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Sri Lankan Health System Response to the COVID-19 Pandemic: A Post Evaluation to Assess the Strengths and Weaknesses by Using Health Systems Building Blocks

Year 2023, Volume: 5 Issue: 2, 135 - 151, 26.12.2023

Ranga Sabhapathige Dilrukshi Deerasinghe

https://doi.org/10.52675/jhesp.1344195

Abstract

The COVID-19 pandemic spread across the globe, threatening almost all health systems, from the strongest to the most vulnerable, and the Sri Lankan health system was no exception. Since the COVID-19 pandemic became a serious public health threat in China, India, and other parts of the world, Sri Lanka has been on high alert and ready to respond.
Objectives
The purpose of this research is to describe how Sri Lanka's health system dealt with the COVID-19 pandemic using the world health organization's health systems building blocks framework, to assist policymakers in better understanding the deficiencies and planning future crisis management.
Methods
COVID-19-related documents about Sri Lanka were manually and electronically searched, including peer-reviewed articles in local and international journals, government publications such as circulars, guidelines, and reports, WHO and World Bank publications, regional and international news websites, and non-governmental organizations. Thematic analysis was used.
Results and conclusions
The Sri Lankan health system responded in a proactive and multi-sectoral manner. Before the pandemic hit the country, the hospital system and a well-established preventive health sector were prepared. However, issues such as human resource shortages, drug shortages, and other medical equipment shortages, as well as financial constraints, were difficult to manage. Delays in decision-making during the third wave led to negative outcomes for the country. However, the country was protected during the fourth wave due to committed vaccination and other timely preventive measures.
Keywords: COVID-19, Response, Health system, Sri Lanka, Building blocks approach,

Keywords

Covid-19 Health system approach, Sri Lanka Post evaluation

Supporting Institution

Ministry of Health Sri Lanka

Thanks

Deputy Director General Medical Services

References

  • Amaratunga, D., Fernando, N., Haigh, R., Jayasinghe, N. (2020). The COVID-19 outbreak in Sri Lanka: A synoptic analysis focusing on trends, impacts, risks and science-policy interaction processes. Progress in Disaster Science, 8, 100133.
  • Athapattu, P., Wijenayake, P. H., Weediyawatta, P. K. G. P. (2021). Establishment of a national focal point to monitor the Performance of PCR Centres in Sri Lanka. Sri Lankan Journal of Medical Administration, I, 49-55.
  • Chen, H., Shi, L., Zhang, Y., Wang, X., Jiao, J., Yang, M., Sun, G. (2021). Response to the COVID-19 Pandemic: Comparison of strategies in six countries. Frontiers in Public Health, 9, 1-11.
  • CMA. (2020). GRID Index: Tracking the global leadership response in the COVID-19 crisis. CMA
  • Australia On Target. (Access Address: https://cmaaustralia.edu.au/ontarget/grid-index-trackingthe-global-leadership-response-in-the-covid-19-crisis) (Access Date: April 24, 2022)
  • De Silva, C., Jayakody, H. (2020). Essential service delivery in reproductive, maternal and child health services during the pandemic. Journal of the College of Community Physicians of Sri Lanka, 26, 190.
  • Dr. Fernando GHS, Dr. Gunasena BAHM, Dr. Yapa Bandara AS, D. L. P. (2021). Establishment of a Hospital Information Updating System to Augment Hospital Readiness for the Third Wave of COVID-19 in Sri Lanka. 28th Scientific Sessions, Sri Lanka College of Medical Administration, 23.
  • Economynest. (2020). Sri Lanka starts 1390 Coronavirus hotline to call for Covid-19 symptoms – EconomyNext. (Access Address: https://economynext.com/sri-lanka-starts-1390-coronavirushotline-to-call-for-covid19-symptoms-63916/) (Access Date: July 22, 2021)
  • Epidermiology. (2020). Guideline for the Home quarantine / Quarantine in non-health care settings. Epidemiology Unit Ministry of Health-Sri Lanka.
  • Epidemiology Unit. (2020). Provisional Clinical Practice Guidelines on COVID-19 Suspected and Confirmed Patients – In collaboration with Ceylon College of Physicians Coordinated by Epidemiology Unit Ministry of Health-Sri Lanka.
  • Sri Lankan Health System Response to the Covid-19 Pandemic: A Post Evaluation to Assess the Strengths and Weaknesses by Using Health System Building Blocks 149
  • Epidemiology Unit. (2021). Covid 19 Situation Report. Ministry of Health-Sri Lanka.
  • Epidemiology Unit. (2021). Guidelines for COVISHIELD Covid-19 Vaccination Campaign January-February 2021. Ministry of Health-Sri Lanka.
  • Epidemiology Unit. (2022). Epidemiology unit Covid-19 vaccination coverage. (Access Address: https://www.epid.gov.lk/web/) (Access Date: February 19, 2022)
  • GoSL. (1897). Quarantine and Prevention of Diseases Ordinance. In Legislative Enactments of the Democratic Socialist Republic of Sri Lanka. Chapter 222.
  • Gostin, LO., Mundaca-Shah, CC., Kelley, PW. (2016). Neglected dimensions of global security: The global health risk framework commission. JAMA, 315, 1451-1452.
  • Hanson, K., Ranson, M. K., Oliveira-Cruz, V., Mills, A. (2003). Expanding access to priority health interventions: A framework for understanding the constraints to scaling-up. Journal of International Development, 15, 1-14.
  • Hettiarachchi, D., Noordeen, N., Gamakaranage, C., Somarathne, E. A. R. B. D., Jayasinghe, S. (2020). Ethical responses to the covid-19 pandemic—lessons from Sri Lanka. Asian Bioethics Review, 225-233. HPB. (2020). COVID-19 dashboad. (Access Address: https://hpb.health.gov.lk/en) (Access Date: September 14, 2021)
  • Immunization, N., Advisory, T. (2021). Press Release Implementation of the scientifically recommended vaccine priority list. Journal of the College of Community Physicians of Sri Lanka, 27, 1-2.
  • JHCRC. (2021). Mortality analyses – Johns Hopkins Coronavirus Resource Center. Journal of the College of Community Physicians of Sri Lanka. (Access Address: https://coronavirus.jhu.edu/data/ mortality). (Access Date: April 16, 2023)
  • Karanikolos, M., Heino, P., McKee, M., Stuckler, D., Legido-Quigley, H. (2016). Effects of the global financial crisis on health in high-income OECD countries: A narrative review. International Journal of Health Services, 46, 208-240.
  • Kumarasinghe, K. (2021). Sri Lanka teaches the world how not to respond to COVID-19. The Diplomat. (Access Address: https://thediplomat.com/2021/05/sri-lanka-teaches-the-world-how-notto-respond-to-covid-19/) (Access Date: June 27, 2021)
  • Lanka, P. S. S. (2020). Remote work arrangements during the global Corona virus pandemic pandemic. (Access Address: https://cmb.ac.lk/remote-work-arrangements) (Access Date: July 1, 2021) Legido-Quigley, H., Asgari, N., Teo, Y. Y., Leung, G. M., Oshitani, H., Fukuda, K., Cook, A. R., Hsu,
  • L. Y., Shibuya, K., Heymann, D. (2020). Are high-performing health systems resilient against the COVID-19 epidemic? The Lancet, 39, 848-850.
  • Liyanapathirana, A., Ferdinando, R., Palihawadana, P. (2020). COVID-19 outbreak in Sri Lanka: An epidemiological response. Journal of the College of Community Physicians of Sri Lanka, 26.
  • Ministry of Health. (2018). Essential (Health) Services Package (Esp) for Sri Lanka. Sri Lanka Essential Service Package. Draft 2.2
  • Ministry of Health. (2019). Annual Health Bulletin 2019, Sri Lanka.
  • Ministry of Health. (2020). Annual Health Report 2020. Ministry of Health-Sri Lanka.
  • Ministry of Health. (2020). Provisional Clinical Practice Guidelines on COVID-19 suspected and confirmed patients In collaboration with Ceylon College of Physicians Coordinated by Epidemiology Unit (Issue March).
  • Ministry of Health. (2020a). Quarantine Process to be Followed by All Immediate Contacts of a COVID-19 Patient and Any Person Entering into The Country through Ports of Entry during the COVID-19 Pandemic Situation, Sri Lanka.
  • Ministry of Health. (2020b). Sri Lanka Preparedness Response Plan, COVID-19. (Access Address: http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/2020/SPRP. pdf). (Access Date: April 2020)
  • Ministry of Health, S. L. (2021). Sri Lanka Health System Review, 10. (Access Address: https://doi.org/https://apo.who.int/publications/i/item/sri-lanka-health-system-review.) (Access Date: April 2020)
  • Ministry of Health. (2021a). COVID-19 Sri Lanka Strategic Preparedness & Response Plan 2021. 58.
  • Ministry of Health. (2021b). Hospital vaccine program circular.pdf. (Access Address: http://www. epid.gov.lk/web/images/pdf/Circulars/Corona_virus/hospital_vaccine_program.pdf) (Access Date: November 22, 2021)
  • Moynihan, R., Sanders, S., Michaleff, Z. A., Scott, A. M., Clark, J., To, E. J., Jones, M., Kitchener, E., Fox, M., Johansson, M., Lang, E., Duggan, A., Scott, I., Albarqouni, L. (2021). Impact of COVID-19 pandemic on utilisation of healthcare services: A systematic review. BMJ Open, 11, 11-17.
  • NOCPCO. (2020). “Self-quarantining does not mean that they are positive cases” – Head, NOCPCO. WHO South-East Asia Journal of Public Health, 8, 21-25.
  • Perera, S., Nieveras, O., de Silva, P., Wijesundara, C., Pendse, R. (2019). Accelerating reforms of primary health care towards universal health coverage in Sri Lanka. WHO South East Asia J Public Health, 8, 21-25.
  • Ranga SDUM, Dilrukshi DARK, Abeysekara CM, O. S. (2021). Cost of managing COVID 19 patients in a tertiary care hospital in Sri Lanka. Journal of Medical Administration, 22, 42-48.
  • Seneviwickrama, M., Kantharuban, D., Rodrigo, C., Karunarathna, B., Talagala, I., Gunatilake, I., Jayawardana, P.,Goonewardena, S. (2020). COVID-19: the first coronavirus pandemic. Journal of the College of Community Physicians of Sri Lanka, 26.
  • Sirintrapun, S. J., Artz, D. R. (2015). Health information systems. Surgical Pathology Clinics, 8, 255-268.
  • Sltda. (2020). Sri Lanka tourism development. In Sri lanka tourism development authority. (Access Address: https://www.sltda.gov.lk/en) (Access Date: October 23, 2021)
  • The Island. (2021). Epidemiology Unit accused of manipulating pandemic data – The Island. (Access Address: https://island.lk/epidemiology-unit-accused-of-manipulating-pandemic-data/) (Access Date: June 7, 2021)
  • Timothy Roberton, Emily D Carter, N. W. (2020). Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: A modelling study. Lancet Glob Health, 8.
  • Unit, E. (2005). Surveillance case definitions for notifiable diseases in Sri Lanka. Ministry of Health, Sri Lanka, 19-20.
  • Wanigasinghe, J., Jayawickrama, A., Hewawitharana, G., Munasinghe, J., Weeraratne, C. T., Ratnayake, P., Wijesekara, D. S., Fernando, S., Rupasinghe, P. (2021). Experience during COVID-19 lockdown and self-managing strategies among caregivers of children with epilepsy: A study from low middle income country. Seizure, 84, 112-115.
  • Sri Lankan Health System Response to the Covid-19 Pandemic: A Post Evaluation to Assess the Strengths and Weaknesses by Using Health System Building Blocks 151
  • WHO. (2007). Everybody business: strengthening health systems to improve health outcomes:
  • WHO’s framework for action. (Access Address: www.who.int/healthsystems/strategy/everybodys_business.pdf.) (Access Date: July 8, 2021)
  • WHO. (2020a). Coronavirus disease 2019 (COVID-19) Situation Report. World Health Organisation, 2019 (April), 1-13.
  • WHO. (2020b). Sri Lanka: Training on COVID-19 infection prevention and control for healthcare workers. WHO COVID Infection Prevention Control for Health Care Workers. (Access Address: https://www.who.int/news-room/feature-stories/detail/sri-lanka-training-on-covid-19-infectionprevention-and-control-for-healthcare-workers)
  • WHO. (2021). WHO Dialogues: Sri Lanka shares digital innovations made during pandemic. (Access Address: https://www.who.int/southeastasia/news/feature-stories/detail/who-dialogues-sri-lanka-shares-digital-innovations-made-during-pandemic) (Access Date: January 17, 2022)
  • Ying, W., Qian, Y., Kun, Z. (2020). Drugs supply and pharmaceutical care management practices at a designated hospital during the COVID-19 epidemic. Res Social Adm Pharm, 17, 1978-1983.

Year 2023, Volume: 5 Issue: 2, 135 - 151, 26.12.2023

Ranga Sabhapathige Dilrukshi Deerasinghe

https://doi.org/10.52675/jhesp.1344195

Abstract

References

  • Amaratunga, D., Fernando, N., Haigh, R., Jayasinghe, N. (2020). The COVID-19 outbreak in Sri Lanka: A synoptic analysis focusing on trends, impacts, risks and science-policy interaction processes. Progress in Disaster Science, 8, 100133.
  • Athapattu, P., Wijenayake, P. H., Weediyawatta, P. K. G. P. (2021). Establishment of a national focal point to monitor the Performance of PCR Centres in Sri Lanka. Sri Lankan Journal of Medical Administration, I, 49-55.
  • Chen, H., Shi, L., Zhang, Y., Wang, X., Jiao, J., Yang, M., Sun, G. (2021). Response to the COVID-19 Pandemic: Comparison of strategies in six countries. Frontiers in Public Health, 9, 1-11.
  • CMA. (2020). GRID Index: Tracking the global leadership response in the COVID-19 crisis. CMA
  • Australia On Target. (Access Address: https://cmaaustralia.edu.au/ontarget/grid-index-trackingthe-global-leadership-response-in-the-covid-19-crisis) (Access Date: April 24, 2022)
  • De Silva, C., Jayakody, H. (2020). Essential service delivery in reproductive, maternal and child health services during the pandemic. Journal of the College of Community Physicians of Sri Lanka, 26, 190.
  • Dr. Fernando GHS, Dr. Gunasena BAHM, Dr. Yapa Bandara AS, D. L. P. (2021). Establishment of a Hospital Information Updating System to Augment Hospital Readiness for the Third Wave of COVID-19 in Sri Lanka. 28th Scientific Sessions, Sri Lanka College of Medical Administration, 23.
  • Economynest. (2020). Sri Lanka starts 1390 Coronavirus hotline to call for Covid-19 symptoms – EconomyNext. (Access Address: https://economynext.com/sri-lanka-starts-1390-coronavirushotline-to-call-for-covid19-symptoms-63916/) (Access Date: July 22, 2021)
  • Epidermiology. (2020). Guideline for the Home quarantine / Quarantine in non-health care settings. Epidemiology Unit Ministry of Health-Sri Lanka.
  • Epidemiology Unit. (2020). Provisional Clinical Practice Guidelines on COVID-19 Suspected and Confirmed Patients – In collaboration with Ceylon College of Physicians Coordinated by Epidemiology Unit Ministry of Health-Sri Lanka.
  • Sri Lankan Health System Response to the Covid-19 Pandemic: A Post Evaluation to Assess the Strengths and Weaknesses by Using Health System Building Blocks 149
  • Epidemiology Unit. (2021). Covid 19 Situation Report. Ministry of Health-Sri Lanka.
  • Epidemiology Unit. (2021). Guidelines for COVISHIELD Covid-19 Vaccination Campaign January-February 2021. Ministry of Health-Sri Lanka.
  • Epidemiology Unit. (2022). Epidemiology unit Covid-19 vaccination coverage. (Access Address: https://www.epid.gov.lk/web/) (Access Date: February 19, 2022)
  • GoSL. (1897). Quarantine and Prevention of Diseases Ordinance. In Legislative Enactments of the Democratic Socialist Republic of Sri Lanka. Chapter 222.
  • Gostin, LO., Mundaca-Shah, CC., Kelley, PW. (2016). Neglected dimensions of global security: The global health risk framework commission. JAMA, 315, 1451-1452.
  • Hanson, K., Ranson, M. K., Oliveira-Cruz, V., Mills, A. (2003). Expanding access to priority health interventions: A framework for understanding the constraints to scaling-up. Journal of International Development, 15, 1-14.
  • Hettiarachchi, D., Noordeen, N., Gamakaranage, C., Somarathne, E. A. R. B. D., Jayasinghe, S. (2020). Ethical responses to the covid-19 pandemic—lessons from Sri Lanka. Asian Bioethics Review, 225-233. HPB. (2020). COVID-19 dashboad. (Access Address: https://hpb.health.gov.lk/en) (Access Date: September 14, 2021)
  • Immunization, N., Advisory, T. (2021). Press Release Implementation of the scientifically recommended vaccine priority list. Journal of the College of Community Physicians of Sri Lanka, 27, 1-2.
  • JHCRC. (2021). Mortality analyses – Johns Hopkins Coronavirus Resource Center. Journal of the College of Community Physicians of Sri Lanka. (Access Address: https://coronavirus.jhu.edu/data/ mortality). (Access Date: April 16, 2023)
  • Karanikolos, M., Heino, P., McKee, M., Stuckler, D., Legido-Quigley, H. (2016). Effects of the global financial crisis on health in high-income OECD countries: A narrative review. International Journal of Health Services, 46, 208-240.
  • Kumarasinghe, K. (2021). Sri Lanka teaches the world how not to respond to COVID-19. The Diplomat. (Access Address: https://thediplomat.com/2021/05/sri-lanka-teaches-the-world-how-notto-respond-to-covid-19/) (Access Date: June 27, 2021)
  • Lanka, P. S. S. (2020). Remote work arrangements during the global Corona virus pandemic pandemic. (Access Address: https://cmb.ac.lk/remote-work-arrangements) (Access Date: July 1, 2021) Legido-Quigley, H., Asgari, N., Teo, Y. Y., Leung, G. M., Oshitani, H., Fukuda, K., Cook, A. R., Hsu,
  • L. Y., Shibuya, K., Heymann, D. (2020). Are high-performing health systems resilient against the COVID-19 epidemic? The Lancet, 39, 848-850.
  • Liyanapathirana, A., Ferdinando, R., Palihawadana, P. (2020). COVID-19 outbreak in Sri Lanka: An epidemiological response. Journal of the College of Community Physicians of Sri Lanka, 26.
  • Ministry of Health. (2018). Essential (Health) Services Package (Esp) for Sri Lanka. Sri Lanka Essential Service Package. Draft 2.2
  • Ministry of Health. (2019). Annual Health Bulletin 2019, Sri Lanka.
  • Ministry of Health. (2020). Annual Health Report 2020. Ministry of Health-Sri Lanka.
  • Ministry of Health. (2020). Provisional Clinical Practice Guidelines on COVID-19 suspected and confirmed patients In collaboration with Ceylon College of Physicians Coordinated by Epidemiology Unit (Issue March).
  • Ministry of Health. (2020a). Quarantine Process to be Followed by All Immediate Contacts of a COVID-19 Patient and Any Person Entering into The Country through Ports of Entry during the COVID-19 Pandemic Situation, Sri Lanka.
  • Ministry of Health. (2020b). Sri Lanka Preparedness Response Plan, COVID-19. (Access Address: http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/2020/SPRP. pdf). (Access Date: April 2020)
  • Ministry of Health, S. L. (2021). Sri Lanka Health System Review, 10. (Access Address: https://doi.org/https://apo.who.int/publications/i/item/sri-lanka-health-system-review.) (Access Date: April 2020)
  • Ministry of Health. (2021a). COVID-19 Sri Lanka Strategic Preparedness & Response Plan 2021. 58.
  • Ministry of Health. (2021b). Hospital vaccine program circular.pdf. (Access Address: http://www. epid.gov.lk/web/images/pdf/Circulars/Corona_virus/hospital_vaccine_program.pdf) (Access Date: November 22, 2021)
  • Moynihan, R., Sanders, S., Michaleff, Z. A., Scott, A. M., Clark, J., To, E. J., Jones, M., Kitchener, E., Fox, M., Johansson, M., Lang, E., Duggan, A., Scott, I., Albarqouni, L. (2021). Impact of COVID-19 pandemic on utilisation of healthcare services: A systematic review. BMJ Open, 11, 11-17.
  • NOCPCO. (2020). “Self-quarantining does not mean that they are positive cases” – Head, NOCPCO. WHO South-East Asia Journal of Public Health, 8, 21-25.
  • Perera, S., Nieveras, O., de Silva, P., Wijesundara, C., Pendse, R. (2019). Accelerating reforms of primary health care towards universal health coverage in Sri Lanka. WHO South East Asia J Public Health, 8, 21-25.
  • Ranga SDUM, Dilrukshi DARK, Abeysekara CM, O. S. (2021). Cost of managing COVID 19 patients in a tertiary care hospital in Sri Lanka. Journal of Medical Administration, 22, 42-48.
  • Seneviwickrama, M., Kantharuban, D., Rodrigo, C., Karunarathna, B., Talagala, I., Gunatilake, I., Jayawardana, P.,Goonewardena, S. (2020). COVID-19: the first coronavirus pandemic. Journal of the College of Community Physicians of Sri Lanka, 26.
  • Sirintrapun, S. J., Artz, D. R. (2015). Health information systems. Surgical Pathology Clinics, 8, 255-268.
  • Sltda. (2020). Sri Lanka tourism development. In Sri lanka tourism development authority. (Access Address: https://www.sltda.gov.lk/en) (Access Date: October 23, 2021)
  • The Island. (2021). Epidemiology Unit accused of manipulating pandemic data – The Island. (Access Address: https://island.lk/epidemiology-unit-accused-of-manipulating-pandemic-data/) (Access Date: June 7, 2021)
  • Timothy Roberton, Emily D Carter, N. W. (2020). Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: A modelling study. Lancet Glob Health, 8.
  • Unit, E. (2005). Surveillance case definitions for notifiable diseases in Sri Lanka. Ministry of Health, Sri Lanka, 19-20.
  • Wanigasinghe, J., Jayawickrama, A., Hewawitharana, G., Munasinghe, J., Weeraratne, C. T., Ratnayake, P., Wijesekara, D. S., Fernando, S., Rupasinghe, P. (2021). Experience during COVID-19 lockdown and self-managing strategies among caregivers of children with epilepsy: A study from low middle income country. Seizure, 84, 112-115.
  • Sri Lankan Health System Response to the Covid-19 Pandemic: A Post Evaluation to Assess the Strengths and Weaknesses by Using Health System Building Blocks 151
  • WHO. (2007). Everybody business: strengthening health systems to improve health outcomes:
  • WHO’s framework for action. (Access Address: www.who.int/healthsystems/strategy/everybodys_business.pdf.) (Access Date: July 8, 2021)
  • WHO. (2020a). Coronavirus disease 2019 (COVID-19) Situation Report. World Health Organisation, 2019 (April), 1-13.
  • WHO. (2020b). Sri Lanka: Training on COVID-19 infection prevention and control for healthcare workers. WHO COVID Infection Prevention Control for Health Care Workers. (Access Address: https://www.who.int/news-room/feature-stories/detail/sri-lanka-training-on-covid-19-infectionprevention-and-control-for-healthcare-workers)
  • WHO. (2021). WHO Dialogues: Sri Lanka shares digital innovations made during pandemic. (Access Address: https://www.who.int/southeastasia/news/feature-stories/detail/who-dialogues-sri-lanka-shares-digital-innovations-made-during-pandemic) (Access Date: January 17, 2022)
  • Ying, W., Qian, Y., Kun, Z. (2020). Drugs supply and pharmaceutical care management practices at a designated hospital during the COVID-19 epidemic. Res Social Adm Pharm, 17, 1978-1983.
There are 52 citations in total.

Details

Primary Language English
Subjects Health Management
Journal Section Review Articles
Authors

Ranga Sabhapathige 0000-0001-6056-261X

Dilrukshi Deerasinghe 0000-0002-2620-4293

Early Pub Date December 1, 2023
Publication Date December 26, 2023
Published in Issue Year 2023 Volume: 5 Issue: 2

Cite

APA Sabhapathige, R., & Deerasinghe, D. (2023). Sri Lankan Health System Response to the COVID-19 Pandemic: A Post Evaluation to Assess the Strengths and Weaknesses by Using Health Systems Building Blocks. Journal of Health Systems and Policies, 5(2), 135-151. https://doi.org/10.52675/jhesp.1344195
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Contents of the Journal of Health Systems and Policies (JHESP) is licensed under a Creative Commons Attribution 4.0 International License.