Behavioral Sciences, Vol. 12, Pages 495: Population Perspectives on Impact of the COVID-19 Pandemic on Essential Health Services—Behavioral Insights from the Federation of Bosnia and Herzegovina

4.2. Interpretation and Comparison with Published LiteratureBiH administratively consists of and is governed as two independent political entities—the Republika Srpska (RS) and the FBiH (in which the presented survey was implemented), and one autonomous district—the Brcko District of BiH [19]. In the FBiH, each of the cantons has its own decentralized system. The reform of the health care system started in 1995 with the main aim of strengthening PHC to include family medicine. The health system in the country is complex, and this posed a challenge when organizing a response to the COVID-19 pandemic [20,21]. The universal health coverage (UHC) index, which aims to represent service coverage across population health needs and the extent to which these services could contribute to improve health, was estimated at 64.2 in 2019; while this is an increase from 54.2 in 1990, it is still below the value for most Western European countries (above 80) [22].One of the key challenges in the provision of health care in the FBiH is the shortage of health care workers (HCWs). According to a recent analysis [11], while the number of medical doctors has been increasing in recent years, it is still below the EU average (232 vs. 353 MDs per 100,000) [23]. Similarly, the number of hospital beds available before the pandemic were considerably lower than the EU average (370 vs. 553/100,000) [12]. Such shortages may pose challenges in cases of health emergencies, and they may be a contributing factor to the findings that non-availability of appointments and long waiting times were among main reasons for postponements of care (reported by 68% of respondents). Indeed, this finding is in line with the generally high number of countries reporting HCW-related disruptions (e.g., staff shortages, infections among HCWs, etc.) as a cause of disrupted EHSs during the COVID-19 pandemic (66% of countries) [2]. In addition, HCWs are among the most vulnerable to COVID-19 [24,25] and are prone to severe burdens on mental health caused by work-related stress during the pandemic [26,27], which can further disrupt the available capacities. Therefore, addressing HCW shortages is a critical strategy in increasing preparedness and resilience for future emergencies. The WHO outlines the domains that require attention to address these shortages, including supporting and protecting HCWs at the workplace, strengthening and optimizing HCW teams, increasing capacity and strategic HCW deployment, and health system human resources strengthening through assessment and planning of HCW needs or strengthening governance and intersectoral collaboration mechanisms [28]. WHO policy considerations also provide evidence-based strategies for engaging and motivating HCWs [29]. The CDC divides strategies into contingency (e.g., adjusting staff schedules) and crisis-capacity strategies to be implemented after contingency strategies (e.g., implementing regional plans to transfer patients with COVID-19 to designated institutions) [30].In the survey, people with chronic conditions needed care more often than those without and can thus be considered more vulnerable to any disruptions of EHS. Moreover, the presence of chronic disease reported by the respondents in the survey was found to be the single strongest factor associated with need of care, with postponement of the needed care, and with reported increased expenses for medicines and health care. This is of significant concern, as these conditions (such as ischemic heart disease, stroke, cancer, and diabetes) are the leading cause of death and disability in BiH [31]. Adding to this significance is the fact that disruptions of non-communicable disease (NCD)-related health services due to the COVID-19 pandemic were seen globally in 75% of countries. In addition, countries were shifting funds from NCD-related budgets to fund the COVID-19 response, which further disrupted these services [32]. There is strong evidence that some NCDs are risk factors for severe COVID-19 [33], making one-fifth of the global population susceptible to such events [34]. Thus, there is a two-way relationship between NCDs and COVID-19 that has been observed globally [35,36,37] and has been confirmed by the findings of this study for the FBiH. This new dimension of NCD prevalence and care should be considered in efforts to prevent and improve care for NCDs in the country. A recent report by the NCD coalition [38] provided good practices for better integrating NCD care into the COVID-19 response and beyond, for example by expanding the use of telehealth consultations, encouraging home visits by community health care workers, supporting home care, introducing multi-month prescriptions, and making medicine refills easier. Another study presented solutions to improve access to medication for people with NCDs and improve NCD care in general, including the use of remote options for prescriptions, authorizing a wider range of professionals to prescribe medication, creating electronic systems to support patients in long-term treatment, and encouraging patient empowerment and patient-centered care [39]. Furthermore, the COVID-19 pandemic has emphasized the need for a supply chain that can quickly adjust to changing needs through strategies such as regular evaluation of critical supply stock, ensuring longer-term stockpiles, improving storage facilities, and improving supplier monitoring [40]. It is important that measures and improvements implemented during the COVID-19 pandemic are maintained so that health systems are strengthened and more resilient for future emergencies.The behavioral insights survey found reported increases in unhealthy behaviors relating to use of tobacco andalcohol, diet, and physical exercise, which are considered risk factors for NCDs. When asked about their behaviors during the last two weeks compared with pre-pandemic behaviors, 38% reported having exercised less than usual, 21% reported having eaten unhealthier food, and 6% reported having been drinking more alcohol [41]. These behaviors are generally more common among respondents who have experienced worsening financial situations. Quarantine was associated with less exercise and more unhealthy food specifically. Besides health care, it is crucial to consider the broader implications of pandemic response interventions on population health, as well as to uphold the support for healthy behaviors for children and adults and maintain population-level interventions for these risk factors.Along with people with chronic conditions, women and the elderly were identified in this study as being among those most in need of care, and therefore most vulnerable to EHS disruptions. This is in line with findings from previous studies. Women (compared to men) were about 1.3 times, and the elderly between 65 and 75 years were 1.4 times more likely (compared to 45–54 years old) to experience EHS disruptions [42]. Women, in addition, are especially more vulnerable due to their need for specific types of health care, such as maternal or neonatal care, which were also shown to be disrupted [43]. Such disruptions can in turn increase the occurrence of related undesired health outcomes (e.g., stillbirths, maternal deaths, ruptured ectopic pregnancies, and higher maternal depression rates) [44,45], especially in countries with lower incomes [46]. The elderly, as a vulnerable group, are of great concern, as the population structure of BiH is projected to shift towards older age groups [47]. The elderly have been shown to be prone to experiencing EHS disruptions in general [46,48], and especially in hospital care [46]. Thus, both the evidence from this survey and the mounting evidence from the published literature call for attention to these two population groups and for efforts to ensure their access to EHSs during emergencies such as the COVID-19 pandemic. Specifically for increasing consumption of alcohol during the pandemic, men were found to be at higher risk.Another significant finding is that 41% of respondents reported increased out-of-pocket payments for medicines, and 30% reported such an increase for health-service-related payments. Although a health insurance system in the FBiH is well established, it is fragmented—there are in total 13 health insurance funds, and reimbursement policies vary between them [21]. As a result, for example, inequities existed in access to essential medicines for inhabitants living in different administrative regions, even before the pandemic [49]. The problem is not isolated to the FBiH. A recent WHO report stated that out-of-pocket payments remain the dominant source of health care financing in most lower-middle-income and in about a third of upper-middle-income countries and called for reducing these payments to progress towards UHC [50]. Another study has linked COVID-19 mortality with out-of-pocket expenditure in general [51]. While based on the data obtained in this survey it is not possible to directly make such link for the FBiH, the COVID-19-related mortality in the country has been shown to be among the highest overall in the global context [47]. Therefore, efforts should be made to mitigate the problem and recognize it as one of the possible drivers of undesired health outcomes during the COVID-19 pandemic. In general, COVID-19 has placed health as a strategic sector in the economy and put additional emphasis on the ability quickly to adjust to changing needs of the population.The survey also assessed the satisfaction with health care in 23 domains and found an average satisfaction score of 3.2 (95% CI: 3.2–3.3). While it is difficult to interpret these findings in absolute terms, a comparison with similar surveys in one of the regions of the FBiH in 2011 (yielding a mean score 3.2, range 2.6–3.8) and in 2017 (yielding a mean score of 3.5, range 3.1–3.9) [15] suggests that, due to the pandemic, the satisfaction with health care during the COVID-19 pandemic declined from 2017 levels to levels similar to those measured in 2011. An in-depth study is needed to elaborate on these differences. However, based on these comparisons, the COVID-19 pandemic caused a decline in overall patient satisfaction with care in the country.We note that since the data collection for this study took place, the numbers of cases of COVID-19 have declined throughout Europe, including in the FBiH [1], which led to the gradual lifting of restrictions of movement and reinstalment of most services to pre-pandemic levels [51]. This, in turn, likely led to fewer disruptions of EHSs, to the mitigation of barriers of access to care and health-seeking behavior, and to the general improvement of health care service availability and use. Despite these improvements, the findings of this study present important lessons that can be used to avoid disruptions of EHSs during future emergencies, as well as to improve resilience and preparedness for such events.

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