Planning for health system recovery: guidance for application in countries

Planning for health system recovery Guidance for application in countries

Planning for health system recovery Guidance for application in countries Planning for health system recovery: guidance for application in countries ISBN 978-92-4-009781-0 (electronic version) ISBN 978-92-4-009782-7 (print version) © World Health Organization 2024 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/ copyright. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Contents Acknowledgements v How to use this technical guidance vi 1. Introduction 1 1.1 Context 2 1.2 Aim and objectives 3 1.3 Scope and target audience 3 2. The concept of health system recovery planning 4 2.1 Overview of health system recovery 5 2.2 The planning process 6 2.3 Recovery planning and national health sector planning 8 2.4 Benefits of planning for health system recovery 9 2.5 Guiding principles 10 3. Stages and requirements for health system recovery planning 12 3.1 Before shock: pre-positioning and mainstreaming requirements for potential recovery planning 13 3.2 During shock events: developing a shock-specific recovery plan 17 3.2.1 Stakeholder coordination and participation 18 3.2.2 Joint, fast-tracked situational analyses 18 3.2.3 Developing the joint recovery plan 20 3.2.4 Communication and dissemination 23 3.2.5 Resource mobilization 23 3.2.6 Facilitating monitoring and evaluation and maintaining the plan 24 3.3 Post-shock context: sustaining and transitioning the recovery plan 24 3.3.1 Maintaining joint working and coordination with shared accountability 24 3.3.2 Updating and transitioning the plan 25 3.4 Summary illustration of country application 25 4. Conclusion 28 iii References 30 Annex 1. Checklist of key actions for health system recovery planning 32 Annex 2. Sample planning template for health system recovery in the context of disruptive shocks 35 Annex 3. Supportive frameworks and approaches 38 Annex 4. Method 41 Figures Figure 1. Emergency management cycle and interlinkages with people and communities and health and allied sectors 5 Figure 2. Conceptual linkages between health system resilience, emergency management and recovery with transformation 6 Figure 3. Health system recovery planning: context and priorities 8 Figure 4. Benefits of investing in recovery and resilience of health systems in the context of health system shocks 9 Figure 5. Components of South Sudan health system stabilization and recovery plan 22 Figure A4.1. Document search flow chart 43 Boxes Box 1. Health system recovery plan 10 Box 2. Example terms of reference for the entity responsible for health system recovery 15 Box 3. Mapping health system actors in fragile, conflict-affected and vulnerable settings 20 Box 4. Strengthening the health system in post-conflict South Sudan 22 Box A4.1. Search strategy employed in PubMed 41 Tables Table 1. Changes needed in approaches to planning for recovery 7 Table 2. Key stakeholders: categories and examples of roles 16 Table 3. Key questions to guide development of a shock-specific recovery plan 17 Table 4. Integrating and mainstreaming recovery planning in routine and emergency contexts in countries 26 Table A4.1. Inclusion and exclusion criteria 42 iv Planning for health system recovery: guidance for application in countries Acknowledgements This guidance document was developed by Redda Seifeldin, Health System Resilience and Essential Public Health Functions Team, Special Programme on Primary Health Care, Universal Health Coverage and Life Course Division, World Health Organization (WHO), with inputs from Geraldine McDarby, Yu Zhang, Samuel Tweed, Desmond Hickey and Mila Petrova, Health System Resilience and Essential Public Health Functions Team, WHO. The supervision and strategic coordination for this work was provided by Sohel Saikat, Health System Resilience and Essential Public Health Functions Team, WHO. Sincere thanks to the following colleagues from WHO headquarters and regional offices for their contributions: Ali Ardalan, Giorgio Cometto, Andre Griekspoor, Genevieve Howse, Benjamin Lane, Awad Mataria, Denis Porignon, Lluis Vinals Torres, and the WHO Joint Working Team for Primary Health Care and Universal Health Coverage. Special thanks to Gerard Schmets (Deputy Director, Special Programme on Primary Health Care, WHO) for reviews and valued guidance in the delivery of this activity. Sincere appreciation goes to Suraya Dalil (Director, Special Programme on Primary Health Care, WHO) for her support. Sincere thanks to the Assistant Director-General’s Office, Universal Health Coverage and Life Course Division, and the Director’s Office, Special Programme on Primary Health Care, WHO headquarters, for their administrative support. This publication was produced with support from the Universal Health Coverage Partnership (UHC Partnership), one of WHO’s largest platforms for international cooperation on universal health coverage and primary health care. It is funded and supported by Belgium, Canada, European Union, Germany and Luxembourg, as well as Irish Aid, Ireland; Ministère de l’Europe et des Affaires étrangères, France; Ministry of Health, Labour and Welfare, Japan; and the Foreign, Commonwealth and Development Office, United Kingdom of Great Britain and Northern Ireland. v How to use this technical guidance The following illustration depicts how to use this technical guidance. First, familiarize yourself with the conceptual aspects of health system recovery Identify and adopt or adapt priorty actions across the stages and requirements for recovery planning, considering the supportive approaches Refer to the summary Illustration of country application of the planning guide Use the checklist and template to facilitate recovery planning Section 1 and 2 (pages 1-11) Section 3.1 to 3.3 (pages 12-25) Section 3.4 (pages 25-27) Annex 1 and Annex 2 (pages 32-37) vi 1 Introduction 1.1 Context Countries are impacted by an increasing number and scale of public health emergencies from various hazards, such as those relating to the natural environment, cyberattacks, conflict and infectious diseases. The COVID-19 pandemic represents a recent example of a public health emergency that has resulted in a significant and ongoing impact on health systems and wider society in all global regions. As of March 2024, the World Health Organization (WHO) was responding to 42 graded emergencies globally (1, 2). These events, which may occur concurrently or in rapid and multiple succession, lead to substantial direct (for example, through injuries and illness) and indirect (for example, through interruption of key services due to damaged health infrastructure, disrupted supply chains or staff shortages) impacts on the health system and its services to the population and well-being. The widespread effects of such shocks can impair, or even completely interrupt or destroy, the capacity of health systems to deliver a range of critical clinical care and essential public health services, frequently further compounded by the additional population health needs that arise during emergencies. These impacts can have protracted consequences depending on the state of resilience of the health system prior to the event, as well as the degree to which countries effectively implement intentional, robust and comprehensive recovery processes that serve to optimally restore health system functionality and build back better. Recovery, however, does not always receive the necessary attention and investments for implementation at country level (3). The window of opportunity to consider recovery is also short. Where recovery is prioritized across sectors, gaps often exist in the adequate and targeted consideration of health systems, for example, socioeconomic recovery planning with limited attention to health, or siloed, fragmented efforts focusing on recovery of separate health programmes or services. These result in missed opportunities to address foundational, systemwide issues, further perpetuating the pre-existing weaknesses in, inefficiencies in, and poor sustainability of health systems. WHO advocates the need for investing in health system recovery through an integrated approach that enables better resilience and equity with strong public health capacities. This is in line with its promotion of a primary health care approach (4) and its role in managing public health emergencies, including recovery aspects (3). The benefits of investing in health system recovery cuts across global health targets such as universal health coverage, health security and all health-related Sustainable Development Goal targets, therefore better positioning health systems to deliver their part in the socioeconomic growth and stability of countries. Facing the current reality of a global environment where shocks related to crises such as climate change, natural havoc, humanitarian crisis, war and conflict, economic contraction and pandemic are increasingly complex and likely, it is crucial that planning for recovery not only focuses on restoring health systems to pre-shock levels, but also systematically identifies and applies lessons to build back better and fairer health systems that are more resilient to the future shocks that will inevitably occur. The lack of integrated and sectorwide planning hinders effective recovery and resilience building in health systems (3, 5). Yet, there is a scarcity of guidance focusing on how to plan for health system recovery. The WHO Health Systems Resilience Toolkit highlighted gaps in the technical resources on integrated planning as well as the recovery aspects of managing health system shocks (5). Lessons from past and recent shocks also highlight the need to align routine health sector, health security, humanitarian, disease-specific and other health plans in countries in order to address fragmentations and the associated inefficiencies (6). 2 Planning for health system recovery: guidance for application in countries 1.2 Aim and objectives This WHO technical product aims to support countries to prioritize and mainstream health system recovery through effective planning as part of building health system resilience in support of universal health coverage, health security and socioeconomic development. While this document is developed for application in a recovery context, it is adaptable to other health system strengthening and reform processes initiated in recognition of gaps in health system functions, not necessarily in the context of a shock event. The specific objectives are to: • provide a step-by-step guide for health system recovery planning in the context of disruptive events or shocks, ensuring alignment between various health system and health security planning efforts; • facilitate application of the guide by providing tools, including checklists and templates, as well as case examples that can be adapted to different contexts in planning for health system recovery; • support advocacy for policy and other requirements to enable integrated recovery planning in routine health sector and emergency planning, so that health system recovery can be factored into emergency response and health sector development. 1.3 Scope and target audience The scope of this product focuses on the planning aspect of health system recovery within the context of shocks, which have direct or indirect impacts on health system functions and services. It acknowledges that planning must be supported by appropriate investments and implementation for successful recovery. The guide emphasizes systemwide, integrated planning, rather than planning for recovery of separate components or programmes within the health system. The guidance provided is generic to allow application and adaptation to a wide range of contexts. The operational details for each of the key actions need to be determined at country level, as appropriate for each setting and shock context. The target audience for this guide is health authorities at national and subnational levels in countries, WHO, other United Nations agencies, technical partners, and donors with a role to support health systems and service delivery in any context. 31. Introduction 2 The concept of health system recovery planning 2.1 Overview of health system recovery Health system recovery is commonly defined as the process of restoring a health system to its pre-shock state after a crisis or catastrophic event including those which are not directly health emergencies but negatively impact the health system and population health (e.g., war and conflict, economic recession). This can include maintaining assets mobilized during response, rebuilding infrastructure, replenishing medical supplies, re-establishing administrative processes for health workforce management, and improving access to and quality of health services. In this planning guide the term “health system recovery” is used more broadly, emphasizing that health system recovery should not simply aim to return to pre-crisis levels but rather use crisis management as an opportunity to address existing gaps, weaknesses and inequities through continuous and systematic improvement leading to better performance and resilience. Terms such as “transformation” and “building back better” have also been used to represent this broader scope of the recovery process. Other ways in which the recovery agenda has been framed in different settings include health sector or public health reforms, investment planning, and building health system resilience. Recovery is recognized as one of the key stages in the emergency management cycle, along with prevention, preparedness and readiness and response (Figure 1). The emergency management cycle is a continuum in which the phases often overlap, for example where there are multiple public health emergencies that happen in quick succession or are concurrent, or in protracted and humanitarian emergencies, enabling recovery efforts while response is ongoing. The type of shock, setting, affected population and other contextual considerations determine the nature of recovery activities, stakeholders, investments and support. For example, recovery in fragile, conflict-affected and vulnerable settings where foundational capabilities of health and allied sectors are severely damaged, weakened or absent would differ from recovery efforts in settings where the health system is functional or semi-functional but needs to regain full functionality while learning from experience and doing things differently. However, no matter the context, the responsibility for recovery involves the health sector as well as other relevant sectors and the communities affected, taking into account the wider determinants of health (7) (Figure 1). Figure 1. Emergency management cycle and interlinkages with people and communities and health and allied sectors Alli ed sec to rs Pe op le an d c om mu nitie s Health sector / system Prevention Response Recovery Preparednessand readiness 52. The concept of health system recovery planning Recovery from disruptive events is one of the critical entry points for health system strengthening and resilience building. It presents a window of opportunity for substantial improvements through systematic identification and application of lessons learned from ongoing or past experiences with shocks to build back better. It is also an opportunity for assets and resources mobilized during response to be retained, transitioned and improved with local ownership. These are key demonstrations of the transformative attributes of resilience in health systems and its potential to proactively contribute to addressing gaps in other attributes, including awareness, mobilization, diversity, and self-mitigation, with integration as a cross- cutting attribute (Figure 2). Consideration of building resilience is therefore central to planning for health system recovery and making the most of available resources to improve functionality and resilience in the face of ongoing and future health threats and a likely decline in resources. Figure 2. Conceptual linkages between health system resilience, emergency management and recovery with transformation Identify and apply lessons for building back better (Transformation) Emergency management continuum Health system strengthening Prevention, preparedness, readiness Recovery to build back better Response Health system resilience attributes - capacity to: Recognize its risk and capabilities (Awareness) Mobilize resources and coordinate support (Mobilization) Maintain the range of services needed (Diversity) Make timely informed decisions (Self- mitigation) Integrate health systems strengthening, health security and other public health eorts, e.g., in policies and planning (Integration) 2.2 The planning process Health system recovery planning refers to the entire process involved in developing a plan to guide recovery and associated transformation efforts by stakeholders within and beyond the health sector. It entails a timely, evidence-based, inclusive process, from the decision-making and actions that lead to and inform the plan to content development, dissemination, review, and modification of the plan as needed to ensure effective implementation in the short, medium or long term. In most settings, this would require doing things differently to improve current approaches to recovery planning (Table 1). 6 Planning for health system recovery: guidance for application in countries Table 1. Changes needed in approaches to planning for recovery From To Recovery focus on health is obscure in disruptive public health event or humanitarian crisis Health sector recovery is a policy consideration in national health sector and wider recovery objective Lack of focused planning for health system recovery in national health sector and emergency-related plans Prioritizing health system recovery in relevant plans within and beyond the health sector, for example in routine health sector planning Planning as an afterthought following shock Timely planning for recovery while responding to shocks Lack of institutional structures and capacity to lead and coordinate the planning process Proactive establishment of responsible institutional structure with defined functions and capacity required to lead, coordinate and facilitate for effective recovery Fragmented planning by programme area, for example specific to disease priorities Application of systemwide and sector wide thinking to support and strengthen the whole system Poor engagement and participation of key stakeholders Inclusive planning with multidisciplinary and multisectoral participation and responsibility Inadequate consideration of baseline capacities Scoping and leveraging existing resources and capacities in planning, including budgeting, informed by systemwide situational analysis Dependence on external support, including funding as a driver National and subnational political commitment and actions to drive the coordination efforts, including resource allocation Lack of funding and accountability for implementation of recovery plans Clear funding and accountability mechanisms, including monitoring and evaluating implementation Unclear pathways for reviewing and updating recovery plans Defined mechanisms for reviewing and updating the plans as needed, reflecting lessons The planning process can be organized in relation to the phases prior to, during and following shock contexts, including complex emergencies with multiple shocks that cause fluctuations between these phases. Figure 3 shows how these phases relate with the three areas of health system recovery planning: pre-positioning and mainstreaming requirements for potential recovery planning (pre-shock); shock-specific recovery planning and resourcing (during shock); and sustaining and transitioning the plan as needed (post-shock). Implementation of the plan is identified during and following the shock as part of the wider context, taking account of the need for integration and alignment of recovery planning with national health plans, policies and strategies (including the national health sector strategic development plan, the national action plan for health security, and plans related to the humanitarian-development-peace nexus) (see section 3.4). Figure 3 also highlights the complementarity between recovery planning and maintaining routine health services, emergency management and socioeconomic recovery. Ideally, policies and capacities for recovery planning should be established prior to shocks. However, if this was not done and a country is already experiencing shock events, it should integrate critical pre-shock priorities and lessons (as applicable) into the response phase and shock-specific recovery planning. The during and post-shock reviews can recommend mainstreaming of capacities and arrangements for recovery in routine health system strengthening so that lessons learned are actioned before and during subsequent crises. 72. The concept of health system recovery planning Figure 3. Health system recovery planning: context and priorities Health system recovery contexts Sustain, update the recovery plan as needed Implement the recovery plan – transitioning from response to recovery, and recovery to longer term development Health system functions and services recovered & strengthened Resilience improved and sustained, advancing UHC, health security, SDGs, socioeconomic recovery and growth Pre-position and mainstream requirements for potential recovery planning Pre-shock contexts (prevention & preparedness) During shock contexts (response & early recovery) Health system recovery priorities in planning Integration and alignment with national health policies and plans, related assessment and structures Progressive transition to health sector development planning, applying the HDPN Develop shock-specific recovery plan Implement the recovery plan – transitioning to early recovery Post-shock contexts (recovery & transformation) On go in g, h ea lth p ro te ct io n, p ro m ot io n an d pr ov isi on o f r ou tin e e ss en tia l he al th se rv ice s f or in di vid ua l a nd p ub lic h ea lth n ee ds 2.3 Recovery planning and national health sector planning Health system recovery planning does not start in a vacuum. It is often undertaken within a context where a national health policy, strategy or plan already exists along with its targets, monitoring framework and monitoring mechanisms, which guide stakeholders’ actions on health (8). The pre-existence of a national health plan (for example, health sector strategic development plan, national action plan for health security, or plan for the humanitarian-development-peace nexus) serves as a foundational mechanism to anchor and integrate recovery requirements and planning before, during and after shocks in the context of long-term system strengthening. This includes incorporating pre-shock recovery requirements in the routine health sector plan, while ensuring that health system recovery plans incorporate the priorities and targets identified in the national health sector plan. In most countries, there is a department or team within the ministry of health in charge of planning, which can include responsibility for incorporating recovery requirements in the routine health sector plan and its associated assessments, annual reviews and other processes. Alignment and integration of recovery plans with routine health sector plans therefore enables mainstreaming and sustainability of focused recovery planning. 8 Planning for health system recovery: guidance for application in countries 2.4 Benefits of planning for health system recovery In the absence of an intentional focus on comprehensive recovery and resilience in planning and investment, there is a tendency for impacted health systems to passively revert towards, or even drop below, pre-existing performance and resilience levels (Figure 4). This could potentially lead to excess mortality, morbidity, distress and economic loss. Such an eventuality applies to countries across all income groups and accounts for continuous and increasing susceptibility of health systems to shocks, despite previous experiences and lessons within and beyond their settings. Appropriate joint planning for recovery can lead to far-reaching and lasting benefits in such areas as tackling deterioration, managing backlog due to disruption in services, improved health system performance, resilience, and population health. Appropriate planning for recovery facilitates: • clear identification and engagement of internal and external stakeholders in specific roles; • joint working and shared accountability among stakeholders towards a common objective; • prioritization of recovery of the health system; • clear identification of objectives and areas for investment to inform mobilization of resources; • effective implementation of activities required for recovery, as appropriate to the context; • timely and clear definition and implementation of accountability mechanisms; • future reviews and improvements on past efforts by serving as a documented reference. Box 1 presents further information on the development, content and functions of a health system recovery plan. Figure 4. Benefits of investing in recovery and resilience of health systems in the context of health system shocks Typ ical inv estm ent Time He al th sy st em p er fo rm an ce Re sil ien ce bu ild ing Health security, universal health coverage, other SDG targets High performance Higher performance Current performance Gra dua l im pro vem ent Stabilization Continuous decline if without investment in recovery Di vi de nd o f i nv es tin g in re co ve ry a nd re sil ie nc e Shock Shock Re co ve ry 92. The concept of health system recovery planning Box 1. Health system recovery plan A plan for health system recovery is an official document (either on its own or as part of a national recovery plan) that outline activities to be implemented based on a set of objectives to guide decisions, actions, budgeting, resource mobilization and allocation, and accountability for recovery of health systems from disruptive events. The plan includes short- to long-term activities required to restore and improve health systems that have been disrupted by or found to be inadequate in times of shocks or crises, including public health emergencies such as pandemics, natural disasters, or armed conflict- related humanitarian crises. In addition to the outline of activities, the plan includes such elements as budget, stakeholders’ roles, and monitoring and evaluation to track effective implementation. While the above elements are common to different plans, recovery plans can be distinguished by their scope and focus on short to long term recovery and transformation. The scope can include complementary priorities like ensuring continuity of essential health services and emergency response capacities in the short to long term (beyond the emergency), in alignment with relevant plans specific to these areas. However, recovery plans should not be confused with other complementary plans, such as plans for health service continuity (9), that focus on maintaining routinely delivered health services and associated operations to minimize disruption during a shock event, or plans focusing on health system response to ongoing or future emergencies. A recovery plan may not necessarily be titled or presented as such. Irrespective of how a plan is titled or framed, if the objectives and content serve the purpose, it should be identified and implemented as a recovery plan. Titles used for recovery-related plans may include terms such as recovery, transformation, reform, resilience, restoration, reconstruction or investment. The scope and method used for developing a recovery plan may also differ depending on the context. A recovery plan may be developed as a distinct or separate document; as part of a wider or routine health sector plan; as part of an emergency management plan; or as part of a multisectoral plan for socioeconomic recovery. In terms of levels of planning, the plan could be developed at national, subnational or institutional level. While the title, packaging and scope of a recovery plan may differ based on contextual considerations such as feasibility and stakeholders’ preference, there are key guiding principles that should be applied to make it fit for purpose (see next section). 2.5 Guiding principles Effective recovery and transformation of health systems requires application of several interconnected and cross-cutting principles to ensure a holistic and inclusive approach that maximizes efficiency while minimizing harm and risks. The guidance provided in this document is based on these principles. Key frameworks that support these principles include the health system framework (10), primary health care (4), essential public health functions (11) and the humanitarian-development-peace nexus (12) (see Annex 3). This guide therefore promotes prioritization of these globally acknowledged approaches in planning for health system recovery. Timing. Time is of the essence in recovery planning. Timely planning facilitates leveraging of routine and response-related assets, opportunities, and lessons for early and long-term recovery. Proactively establishing an enabling environment and prearrangements for potential recovery needs (prior to major shock events) can also reduce the time needed for recovery planning, resourcing and implementation in shock contexts. Recovery planning priorities should be timed to ensure that they do not interrupt or reduce capacity for meeting immediate health needs. National leadership, local ownership and contextualization. This entails leadership and ownership by the government, the people and other stakeholders at national and local levels in a country. External entities or partners involved therefore aim to support or strengthen the role of the national and local authorities, institutions, communities and other stakeholders and to build their capacity for the long term. The nature and effects of shocks and stressors are not equally distributed across populations or regions, which requires the contextualization of recovery efforts. Priorities need to be identified at local and subnational levels, based on local data to allow the targeting of resources to those places and populations most in need. 10 Planning for health system recovery: guidance for application in countries Equity. Health equity is achieved when everyone can reach their full potential for health and well-being and there is an absence of unfair, avoidable and remediable differences in health status between groups of people (13). The impacts of shocks and stressors are not experienced equally across populations and disruptive events tend to expose and exacerbate pre-existing inequities. Recovery planning should advance universal health coverage with special attention to vulnerable and marginalized groups, ensuring that services meet routine as well as shock-specific needs. Systems thinking. Like any system, the health system is a set of interconnected parts and processes, working together for a common purpose to serve individuals and communities. Effective health system recovery planning requires an understanding of and strengthens all health system components1 and their interactions, as well as the allied systems with which the health system interacts. It is also prudent to take account of the wider recovery process and the political, economic and social context. This kind of systems approach supports contextualization of interventions for improved effectiveness. Integration and alignment. An integrated approach to health system recovery can reduce or prevent health system and service fragmentation, whereby parallel and overlapping efforts impede efficient and effective use of resources. Such an approach can be institutionalized through collaborative recovery planning by ensuring that the process and results serve the health needs of various populations, bridge gaps in the health system, facilitate collaboration and coordination between stakeholders, and align with other relevant national plans, policies and investments in health. Sustainability. Recovery planning should support the transition from immediate and short-term goals to longer-term priorities. Adapting response investments as well as investments targeted at broader socioeconomic recovery towards health system strengthening can ensure that the resources made available in the initial response period can support longer-term health system strengthening for sustainability of recovery and transformation. Resilience focus. Recovery efforts must sustain response capacity in ongoing emergency and humanitarian contexts, while enabling reform and transformation when rebuilding or recommencing services that have been disrupted or destroyed. Embedding resilience considerations within recovery planning supports improvements in the health system while ensuring a focus on reducing the occurrence and impacts of future shocks. 1 The WHO Health Systems Framework defines six interconnected building blocks: leadership and governance; service delivery; health workforce; information; medical products, vaccines and technologies (including infrastructure); and financing. It highlights the importance of people and communities within which the health system functions. 112. The concept of health system recovery planning 3 Stages and requirements for health system recovery planning This chapter focuses on the key actions for planning health system recovery. The actions are applicable and adaptable to recovery from different causes and types of shocks to health systems, whether they are primarily ecological and environmental (for example, natural disasters, disease outbreaks) or anthropogenic (for example, conflict, economic instability). The key actions are organized under three phases: before, during and after shock contexts. A checklist consolidating activities across the three phases is provided in Annex 1, which can be used or adapted as a reference for guiding the health system recovery planning process at country level. 3.1 Before shock: pre-positioning and mainstreaming requirements for potential recovery planning The period before or between major public health emergencies or shock events is an opportunity to proactively establish and mainstream the right policies, institutional set-up, resources, coordination and collaborative arrangements, and technical and operational capacities for future recovery planning when the need arises. The pre-positioning and mainstreaming recovery requirements need to be integrated and aligned with the existing health sector policy and plan (for example, health sector strategic development plan), considering the risk profile of that setting and lessons from past and ongoing shocks. The pre-positioning and mainstreaming process fosters sustainable capacities and mobilization of requirements for timely and effective planning for recovery, which can be challenging to prioritize in the midst of a response to disruptive emergencies that directly or indirectly impact routine health system functions and services (14). Such foresight also prevents a reactive approach or complete absence of the needed considerations for recovery in managing public health emergencies. If that contingency planning had not been done prior to a shock event, then relevant commitments and institutional capacities should be put in place early in the response phase, for example by initiating a recovery working group in the emergency response structure or emergency operations centre. Key actions • Identify health system recovery as a policy priority. Such prioritization would take place within national policy objectives for health system strengthening, resilience and emergency management. To be meaningful, prioritization needs to be reflected in legislation, policies, strategies, plans and associated assessments relevant to routine health system functions, public health emergency management, health system strengthening, and multisectoral participation in health. Relevant provisions and arrangements include public health legislation; interministerial committee focusing on health; health sector strategic development plan with provision for contingency funding; all hazards emergency preparedness and response plan; national risk register; and national guidance or policy on emergency and disaster risk management. It is also important to have health system recovery identified as a shared objective and commitment in relevant public health platforms, such as those for interministerial or intersectoral coordination for health, the One Health forum, and partnerships for disaster risk management and health sector coordination. • Designate or establish (as applicable) a responsible structure. A structure or entity should be in place with responsibility for leading, advocating and coordinating recovery-related activities and representing health in multisectoral actions prior to, during and beyond disruptive events. The responsible entity should have the capability to function in the long term, that is, prior to, during and beyond the response phase of any shock to the health system, including protracted emergencies. The entity needs to be positioned high enough in hierarchy to be able to deliver their mandate effectively. Key considerations for defining the terms of reference are outlined in Box 2. Where feasible, the responsibilities of the focal point should be embedded in and leverage existing structures responsible for strengthening the health system and managing health emergencies, for example, the ministry of health, national public health institutions, multisectoral coordination platforms or the incident management system. 133. Stages and requirements for health system recovery planning • Establish collaboration and coordination among key stakeholders. With the leadership of the focal point for recovery, it is important to map, mobilize and define the roles of key stakeholders and provide necessary orientation, considering the national and local risk profile and other contextual realities (see Table 2 for categories of stakeholders and examples of their roles). This is important to ensure joint ownership, joint working, resource sharing and shared accountability for recovery planning and other aspects of recovery. The process includes strengthening or establishing a collaborative multidisciplinary and multisectoral coordination platform that has a focus on recovery and is interconnected with the emergency response and health system strengthening mechanisms in the country. Recovery working groups could also be established for specific tasks such as planning and resource mobilization. If there is no pre-existing mechanism for collaboration, it is advisable to examine what is existing to see how to best leverage or adapt those resources. The collaborative platform should be routinely active and include all relevant partners. Inclusive communication and information-sharing approaches should be adopted to ensure that all stakeholders are involved and up to date on activities, gaps and their roles. • Identify and implement recovery-related activities prior to shock events. This requires the leadership of the responsible authority in collaboration and coordination with other stakeholders, and can involve pre-planning using an all-hazards approach informed by available data, including relevant risk profiles, anticipated scenarios, simulation exercises, after-action reviews, health system performance analyses and population health reports. A pre-shock recovery plan can serve as a template to be readily adapted and built on for shock-specific recovery planning, thereby reducing delays (15). Recovery requirements that can be pre-positioned and mainstreamed prior to shocks include strengthening the responsible entity; stakeholder mapping, orientation and coordination; resource mobilization; mutual aid arrangements; identifying alternative platforms or power sources for potentially disrupted services; community engagement; and developing standard operating procedures and guidelines. Where possible, those provisions can be integrated in health sector and health security plans, disaster risk management strategies and plans, or as a separate plan that is aligned with and complementary to other national plans for strengthening the health system and managing disasters, humanitarian crises and other emergencies. • Factor in financial, human and material resources needed for recovery. Resources for recovery- related activities will be required across all phases, before, during and after shocks. Appropriate budgetary and financing mechanisms should be instituted to support resource allocation for recovery, including contingency funds and potentially leveraging resources from acute emergency and humanitarian response funds. Investment in recovery capacity will include routine health sector financing and public health workforce development, information management, supply chain articulation, technological innovation and infrastructure development (16). 14 Planning for health system recovery: guidance for application in countries Box 2. Example terms of reference for the entity responsible for health system recovery The responsible entity (for example a government-led structure) for health system recovery is designated as focal point with the mandate and resources to represent health in wider recovery efforts and to spearhead, convene and coordinate stakeholders, draw the needed contributions from within and beyond the health sector, and provide accountability for recovery of the health system from shocks. The following are examples of responsibilities to include in the terms of reference for this focal point. • Identify health system recovery as a health sector policy objective for application as and when needed • Serve as a liaison with the government at national and subnational levels and with communities • Initiate and lead pre-shock and shock-specific recovery planning processes, either separate from but complementary to, or as part of, other recovery and health sector planning processes • Embed recovery considerations in the national emergency preparedness plan, national emergency response plan, humanitarian response plan or emergency operations centre • Establish or convene an appropriate body (for example, a recovery working group) and coordinate with stakeholders in the health and other sectors, including communities and service delivery platforms, on recovery-related actions • Advocate inclusion of recovery considerations in response planning and investment, as well as in health sector plans, multisectoral recovery plans and other relevant plans • Develop plans for health system recovery in collaboration with key stakeholders • Communicate with, disseminate information to, and orient stakeholders on the plan • Mobilize resources for recovery • Monitor and evaluate and report on progress in implementing the plan • Develop supporting tools, resources and guidance for recovery-related actions • Participate in other recovery planning processes, for example socioeconomic recovery planning and community recovery planning, to embed health system recovery considerations in support of wider recovery objectives. 153. Stages and requirements for health system recovery planning Table 2. Key stakeholders: categories and examples of roles Stakeholders Examples of common and potential roles in pre-planning for health system recovery National and subnational (regional, county, state, zonal, district, local) health sector stakeholders (public and private sectors), including health and public health authorities, health facilities, academic institutions, allied non- health authorities (for example, agriculture, transport, security, water, environment, education), businesses, religious organizations, nongovernmental organizations, academia, professional bodies • Ensuring political commitment and prioritizing health system recovery in national policies, strategies and plans relevant to health • Coordinating with key stakeholders to ensure an integrated approach to health system recovery planning • Developing health system recovery plans in the context of health system shocks, informed by joint situational analyses • Mobilizing, leveraging and allocating resources from various stakeholders in health and allied sectors and communities, in the public and private sectors • Ensuring that response efforts and investments transition to support recovery and strengthening and development of the health system • Monitoring and evaluating implementation of the plan by responsible stakeholders • Maintaining routine health service continuity while planning for recovery • Advocating and developing competency and skills development of the health and wider public health workforce in recovery processes • Enabling learning by documenting and applying lessons, conducting research, and developing guidance and tools to guide stakeholders National and local authorities in sectors allied to and outside the health sector (public and private), for example, agriculture, transport, security, water, environment, education, finance; community leaders and members, religious groups and leaders, civil societies, businesses, schools • Including health as a priority in policies and plans for multisectoral socioeconomic recovery • Participating in coordination platforms for health system recovery • Participating in developing and implementing plans for health system recovery with necessary accountability • Supporting community engagement and participation in health system recovery processes • Considering recovery and long-term development in providing support for emergency planning, including humanitarian response applying the principles of the humanitarian-development-peace nexus • Contribute to developing relevant guidance and tools, knowledge sharing and research that support recovery of health systems Global and international stakeholders, for example, United Nations agencies, international donors, international professional bodies and associations, international humanitarian organizations and coordination platforms, regional governing bodies • Steering the global health agenda and leveraging resources to identify, prioritize and invest in early to long-term health system recovery and transition • Influencing political commitment to support health systems in recovery • Providing technical and financial support to countries for recovery planning • Supporting research and development of technical guidance and tools for adaptation in countries • Facilitating coordination and bridging between humanitarian response and development, as well as the peace agenda, in fragile, conflict- affected and vulnerable settings • Fostering collaboration between international entities representing different sectors relevant to health for multisectoral responsibility and accountability for health Note: The recovery roles outlined below cut across all stages of recovery activities before, during and after shocks to the health system. Stakeholders included are provided as examples for reference. The actual composition will be informed by national and subnational risk mapping, risk register and priorities. 16 Planning for health system recovery: guidance for application in countries 3.2 During shock events: developing a shock-specific recovery plan The process of developing a shock-specific recovery plan involves considering and answering the key questions set out in Table 3, which reflect the past, present, and expected future of the disrupted health system. Those plans should align with and complement existing health sector plans and facilitate transition to longer-term health sector development planning. It is crucial that this process stops further deterioration and does not disrupt critical response activities, such as lifesaving services and surveillance, or routine essential health services. Table 3. Key questions to guide development of a shock-specific recovery plan Stage in development of recovery plan Key question Importance for planning is to: Before developing the plan • Where are we now? • Determine the baseline before the plan is developed, e.g., based on recent assessment of health system performance, affected population, and service availability • How did we get here? • Identify strengths, gaps and weaknesses, disruptions, and lessons before the plan is developed, e.g. areas of health service disruption, lessons from previous after- action reviews Before and during plan development • Where do we want to be? • Define the shared goals and objectives • How do we get to where we want to be? • Determine the course of action and activities, including what will be done across the health system building blocks and sequencing When developing the plan • What do we need to get there? • Indicate the required resources, e.g. staffing of primary care facilities • What do we currently have compared to what we need to get there? • Reflect the existing resources to avoid unnecessary cost, e.g. proportion of primary care facilities already adequately staffed per defined criteria • What do we not have compared to what we need? • Identify the resource needs for costing the plan, e.g. proportion of health facilities without number of staff needed with details of gaps • How will we know we are there? • Define the indicators and measurement framework for monitoring and evaluation, including selection of resilience-focused indicators After developing the plan • Are we on track? • Ensure all stakeholders have access to the plan and are aware of their roles • Review, update and transition the plan as needed, considering current realities and needs • Transition recovery-specific plans to routine health sector development planning or equivalent, as applicable 173. Stages and requirements for health system recovery planning 3.2.1 Stakeholder coordination and participation During a shock, various stakeholders within and beyond the health sector rapidly convene to respond to the emergency. It is important that they are responsible for maintaining the routine functions of the health system, including service delivery, and are involved in working towards early recovery by embedding these considerations in response arrangements and other complementary activities. A coordinated and collaborative approach is essential. This should leverage the coordination mechanisms, capacity-building, planning and other recovery-related arrangements established prior to the event to ensure timely and effective planning for recovery. Key actions • Engage and convene a recovery working group. This body will develop the health system recovery plan in its own right or as part of other multisectoral recovery planning. Development of the plan can benefit from pre-shock context planning preparation (see section 3.1). The process should be inclusive of all key stakeholders, including the affected communities and populations, the private sector, civil society, academia and the military sector (as applicable based on context), while being led and coordinated by the designated authority or focal point. • Identify and engage new stakeholders. Engagement of stakeholders will be informed by context and the extent and type of shock. They may not have been part of pre-shock recovery processes, for example, new organizations involved in the response activities and marginalized populations. Stakeholders can be engaged through area-based resource mapping, for example by adopting a “who does what and where” (3W) approach across a broad range of stakeholders with an impact on health, including domestic actors and external actors, with communities and affected populations at the centre. • Provide orientation to responsible stakeholders on their roles. Orientation can be carried out through stakeholder coordination meetings based on identified capacity gaps. It can also be incorporated in relevant training courses and workshops and technical and advocacy tools, such as those focusing on emergency management, strengthening the health system and multisectoral participation in health. • Review actions to ensure synergy with complementary initiatives and planning processes. Relevant processes include those aimed at addressing population health needs and gaps in the health system and health security and other health priorities, including priority diseases (both infectious and noncommunicable diseases, including those concerned with mental health, reproductive, maternal, child and adolescent health, and the health of the elderly). 3.2.2 Joint, fast-tracked situational analyses Situational analyses should be fast-tracked in order to understand the current baseline of health system capacities and resources, the impact of the shock (service disruption), and pre existing and emerging shock- induced risks (encompassing related hazards and vulnerabilities) across all components of the health system (governance and leadership, health workforce, financing, information system, medical products, technologies, and infrastructure, and individual and public health services) and the affected populations and communities. The process requires rapid but coordinated assessments and analyses of available information, which can be collated from existing monitoring sources. The findings of the situational analysis should inform the goals, objectives and priorities of the recovery plan. 18 Planning for health system recovery: guidance for application in countries Key actions • Undertake a joint, fast-tracked situational assessment. The assessment process will be coordinated by the responsible recovery working group, using standardized tools as appropriate to the setting, type and scale of shock, and recovery needed. While the assessment needs to be comprehensive enough to capture key information needed for planning, timely completion of this exercise is important to avoid delays in planning, which may result in missed opportunities for early recovery. The preparations for and implementation of the assessment and analysis involve a series of important actions and considerations, as set out in the following paragraphs. – Determine the scope of and tools to be used in the analysis. The standardized tools to be adapted for and applied in the situational assessment and analysis should be determined using a collaborative approach and context-specific considerations. For example, in fragile and conflict-affected settings the situational assessment would consider resources and needs for humanitarian, development and peace efforts as well as for transition and bridging efforts (see Annex 3). Examples of tools are the joint operational review, post- disaster needs assessment and the Health Resources and Services Availability Monitoring System (HeRAMS) (17-19). – Identify and access a range of sources and resources. In order to inform planning, it is necessary to identify, engage and leverage a range of sources and resources for data collection and analysis reflecting the various health priorities and the expertise and skills of stakeholders. The exercise will include definition of the available resources, gaps, capacities, impact of shock, and assets to be transitioned and sustained during the planning process. Potential sources include existing information systems for health and allied sectors, for example security systems, emergency operations centres, and urban planning and finance sectors. Civil society, local informal and formal networks, and communities are also key sources of information for understanding the situation, including the impact of the shock. Reviewing evidence from past experiences with shock, including documented lessons (what worked, what did not work and why?) from past emergency response and recovery efforts can also provide valuable insight. – Give due attention to affected, vulnerable and marginalized populations. Deliberate efforts are needed to identify and reflect the situation and needs of populations or communities that are most vulnerable, as they may not have been previously covered in routine health information data. These include displaced populations and those vulnerable to new or emerging health threats - for example, COVID-19-related mental health conditions or post-COVID-19 condition (“long COVID”). – Document, validate and disseminate the findings of the situational analysis. This will help to define priorities across key stakeholders, provide an opportunity for feedback and revision as necessary, and facilitate a common understanding of the overall situation. The situational analysis provides a basis for developing an evidence-based recovery plan by informing the priorities and objectives, activities, costing, and monitoring and evaluation included in the plan. 193. Stages and requirements for health system recovery planning Box 3 present additional information on mapping health system actors in fragile, conflict-affected and vulnerable settings. Box 3. Mapping health system actors in fragile, conflict-affected and vulnerable settings To facilitate comprehensive recovery planning, an initial exercise may be required to map service delivery actors in humanitarian response settings. Typically, there is an influx of new providers in humanitarian crises, including those specifically targeted at an emergency response. Understanding which services are likely to remain in the recovery phase and which will require reorganization or incorporation into routine health systems is important for successful recovery. Providers may include: – temporary or mobile treatment centres – specific services at points of entry – emergency clinics provided by humanitarian agencies or nongovernmental organizations – military treatment centres – community health workers and primary care facilities – government-funded hospitals – privately funded medical facilities – traditional medicine practitioners. 3.2.3 Developing the joint recovery plan At this stage, the coordinating entity or recovery working group dedicates efforts to develop a health system recovery plan. The plan can take various forms and titles, as suitable for the context. For example, the plan can be a separate document as a health sector recovery plan, or incorporated in wider planning processes, such as health sector strategic or investment plans, multisectoral recovery plans, action plans for the humanitarian-development-peace nexus, or health sector or public health reform plans. The focus here is on systemwide planning towards recovery as a catalyst for resilience and building back better. The plan therefore needs to address all required components (or building blocks) of the health system and essential public health functions. To improve outcomes for various population health priorities, a comprehensive public health and primary health care approach, incorporating the humanitarian- development-peace nexus, is therefore essential to anchor the plan in the health system while ensuring multisectoral inputs. It should be clear how to transition from short- to medium- and long-term recovery goals to routine system strengthening and development with the necessary flexibility and agility to adapt if the situation requires, for example in the case of deterioration in the present situation or the advent of a new shock to the health system. Key actions • Jointly develop and finalize the contents of the plan. This will be in the form of a written document informed by findings, including lessons from a joint situational analysis applying the principles outlined in Chapter 2. The language and presentation of the plan needs to clear, action oriented and as concise as possible for easy usability by all stakeholders responsible for its implementation. Key contents of the plan are highlighted in the actions below. – Define the context and objectives. These will highlight the current situation, planning assumptions, scope, expected outputs and outcomes. The rest of the plan is guided by this introductory section. – Outline the activities to be implemented. Those activities will aim to deliver the expected outputs and outcomes and achieve the agreed objectives. Specific stakeholders responsible for implementing the plan at different levels should be identified. 20 Planning for health system recovery: guidance for application in countries – Prioritize and sequence activities. Attention to this component will help to address gaps and maintain the relevance of the plan in situations that are fluid and rapidly changing. Sequencing should be done by identifying the best time frame for different types of investment - for example, physical infrastructure versus human capital development - synchronized according to subnational context rather than at national level (see example in Box 4). Short- to medium- and long-term priorities should be identified; for example, in the short term interim health care options (e-health and tele-health, temporary facilities and partnerships) can help meet the backlog of discontinued services, while in the medium to longer term actions can be identified to enable the national health system to mainstream service delivery, depending on the situation. – Identify and define indicators and targets. These are set in relation to the baseline, scope, and objectives to attain a new and higher baseline from the pre-shock baseline. The indicators should measure the inputs, processes, outputs, outcomes and impacts relevant to the recovery objectives. – Develop the budget and financing arrangements. These will reflect the estimated but realistic cost of implementing each activity, taking into consideration public financial management, available the funds and other resources that have implications for the costs of activities, such as the availability of trained health workers. It is important to avoid duplication or overlap, which can inflate the budget, reduce confidence and cause inefficiencies in spending. Involvement of health financing departments, ministry of finance or similar, is key. – Establish criteria and principles to guide funding modalities. Prioritization, allocation and monitoring of funds will consider such factors as the proposed beneficiaries, needs of specific groups, the form of assistance to be provided, any conditions or obligations attached to assistance from internal and external partners, monitoring of compliance, and accessibility of funds at various levels. – Identify available and potential funding options. Options for funding and mobilizing other resources needed for the plan include material, human and infrastructure resources. Assessment of the options will take into account cost sharing between stakeholders and mutual aid arrangements secured before and during the shock. – Define a results-based monitoring and evaluation framework. The framework will support implementation through a clear baseline, targets, expected outputs and outcome indicators, while supporting the existing health information system and other data sources to track implementation of the plan. It will include reference to relevant tools and mechanisms for data collection and analysis and will embed systematic learnings for enhancement of system resilience. • Secure required official approval for the plan to be adopted. This will be an official national requirement for which the lead entity, government and other responsible stakeholders are accountable, demonstrating leadership commitment and political buy-in. Official approval is essential for the mobilization and allocation of financial, human and other resources needed for implementation with shared accountability. • Agree on and document a communication and dissemination strategy. The strategy will complement the recovery plan and help make the plan accessible and available to all stakeholders in a transparent manner, and facilitate its use at all levels. A planning template that can be adapted for use in countries according to their national context is presented in Annex 2. 213. Stages and requirements for health system recovery planning Box 4. Strengthening the health system in post-conflict South Sudan The diminished role of the national and subnational health authorities due to the impact of conflict and protracted humanitarian crises presents unique challenges for strengthening the health system following conflict. The presence of multiple nongovernmental organizations and other humanitarian agencies filling the gap with inadequate focus on national health system strengthening, and the decline in funding and other resources from the response phase, also add to the challenges. In post-conflict South Sudan, it was therefore pertinent that the government and partners should work together to facilitate identification of and address the foundational gaps to make the health system building blocks more functional through context-appropriate interventions. A stepwise and integrated implementation approach was used to sequence and mainstream system strengthening and health security priorities, with a focus on learning, progressive improvement and sustainability. The initial actions included joint working between national and international stakeholders to develop and facilitate implementation of a health system stabilization and recovery plan, which encompassed activities for re-establishing and strengthening the coordination and stewardship role of the Ministry of Health, improving access to and quality of essential health services particularly at primary care level, and capacity-building for public health emergency management. Figure 5 illustrates the components of the recovery plan. Figure 5. Components of South Sudan health system stabilization and recovery plan Sta Medicines Infrastructure Delivery mechanisms Governance mechanisms Information systems Financing systems Boost numbers of health workers and reduce attrition Build resilience, Eliminate bottlenecks, Catalyse performance, Re-establish take o baseline Ensure critical products are available as/when needed Basic infrastructure made more functional Bring essential services of good quality closer to where people are Strengthen oversight of the health agenda at all levels Information for real-time decision making and performance monitoring Predictable funding for critical inputs 22 Planning for health system recovery: guidance for application in countries 3.2.4 Communication and dissemination The communication and dissemination strategy should be in place from the early stages to finalization of the plan. Implementing the communication and dissemination strategy is essential for key stakeholders to be aware of the final plan, their roles and timelines. The strategy should be implemented in a focused, fast-tracked and targeted manner, as recovery is time sensitive. The stakeholder mapping prepared earlier is useful as a reference for identifying with whom to share the plan. Any additional stakeholders can be identified and included. Key actions • Disseminate copies or weblinks of the plan. The plan should be shared with persons, groups, organizations and facilities that will have a role in its implementation. It can be accompanied by supporting tools to guide adoption, integration and application of the plan at various levels. All stakeholders at all levels should be oriented on the plan using appropriate means of communication, including presentations at relevant meetings and highlighting in communication materials and newsletters, technical and political publications, and training programmes. • Advocate sustained political commitment and leadership. Garnering support to implement the agreed plan with necessary resourcing may require developing and using targeted communication and advocacy products to reach decision-makers within and outside the health system to make the case for sustained investments in health system recovery. The possible far-reaching benefits of health system recovery should be showcased, including the positive impacts on other sectors, attainment of the Sustainable Development Goals, national economic growth and development, and social cohesion. • Maintain open and transparent communication with all stakeholders. Clear communication will help to maintain trust and manage expectations, and includes providing regular updates on the progress of the plan and the need for updating the plan due to lessons learned during the early stages of implementation, gaps identified, or changes in priorities. Feedback should be solicited from stakeholders to identify areas for improvement and recognize good examples. 3.2.5 Resource mobilization The resources to be mobilized include financial, material and human resources across the health sector and allied sectors, building on the established collaboration and joint working relationships with potential funding sources. This mobilization will primarily address gaps identified through the situational analyses and resource mapping at the beginning of the planning process. Resource mobilization is considered an important part of the planning process, because no matter how good a plan is, it is not implementable without resources. Key actions • Ensure access to the funding sources identified for the plan. Accessing available resources will require follow-up with responsible internal and external authorities and agencies and other stakeholders at national, subnational, and donor levels to allocate and release the resources identified in the plan, for example from contingency and other available funds. Clarity will be needed on how to leverage emergency response investments that can also service recovery priorities in the short to long term, and other investments in the health sector and disease-specific programmes that can support recovery. The process of leveraging existing resources can also be expedited if recovery considerations were already embedded in the budgeting of the health sector, programme-specific and emergency funds. • Continue exploring options for cost and resource sharing. Such options will include financial, material, human and technical support, and sharing other resources between stakeholders to make the most of available resources. Some transfer of resources can take place from nearby areas unaffected or less affected by a shock to shock-affected zones. Resource sharing can expand on and learn from similar arrangements established through pre-shock mutual aid agreements, for example with the private sector, development partners, charities and insurance providers. It may be necessary to establish a mechanism for pooling available funds (including those from response, development and peace initiatives) to support early to long- term recovery and system strengthening with greater efficiency. • Ensure that mechanisms for accountability and transparency are functional. Mechanisms include those for tracking resource allocation and utilization and for identifying potential gaps in funding that might require adjustment or reprioritization, as needed. 233. Stages and requirements for health system recovery planning 3.2.6 Facilitating monitoring and evaluation and maintaining the plan Action is needed to enable effective application of the monitoring and evaluation (M&E) framework defined in the plan. The aim would be to strengthen and facilitate the role of the national health information system where feasible, or to identify interim mechanisms that will be transitioned to a routine health information system as the health system recovers and is strengthened. The designated authority would be responsible for applying the M&E framework to track and report on implementation of plan. Key actions • Indicate the available data sources. These will form the basis for the indicators selected for monitoring and evaluating the recovery plan. It may be necessary to identify and leverage ad hoc data sources in cases where the routine health information system has collapsed due to the shock or was not functional or comprehensive prior to the shock, and is therefore unable to provide the required information needed to monitor and evaluate recovery. For example, in the context of the COVID-19 pandemic response and recovery, pulse surveys were conducted by WHO to generate data from counties on health service disruptions and recovery considerations, as this information was not readily available to inform the response, ensure health service continuity, and support the recovery process (20, 21). • Utilize information from M&E to track, maintain or update the plan. Updating the plan may prove necessary to reflect the recovery that is happening (for example, reduction in backlog of services, increased utilization of health services) and address changes in the emergency context, including deactivation of current response measures or response to additional threats. Major lessons from the emergency and recovery processes can also necessitate reviewing and updating the plan to ensure its success. Findings from intra action reviews, simulation exercises and any formative evaluation of implementation also provide valuable information for maintaining or updating recovery plans during the response phase (22). 3.3 Post-shock context: sustaining and transitioning the recovery plan The planning process does not end with developing, adopting, and disseminating the document. It includes complementary and supportive planning-related activities to be conducted prior to or during implementation of the recovery plan. These activities do not necessarily need to be implemented in the sequence outlined below; various actions can be conducted concurrently, for example resource mobilization while communication and dissemination of the plan are ongoing. This phase also provides an opportunity to adjust the plan if needed, for example, based on the outcome of simulation exercises on the plan. The role of the responsible recovery working group and other responsible stakeholders should therefore extend beyond having the plan developed to include these complementary actions that allow implementation. 3.3.1 Maintaining joint working and coordination with shared accountability In the phase following development of the plan, joint working and coordination between stakeholders within and beyond the health sector remain essential to drive translation of the plan into actions at all levels. The responsible health authorities (such as the ministry of health and national public health institute) along with relevant partners and platforms (such as the health cluster) and other line ministries, will need to remain accountable for implementation of the plan with adequate financing. Key actions • Continue regular coordination meetings and engagement of stakeholders. Regular interaction is crucial for stakeholders to review, maintain and agree on roles and actions for the next steps, including communication, mobilization of resources, implementing the plan and undertaking M&E. It will also facilitate participation of new stakeholders who may not have been previously identified or engaged, and foster collaboration to address challenges. Example, it may be necessary to convene donors, partners, and private sector entities to secure joint funding to complement that from domestic financing. • Provide regular updates to stakeholders and the public. Reporting on the status and next steps of plan implementation or its transition is important to maintain transparency and accountability and to ensure trust and joint working among stakeholders in addressing new challenges as the situation evolves. 24 Planning for health system recovery: guidance for application in countries 3.3.2 Updating and transitioning the plan Health system recovery planning involves flexibility to review and update the content of the plan to align with sometimes frequently evolving needs or lessons learned from its implementation. The plan should include considerations for transitioning from the short- or medium-term to the long-term needs of the health system, and for integrating the recovery plan in the routine health sector development plan. To support that process, the accountability, oversight and leadership of the plan need to be maintained, as well as the organizational, technical, human and financial capacity, and the resources to continuously review, update and transition the plan as needed, based on up-to-date information. Key actions • Jointly adjust the plan as necessary. Adjustment will be based on the findings from monitoring and evaluating implementation of the plan or changes in the situation, for example due to new or deteriorating emergencies or the presence of displaced populations increasing the demands on the health system. The plan will also need to be updated to reflect progress in recovery, thus facilitating the transition from short- and medium-term to long-term priorities for recovery with transformation. • Transition of recovery plan into health sector planning processes. To the extent that early situation scoping allows, a stand-alone recovery plan needs to be progressively transitioned into available health sector strategic development planning in order to avoid parallel efforts or duplication, thus ensuring efficient use of limited resources. In fragile and conflict-affected settings where the health system is not functioning properly, when the recovery plan has been implemented and the health system stabilized, the recovery plan should give way to routine health sector development planning incorporating lessons learned, investments and resources from the recovery process in line with the humanitarian-development- peace nexus. • Mainstream lessons learned. Innovations developed and found to be effective during the recovery planning process, for example intersectoral coordination and community engagement platforms, and data and cost analysis innovations used for the situational analysis can be adapted to enhance future planning and national objectives for building health system resilience. 3.4 Summary illustration of country application Table 4 illustrates how the framework (see Figure 3) and some key actions outlined above can be applied by countries before, during and after a shock, with a focus on integrating and mainstreaming recovery planning through complementary plans and other activities and structures relevant to health system recovery from shocks. 253. Stages and requirements for health system recovery planning Table 4. Integrating and mainstreaming recovery planning in routine and emergency contexts in countries When? What? (priority considerations) Where? (key assessments, structures and plans) How? (examples of actions) Pre-shock context Recovery considerations in assessments • Risk assessments: vulnerability and risk analysis and mapping, Strategic Tool for Assessing Risks, risk register • Health system or service assessments: Service Availability and Readiness Assessment, Harmonized Health Facility Assessment • Population health needs assessment • Community assessment • Incorporate recovery roles in the terms of reference and assessment tools • Where feasible, this is led by the designated authority responsible for recovery processes Recovery considerations in health sector policies and plans • Public health act or equivalent • Health sector development plan • National action plan for health security • National development plan • Review existing policies and plans • Develop or update with clear and focused considerations for health system recovery • Where feasible, this is led by the designated authority responsible for recovery processes Recovery considerations in emergency-related policies and plans • All-hazards emergency preparedness and response plan • Disaster risk management plan • Health service continuity plan • Business continuity plan During shock context Recovery consideration in emergency response structures • Incident management system • Public health emergency operations centre, national emergency coordination centre • Humanitarian-development-peace nexus platform • Multisectoral and intersectoral coordination forums • Socioeconomic recovery platforms • Health cluster coordination • Identify recovery function and focal point in the organogram and terms of reference of respective structures • Establish and coordinate with recovery working group, tailored to the type of shock and context Recovery consideration in emergency-related assessments and response planning • Situational assessment • Emergency, disaster, humanitarian response plans and monitoring • Health service continuity plan • Socioeconomic response plan • Transition plan • Include recovery considerations in situational assessments that inform response-related plans • Consider early recovery priorities in response planning to support transition • Recovery input is led by the responsible authority or equivalent, as applicable 26 Planning for health system recovery: guidance for application in countries Table 4 (cont.) Integrating and mainstreaming recovery planning in routine and emergency contexts in countries When? What? (priority considerations) Where? (key assessments, structures and plans) How? (examples of actions) Post- shock context Recovery of the health system • Recovery or early recovery plan, including transition planning aligned or integrated with available: • Health sector development plan • Socioeconomic recovery plan • Emergency management plan • Health service continuity plan • Multisectoral recovery plan • Establish and maintain a functional recovery working group • Recovery working group coordinates the process of developing the health sector recovery plan, either as stand-alone plan or as part of socioeconomic recovery or other multisectoral plan • Consult on, agree on, adopt, and implement the plan with required resourcing and accountability Sustaining recovery • Health system recovery plan that is operational, along with emergency management structure • From early stages of planning clarify the ownership, responsibilities for implementation and accountability for the plan • Track recovery in monitoring and evaluation of response, deactivation of emergency measures and health sector development • Use the data to inform decisions and actions during response, transition from response, and post-recovery phases, including updating or adapting the plan with changes in the situation Recovery transition and exit from recovery phase • Recovery plan with transition or exit strategy • Health sector investment plan • Health sector development plan • Health sector reform • Public health reform • National development plan • Embed an exit strategy early in the recovery planning process • Develop routine health sector development plans reflecting the lessons learned, building on achievements and addressing gaps from the recovery phase • Document and apply lessons for improvement 273. Stages and requirements for health system recovery planning 4 Conclusion Public health emergencies and their disruptive and destructive impacts are increasing in frequency and magnitude across the world. To build resilience to these threats, health systems must have the capability to recover from these experiences and transform for the better, while developing plans to prevent, prepare for, and respond to future shocks. However, health system recovery, which presents an opportunity for building back better, is often inadequately considered in planning for public health emergencies, health sector development and wider socioeconomic recovery. This technical guide can help stakeholders to develop and integrate health system recovery as policy and planning requirements, catalysing efforts to build back better and consolidate health system resilience. 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Application of the essential public health functions: an integrated and comprehensive approach to public health. Geneva: World Health Organization; 2024 (https://iris.who.int/handle/10665/375864, accessed 10 April 2024). 12. Talisuna A, Mandalia ML, Boujnah H, Tweed S, Seifeldin R, Saikat S et al. The humanitarian, development and peace nexus (HDPN) in Africa: the urgent need for a coherent framework for health. BMJ Global Health. 2023;8:e013880. doi:10.1136/bmjgh-2023-013880. 30 13. It’s time to build a fairer, healthier world for everyone, everywhere. World Health Day 2021. Health equity and its determinants. Geneva: World Health Organization; 2021 (https://cdn.who.int/media/docs/default- source/world-health-day-2021/health-equity-and-its-determinants.pdf, accessed 16 June 2024). 14. Build back better in recovery, rehabilitation and reconstruction [consultative version]. Geneva: United Nations Office for Disaster Risk Reduction; 2017 (https://www.unisdr.org/files/53213_bbb.pdf, accessed 16 June 2024). 15. United Nations Office for Disaster Risk Reduction, International Recovery Platform. Guidance note on recovery: pre-disaster recovery planning. Kobe: International Recovery Platform Secretariat; 2012 (https://www.undrr.org/publication/guidance-note-recovery-pre-disaster-recovery-planning, accessed 16 June 2024). 16. Cometto G, Buchan J, Dussault G. Developing the health workforce for universal health coverage. Bull World Health Organ. 2020;98:109–16. doi:10.2471/BLT.19.234138. 17. Recovery and peacebuilding assessment guidance and toolkit. United Nations, World Bank, European Union; 2017 (https://www.recoveryandpeacebuilding.org/content/rpba/en/home/partnership- documents.html, accessed 16 June 2024). 18. European Union, Global Facility for Disaster Reduction and Recovery, World Health Organization. Post-disaster needs assessment guidelines. Volume B: Social sectors - Health. Geneva: World Health Organization; 2014 (https://www.who.int/publications/i/item/post-disaster-needs-assessment-guidelines, accessed 16 June 2024). 19. Health Resources and Services Availability Monitoring System (HeRAMS). Geneva: World Health Organization (https://www.who.int/initiatives/herams, accessed 16 June 2024). 20. Fourth round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic: November 2022–January 2023. Geneva: World Health Organization; 2023 (https://iris.who.int/ handle/10665/367352, accessed 17 June 2024). 21. Rivas-Morello B, Horemans D, Viswanathan K, Taylor C, Blanchard A, Karamagi H et al. Assessing capacities and resilience of health services during the COVID-19 pandemic: lessons learned from use of rapid key informant surveys. Front Public Health. 2023;11:1102507. doi:10.3389/fpubh.2023.1102507. 22. Geerts JM, Kinnair D, Taheri P, Abraham A, Ahn J, Atun R et al. Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. JAMA Network Open. 2021;4:e2120295-e. doi:10.1001/jamanetworkopen.2021.20295. 31References Annex 1. Checklist of key actions for health system recovery planning The following checklist can be used to ensure key actions and principles for health system recovery planning before, during and after shocks. In the pre-shock phase, please check if the following key actions are implemented or not Key action Status (tick as applicable) Identify health system recovery as a priority for managing all shock events Designate or establish the governance structure with clearly identified roles and responsibility for recovery related activities Establish collaboration and coordination mechanism among key stakeholders Identify and implement recovery-related activities which need to and can be undertaken prior to shocks Factor in likely financial, human, and material resources needed, e.g., from regular domestic funds During shock events, please check if the following key actions are implemented or not Areas Key action Status (tick as applicable) Stakeholder coordination and participation Convene a recovery planning working group Identify and engage new stakeholders Provide orientation of the responsible stakeholders with reference to their roles Review actions to ensure synergy with complementary initiatives and planning processes 32 Areas Key action Status (tick as applicable) Situational analysis Undertake a fast tracked joint situational assessment and check the following sub-actions Determine the scope and standardized tools to be applied and adapted Identify, engage, and leverage a range of sources and resources Ensure due attention to all affected, vulnerable, and marginalized populations Clearly document, validate, and disseminate the findings of the situational analysis Developing the plan for recovery Jointly develop and finalize the contents of the plan as a written document and check the following sub-actions. Define the context and objectives Outline the activities to be implemented to deliver the expected outputs and outcomes and achieve the agreed objectives Prioritize and sequence activities as needed to address gaps and maintain the relevance of the plan considering fluidity and changes in the situation Identify and define indicators and targets Develop the budget reflecting the estimated but realistic cost Establish criteria and principles to guide prioritization, allocation, and monitoring of funds Identify available and potential options for funding and mobilizing other resources needed Define results-based M&E framework Secure required official approval for the plan Define and agree on communication and dissemination strategy for the plan Communication and dissemination Disseminate copies or weblinks of the plan as appropriate Advocate sustained political commitment, leadership, and support Maintain open and transparent communication with all stakeholders Resource mobilization Ensure access to the funding sources identified for the plan, e.g. contingency funds Continue exploring options for cost and resource sharing and pooling of funds Ensure that the mechanisms for accountability and transparency are functional Facilitating M&E and maintaining the plan Indicate the data sources for each of the indicators selected Utilize information from M&E to maintain or update the plan as necessary 33Annex 1. Checklist of key actions for health system recovery planning Following a shock, please check if the following key actions are implemented or not Areas Key action Status (tick as applicable) Maintaining joint- working and coordination Continue regular coordination meetings and engagement of stakeholders Provide regular updates to stakeholders on plan implementation Updating and transitioning the plan Jointly adjust the plan as necessary based on findings from M&E Transition priorities of recovery plan into available health sector strategic development planning (in case of a stand-alone recovery plan being developed) Mainstream innovations, e.g. those developed as part of response Please check the following to ensure that the guiding principles and approaches are applied in the planning process • Is this timely in terms of leveraging ongoing response to transition to recovery? • Is it based on a thorough understanding of the context including existing local capacities and response mechanisms? • Does it promote and enable national leadership and local ownership? • Does it clearly link to and build on other national plans (health sector plans etc.)? • Does it reflect population health priorities and risks? • Does it facilitate meaningful participation and trust of communities and people affected? • Does it reflect and facilitate other sectors roles (public and private)? • Does it reduce inequity and vulnerabilities? • Will the way it is done cause harm? • Does it contribute to accountability to affected populations? • Does it include the role of all health system building blocks and tackle gaps in health system foundations? • Does it duplicate any existing national mechanism that it could strengthen? • Is it conflict sensitive (in conflict or / post- conflict settings)? • Will it leverage and transition response resources to build back better and contribute to long term resilience in line with the HDPN way of working? • Does it strengthen primary care? • Does it strengthen all aspects of the essential public health functions? 34 Planning for health system recovery: guidance for application in countries Annex 2. Sample planning template for health system recovery in the context of disruptive shocks This template is developed for adaptation and use in developing overarching, strategic plans for health system recovery. It contains simple headers and descriptions that can guide national and subnational planning and inform more detailed operational planning at different levels and by different actors, based on the scope of their roles in health system recovery. The content and focus of this template can be adapted and used for stand-alone recovery planning and for incorporating recovery needs and processes in health sector or other plans aimed at improving progress towards universal health coverage and health security. The template can also be used for developing a pre- shock recovery plan, which would be updated for shock-specific recovery planning as needed. Context Based on the situational analyses to inform the plan, summarize the current situation and findings relevant to the occurrence and impact of the shock from which the health system needs to recover. This should reflect population health needs, risks for additional shocks, performance and resilience of the health system before and during the shock, lessons from the experience, the availability of and gaps in required resources and capacities within health and allied sectors., Other contextual information to highlight include the stakeholders, legal and policy frameworks within which to operate, complementary plans etc. Scope and time frame Define what is covered and what is not covered in the plan, including the time frame. This should highlight complementarity to other related plans, for example national health sector plans or multisectoral recovery plans, that cover other important aspects that are not covered by the recovery plan. Explain the reasons for the current scope of the recovery plan, for example, based on a stepwise approach to address foundational, urgent and affordable issues before the next steps. Guiding principles which inform the scope and other aspects of the plan can also be highlighted in this section. Overall goal and objectives Define the shared goals and objectives of the plan, reflecting the needs of the health system and populations served in line with the findings of the situational assessment. 35 Priority areas of need or investment Based on results of the gap analysis and lessons from the situational analyses and objectives, identify more specifically the priorities to be addressed by the plan. These should reflect the immediate to medium- and long- term needs for recovery and strengthening of the health system’s foundations, functionality, and resilience across all building blocks, namely governance and leadership; financing; workforce; information; medical products, technologies and infrastructure; and service delivery (individual and public health services) as well as the people and communities served. They should also reflect aspects of public health and health determinants that are the responsibilities of other sectors, in line with the essential public health functions. Activities Identify specific key actions under each of the priority areas above with time frame and responsible stakeholders. The activities should be prioritized and sequenced recognizing different time frames for different types of investment (for example, weeks to months for immediate and short term; months to years for medium to long term), with attention to subnational contexts as well as national-level inputs. Consider different scenarios (best to worst case in planning), for example, if the shock continues to deteriorate or there are no additional resources to invest in recovery and building. Activities with responsible stakeholders and time frame Priority areas of need or investment Priority activities and actions Time frame Responsible stakeholders Leadership and governance capacity Establish a sustainable mechanism for intersectoral coordination and collaboration Immediate, e.g. in one month Responsible team or entity for health system recovery, e.g. health minister’s office Monitoring and evaluation Identified a results-based M&E framework with baseline, targets and indicators, which would be used to regularly monitor and evaluate progress in implementing the plan. Where possible, this should be aligned with and applied within the routine health information system and other regular M&E mechanisms in the country. Include the data source for each indicator. Estimated cost of implementing planned activities, by scenario and time frame Overall goal Population health outcome metrics to be improved, e.g. those related to health care access and utilization, mortality rates, health determinants Objectives Outcome indicators Description of the priority areas Indicators Baseline as at specified period Data source Target (in relation to defined timelines) e.g.in 1 year e.g., in 2 years 36 Planning for health system recovery: guidance for application in countries Costing and budget Outline an estimated and realistic cost of implementing each priority area in the short to long term based on a realistic gap analysis which leverages and reflects available resources and investments (e.g., from emergency response, health sector financing, disease specific programmes, contributions to health from other sectors, donor funds etc. Highlight actual funding gap. Identify sustainable financing mechanisms to address the gap, and highlight assumptions made provide clarity on how to interpret the costing. E.g., how the planned costs complement costing of other relevant plans. Estimated cost of implementing planned activities by scenarios (e.g., worst- case scenario) and timeframe Objectives and priority areas Activities Cost e.g., Year 1 e.g., Year 2 e.g., Year 3 Mapping of priority areas of investment against existing funded initiatives and available funds: gap analysis by scenario (e.g. worst-case scenario) Priority area Available funds from initiatives and plans related to respective priority areas Total available from existing sources Total cost Total funding gap or need Initiative A (e.g. health sector plan) Initiative B (e.g. national action plan for health security, emergency response or humanitarian response plan) Initiative C (e.g. programme on noncommunicable diseases Assumptions used in estimating the cost of the plan Measures to ensure sustainable financing and institutionalized implementation These can include clear explanations of how efficiency will be ensured to make the most of available resources, how resources will be mobilized to fill the funding gap, and what will be done to reduce dependence on external support. References and appendices Add the reference list and additional information that would be helpful for better understanding and using the plan, for example: • risk profile of the affected population and setting • contact list of responsible stakeholders and alternatives (if those on main contact list are unavailable) • communication strategy and dissemination list • inventory of resources and assets • list of complementary plans and how they are linked with the recovery plan 37Annex 2. Sample planning template for health systems recovery and transformation in the context of disruptive shocks Annex 3. Supportive frameworks and approaches Key approaches that facilitate the application of the principles and actions in this planning guide include health system framework, primary health care, the essential public health functions, and the humanitarian- development-peace nexus. The Health System Framework Health systems are broadly understood to consist of the people and actions whose primary purpose is to improve health (1). These have been organized into six interconnected and interdependent components known as the health systems building blocks: governance; financing; workforce; medicines, supplies, technologies, and infrastructures; information systems; and service delivery with people and communities recognized as central to decision-making and actions. Like any other system, all parts of the health system are interdependent and must work together to be effective, as well as functioning in synergy with wider systems that contribute to health and its determinants (2). The functionality of the health system is demonstrated in the delivery of comprehensive individual and population services to meet individual and population health from prevention to palliation. This framework allows health system recovery planning and other processes to ensure and sustain the recovery of all components of the health system, as well as the role of each building block in enabling the recovery and transformation of the other components and the entire system. Example, restoration and improvements in service delivery requires sustained inputs from all the other building blocks. The primary health care approach The primary health care approach is essential to build health system resilience as the foundation for health security and the pathway towards universal health coverage, eventually enabling a healthier population and society (3). The primary health care approach has three interrelated and synergistic pillars: (a) integrated health services with primary care and essential public health functions at the core; (b) multisectoral policy and action for health; and (c) empowered people and communities (4). Primary care is at the foundation of health systems and is often the first point of contact with communities. These three components can strengthen primary care to deliver a continuum of health services ranging from health promotion, disease prevention, screening, and early diagnosis to treatment, rehabilitation and supportive care; to work with communities to deliver services that are prepared for and responsive to population health needs; and to work with the rest of the health system (for example, hospitals) and allied sectors to connect communities to the health (for example, surgery) and social services (for example, social protection programmes) they need. Primary care should be prioritized for effective recovery and transformation of health systems following any shock event in any context. In recovery planning, focus can be given to identifying and strengthening the role of primary care in delivering people-centred, comprehensive, integrated, quality services in both emergency and routine circumstances; in creating supportive environments that promote positive behaviours for health and facilitate social participation in health; and in serving vulnerable and marginalized populations to overcome inequities. Primary care is also utilized to perform many public health functions and services in the event of emergencies; institutionalizing these good practices as health systems move into the recovery phase and beyond is critical for making health systems more resilient to multifaceted public health and sociopolitical challenges (5). 38 Essential public health functions The essential public health functions describe the fundamental and interdependent activities required for countries to ensure comprehensive delivery of public health actions, prevent disease, promote and protect health and well-being, and address the wider determinants of health (6). A public health approach to population health is often considered to reduce costs and to promote sustainability and equity. Applying the essential public health functions is a comprehensive and integrated approach to public health, bringing together the four functions of major public health services (health promotion, disease prevention, health protection, and emergency management) and the associated cross-cutting functions that enable those services (for example, public health stewardship, multisectoral planning, public health workforce, community engagement, public health surveillance and monitoring). In recovery planning, the essential public health functions can be applied to review the baseline public health capacity in situational analysis; improve promotive, preventive, curative, rehabilitative and palliative services; build capacity for health protection against ongoing and future public health emergencies and their direct and indirect impacts; and identify stakeholders and structures, from national to local levels, that must work together to deliver public health functions and services. Application of the essential public health functions in recovery and transformation efforts would lead to more comprehensive public health capacities within health and allied sectors and help orient health system capacities based on population health needs, thus ensuring more coordinated delivery of health system strengthening, health security, disease-specific programmes, and other public health agendas. Health in the humanitarian-development-peace nexus The health in humanitarian-development-peace nexus framework represents a comprehensive approach to integrating considerations for health into the collaborative efforts of humanitarian, development and peacebuilding actors, while addressing the interconnected challenges (7). In times of crisis or acute shock, humanitarian actors provide a key role in the provision of essential health services to vulnerable populations in many contexts. Recovery planning should anticipate the changing role of humanitarian and development actors over the recovery process and the associated changes in coordination and funding mechanisms. The humanitarian-development-peace nexus approach recognizes that transition to recovery is not always linear, with crises increasingly protracted and complex, and thus aims to better align actors around agreed shared objectives and flexible planning. Incorporating humanitarian-development-peace nexus principles into health system recovery planning facilitates effective transition and leveraging of humanitarian response and resources to strengthen the health system and build resilience in future humanitarian crises (8). The health in humanitarian-development-peace nexus framework outlines the changes needed in five cross-cutting areas (enabling policy and governance; planning and intersectoral coordination; budgeting and financing; integrated service delivery; and monitoring and information management) to ensure health as a priority in the actions of humanitarian, development and peacebuilding actors. These required changes must be integrated in each step of recovery planning, especially in fragile, conflict-affected and vulnerable settings. 39Annex 3. Supportive frameworks and approaches References: 1. The world health report 2000: health systems: improving performance. Geneva: World Health Organization; 2000 (https://iris.who.int/handle/10665/79020, accessed 21 June 2024). 2. Systems thinking for health systems strengthening. Geneva: World Health Organization; 2009 (https://iris. who.int/handle/10665/44204, accessed 21 June 2024). 3. Reorienting health systems to primary health care as a resilient foundation for universal health coverage and preparations for a high-level meeting of the United Nations General Assembly on universal health coverage. Report by the Director-General. Geneva: World Health Organization; 2023 (https://apps.who.int/ gb/ebwha/pdf_files/WHA76/A76_6-en.pdf, accessed 18 June 2024). 4. World Health Organization, United Nations Children’s Fund. Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization; 2020 (https://iris.who.int/ handle/10665/337641, accessed 15 June 2024). 5. Realising the potential of primary health care. Paris: Organisation for Economic Co operation and Development; 2020 (https://www.oecd-ilibrary.org/content/publication/a92adee4-en, accessed 18 June 2024). 6. Application of the essential public health functions: an integrated and comprehensive approach to public health. Geneva: World Health Organization; 2024 (https://iris.who.int/handle/10665/375864, accessed 10 April 2024). 7. Talisuna A, Mandalia ML, Boujnah H, Tweed S, Seifeldin R, Saikat S et al. The humanitarian, development and peace nexus (HDPN) in Africa: the urgent need for a coherent framework for health. BMJ Global Health. 2023;8:e013880. doi:10.1136/bmjgh-2023-013880. 8. Bridging the divide: a guide to implementing the humanitarian-development-peace nexus for health. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2021 (https://iris.who.int/ handle/10665/351260, accessed 18 June 2024). 40 Planning for health system recovery: guidance for application in countries Annex 4. Method The aim of the review was to identify any practical guidance to support recovery planning in the context of the health system and sector, and to identify any gaps in such guidance. This was achieved using the following methods: a search of peer-reviewed literature, and a search of organizations’ websites. Peer-reviewed literature review Given the varied terminology within the literature, a scoping review was undertaken to identify articles of relevance to health system recovery planning. Key words included recovery or similar concepts such as strengthening, stabilization, restoration or reform, health system or similar and concepts related to planning. The search was further refined using MeSH headings relating to planning, policy, strategy and implementation. The final search strategy employed within PubMed is presented in Box A4.1. No publication type or language limits were applied, and the database was searched from 2015 onwards to capture relevant aspects of recovery following the 2013–2016 outbreak of Ebola virus disease in West Africa. Box A4.1. Search strategy employed in PubMed ((“recovery”[Title] OR “strengthen*”[Title] OR “build back better”[Title] OR “building back better”[Title] OR “restoration”[Title] OR (“stabilization”[Title] OR “stabilisation”[Title]) OR “transformation”[Title] OR “reform*”[Title] OR “resilien*”[Title]) AND (“plan*”[Title] OR “strateg*”[Title] OR “guidance”[Title] OR “polic*”[Title] OR “policy”[MeSH Terms] OR “health policy”[MeSH Terms] OR “health systems plans”[MeSH Terms] OR “state health plans”[MeSH Terms] OR “regional health planning”[MeSH Terms] OR “health planning technical assistance”[MeSH Terms] OR “health plan implementation”[MeSH Terms] OR “strategic planning”[MeSH Terms] OR “invest*”[Title]) AND (“health system*”[Title/Abstract] OR “healthcare system*”[Title/ Abstract] OR “health care system*”[Title/Abstract] OR “Health Services”[MeSH Terms:noexp] OR “delivery of health care, integrated”[MeSH Terms])) AND (2015:2022[pdat]) The retrieved articles (763) underwent title and abstract screening using two independent reviewers against the inclusion and exclusion criteria presented in Table A4.1, with conflicts resolved through discussion. Following this process, 41 articles were identified for full text review. Data were ultimately extracted from two (Figure A4.1). The most common reason for exclusion at full text stage was that the articles contained no relevant information to inform recovery planning. 41 Table A4.1. Inclusion and exclusion criteria Inclusion criteria Exclusion criteria A. The following three requirements are met simultaneously: 1. Considers a country’s health system as a whole (or the health systems of a group of countries). 2. Considers “recovery” or similar goals, such as health system strengthening, transformation, stabilization, reconstruction or reform. 3. Presents plans, strategies, guidance, policies, investment mechanisms or other instruments whose goal is to operationalize and specify the work on recovery, i.e. to answer the questions of “what to do” and “how to do it” to enable the recovery of a health system. Alternatively, offers an overview or a critique of such instruments. – Contents limited to individual building blocks, elements or aspects of health sys- tems (such as workforce, financing, infor- mational infrastructure; specific health care settings, specific health care services, such as maternity services) as opposed to taking a systemwide perspective – Considers the recovery of health system(s) in the abstract, without offering specific enough suggestions on the “what” and “how” of it (no plan, strategy, guidance, etc.) – Has a health system and planning focus, but only in terms of prevention, preparedness or response to public health emergencies; does not address recovery – Considers “recovery” as a clinical phenom- enon, related to specific diseases or groups and populations suffering from these. B. Plans, strategies, guidance documents, policies, investment mechanisms, etc. on the broader recovery of a country or a group of countries, following a significant shock (such as COVID-19 or another epidemic or pandemic, war and conflict, economic crisis). With such documents, the goal will be to explore to what extent the recovery of health systems is addressed at all in them and in what ways. Search of organizations known to have a role in recovery The websites of all United Nations programmes, funds and agencies, as listed on the United Nations system webpage (https://www.un.org/en/about-us/un-system), were searched between October 2022 and May 2023. The websites of “other entities and bodies” and “related organizations” from the United Nations system list of organizations (https://www.un.org/en/about-us/un-system) were not searched. The year was limited to 2015 to coincide with post-Ebola recovery efforts. A first-line search involved the free text word “recovery” to search the publications section of the website of each agency, fund or programme. If no publication section existed, the whole website was searched. Given the variability in the organization of content and degree of sophistication of their search functions, the strategy was adapted in response to the sophistication of search facilities and the approach to classification of documents. The strategy was further adapted to manage retrieval size, with a retrieval of up to 250 citations considered feasible without further adjustment. For example, large retrievals on websites with good search facilities were contained by searches in title only or under specific publication types, while large retrievals on websites with basic search functions were managed using rules of thumb based on relevance. Medium-sized retrievals whose initial pages provided highly relevant documents were fully screened (for example, 450 “working papers” of the International Monetary Fund). If no documents were returned on recovery, searches were run for “plan” or “strategy” to identify documents attending to recovery but using a different term, such as reconstruction or growth. And finally, searches were run for “health” if the above returned no relevant citations. This approach yielded a total of 49 documents. Word frequency analysis was run on these documents using the terms “health”, “health system”, “recovery” and “plan”. Documents with reference to “health” and/or “health system” AND “recovery” and/or “plan” were pulled for full text review. This resulted in the full text review of 29 documents, with data extracted from four documents. The most common reason for exclusion at full text review stage was a lack of practical guidance to support health system recovery or planning. 42 Planning for health system recovery: guidance for application in countries Documents identified through other sources A further 11 documents were identified through other means, including consultation with experts (nine) and hand search of references (two). The same inclusion and exclusion criteria were applied, with data extracted from one of these sources. Limitations Limitation of the literature search was year limit to 2015 in order to reduce the number to manageable size (less than 1000). Figure A4.1. Document search flow chart Excluded N=722 Data extraction N=7 (Academic= 2; organizational=4; other=1) Excluded N=39 Excluded N=11 Excluded N=28 Excluded N=17 Fu ll te xt re vi ew Da ta e xt ra ct io n Se ar ch a nd sc re en in g * Other sources included sources identified through expert consultation and reference lists Documents identified through other sources* N=12 Academic literature N=763 Organizational documents N=49 43Annex 4. Method

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