# Strategies to maintain health service provision during the COVID-19 pandemic in refugee settings in Jordan and Uganda

## TL;DR

This paper examines how health services for refugees in Jordan and Uganda were adapted during the pandemic to ensure continued care while preventing virus spread.

## Contribution

The study provides a detailed characterization of health system adaptations in refugee settings during the pandemic, emphasizing their implementation and success factors.

## Key findings

- Adaptations focused on community screening, isolation, and facility-level infection prevention.
- Successful adaptations relied on integration of refugees into national health systems and strong partner relationships.
- Modifications included task shifting, staffing surges, and vaccine strategies to maintain care access.

## Abstract

Health system adaptations were rapidly introduced at the start of the COVID-19 pandemic to protect the public and maintain access to health services. Given the specific vulnerabilities of forced displacement settings, understanding which adaptations were used, how they were implemented, their success, and challenges is important for preparedness and response efforts. In this paper, we characterize adaptations in health service delivery implemented by Ministries of Health, the UN Refugee Agency, and partners to maintain health services provision for refugees in Jordan and Uganda. We conducted 21 key informant interviews with managerial and operational staff across 12 organizations who delivered healthcare services for refugees in Uganda and Jordan during the COVID-19 pandemic and applied a framework analysis to the adaptations characterized. The results are presented by WHO health system building blocks. Most adaptations focused on health service delivery specifically procedures for screening and isolation in the community, COVID-19 community support, and facility-level infection prevention measures. Health service delivery adaptations focused not only on ensuring capacity for COVID-19 patients but on adapting mechanisms to support access for those needing regular care. Many adaptations worked in tandem with others as packages to achieve this. Workforce adaptations included task shifting and staffing surges. Modifications related to medical products, vaccines, and technologies focused on procurement, medication management, supporting vaccine strategies, and building testing capacity. Adaptations in leadership and governance, financial and health information systems were identified but mainly described as essential enablers for other adaptations. Key enablers to successful adaptation in this context included the integration of refugees in National Health systems, strong relationships between partners and a supportive environment for adaptation, existing preparedness plans and access to financing. This study highlights the scale, scope and diversity of innovative adaptations implemented to maintain health services for refugees in Jordan and Uganda during the COVID-19 pandemic.

COVID-19 saw the rapid introduction of health system adaptations to maintain access to health systems. These adaptations helped protect patients from the virus as well as support access to existing care, minimizing interruptions. This research summarizes the adaptations introduced in refugee settings in Jordan and Uganda to support documentation and learning for future outbreaks. We highlight the breadth of adaptations described to us by staff responsible for their introduction and application. Adaptations were numerous and implemented across all aspects of the health system. They included more universal infection control adaptations and those specific to camp and settlement settings to protect new arrivals, as well as mechanisms to ensure patients could continue to access routine care through pregnancy and for long-term illnesses, for example. The longstanding relationships between partners and the government, as well as the integration of refugees in national health systems, were fundamental to fostering an adaptive environment that supported the COVID-19 health response.