweden, in the ACM at the opposite quadrant to the best-performing group, adopted the strategy of not implementing recommended preventive measures related to physical distancing or surveillance. Even with mitigation measures, there were failures in providing care to more vulnerable groups, such as older adults [ 38 ]. The government's strategy was the object of harsh criticism by the scientific community and was partially contested by the Commission of General Investigation. The Commission made up of professionals with experience in various areas beyond health, such as law, defence, economics, and social sciences, concluded that "earlier and more extensive measures should be taken, particularly during the first wave" [ 40 ].The Commission's report also highlighted that Sweden's strategy would have failed to protect older people and other vulnerable groups. Despite these criticisms, the Commission supported the government's decision to consider the control measures as voluntary, which would have maintained the individual freedom of Swedes during the pandemic (Ludvigsson, 2023). One of the common aspects among these countries with problems in controlling the pandemic can be considered the lack of valorization of thinking supported by scientific evidence, as was the case in Sweden, the US, and the UK. This fact resulted in moments of non-use of the required interdisciplinary expertise and, in particular, epidemiology [ 5 , 9 , 15 ] On the other hand, in countries with more adequate responses, there was articulation between the Executive, Legislative, health authority, and scientific community - as in the case of Germany[ 6 ] and Portugal [ 10 , 41 ]). Finally, it is more difficult to identify the main strategy among intermediate response countries. However, a mixture of mitigation and containment actions, depending on the circumstances, can be highlighted over time. Italy was one of the first countries considered unsuccessful, despite having a public and universal health system. However, there was a change in strategy with improved control at various stages of the pandemic. Rapid response from government officials such as Portugal [ 41 ] (Barros et al., 2023) and Uruguay, with non-pharmacological measures focused on physical distancing and voluntary confinement (Uruguay) or mandatory confinement (transgression of rules considered a civil disobedience crime in Portugal), allowed a relative success in relevant periods, even before vaccination. In France, despite the strict blockades in the first two waves, the increase in health investments, compensatory policies and the protection of the economy, there was a delay in preparing and implementing the plan to confront it. Germany, however, which has an extensive infrastructure of hospital beds, adopted severe measures related to the containment strategy, obtaining results superior compared to Portugal and France. Mozambique, in the intermediate response group, requires caution in interpreting results due to the scarcity of scientific studies on pandemic control and the use of government-origin information in the review. However, the timely elaboration of a coping plan, previous experience in epidemic control, the use of community agents, and epidemiological surveillance may partially explain the adequacy of its response to the COVID-19 pandemic, despite the difficulties in ensuring physical distancing and obtaining vaccines. The participation of society, supporting and even assisting in the implementation of measures, as in Mozambique and Cuba, can also be considered as facilitating aspects. On the other hand, the denialist and anti-vaccine movements that opposed the control policies made it difficult to create consensus about the effectiveness of that measure. This may explain why vaccination coverage was below 80% in December 2021 in countries with easy access to vaccines, such as the US, with 63%, and the UK, with 70% [ 42 ] Even in capitalist countries with neoliberal policies, state intervention was fundamental for controlling the health emergency, partially ensuring the conditions for physical distancing, through emergency aid to companies and individuals. The countries that performed best in controlling the pandemic, such as South Korea, activated, in addition to timely and efficient surveillance, testing, isolating cases, quarantining contacts, and ensuring that treatment was free of charge [ 43 ], instead of the most frequent co-participated medical care by users direct disbursement [ 44 ]. In France, partial reimbursement has been increased to 100% of diagnosis and treatment of COVID-19 costs, and several insurers waived copays in the US [ 45 ]. The analysis of the 15 cases showed that in practically all countries, except for Sweden, in the first months, there was the adoption of some exceptional political status aimed at giving governments powers to enact measures that limited people´s mobility, a the closure of schools, borders, and commerce. In addition to these common aspects, several countries presented specificities that deserve to be highlighted in the analysis of their responses. Among these is the interruption of transmission that occurred in New Zealand [ 15 ](the four-level surveillance model with different social protection measures in Vietnam [ 15 , 46 ], the articulation of the Executive, Legislative, health authority and scientific community in Germany [ 6 ](and Portugal with the creation of the red lines monitoring instrument[ 41 , 47 ] Primary Healthcare (PHC) performance in Cuba deserves to be highlighted, carrying out an intense process of active search, from door to door, for tracing cases and contacts. The timely action of epidemiological surveillance integrated with PHC allowed the early identification of cases, isolation, follow-up, and recovery. Medical students and a diverse group of professionals participated in this process. Therefore, Cuba was the only country among the 15 studied that broadly complies with the principle of the integrality of care, articulating PHC with health surveillance, in addition to contemplating the continuity of care at different levels of the health system[ 34 ] This practice has not been verified in other countries with successful responses (Canada, Germany, France, China, South Korea) which, in general, continue to reproduce the separation and dichotomy between medical-hospital care and the so-called Public Health. In addition, the strengthening of the health production complex and the high national production capacity of inputs and equipment are aspects to be valued, as seen in the German and Cuban responses. In Cuba, vaccines were produced and distributed to the population in massive quantities with rapid acceptance, reaching a 70% vaccination rate, first in America. Germany stood out for its science and technology system and national industry, which focused on producing tests, vaccines, various inputs, medical-hospital equipment, and personal protective equipment (PPE). Regarding interdisciplinarity, although there was a specificity of knowledge about epidemics from Public Health and, in particular, epidemiology, a consensus was also reached, translated by the aforementioned Delphi panel, on the need for intersectoral and whole-of-society responses for greater effectiveness of control policies [ 1 ]). Although Public Health experts were a minority in the panel above, this thesis, which was the subject of great consensus, was already part of the consolidated knowledge of researchers in the field of health policies and epidemiology, appearing in documents from international organisations such as the WHO since 1961. In Sweden, the strategy was defined by a few people from the Public Health Agency. No scientific advisory committee was formed. After criticism of not incorporating expertise outside the Public Health Agency, its director formed a commission with clinicians, virologists and infectologists. There were no epidemiologists or public health experts. The questioning of the control policy adopted was progressively inhibited, and critics were discredited or considered as hobby epidemiologists[ 38 ]. Several initiatives by isolated scientists and groups of scientists from various disciplines gathered informally to study the pandemic and make recommendations, and even from the Royal Swedish Academy of Science, were ignored by the government and the Public Health Agency. None of the countries studied were effectively prepared for the pandemic. Although many had performance classified as adequate or very adequate, there were various criticisms from different population sectors. In some countries, such as Sweden and the UK, Commissions of Inquiry have been created to assess the responsibilities of the pandemic. In 2021, the Office of the Auditor General of Canada (OAG) concluded that the Public Health Agency was not adequately prepared to respond to a pandemic and did not address long-standing health surveillance information issues before the COVID-19 pandemic[ 48 ]. It was found that it was not enough for a country to have an organised, public and universal health system. Structural (social inequalities), historical-institutional (limited investments in public systems, fragmentation/segmentation, little appreciation of PHC and integration with health surveillance, etc.), political-conjunctural (difficulties in coordination, resistance against restrictive measures to economic activities and decisions without scientific basis) and societal ( fake news , low adherence to distancing and the use of masks, vaccine hesitancy, etc.) constraints are pointed out as unfavourable responses to the pandemic [ 4 ]. The functioning of the system and the mobilisation of resources depended a lot on the strategy adopted. Final considerations The results presented in this study should be examined considering the limits of comparative analyses based on literature review and official sources, as well as certain theoretical and methodological particularities. The first aspect to bear in mind is the complexity and insufficient theorisation about health systems and their relations with other spheres of governments and societies, with their historical and cultural peculiarities in constant movement. This fact results in most of the problems related to comparing countries. The pandemic is a dynamic phenomenon with different repercussions in national territories. The analysis carried out has limitations because it tries to represent a portrait of a constantly changing reality. Secondary data is used in research involving several countries, but its scope and quality are not always uniform and comparable. International databases such as the WHO, OECD, and World Bank, among others, can reduce these problems but do not guarantee the faithful expression of reality. In the bibliographic review, even when inclusion and exclusion criteria are explained or if a critical reading of selected articles methodology is carried out, there is always a possibility of absorbing an authors´ mistaken interpretation or a given opinion, not always adhering to the knowledge produced. In addition, countries with a significant base of research production and that widely publish their articles in journals allow for the confrontation between divergent or consensual results, enabling a more informed judgment of the conclusions. While the analysis of narrower scientific-technological production countries or with a low presence of articles published in international journals reduces the possibility of evaluating their results and conclusions more confidently. As editorial policies are not neutral and can be influenced by economic, political, and ideological conditions, access to articles is also not free of bias. The contradiction between depth and scope and the concern with the historicity of countries should be an object of attention in comparative studies. The view of foreign researchers on the experience of other countries has the advantage of a certain critical distance but also the disadvantage of not perceiving nuances that can be identified when living in the country, especially about the predominant values, culture, ideologies and the respective history. In the present study, the theoretical-methodological option was to seek an objectification as far as possible, guided by a theoretical frame of reference, elaborating a logical model, adopting consensus techniques (Delphi), systematising typologies, defining scales and quantification procedures (assigning grades according to explicit criteria), in addition to triggering peer reviews. Still, different questions can be raised when assessing countries' responses to the COVID-19 pandemic, before and after vaccines became available, or in the face of other waves and variants of the virus. Thus, it becomes quite problematic to affirm the existence of an entirely adequate response that, a priori, would ensure the success of the intervention in prevention and control. Even if the WHO's recommendations were adopted as the "gold standard", there would be a need to contextualise and recognise changes in this organisation's guidelines over time, as in the example of using masks. From this perspective, the study avoided being definitive about the success or failure of the countries, preferring to classify the answers by reference to a goal oriented framework, submitted to a Delphi technique, as "adequate (by reference to this goal oriented framework)", "not very adequate" and "intermediate". MCA can point to the proximity or distance of the different cases with these outcomes. Another aspect that made objectification through scoring challenging was the changes during the pandemic, with the emergence of new waves and variants of the virus and the direction of government responses, which changed in several countries. Almost all the countries studied went through ups and downs, and several lessons were learned in the dynamics of the pandemic. The comparative analysis presented in this article sought to inquire about the relationship between the characteristics of health systems and responses to the pandemic. The findings point to the absence of a univocal relationship between the type of health system and the more or less successful response of the countries analysed. The greater adequacy of the response about the designed goal oriented framework and the best results measured in excess mortality were related to the strategy adopted and the crisis management through coordination, risk communication and timeliness of the measures adopted. Good management was also capable of enhancing and expanding the capacities of health systems in terms of material and human resources necessary for developing surveillance actions – risk control, and care for clinical cases – damage control. However, national responses were diversified, with many specificities related to historical and social characteristics and government and pandemic management. Given the complexity of the social determination of health and disease, which was confirmed in an exemplary way in the COVID-19 pandemic, the best preparation for future pandemics is related to the improvement of the analysis of the health situation, guiding planning, as well as the development of sustainable environmental policies, promoting health. Integrated government coordination, subsidies to the most vulnerable people and companies, and the mobilisation of public and private resources to assist people and expand the scale of surveillance were only possible due to state action in the various countries investigated. On the other hand, the participation of the organised population filled several gaps left by the omission or limitation of the State's action. The dynamics of the pandemic have shown the importance of global coordination through the WHO[ 49 ]. Although the responses have been fundamentally national, the WHO has established itself as a reference, as a pole builder of positions based on scientific evidence and as an articulating instance of supranational initiatives aimed at reducing inequalities, such as the Covax facility, aimed at the solidary distribution of vaccines. Finally, despite several consensus built around the technical-scientific pole of the health field, on a global scale, many obstacles have emerged to conclude a new global agreement to confront pandemics capable of overcoming problems in access and equity in the distribution of resources. Declarations Funding National Council for Scientific and Technological Development (CNPq), in partnership with the Ministry of Science, Technology, Innovations and Communications (MCTIC), and the Ministry of Health (MS), through the Department of Science and Technology of the Secretariat of Science, Technology, Innovation and Strategic Health Supplies. Call (Decit/SCTIE) - MCTIC/CNPq/FNDCT/MS/SCTIE/Decit No. 07/2020. Conflict of interest statement: I declare that none of the authors have any conflict of interest in relation to the content of this article. Ethics declaration: not applicable Clinical trial number: not applicable Author Contribution LMVS, JSP, and MAS conceived and designed the study, conducted the research, and were responsible for drafting and revising the manuscript.TRAR and SGB contributed to data production, data analysis, and participated in manuscript writing and revision.All authors read and approved the final manuscript. Acknowledgement We thanks Denise Nogueira Cruz, Alcione Brasileiro Oliveira, Catharina Leite Matos Soares, Gerluce Alves Pontes Silva, Jamacy Costa Souza, Lívia Silva Angeli, Sonia Cristina Lima Chaves, Melsequisete Daniel Vasco, Camilla Andrade Silva Ribeiro, Everly Caroline Teixeira e Maria da Conceição Nascimento Costa for the contributions to the analysis carried out. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8952346","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627223753,"identity":"694f80c7-5eee-4259-ac5e-bd604048a467","order_by":0,"name":"Ligia Maria Vieira-da-Silva","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYBACPmYGhgMgBj+ISCggQgsbTItkA0iLATFaYAwDsEaitLCzXzzwM+ewvfH51YkfHhgwyPOLHSDkMJ6Cg73bDiduu/F2swTQYYYzZycQ1JJwgHdbWoLZjbMbQFoSDG4ToeXg321p9sYzzm7+QaQW9gOHebfZMG7g791GtC0Mh2W32STOuMG7zSLBQIKwX/j5jz/++HabhD1//9nNN39U2MjzSxPQwsDAA40LCbBKCULKQYD9AdS+A8SoHgWjYBSMgpEIAC5JQsBrxaZXAAAAAElFTkSuQmCC","orcid":"","institution":"Federal University of Bahia","correspondingAuthor":true,"prefix":"","firstName":"Ligia","middleName":"Maria","lastName":"Vieira-da-Silva","suffix":""},{"id":627223756,"identity":"f5c0da1c-5dde-4208-9fb2-0ac98b399a84","order_by":1,"name":"Jairnilson Silva Paim","email":"","orcid":"","institution":"Federal University of Bahia","correspondingAuthor":false,"prefix":"","firstName":"Jairnilson","middleName":"Silva","lastName":"Paim","suffix":""},{"id":627223757,"identity":"64908d2d-7bec-44a4-9393-0813f99b5f62","order_by":2,"name":"Monique Azevedo Esperidião","email":"","orcid":"","institution":"Federal University of Bahia","correspondingAuthor":false,"prefix":"","firstName":"Monique","middleName":"Azevedo","lastName":"Esperidião","suffix":""},{"id":627223759,"identity":"f317643b-91fa-48fa-ae09-fd4f2b19b267","order_by":3,"name":"Sandra Garrido de Barros","email":"","orcid":"","institution":"Federal University of Bahia","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"Garrido","lastName":"de Barros","suffix":""},{"id":627223761,"identity":"0ff5a36d-239a-4d70-8973-31b55478f512","order_by":4,"name":"Thais Regis Aranha Rossi","email":"","orcid":"","institution":"State University of Bahia","correspondingAuthor":false,"prefix":"","firstName":"Thais","middleName":"Regis Aranha","lastName":"Rossi","suffix":""}],"badges":[],"createdAt":"2026-02-24 03:55:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8952346/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8952346/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107574096,"identity":"5ab1fe38-e037-413d-8a26-38460247db05","added_by":"auto","created_at":"2026-04-22 19:27:49","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93469,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/f2094554209a8d0fb627e64f.jpeg"},{"id":107574097,"identity":"92f750f0-c5cc-4760-ace8-6e60c41a9b2e","added_by":"auto","created_at":"2026-04-22 19:27:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3288362,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/d817daf0e29075408cc0b3d4.jpg"},{"id":107706211,"identity":"9a3c92d6-7cf0-4064-8cfb-0ff784a925d1","added_by":"auto","created_at":"2026-04-24 09:17:40","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":121437,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/57882aba428a612b74c6d493.jpeg"},{"id":107706372,"identity":"84b83f0a-3d7f-4181-a75c-37dbf887a3fd","added_by":"auto","created_at":"2026-04-24 09:17:57","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":44377,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/9c5789225f2cb519723d9b5d.jpg"},{"id":107574099,"identity":"b7a2967b-4d55-48cc-a41a-f1244f66da6f","added_by":"auto","created_at":"2026-04-22 19:27:49","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":53459,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/9370747d11ea37e6bfaa0097.jpg"},{"id":107706794,"identity":"f9cd5c82-de09-4fe2-bf50-b7adbdc136f8","added_by":"auto","created_at":"2026-04-24 09:18:45","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":144137,"visible":true,"origin":"","legend":"\u003cp\u003eSelected countries, according to the degree of classification of the response to COVID-19 (2020).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/63cc1b375f00e6f8c1071dee.png"},{"id":107574102,"identity":"191b5ef3-791f-4d10-9177-ffe741e8efad","added_by":"auto","created_at":"2026-04-22 19:27:49","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":165167,"visible":true,"origin":"","legend":"\u003cp\u003eSelected countries, according to the degree of classification of the response to COVID-19 (2021).\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/2d961c533063d84fe149c436.png"},{"id":109441088,"identity":"31a83f3e-0811-4784-aa9f-75460f8c2d7d","added_by":"auto","created_at":"2026-05-18 07:12:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1423626,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8952346/v1/30b78d22-6e17-4b83-909f-42e5f164a5b4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health systems in the world and COVID-19","fulltext":[{"header":"Highlights","content":"\u003cp\u003e1. Type of strategy adopted shaped pandemic outcomes more than health system design\u003c/p\u003e\u003cp\u003e2. Coordination, timely measures and risk communication drove better performance\u003c/p\u003e\u003cp\u003e3. Cross-country cases exposed structural gaps and preparedness needs\u003c/p\u003e\u003cp\u003e4. The comparative framework enabled robust cross-country comparison\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eBefore the COVID-19 pandemic, knowledge about the social determinants of health and the need for global coordination of intersectoral actions in cases of health emergencies was already consolidated. However, the responses showed little preparation for crises of this type and were fundamentally implemented by national states that developed differentiated control strategies with sometimes different outcomes[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe various institutional arrangements corresponding to health systems were strained to the maximum during the successive epidemic waves between 2020 and 2022.\u003c/p\u003e \u003cp\u003eSeveral cross-country comparative analyses have been carried out to understand the similarities and differences between responses to the pandemic, identifying the most successful approaches[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe period analysed, the scope of the comparison, the countries involved, and the methodologies used are varied, which makes it difficult to synthesise these studies. To develop hypotheses about the main processes related to the success or failure of control strategies, a certain systematisation is necessary, given the inaccuracy and inability of previous estimates to gauge countries' preparation. This was the case with the Global Health Security Index (GHSI), published in 2019. The comparison between the countries' GHSI scores and their performance in the pandemic, measured using standardised mortality indicators, among others, revealed discrepancies[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe comparative analysis of health systems implies a choice between theoretical depth and the number of countries included[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. The number of countries evaluated in the reviewed studies varied between 3 and 43 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The authors used several criteria to select countries that would be part of each investigation. Some authors selected countries based on the number of cases and deaths[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e] and testing and vaccination coverage[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. Others included, in addition to deaths, economic characteristics and health systems[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Other selection criteria involved the geographic location of countries [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], available information[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e], characteristics of government, health systems, and their responses to the pandemic[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e], population density [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e], and income levels[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacterization of comparative studies on health system responses to the COVID-19 pandemic, according to objectives, methods, theoretical frameworks, countries analyzed, and selection criteria.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eArticle Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eObjective\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eMethodological aspects\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eTheoretical Reference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eN countries\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSelection criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAbbey and Khalifa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe Global Health Security Index is not predictive of coronavirus pandemic responses among Organization for Economic Cooperation and Development countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo evaluate the utility of the GHS index in predicting the current responses of 36/37 OECD countries, for which data are available, to the COVID-19 pandemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThis is a comparative study with a quantitative approach with OECD countries, except France.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOECD countries with data on covid-19 available, such as tests/thousand people.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBurau et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January‐May/June 2020), and to assess how health systems prerequisites influence these capacities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative study of countries with different types of health systems and pandemic burdens. The analysis was based on case studies of the countries, using written secondary and primary sources and expert information.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth workforce, profession studies, and comparative health systems, governance, and policy studies Bal et al., 2020; Thomas, Sagan, Lakin, 2020; Blank, Burau, Kuhlmann, 2018; Burau, 2018; Hulmann, Batenburg, Wismar, 2018. Also cited are the literature on health system resilience Van Schalkwyk, Bourek, Kringos, 2020; Chamberland-Rowe, Chiocchio, Bourgeault, 2019; Hanefeld et al., 2018; European Commission, 2021; Sagan et al., 2021.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDifferent types of health systems, which in turn influence the capabilities of the health workforce\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDesson et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAn analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe paper presents an overview and comparative analysis of the epidemiological situation and the policy responses in France, Belgium, and Canada during the early stages of the 2020 Covid-19 pandemic (Feb.-Aug. 2020).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRapid review with government, international database, and local media data sources.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOECD countries with different governance structures.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDesson et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEurope’s Covid-19 outliers: German, Austrian and Swiss policy responses during the early stages of the 2020 pandemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe paper presents an overview of the policy responses in Germany, Austria and Switzerland (the DACH region) during the early stages of the 2020 Covid-19 pandemic (Feb.-June 2020), which provides the context for a comparative policy analysis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative analysis of available data on covid-19 from the countries of the DACH region.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTheoretical works focused on federalism, social policy and health systems during a crisis (Federalism - Erk, 2008; Study of critical conjunctures - Capoccia, Kelemen, 2007)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThree neighbouring countries (DACH Region - Germany, Austria, Switzerland) with systems with two COVID-19 responses that prevented the virus from spreading rapidly\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDjalante et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCOVID-19 and ASEAN responses: Comparative policy analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo document and analyze individual and collective responses to COVID-19 by ASEAN member states in the period from January 2020 through to August 2020.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCase studies, based on content analysis of ASEAN and member countries' statements and policies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eASEAN member countries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDos Santos et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCOVID-19 in Latin America: inequalities and response capacity of health systems to health emergencies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo identify correlations between COVID-19, demographic and socioeconomic characteristics, and the capacity of Latin American health systems to respond to health emergencies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEcological study, using secondary data from 20 Latin American countries regarding incidence, mortality, testing, and vaccination coverage for COVID-19 in the period from 2020 to 2021, as well as demographic and socioeconomic information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLatin American Countries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHaldane et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth systems resilience in managing the COVID-19 pandemic: lessons from 28 countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo analyze 28 national responses to COVID-19 using a new conceptual framework for resilience in health systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative study with triangulation of literature review, semi-structured interviews and written responses, in-depth case studies, validation of country data by experts, and validation in expert roundtables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cem\u003eExpanded health systems resilience framework\u003c/em\u003e, World Health Organization’s (WHO) health systems framewor.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIntentional selection of 28 countries including positive and negative outliers in relation to COVID deaths per capita recorded among populous countries, as well as a selection of intermediate countries (as of November 6, 2020)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHernandez-Pineda et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCovid-19 vaccination: a mixed methods analysis of health system resilience in Latin America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo capture the impact of the stages of health system resilience (HSR) and the factors underlying differences in HSR during the covid-19 pandemic, especially in vaccination, and identify potential improvements for future crises and for vaccination programs in general.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMixed methods study, consisting of a quantitative and a qualitative phase.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe background on health system resilience (HSR) consists of the largely system-wide culture, economics, politics, and system characteristics (Mirzoev et al., 2017) that can condition causal mechanisms to hinder or drive certain outcomes (Pawson \u0026amp; Tilley, 1997). This background was represented by the “Sustainable Economic Development Assessment” (SEDA) index (Boston Consulting Group, 2023), and the HSR was measured through the proxy of vaccination performance indexes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e21 (quantitative phase)\u003c/p\u003e \u003cp\u003e7 (qualitative phase)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLatin American countries. The selection for the second phase was guided by the quantitative stage, with the countries with the highest Sustainable Economic Development Assessment - SEDA - and performance in vaccination coverage (Uruguay and Chile) and those in group 5 being selected, according to the interest of the researchers, since any of the other groups did not show a relationship between vaccination coverage and SEDA.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIrfan et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCoronavirus pandemic in the Nordic countries: Health policy and economy trade-off\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo determine how the Nordic countries have balanced this trade-off between the restrictive COVID-19 health policy and response measures and their impact on the economy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative analysis of the health policies of the Nordic countries in the response to COVID-19 using public databases such as WHO, European CDC, OECD, for the period between January 2020 and January 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNordic countries with similar health systems, but different policy responses.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eKeleş and Keles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eA comparative analysis of world health systems and COVID-19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo assess the adequacy of global health systems in the face of this pandemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative study of 12 countries with a quantitative approach. Information on health systems and COVID-19 was obtained from data from the Organization for Economic Cooperation and Development 2018, World Health Organization 2020, and Deep Knowledge Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNumber of COVID-19 cases and deaths\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eKo et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLessons from health insurance responses in counteracting COVID-19: a qualitative comparative analysis of South Korea and three influential countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo present the directions for health insurance support by comparing countries in terms of the domains and contents of COVID-19 health insurance support to ensure timely support in case of future pandemics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative qualitative analysis, considering an analysis framework that compared health insurance interventions for COVID-19 and non-COVID patients, considering space, personnel, and supplies as subdimensions. Considering that insurance should create conditions for the care of people with COVID-19 and maintain care for non-COVID patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe authors developed an analytical framework for the analysis of domains in which financial support (in the form of health insurance) was provided in response to COVID-19m based on WHO (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSouth Korea and countries that influenced its health insurance model\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLupu et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCovid-19 and the efficiency of health systems in Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo analyze the efficiency of the health systems of 31 European countries in the treatment of COVID-19, for the period from January 1, 2020 to January 1, 2021, incorporating some factors from a multidimensional perspective analysis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe study used data envelopment analysis, a qualitative method to analyze the efficiency of the health systems of 31 European countries in responding to covid-19.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMember countries of the European Union, Iceland, Norway, Switzerland and the United Kingdom\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMachado et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe response to COVID-19 in Argentina, Brazil, and Mexico: challenges to federative coordination of health policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo identify the main characteristics, constraints, positive elements, and limits in the responses to the COVID-19 pandemic in these Latin American nations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMultiple case study with comparative perspective. Literature review, documentary analysis and secondary data.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHistorical-comparative approach to the Social Sciences and literature on health systems.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLatin American countries with different health systems and similar federative challenges.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMoola and Hiilamo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth system characteristics and COVID-19 performance in high-income countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo analyze how characteristics of health systems influenced COVID-19 mortality rates.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative study of 43 OECD countries and selected economies, with data from the WHO and OECD, considering their financing models, service provision and public health characteristics.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e43 OECD countries and selected economies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe countries were selected because they represent distinct health systems from different geographic regions and because they are OECD members or selected non-member economies (Brazil, China, Costa Rica, Indonesia, Russia, and South Africa), which are strategic partners of the OECD and some of the world's largest economies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRafieepour, Masoumi, Dehghani\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth responses during the COVID-19 pandemic: an international strategy and experience analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo review the measures taken in selected countries to combat the COVID-19 and analyze international policies and experiences to develop appropriate health guidelines to deal with the inevitable health threats of the future\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThis is a comparative study, following 10 effective indicators in the response to covid-19, based on literature review, government reports, interviews with professors and epidemiologists, through a content analysis matrix.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCanada, Japan, Germany, Korea, Turkey, and Iran, which are not only among the leading countries in the fight against COVID-19, but have also been significantly affected by this disease. In the selection of these countries, we sought to include at least one country from each continent.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSaunes et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo explore and compare the Nordic health systems responses to the COVID-19 pandemic in the context of governance features and provide insight into differences and similarities in terms of policy responses to the epidemiological situation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative analysis of 5 countries based on Covid-19 Health System Response Monitor and public sources.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNordic countries with similar health systems, but different policy responses to the covid-19 pandemic.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTan et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMitigating the impacts of the COVID-19 pandemic on vulnerable populations: Lessons for improving health and social equity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo analyze mitigation strategies adopted by governments to support vulnerable populations during the pandemic.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThis was a comparative study of 15 countries, with a systematic review of the literature and interviews with key informants.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe authors adopted a vulnerability framework by Li et al. (2023) while simultaneously incorporating established vulnerability definitions by the National Bioethics Advisory Commission of the United States (NBAC (National Bioethics Advisory Commission of the United States), 2001).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCountries representing all WHO regions, with different income levels and health arrangements.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTsalampouni\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth systems in the European Union and policy responses to Covid-19: A comparative analysis between Germany, Sweden, and Greece\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo analyze the characteristics of the health care systems in three EU countries-Germany, Sweden, and Greece-that represent three different health care system types in Europe as well as their health policy response, to the COVID-19 pandemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative study of 3 countries on population coverage, degree of decentralization, ownership and management of health structures, sources of financing, private sector participation and employment status of physicians, using data from the European Observatory on Health Systems and Policies, as well as from the OECD Health System Characteristics Database and national health legislation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSocial welfare systems (Esping-Andersen, 1990); Welfare state and the case of health care (Moran, 2000); Types of health systems: a conceptual framework for comparison (Wendt, Frisina, Rothgang, 2009); Theory and method for the transnational study of health systems (Elling, 1994)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThree different types of health systems in Europe, as well as their health policy response to the COVID-19 pandemic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eVan De Pas et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCOVID-19 vaccine equity: a health systems and policy perspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo analyze equity in the distribution of COVID-19 vaccines and the impact of health systems.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative analysis of vaccination policies in countries of different continents.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTanahashi health systems framework (1978).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAvailability of data on vaccination and equitable access.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eWaitzberg et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEarly health system responses to the COVID-19 pandemic in Mediterranean countries : A tale of successes and challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTo compare initial health systems responses to COVID-19 in Mediterranean countries.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative analysis of 7 countries based on the Covid-19 Health System Response Monitor.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIt was not explicitly mentioned in the text\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMediterranean countries with similar health systems.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eSource: integrative review ( Web of Science, Science Direct, Scopus and PubMed Central (PMC))\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eThere is also great theoretical-methodological diversity in analysing health systems, and there is no canon to follow[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. By elaborating a theoretical framework and systematizing what emerges from the cases, it becomes possible to \"open a range of hypotheses and possible conclusions\" and to obtain inferences based on the comparative method [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although they did not specifically analysed the COVID-19 pandemicClique ou toque aqui para inserir o texto., Immergut et al., updated the situation of European health systems between 1989 and 2019, supported by neo-institutionalism [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most commonly used approaches in the reviewed studies included: a) Adaptation of the WHO framework for health systems assessment [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]; b) Articulation between extensive indicator analyses and in-depth case studies [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]; c) Case studies guided by a common framework[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. The use of typologies to classify health systems and the type of welfare state, found to be less frequent, has encountered difficulties related to the dynamics of the evolution of institutional arrangements that characterise health systems, leading to generic conclusions regarding their influence on responses[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, in most studies reviewed, the theoretical references are not made explicit, except in Machado et al. (2024) [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e], which were based on a historical-comparative approach from the Social Sciences.\u003c/p\u003e \u003cp\u003eIn addition to initiatives such as the Delphi panel involving 386 academics and experts on COVID-19 from 112 countries [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e], comparative studies are necessary to aggregate theoretical-methodological approaches and different perspectives of analysis capable of filling gaps that consensus panels of experts leave, such as the use of theoretical references and more consistent and detailed logical models. This study aims to identify possible relationships between national responses to the COVID-19 pandemic and characteristics of health surveillance systems, seeking to determine the most successful strategies.\u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e "},{"header":"Reference Framework","content":"\u003cp\u003eHealth systems have been considered instruments to achieve the coordination of resources and can be defined as \"(...) all organisations, people and actions whose primary intent is to promote, restore or maintain health\"[\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. From another perspective, health systems are historical constructions and constitute one of the forms of organised social response to the population's health problems and needs. Each society engenders its health system based on historical and structural determinants, although it is subject to constraints derived from international relations[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConsidering the adoption of pro-market reforms of health systems in the last 40 years, with limitations in coverage and increased inequalities[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], it would be understandable to be cautious about the real possibilities of health systems presenting an adequate response to control this pandemic. Several opinions disseminated in the international media and statements by experts suggested that there could be a revival of the recognition of universal and public health systems, as they would have better conditions to face COVID-19. Some investigations have also highlighted the types of health systems [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e] and their efficiency[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e] in the effort to explain the results in facing the pandemic.\u003c/p\u003e\u003cp\u003eConcerning health systems, except for Cuba, most countries have some segmentation, either differentiated models of social security for public servants or the military, or for the population defined as vulnerable, or through complementary private insurance for workers and higher-income strata. Funding ranged from predominantly public to fundamentally private, with sources including taxes, employee and employer contributions, and/or direct disbursement. The provision of services also involves a public-private articulation that varies in proportion between the countries studied [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe comparative study intentionally included 15 countries from five continents (Canada, China, Cuba, France, Germany, Italy, Mozambique, New Zealand, Portugal, South Korea, Sweden, the United States (US), the United Kingdom (UK), Uruguay and Vietnam), based on their health systems, geographic location, and state characteristics.\u003c/p\u003e\u003cp\u003eThe research strategy consisted of four steps: in-depth case studies, construction of logical models and analysis matrices, multiple correspondence analysis (MCA), and graphical analysis, detailed more elsewhere [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCase studies were carried out for each country, supported by an integrative literature review (adapted from the proposal by Whittemore and Knafl, 2005)[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. Searches were carried out between May 2020 and December 2022 in Web of Science, Science Direct, Scopus and PubMed Central (PMC) databases, using combinations of the descriptors \"Country name\" and \"COVID-19\" with \"health system\", \"national response\" and \"surveillance\", applying advanced search engines.\u003c/p\u003e\u003cp\u003eData from the WHO's COVID-19 monitoring database, the Our World in Data portal and WHO reports from the European Observatory on Health Systems and Policies were also used. Information on mobility in different locations and types of establishments was also used, obtained from the Google Mobility database.\u003c/p\u003e\u003cp\u003eThe preliminary establishment of a logical framework, based on a theoretical model of health surveillance [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e], with a goal-oriented framework defined through a consensus technique, enabled the construction of a reference framework for comparative analysis of the responses of various countries. Three logical models were then constructed: a macro model of the waves (Fig.\u0026nbsp;1), a causal model (Fig.\u0026nbsp;2) and an intervention model (Fig.\u0026nbsp;3). The logical models guided the selection of dimensions and criteria, resulting in a second matrix for comparing countries containing five dimensions and twenty-two evaluation criteria. These dimensions included management, measures adopted, structures and agents mobilised, and civil society action and effects.\u003c/p\u003e\u003cp\u003e[Insert Fig.\u0026nbsp;1 here]Clique ou toque aqui para inserir o texto.\u003c/p\u003e\u003cp\u003e[Insert Fig.\u0026nbsp;2 here]Clique ou toque aqui para inserir o texto.\u003c/p\u003e\u003cp\u003e[Insert Fig.\u0026nbsp;3 here]Clique ou toque aqui para inserir o texto.\u003c/p\u003e\u003cp\u003eSecondary data from Our World in Data and the WHO were used for mortality, vaccination coverage, tracking, and testing indicators, with distribution by quartiles.\u003c/p\u003e\u003cp\u003eAfter constructing and validating the matrices for each country in 2020 and 2021, based on the criteria for analysing responses to COVID-19, the Multiple Correspondence Analysis (MCA was conducted. The study used the MCA to examine the relationship between the matrices over the years, identifying homogeneities and heterogeneities and defining subgroups close to or far from the most appropriate pandemic response.\u003c/p\u003e\u003cp\u003eThe active variables in the MCA in 2020 were coordination, strategy, mobility, Stringency Index (SI), surveillance, and excess mortality. In 2021, these variables were maintained, with the addition of complete vaccination coverage against COVID-19 in December. The other variables were considered supplementary. Statistical analysis was performed with the R software. After defining the groups and subgroups, radar charts were created for each subgroup and year, covering all the matrix criteria to understand the response patterns better.\u003c/p\u003e\u003cp\u003eThe scores related to the responses to each criterion in the matrices were categorised based on the proximity of the goal oriented framework, classifying the countries as most adequate (MA), adequate (A), least adequate (LA) and an intermediate classification (INT) for those located among the other categories. Each criterion or variable received a score within these categories: Least Adequate (LA): 0 and ≤ 3.3; Intermediate (INT): \u0026gt; 3.3 and ≤ 6.6; Adequate (A): \u0026gt; 6.6 and ≤ 9.5; Most Adequate (MA): \u0026gt; 9.5 and ≤ 10.0.\u003c/p\u003e\u003cp\u003eThe final stage of the study involved graphical analysis to compare the criteria and indicators of the matrix across countries, also considering the groups/subgroups established by the ACM. The answers were classified into three categories: most adequate (lines closer to the end of the graphs, with high scores), less adequate (more central lines, with low scores), and intermediate (with more significant variation).\u003c/p\u003e\u003cp\u003eThe conformation of groups and subgroups based on the classification made it possible to compare and better understand the characteristics of the responses to COVID-19 that influenced the course of the pandemic in each country. The in-depth case studies of the 15 countries brought possible explanations for these identified proximities and distances, resulting from the multiple correspondence analysis supported by the evaluation matrix score.\u003c/p\u003e"},{"header":"Results and discussion","content":"\u003cp\u003eAlthough there are no specific response patterns in the proposed classification, especially for those countries with an intermediate response, the results of the ACM suggest the constitution of groups and subgroups with similarities and approximations.\u003c/p\u003e \u003cp\u003eIn 2020, Asian countries (China, Vietnam, and South Korea), island countries (New Zealand and Cuba), and Canada were those with the most adequate responses. Among the least suitable were the US, the UK and Sweden, the latter as an \u003cem\u003eoutlier\u003c/em\u003e. Portugal and Germany were the intermediaries closest to the appropriate group. In the intermediate range, France, Italy, Mozambique and Uruguay presented responses closer to the least adequate (Fig.\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e[Insert Fig.\u0026nbsp;4 here]Clique ou toque aqui para inserir o texto.\u003c/p\u003e \u003cp\u003eAmong countries with most adequate responses, in 2020, we have some capitalist (South Korea, New Zealand and Canada), socialist (Cuba and Vietnam) and state capitalist (China) countries with a variety of health systems: National Health Service, universal public with predominant financing of tax resources and predominantly public service provision (New Zealand); segmented system with greater weight of public funding, financed by general taxes (Canada); a universal health system with a state monopoly (Cuba); segmented social insurance with a greater weight of public financing (China and Vietnam) and segmented social insurance with a greater weight of private (South Korea). The Socialist Republic of Vietnam has universal public insurance, but with the presence of the private sector, especially at specialised and hospital level, unlike Cuba, whose health system is entirely state-owned Clique ou toque aqui para inserir o texto..\u003c/p\u003e \u003cp\u003eThe countries with the least adequate responses are all capitalist and have different segmented health and social protection systems. The US has a market-bound healthcare system with no comprehensive social insurance. Sweden was one of the precursors of the social-democratic welfare state, with a universal social protection system and a national health service, which has undergone pro-market modifications in recent decades. The UK has a universal social protection system and a paradigmatic health system \u0026ndash; public and universal (NHS), but which has been making its public character more flexible since the 1980s, carrying out pro-market reforms in this century [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis diversity of health and social protection systems is also present in countries classified as intermediate. Thus, we can mention Portugal with a National Health Service of a public and universal nature, France and Germany with a broad social insurance system and universal health system, Uruguay with the social insurance model and segmented health system, with public and private sectors coexisting, and Mozambique with a similar model, but having a National Health Service (SNS) with more limited coverage. In the group of intermediaries closest to the inadequate, Italy enacted a Health Reform in 1978, implementing a National Health Service (SSN), a Beveridgian model, of a public, universal and decentralised nature (Berlinguer, Fleury Teixeira and Campos, 1988), despite adopting incremental pro-market reforms in recent years, with a reduction in public infrastructure [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2021, only China, South Korea, and New Zealand remained as countries with an adequate response. In the intermediate responses, closer to the adequate subgroup, are Germany, Canada, Cuba, Mozambique, Portugal, Uruguay and Vietnam. In the subgroup of countries with an intermediate response closer to inadequate, France and Italy remained, while the US, the UK, and Sweden continued in the group with inadequate response. (Fig.\u0026nbsp;5).\u003c/p\u003e \u003cp\u003e[Insert Fig.\u0026nbsp;5 here]Clique ou toque aqui para inserir o texto.\u003c/p\u003e \u003cp\u003eTo the extent that the types of society, social protection and health systems were not expressed in the most appropriate responses, it would be relevant to discuss some differences concerning the second level of the logical model of intervention: pre-existing and emergency social policies, crisis management, structures and agents mobilised exceptionally (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eThese elements, especially crisis management/response, stand out in the comparative analysis mainly due to their consequences in terms of coordination, risk communication, degree of adherence to the main measures adopted, relevance and adequacy of actions and main strategy (epidemiological surveillance, medical and hospital care, herd immunity, vaccination and exceptional measures) (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e and 7).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the two years analysed, the countries classified as more adequate (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e and 7) had their lines demarcated more at the end of the radar graphs, representing a higher score for the criteria, close to the defined goal oriented framework. The opposite was observed in countries with an inadequate response, with graphic representation closer to the centre. On the other hand, for the countries with an intermediate response, the closer to the adequate, the higher the score, approaching the ends of the graph. The opposite, with some points closer to the centre, was also confirmed in the intermediate countries closest to the least adequate (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e and 7).\u003c/p\u003e \u003cp\u003e[Insert Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e and 7 here]Clique ou toque aqui para inserir o texto.\u003c/p\u003e \u003cp\u003eCountries with more adequate responses showed precise national coordination with science-based decision-making, a rapid response strategy based on careful surveillance of cases and contacts, widespread testing, isolation of cases, and quarantine of contacts with articulation in different spheres of government, which reflected positively on the reduction of mobility. These countries presented a preparedness plan elaborated before the crisis and widely discussed lessons learned from previous epidemics. China and South Korea had great learnings, especially with SARS and H1N1, and South Korea with MERS [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. New Zealand's learning from previous communicable diseases is cited [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Although there are not many reports of significant epidemics in Cuba, the lessons learned from the Ebola epidemic in 2013 stand out (Vasco et al., 2023).\u003c/p\u003e \u003cp\u003eIn 2020, it is noteworthy that these countries had lower investments in income support, especially Cuba and Vietnam (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e). This can be attributed to the effectiveness of the response to the pandemic, which is based on strict surveillance measures, which have had less impact on the economies of these countries. In Cuba, the economic crisis worsened after the pandemic and had repercussions on tourism, a mechanism adopted in the face of the embargo maintained by the US for decades [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In this more appropriate responses group, South Korea, China, New Zealand, and Canada implemented compensatory policies for different target audiences at various times, ensuring aid in the minimum wage (MW) amount throughout the period or above 50% of the MW in different periods.\u003c/p\u003e \u003cp\u003eThere was a slight variation in the healthcare offered, and the risk communication was clear, consistent, and grounded in scientific evidence. In the group with adequate response, in 2021, China, South Korea, and New Zealand had vaccination coverage above 74% in December 2021 (Fig.\u0026nbsp;7).\u003c/p\u003e \u003cp\u003eAmong the intermediaries, there was a more significant variation in the responses in the two years. Generating subgroups in the intermediate classification after the MCA analysis was helpful for a better understanding of the differences and proximities (Fig.\u0026nbsp;7). France and Italy, countries with an intermediate response closer to the least adequate, showed, especially in 2020, a graphic representation with closer proximity to the centre of the radar graphs, while others, such as Germany and Portugal, remained closer to the drawn goal oriented framework, being the closest intermediate to the appropriate ones (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Canada and Cuba showed higher excess mortality than countries with an adequate response in 2021, as well as changes in testing, SI rates, and collapse structure. Mozambique, in the intermediate response group, presents variations in response to criteria such as mobility, SI rates, testing, and emergency aid, mainly related to the country's economic and social structure. For 2021, there is a certain relaxation of non-pharmacological measures, reflected in lower SI than those observed in 2020, with the main difference in strategies being the start of vaccination (Fig.\u0026nbsp;7).\u003c/p\u003e \u003cp\u003eIn 2021, vaccination coverage for the group classified as intermediate also varies, with Portugal, Canada, and Cuba showing the best results. The closer they are to the not adequately group, the lower the vaccination coverage, as in Uruguay, Germany, Italy, France and Mozambique. In general, there is a relaxation of non-pharmacological measures and greater regularity in the supply of tests in 2021.\u003c/p\u003e \u003cp\u003eAmong the least adequate countries, all had the maximum score in the income benefit in 2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e). They did not perform adequately in the response, despite having respected and internationally recognised public health institutions such as the CDC (US) and the NHS (UK). The scores of these countries for the criteria analysed are mostly below 6.0, approaching the centre, denoting that these institutions could not guarantee an adequate response to COVID-19 despite their technical capacity. Although the UK and the US started vaccination against COVID-19 in December 2020, its coverage did not reach high percentages, possibly due to the anti-vaccine movements and vaccine hesitancy. Vaccination made it possible for economic activities to resume safely so that these countries' investment in emergency aid was reduced in 2021. The graph shows an improvement in some of the categories evaluated in the UK and the US, in the latter more markedly, representing the improvement in coordination, strategy, risk communication, as well as a higher supply of tests with the beginning of the Biden-Harris administration [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTwo poles of conceptions and attitudes incorporated, implicitly or explicitly by the governments of the different countries analysed in facing the pandemic were identified, influencing the strategies adopted. On the one hand, there was the anti-science position, ostensibly disseminated at the beginning of the pandemic by heads of State, as was the case in the US in 2020 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].This position initially denied the very existence of the pandemic and then its severity. There were also disagreements and disputes regarding control strategies. Some countries have advocated the herd immunity thesis, defended by some doctors in the US and the UK [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Sweden has radicalised this point of view in 2020, not approving restrictive measures, closing schools, discouraging the use of masks, and defending the thesis of respect for individual freedoms by adopting these positions [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the opposite pole were heads of government who took the lead in managing the fight against the pandemic and articulated not only with parliament but also with the leaders of health institutions, and incorporated points of view defended by broad segments of the scientific community and by international organisations, such as the WHO, like New Zealand, Germany, Canada, Cuba, China and South Korea. We can identify nuances and variations between these two poles depending on national specificities concerning the interfaces between health institutions and other social spheres.\u003c/p\u003e \u003cp\u003eIt is possible to verify common characteristics of the various answers and specificities that help to understand their dynamics better. As common characteristics that acted favourably in those cases classified as more adequate, it is worth considering the coordination, the strategy adopted, the surveillance, and the relationship between the prioritised measures and the population's adherence in 2020, as well as vaccination coverage in 2021. The participation of society in favour of the measures, as opposed to the denialist and anti-vaccine movements that opposed the control policies, was also facilitating aspects.\u003c/p\u003e \u003cp\u003eThe main strategy of countries with more adequate responses was focused on containment (\"Covid-zero\"), seeking to reduce community transmission and, therefore, suppress the circulation of the virus, thereby \"flattening the curve\" of cases. The lockdown (New Zealand, China, and South Korea) was the preferred measure along with surveillance, extensive testing and tracing of cases and contacts, before the availability of immunisation. South Korea has successfully controlled risks and damage, in addition to taking significant action on social determinants and previous experience with other respiratory epidemics. Cuba and Vietnam had substantial participation and adherence of the population in the control measures, activating revolutionary referents and the \"collective spirit\" to the point that the SI reached 100% on the Caribbean island in June 2020. In New Zealand, good performance was associated with the Prime Minister's leadership alongside the Public Health General Director, a career official at the Ministry of Health since 2004. Clear and consistent messages would have inspired confidence and security, obtaining greater adherence from the population. There was significant national coordination and relevant governance in these countries with more adequate responses.\u003c/p\u003e \u003cp\u003eCountries with less adequate responses had mitigation as their main strategy, emphasising medical and hospital care, while neglecting epidemiological surveillance and physical distancing. The UK and the US, although having health systems with opposite characteristics, saw their health services pressured, if not collapsed, due to the lack of control of the pandemic at various times in 2020, placing it in the quartile with the highest mortality rates and excess mortality in both 2020 and 2021.\u003c/p\u003e \u003cp\u003eThe explanation for the inadequate performance of these two countries, technically classified as the most prepared to face pandemics by the 2019 Global Health Security Index (GHSI), involves several factors [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In the UK, in December 2021, an Independent Commission of Inquiry was established to examine the country's response and the impact of the COVID-19 pandemic and learn lessons for the future (UK Covid inquiry. Available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://covid19.public-inquiry.uk/\u003c/span\u003e\u003cspan address=\"https://covid19.public-inquiry.uk/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 10.08.2023). Numerous testimonies highlighted the unpreparedness of the NHS and the social care system to face the pandemic, mainly due to a decade of budget cuts (OPENING STATEMENT OF THE TRADES UNION CONGRESS MODULE 1. Available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.covid19.public-inquiry.uk/documents/opening-statement-of-trades-union-congress-dated-12-june-2023/Accessed\u003c/span\u003e\u003cspan address=\"https://www.covid19.public-inquiry.uk/documents/opening-statement-of-trades-union-congress-dated-12-june-2023/Accessed\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e on 08/10/2023).\u003c/p\u003e \u003cp\u003eIn the US, in addition to a health system favouring the market and decentralisation, in the first year of the pandemic, they faced problems such as the politicisation against the use of masks recommended by the CDC and conflicts in health communication, with misinformation attributed to the Trump administration. Even the CDC changed some of its published guidelines, despite the objections of its experts [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSweden, in the ACM at the opposite quadrant to the best-performing group, adopted the strategy of not implementing recommended preventive measures related to physical distancing or surveillance. Even with mitigation measures, there were failures in providing care to more vulnerable groups, such as older adults [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The government's strategy was the object of harsh criticism by the scientific community and was partially contested by the Commission of General Investigation. The Commission made up of professionals with experience in various areas beyond health, such as law, defence, economics, and social sciences, concluded that \"earlier and more extensive measures should be taken, particularly during the first wave\" [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].The Commission's report also highlighted that Sweden's strategy would have failed to protect older people and other vulnerable groups. Despite these criticisms, the Commission supported the government's decision to consider the control measures as voluntary, which would have maintained the individual freedom of Swedes during the pandemic (Ludvigsson, 2023).\u003c/p\u003e \u003cp\u003eOne of the common aspects among these countries with problems in controlling the pandemic can be considered the lack of valorization of thinking supported by scientific evidence, as was the case in Sweden, the US, and the UK. This fact resulted in moments of non-use of the required interdisciplinary expertise and, in particular, epidemiology [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOn the other hand, in countries with more adequate responses, there was articulation between the Executive, Legislative, health authority, and scientific community - as in the case of Germany[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and Portugal [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]).\u003c/p\u003e \u003cp\u003eFinally, it is more difficult to identify the main strategy among intermediate response countries. However, a mixture of mitigation and containment actions, depending on the circumstances, can be highlighted over time. Italy was one of the first countries considered unsuccessful, despite having a public and universal health system. However, there was a change in strategy with improved control at various stages of the pandemic. Rapid response from government officials such as Portugal [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] (Barros et al., 2023) and Uruguay, with non-pharmacological measures focused on physical distancing and voluntary confinement (Uruguay) or mandatory confinement (transgression of rules considered a civil disobedience crime in Portugal), allowed a relative success in relevant periods, even before vaccination. In France, despite the strict blockades in the first two waves, the increase in health investments, compensatory policies and the protection of the economy, there was a delay in preparing and implementing the plan to confront it. Germany, however, which has an extensive infrastructure of hospital beds, adopted severe measures related to the containment strategy, obtaining results superior compared to Portugal and France. Mozambique, in the intermediate response group, requires caution in interpreting results due to the scarcity of scientific studies on pandemic control and the use of government-origin information in the review. However, the timely elaboration of a coping plan, previous experience in epidemic control, the use of community agents, and epidemiological surveillance may partially explain the adequacy of its response to the COVID-19 pandemic, despite the difficulties in ensuring physical distancing and obtaining vaccines.\u003c/p\u003e \u003cp\u003eThe participation of society, supporting and even assisting in the implementation of measures, as in Mozambique and Cuba, can also be considered as facilitating aspects. On the other hand, the denialist and anti-vaccine movements that opposed the control policies made it difficult to create consensus about the effectiveness of that measure. This may explain why vaccination coverage was below 80% in December 2021 in countries with easy access to vaccines, such as the US, with 63%, and the UK, with 70% [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEven in capitalist countries with neoliberal policies, state intervention was fundamental for controlling the health emergency, partially ensuring the conditions for physical distancing, through emergency aid to companies and individuals. The countries that performed best in controlling the pandemic, such as South Korea, activated, in addition to timely and efficient surveillance, testing, isolating cases, quarantining contacts, and ensuring that treatment was free of charge [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], instead of the most frequent co-participated medical care by users direct disbursement [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In France, partial reimbursement has been increased to 100% of diagnosis and treatment of COVID-19 costs, and several insurers waived copays in the US [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe analysis of the 15 cases showed that in practically all countries, except for Sweden, in the first months, there was the adoption of some exceptional political status aimed at giving governments powers to enact measures that limited people\u0026acute;s mobility, a the closure of schools, borders, and commerce. In addition to these common aspects, several countries presented specificities that deserve to be highlighted in the analysis of their responses. Among these is the interruption of transmission that occurred in New Zealand [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e](the four-level surveillance model with different social protection measures in Vietnam [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], the articulation of the Executive, Legislative, health authority and scientific community in Germany [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e](and Portugal with the creation of the red lines monitoring instrument[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePrimary Healthcare (PHC) performance in Cuba deserves to be highlighted, carrying out an intense process of active search, from door to door, for tracing cases and contacts. The timely action of epidemiological surveillance integrated with PHC allowed the early identification of cases, isolation, follow-up, and recovery. Medical students and a diverse group of professionals participated in this process. Therefore, Cuba was the only country among the 15 studied that broadly complies with the principle of the integrality of care, articulating PHC with health surveillance, in addition to contemplating the continuity of care at different levels of the health system[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] This practice has not been verified in other countries with successful responses (Canada, Germany, France, China, South Korea) which, in general, continue to reproduce the separation and dichotomy between medical-hospital care and the so-called Public Health.\u003c/p\u003e \u003cp\u003eIn addition, the strengthening of the health production complex and the high national production capacity of inputs and equipment are aspects to be valued, as seen in the German and Cuban responses. In Cuba, vaccines were produced and distributed to the population in massive quantities with rapid acceptance, reaching a 70% vaccination rate, first in America. Germany stood out for its science and technology system and national industry, which focused on producing tests, vaccines, various inputs, medical-hospital equipment, and personal protective equipment (PPE).\u003c/p\u003e \u003cp\u003eRegarding interdisciplinarity, although there was a specificity of knowledge about epidemics from Public Health and, in particular, epidemiology, a consensus was also reached, translated by the aforementioned Delphi panel, on the need for intersectoral and whole-of-society responses for greater effectiveness of control policies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]). Although Public Health experts were a minority in the panel above, this thesis, which was the subject of great consensus, was already part of the consolidated knowledge of researchers in the field of health policies and epidemiology, appearing in documents from international organisations such as the WHO since 1961.\u003c/p\u003e \u003cp\u003eIn Sweden, the strategy was defined by a few people from the Public Health Agency. No scientific advisory committee was formed. After criticism of not incorporating expertise outside the Public Health Agency, its director formed a commission with clinicians, virologists and infectologists. There were no epidemiologists or public health experts. The questioning of the control policy adopted was progressively inhibited, and critics were discredited or considered as hobby epidemiologists[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral initiatives by isolated scientists and groups of scientists from various disciplines gathered informally to study the pandemic and make recommendations, and even from the Royal Swedish Academy of Science, were ignored by the government and the Public Health Agency. None of the countries studied were effectively prepared for the pandemic. Although many had performance classified as adequate or very adequate, there were various criticisms from different population sectors. In some countries, such as Sweden and the UK, Commissions of Inquiry have been created to assess the responsibilities of the pandemic. In 2021, the Office of the Auditor General of Canada (OAG) concluded that the Public Health Agency was not adequately prepared to respond to a pandemic and did not address long-standing health surveillance information issues before the COVID-19 pandemic[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt was found that it was not enough for a country to have an organised, public and universal health system. Structural (social inequalities), historical-institutional (limited investments in public systems, fragmentation/segmentation, little appreciation of PHC and integration with health surveillance, etc.), political-conjunctural (difficulties in coordination, resistance against restrictive measures to economic activities and decisions without scientific basis) and societal (\u003cem\u003efake news\u003c/em\u003e, low adherence to distancing and the use of masks, vaccine hesitancy, etc.) constraints are pointed out as unfavourable responses to the pandemic [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The functioning of the system and the mobilisation of resources depended a lot on the strategy adopted.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eFinal considerations\u003c/h2\u003e \u003cp\u003eThe results presented in this study should be examined considering the limits of comparative analyses based on literature review and official sources, as well as certain theoretical and methodological particularities.\u003c/p\u003e \u003cp\u003eThe first aspect to bear in mind is the complexity and insufficient theorisation about health systems and their relations with other spheres of governments and societies, with their historical and cultural peculiarities in constant movement. This fact results in most of the problems related to comparing countries. The pandemic is a dynamic phenomenon with different repercussions in national territories. The analysis carried out has limitations because it tries to represent a portrait of a constantly changing reality.\u003c/p\u003e \u003cp\u003eSecondary data is used in research involving several countries, but its scope and quality are not always uniform and comparable. International databases such as the WHO, OECD, and World Bank, among others, can reduce these problems but do not guarantee the faithful expression of reality.\u003c/p\u003e \u003cp\u003eIn the bibliographic review, even when inclusion and exclusion criteria are explained or if a critical reading of selected articles methodology is carried out, there is always a possibility of absorbing an authors\u0026acute; mistaken interpretation or a given opinion, not always adhering to the knowledge produced. In addition, countries with a significant base of research production and that widely publish their articles in journals allow for the confrontation between divergent or consensual results, enabling a more informed judgment of the conclusions. While the analysis of narrower scientific-technological production countries or with a low presence of articles published in international journals reduces the possibility of evaluating their results and conclusions more confidently. As editorial policies are not neutral and can be influenced by economic, political, and ideological conditions, access to articles is also not free of bias.\u003c/p\u003e \u003cp\u003eThe contradiction between depth and scope and the concern with the historicity of countries should be an object of attention in comparative studies. The view of foreign researchers on the experience of other countries has the advantage of a certain critical distance but also the disadvantage of not perceiving nuances that can be identified when living in the country, especially about the predominant values, culture, ideologies and the respective history.\u003c/p\u003e \u003cp\u003eIn the present study, the theoretical-methodological option was to seek an objectification as far as possible, guided by a theoretical frame of reference, elaborating a logical model, adopting consensus techniques (Delphi), systematising typologies, defining scales and quantification procedures (assigning grades according to explicit criteria), in addition to triggering peer reviews. Still, different questions can be raised when assessing countries' responses to the COVID-19 pandemic, before and after vaccines became available, or in the face of other waves and variants of the virus. Thus, it becomes quite problematic to affirm the existence of an entirely adequate response that, a priori, would ensure the success of the intervention in prevention and control. Even if the WHO's recommendations were adopted as the \"gold standard\", there would be a need to contextualise and recognise changes in this organisation's guidelines over time, as in the example of using masks. From this perspective, the study avoided being definitive about the success or failure of the countries, preferring to classify the answers by reference to a goal oriented framework, submitted to a Delphi technique, as \"adequate (by reference to this goal oriented framework)\", \"not very adequate\" and \"intermediate\". MCA can point to the proximity or distance of the different cases with these outcomes.\u003c/p\u003e \u003cp\u003eAnother aspect that made objectification through scoring challenging was the changes during the pandemic, with the emergence of new waves and variants of the virus and the direction of government responses, which changed in several countries. Almost all the countries studied went through ups and downs, and several lessons were learned in the dynamics of the pandemic.\u003c/p\u003e \u003cp\u003eThe comparative analysis presented in this article sought to inquire about the relationship between the characteristics of health systems and responses to the pandemic. The findings point to the absence of a univocal relationship between the type of health system and the more or less successful response of the countries analysed. The greater adequacy of the response about the designed goal oriented framework and the best results measured in excess mortality were related to the strategy adopted and the crisis management through coordination, risk communication and timeliness of the measures adopted. Good management was also capable of enhancing and expanding the capacities of health systems in terms of material and human resources necessary for developing surveillance actions \u0026ndash; risk control, and care for clinical cases \u0026ndash; damage control. However, national responses were diversified, with many specificities related to historical and social characteristics and government and pandemic management.\u003c/p\u003e \u003cp\u003eGiven the complexity of the social determination of health and disease, which was confirmed in an exemplary way in the COVID-19 pandemic, the best preparation for future pandemics is related to the improvement of the analysis of the health situation, guiding planning, as well as the development of sustainable environmental policies, promoting health.\u003c/p\u003e \u003cp\u003eIntegrated government coordination, subsidies to the most vulnerable people and companies, and the mobilisation of public and private resources to assist people and expand the scale of surveillance were only possible due to state action in the various countries investigated. On the other hand, the participation of the organised population filled several gaps left by the omission or limitation of the State's action.\u003c/p\u003e \u003cp\u003eThe dynamics of the pandemic have shown the importance of global coordination through the WHO[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Although the responses have been fundamentally national, the WHO has established itself as a reference, as a pole builder of positions based on scientific evidence and as an articulating instance of supranational initiatives aimed at reducing inequalities, such as the Covax facility, aimed at the solidary distribution of vaccines. Finally, despite several consensus built around the technical-scientific pole of the health field, on a global scale, many obstacles have emerged to conclude a new global agreement to confront pandemics capable of overcoming problems in access and equity in the distribution of resources.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNational Council for Scientific and Technological Development (CNPq), in partnership with the Ministry of Science, Technology, Innovations and Communications (MCTIC), and the Ministry of Health (MS), through the Department of Science and Technology of the Secretariat of Science, Technology, Innovation and Strategic Health Supplies. Call (Decit/SCTIE) - MCTIC/CNPq/FNDCT/MS/SCTIE/Decit No. 07/2020.\u003c/p\u003e \u003cp\u003eConflict of interest statement: I declare that none of the authors have any conflict of interest in relation to the content of this article.\u003c/p\u003e \u003cp\u003eEthics declaration: not applicable\u003c/p\u003e \u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLMVS, JSP, and MAS conceived and designed the study, conducted the research, and were responsible for drafting and revising the manuscript.TRAR and SGB contributed to data production, data analysis, and participated in manuscript writing and revision.All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thanks Denise Nogueira Cruz, Alcione Brasileiro Oliveira, Catharina Leite Matos Soares, Gerluce Alves Pontes Silva, Jamacy Costa Souza, L\u0026iacute;via Silva Angeli, Sonia Cristina Lima Chaves, Melsequisete Daniel Vasco, Camilla Andrade Silva Ribeiro, Everly Caroline Teixeira e Maria da Concei\u0026ccedil;\u0026atilde;o Nascimento Costa for the contributions to the analysis carried out.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe dataset(s) supporting the conclusions of this article is(are) included within the article.Ethics declaration: not applicableClinical trial number: not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLazarus JV, Romero D, Kopka CJ, et al. 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Published online 2022:263.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health systems, covid-19, pandemics, cross country comparisons*","lastPublishedDoi":"10.21203/rs.3.rs-8952346/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8952346/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eUnderstanding how different Health Systems respond to pandemics is essential to identify vulnerabilities and inform preparedness for future events. This article analyzes national response to the covid-19 pandemic in 15 selected countries, investigating the relationship between health systems and the control measures adopted. A logical model was developed based on a goal oriented Framework, defined through a consensus technique, providing an analytical reference for cross-country comparison. Multiple correspondence analysis was applied to classify countries according to their alignment with the goal oriented Framework. The resulting typology enabled the identification of shared patterns and divergences in national responses, further explored through in-depth case studies. National responses were diverse, with many specificities related to historical and social characteristics, as well as government and pandemic management. Successful experiences included New Zealand\u0026rsquo;s rapid transmission-interruption strategy; Vietnam\u0026rsquo;s four-tier surveillance model; the coordinated actions of political authorities, health agencies, and scientific communities in Germany and Portugal; Canada\u0026rsquo;s genomic surveillance; and Cuba\u0026rsquo;s strong primary care response. The comparative analysis point to the absence of a relationship between the type of health system and the more or less successful response. Instead, more adequate responses, reflected in better alignment with the framework and lower excess mortality, were related to the strategy adopted and the management of the crisis with regard to coordination, risk communication and timeliness of the measures adopted.\u003c/p\u003e","manuscriptTitle":"Health systems in the world and COVID-19","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 19:27:44","doi":"10.21203/rs.3.rs-8952346/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9eb92deb-7a64-4cea-bcbf-8da65c617832","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-18T07:02:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T14:33:52+00:00","index":88,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T07:11:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 19:27:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8952346","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8952346","identity":"rs-8952346","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}