Week 1 – Video 1 Transcript

It was the middle of the Crimean war in 1858. A young woman was treating British soldiers in a
hospital tent when she was forced to confront her role as a field nurse. This young woman felt
compelled to go beyond her training and began tallying fatalities and possible causes. She made
copious notes, creating data sets of her observations.

That woman was Florence Nightingale and her discovery on hygiene is true to this day in the era
of masks and sanitizers, in the era of COVID-19.

So if you’re a nurse on the frontlines of a pandemic and if you’re trying to make some sense of
what’s happening to your patients, then perhaps it’s time to examine the data and ask how can
you use data to save their lives?

This week, following in the footsteps of Florence Nightingale, we will do precisely just that. We
will examine the data on COVID-19 and understand how a local health situation has rapidly
assumed global proportions. We will dig deep to learn about different health systems from
around the world and what makes a robust health system. We will explore the role of a nurse
during a health crisis and understand how we can adopt a holistic approach to engage the
community.

You’ll also hear from nurses around the world who found themselves fighting pandemics like
Ebola and SARS. But, first, take a look at the data surrounding patients dealing with COVID-19
in your area and answer the following questions. What is the mortality rate of patients in your
community? Can you describe the segment of your local population that is most impacted by this
pandemic? And what are the reasons for this?

2020 happens to be the bicentenary of the birth of nurse statistician Florence Nightingale, so,
fittingly, welcome to this course where together we will explore how data can be one of the most
powerful tools that can impact the lives of your patients when fighting a global health crisis.

Welcome to the Course

Understanding the COVID-19 Pandemic

Welcome to COVID-19: Effective Nursing in Times of Crisis, a new short course putting front
line nurses at the centre of the global response to an unprecedented health crisis.
Together, we are facing extraordinary challenges. SARS-CoV-2, the virus that causes COVID-
19, has turned the world upside down. The pandemic is a new experience for many of us and we
face a mounting number of cases, rising death tolls and increasing suffering. The pandemic has
found nurses on the frontlines, and casts an important spotlight on the work we do. As nurses
face these challenges, we have to be guided by the data, just as Florence Nightingale was
centuries ago.

COVID-19 has its own timeline and together we will use this course to look at local factors that
influence screening, containment and mitigation. Understanding the data and the evidence for
best practice is our power to make a difference.

Throughout the course, we’ll look at a range of resources, such as those provided in the See Also
section below. You will also hear from experts sharing information in the context of a rapidly
developing and evolving field.

These resources and information will be further illustrated by stories from nurses working on the
front line of health care right now. You will get to see their individual experiences, and have the
opportunity to share your own.

Millions of nurses around the world are facing similar challenges, dilemmas and successes. Your
local context might differ slightly, but the many stories we are hearing reflect the dedication of
nurses around the world.

Through engaging in materials and sharing your perspectives, you can gain a broader
understanding of the issues, and share solutions to the many problems you might be facing. Case
studies will let you investigate best practice strategies that can help you think through problems,
find the best solutions, and adapt your practice to best meet the needs of the individuals, families
and communities you serve.

Before starting, take a moment to browse through the selection of key resources and websites for
COVID-19 in the See Also section.

Join the Community

The threat of infectious diseases has been with us since the beginning of civilization. Many
experts have warned us about pandemics, but never thought that we would be experiencing such
suffering across the world.

The Johns Hopkins University Coronavirus website is a valuable resource to help advance the
understanding of the COVID-19 virus. It also provides access to valuable resources in order to
guide a data driven response to improve care and save lives.

As our opening example shows, Florence Nightingale demonstrated the power of presenting
information for data driven decision making. Today, visualizing cumulative cases demonstrates
the overall toll of Coronavirus on a country over time, which is essential in assessing spread and
developing appropriate responses.

To begin our learning journey, go to the Johns Hopkins University Coronavirus website and click
on the animated maps icon.

Identify where you are living in the world and the number of cases.

 How is your country responding to the pandemic?

 What are the core approaches being used in your setting?

 Finally, how do the experiences you have heard about Florence Nightingale influence
your perceptions of the COVID-19 pandemic?

Use the Discussion section to share your initial thoughts with other learners.

You can also view the additional videos provided in the See Also section below. They provide
additional background to responses to the pandemic, as well as context to differing views and
strategies being adopted.

Answer

The Philippines' response to the COVID-19 pandemic has encompassed a blend of public health
measures, economic assistance, and vaccination initiatives. To curb the virus's spread, the
government has implemented diverse levels of community quarantine and imposed restrictions
on mobility, including lockdowns, travel constraints, and social distancing protocols.
Concurrently, endeavors have been undertaken to fortify the healthcare system, enhance testing
and contact tracing capabilities, and provide support to individuals and businesses affected by the
pandemic. A focal point has been the vaccination rollout, aiming to inoculate a substantial
portion of the population for achieving herd immunity.

Florence Nightingale's observations during the Crimean War, documented in her notes and data
sets, laid the foundation for managing outbreaks. Despite the limited resources and technology of
her era, Nightingale formulated a theory highlighting the connection between the environment
and health. This enduring theory serves as a fundamental pillar of the healthcare system.

Nightingale's environmental theory found practical application during the Philippines' response
to the COVID-19 pandemic. Measures such as monitoring disease progression, segregating
positive patients into dedicated facilities, and maintaining a comprehensive tally of cases
throughout the pandemic reflect the adaptation of her principles to contemporary healthcare
practices.

How to Learn with FutureLearn

Welcome to COVID-19: Effective Nursing in Times of Crisis.

We are excited to work with you in discussing how nursing can respond to the challenges posed
by low resources and high societal uncertainty in the wake of COVID-19. This course, delivered
by the FutureLearn platform and led by a global learning community, will assist you in not just
obtaining information, but interpreting, synthesizing and reflecting on key issues in the COVID-
19 pandemic.

We are developing this course in real time with real experts, capturing their reflections as they
continue to work on the frontline. We are also preparing this course in real time in a fluid
pandemic where information is changing day by day.

Patricia Davidson
 I will be your Lead Educator and will guide you
through this course. In my role as Dean and
Professor at Johns Hopkins School of Nursing,
I’m deeply committed to supporting and
mentoring the next generation of health
professionals.

You can find out more about me from my

FutureLearn profile, and choose to ‘Follow’ me
to share questions and advice on the course.

Throughout this course, we will journey with Sherry Chen, a nurse who answered the call to
return to her home in New Jersey to assist in dealing with the COVID-19 pandemic.
In order to address the course objectives we have presented a range of resources and learning
from leaders in the field to help you in dealing with the COVID-19 pandemic:

 Dr. Jason Farley, an expert from Johns Hopkins University in infectious diseases

 Nurses Kaci Hickox, Nadia Andrade, and Deborah Wilson. All are nurses who have
devoted their careers to helping in emergency situations. Each of them have worked for
Médecins sans Frontières in a range of settings, dealing with epidemics from measles,
cholera and Ebola and working in areas such as South Sudan, Syria, Liberia and
Chechnya

 Kevin Ousman is leading the response in the Democratic Republic of Congo to address
the Ebola crisis, and was personally challenged in these exceptional situations by
COVID-19

 Dr Nancy Reynolds, Associate Dean for Global Affairs at Johns Hopkins University. Dr
Reynolds outlines how the COVID-19 pandemic is highlighting serious deficiencies in
health systems

 Cynda Rushton will talk to us about the importance of the code of ethics in our
professional practice, and also the need to take care of ourselves in these challenging
situations.

We’re also exceptionally proud to partner with JHPIEGO, the Johns Hopkins Program for
International Education in Gynecology and Obstetrics, in this course. They are highly
experienced in working with challenging situations in low-resource settings. You will hear an
insightful interview with Leslie Mancuso and Peter Johnson. As I have worked with each of
these experts, hearing their stories I’ve been incredibly impressed with them as individuals, with
their passion and commitment to nursing and the individuals, families and communities that they
serve.

Your learning

Each week of this course is centred around learning outcomes: statements which express what it
is you will be better able to do by the end of the course. They are a useful way of checking on
how you’re progressing.
The course covers the following learning outcomes:

 Identify key characteristics of COVID-19 and their effect on vulnerable populations

 Evaluate approaches to strengthening health systems

 Reflect on the impact of public health crises in your context

 Describe the characteristics of effective healthcare interventions

 Discuss the applications of data analytics in decision-making

 Apply ethical frameworks to clinical practice in complex situations

 Reflect on the role of leadership in responding to public health crises.

You can revisit steps as you progress through the course so that you feel confident you’re
meeting the learning outcomes. As you are working through the steps and activities, you might
want to refer back to this step to check your progress against the learning outcomes.

Learning together

Through the next weeks of the course, you won’t be learning on your own. You’ll be studying
alongside many learners from around the world.

Use the Comments sections and Discussion steps throughout the course to ask your fellow
learners questions and share problems you are stuck on. Share your stories and provide insights
and advice for your peers around the world. Developing a collaborative learning environment
will lead to a successful and enjoyable course, and will help spread good practice across the
global nursing community.

Additional learning

If you have a general interest in this topic, you can work through the learning steps in around two
and a half hours each week. However, everyone is different, and you may wish to spend more
time on certain steps. Additional videos, links and resources allow you to explore the course
topics and the data in more detail. Make the most of these opportunities to further your
understanding of this topic.
It’s important that you don’t feel pressured to complete all the elements of the course: your
journey is individual and you should decide what elements are relevant to your immediate needs.

Answer

I want to convey my deep appreciation to the team behind this course for imparting crucial
knowledge to healthcare professionals and students. A big thank you to all supporters and groups
dedicated to enhancing healthcare. As someone aspiring to work in healthcare, I've learned a
great deal from this course. I extend my gratitude to the dedicated team for their time and
expertise in helping us learn. Thank you!

Video 2 - COVID-19: what we know, and what we need to do

Answer

I am thankful for the brief and informative video discussion that covered essential information
about COVID-19, its origins, and key aspects. This conversation is helpful in initiating a
comprehension of the virus, stressing the importance of testing, maintaining hygiene, and
practicing social distancing. It particularly emphasizes the need for these precautions among
vulnerable groups, specifically those with respiratory conditions, recognizing the varied impact
of the disease on different segments of the population.

How is the COVID-19 pandemic evolving?

1593 comments

Origins and impact

In December 2019, a novel coronavirus, SARS-CoV-2, was identified as the cause of an

outbreak of viral pneumonia in Wuhan, China. The disease, later named coronavirus
disease 2019 (COVID-19), rapidly spread globally and was subsequently declared a
pandemic by the World Health Organization.

This novel virus presents particular threats: there is no known pre-immunity, no available
vaccine, limited treatments are available, and the virus is manifesting as being highly contagious.
Recent experience with severe acute respiratory syndrome (SARS) and Middle East respiratory
syndrome (MERS), which also are caused by coronaviruses, has helped healthcare systems
prepare for COVID-19. However, the virulence of COVID-19 has left many healthcare systems
exposed, and unable to deal with a pandemic on this scale.

COVID-19 has tested all members of society but particularly healthcare workers, who are facing
the risks of the virus as well as bearing witness to suffering and distress. The spread of COVID-
19 is unprecedented and healthcare systems are battling to respond. Countries around the world
have shut borders and moved to social distancing to limit spread. This has had disastrous effects
on economies around the world, as unemployment soars and stress and anxiety increases.

There is a rapid race around the world to develop a vaccine and to develop appropriate
treatments. However, until these strategies are available, we are left with having to implement
public health strategies, such as handwashing, social distancing and wearing masks. Many of
these strategies have been practiced for decades by nurses.

Testing and tracing

Testing is widely advocated as a means both to understand and to slow the spread and impact of
the virus. Tests allow us to identify infected individuals, take steps to isolate those infected, and
help in the tracing and quarantining of their contacts. Testing for COVID-19 also informs our
understanding of the pandemic. For example, several studies have demonstrated that many
individuals test positive for the symptom before declaring symptoms. At time of writing, there
are two tests available: one for the presence of the virus, establishing whether an individual is
currently infected, and the other for the presence of antibodies. However, many countries have
been unable to initiate widespread testing and contact tracing.

Managing infection rates

The shortage of personal protective equipment (PPE) has been a concern to nurses globally and
has been implicated in infections and spread. This is the case in many high income countries and
the world watches and waits for how the pandemic will impact on low and middle income
countries (LIMC). For many countries however, data on testing is either incomplete or else
unavailable. Similarly, there is a lack of ventilators and other supportive treatments. For LIMC
such as in Africa, who are no strangers to epidemics, 1.2 billion people remain at tremendous
risk.
As COVID-19 is a new disease, we are learning new information about risk factors and spread
every day. Based on currently available information and clinical expertise, older adults and
people of any age who have serious underlying medical conditions might be at higher risk for
severe illness from COVID-19. This includes people with heart, liver and kidney disease and
diabetes. People who are immunocompromised, have poorly controlled HIV or AIDS, and
prolonged use of corticosteroids and other immunotherapy agents are also at an increased risk.

Emerging data suggest a disproportionate burden of illness and death among racial and ethnic
minority groups and our understanding of this is evolving. Living conditions may contribute to
underlying health conditions and we now see that the impact of COVID-19 has accentuated the
impact of social determinants of health. We will be looking more closely at working with
vulnerable communities in the next step in the course.

Over to you

 Based on your own experience, are you able to identify the part of your patient
population who are experiencing more severe cases of COVID-19?

 What factors do you think might be contributing to these complications?

 How do you think nurses can mitigate these circumstances?

Share your thoughts with other learners in the Comments section.

Answer

As a student nurse, I observe that individuals facing severe cases of COVID-19 often include
those with demanding jobs, the elderly, and healthcare workers. The lack of sleep and rest
appears to be a common factor for those with strenuous jobs and healthcare workers,
compromising their immune systems. Healthcare workers, being consistently exposed to the
virus, are particularly affected. The elderly may experience more severe cases due to underlying
health conditions that impact the progression of the disease. Nurses can mitigate these challenges
by advocating for and imparting updated knowledge about COVID-19, fostering public caution
and preventive measures.

Case study: working with vulnerable populations

Finding yourself in a clinical environment where you are unable to provide adequate clinical care
can be a source of moral distress to nurses but drawing on your skills, expertise and colleagues
can be critically important.

In this audio interview, we hear from three nurses working in frontline care with vulnerable
populations - Kaci Hickox, Nadia Andrade and Deborah Wilson.

The interview is 20 minutes long. You can download this audio file and the transcript from this
recording from the Downloads section below.

Kaci Hickox, Nadia Andrade and Deborah Wilson

Kaci Hickox is currently working for Doctors Without Borders, and has responded to the Ebola
outbreak in Sierra Leone in 2014, as well as measles, meningitis, and cholera outbreaks around
the world.

Nadia Andrade is a graduate student at JHU, and also works with Doctors Without Borders,
spending time in Chechnya, South Sudan and Syria. Most recently, she has served as a critical
care nurse specialist and also as an educator for JHU critical care courses.
Deborah Wilson is a Ph.D. student at JHU, and has also worked for Doctors Without Borders in
measles and cholera outbreaks as well as the Ebola outbreak. Recently, she has been working in
Boston Hope, Massachusetts’ largest field hospital for COVID patients.

Answer

The discussion, enriched by the experiences of expert nurses, underscores the need to enhance
nursing education, especially in the context of the risks nurses face on the frontlines. Prioritizing
global nurse education and securing increased funding is crucial for better preparedness in future
crises. Grateful for the insights shared by Kaci Hickox, Nadia Andrade, and Deborah Wilson.

Global perspectives

855 comments

With over 200 countries registering COVID-19 cases, uncertainty and questions envelope
the world. Many questions persist as to how long the pandemic will last. What will the new
world order look like, particularly in the context of economic disruption and geopolitical
instability?

To date, the largest numbers of confirmed cases are in the United States, Italy, Spain, and France,
and there is substantial variability of strategies. Many countries have implemented restrictive
measures, including stay at home orders, to contain the spread of the virus. Differing responses
and timelines have led many to question what is actually the best approach to halting the spread
of the virus, and a range of mathematical models provide varying predictions.

COVID-19 has not only disrupted our lives: it has changed our ways of living and working.
COVID-19 has also fundamentally changed the way nurses work in many ways. The threat of
infection and the need to wear PPE has changed how we provide nursing care. Restricted visiting
has meant many family members have been denied being with their loved one, even as they are
dying.

The uptake of telehealth has been perhaps a positive outcome of COVID-19. The need to isolate
has led to a rapid uptake of a broad range of services via video, telephone or email. This has
enabled access to healthcare and may remain as a more popular mechanism of healthcare
delivery. This rapid growth has led to increased cross-jurisdiction, cooperation, and growth of
expertise. But this has also laid open a wide digital divide where many individuals do not have
access to the internet or smartphones. In this way, COVID-19 is much more than a health crisis,
with the potential to cause far-reaching devastating social, economic and political crises.

The COVID-19 pandemic is a defining global health crisis of our time, challenging global health
infrastructure and governance. As the most trusted profession and as advocates for individuals,
families and communities, nurses need to not only consider the immediate clinical context but
also the broader social, political and economic context of the pandemic. Reflecting on changes in
your country will be important in developing responsive and appropriate health care delivery
systems.

COVID-19 does not affect us in isolation. In some areas of the world there are populations
dealing with multiple conditions. This example from South Africa, published in online journal
The Conversation, describes the increased risks for people with HIV and tuberculosis. In many
countries, the huge economic impact will influence access to food and health services.

Country case study: South Africa

Take your learning further:

You can read more about economic consequences and the impact on health posed by COVID-19
in the additional case study examples in the See Also section below.

As you read, think about the similarities that exist between the countries featured. How well have
each been able to address the social and economic impacts of the pandemic?

Answer

The USA, France, Italy, and the UK have all dealt with the COVID-19 outbreak using a mix of
lockdowns, vaccination initiatives, and public health measures. However, their effectiveness in
managing the social and economic aftermath varies. The success of their endeavors depends on
factors like healthcare infrastructure, vaccine distribution, and financial relief programs. Each
country has unique challenges in addressing the diverse repercussions of the pandemic.

COVID-19: share your perspective

1988 comments
How has the highly fluid environment of COVID-19 impacted your life?

So far we have explored the impact of COVID-19 within vulnerable communities, and in health
systems around the world. In each case, we have seen how the pandemic has exposed
weaknesses and raised questions of the systems, both in terms of practice recommendations and
resource shortages. We have also borne witness to the challenges faced by frontline staff—
physically, emotionally and in the context of care—both in the field and in their home lives.

The COVID-19 pandemic is presenting a huge challenge to public health and the global
economy. The impact of COVID-19 is likely to be felt in both the short- and long-term. Earlier
you identified how your country is dealing with COVID-19. Reflecting on stories from the field
and the changes happening, how has COVID-19 changed your working day?

Share your perspective with other learners in the Discussion section.

Answer

The onset of COVID-19 coincided with my freshman year in college. However, the virus
prompted a shift to remote and online learning. As part of the inaugural batch experiencing
college education primarily through online means, the abrupt transition from in-person to virtual
classes was startling. This change, especially as I began my nursing school journey, instilled a
sense of fear.

The pandemic made me question the value of pursuing nursing through online education.
Traditionally, this degree involves hands-on skills and exposure to the healthcare field, and the
shift to online learning raised concerns about whether the virtual format could adequately
provide the necessary training and experience.

The building blocks of health systems

COVID-19 has laid open the cracks and vulnerabilities of healthcare systems across the
world. Even some of the richest countries in the world have been held hostage to the virus
and are struggling to respond.

Although we have a robust stockpile of scientific knowledge, unfortunately it is not matched by

the power of health systems to deliver them to those with the greatest need, either in a
comprehensive way, or at scale. The COVID-19 pandemic has cast the spotlight on the need to
identify the essential building blocks of health systems and to foster the factors that contribute
both to sustainable development and robust health systems.

According to the World Health Organization, effective healthcare systems are dependent on the
following pillars which contribute to ensuring a safe and robust health system:

 Health service delivery

 Health workforce

 Health information systems

 Access to essential medicines

 Health systems financing

 Leadership and governance

A key purpose of the World Health Organisation’s Framework for Action is to promote a
common understanding of what a health system is and what constitutes health systems
strengthening. This framework also provides a foundation to support countries in scaling up
health systems and services to achieve sustainable system-wide effects.

Across the world, countries have a range of health service funding models as well as mechanisms
of staffing health care systems. Unfortunately a pandemic, such as COVID-19, can disrupt and
disable health care systems that are fragile and where funding is tenuous.

The need for strong and resilient health systems, embedded in just and civil societies, is the
essence of the United Nations Sustainable Development Goals. The nursing workforce has a
huge role to play in strengthening global health systems. We can do this by taking the following
actions that contribute to the robust pillars of health systems:

 providing excellence in clinical care

 leading policy initiatives

 advancing nursing science

 developing evidence, supporting nursing colleagues and other team members

  working with and advocating for patients, their families and communities, and

 collecting data and informing the development of evidence and policy.

JHPIEGO provides excellent resources to identify the building blocks of health systems and
monitor changes over time. You can find links to these in the See Also section.

The decisions that you make everyday as a nurse contribute to the efficiency and effectiveness of
the health system. The 2030 Agenda for Sustainable Development, adopted by all United Nations
Member States in 2015, provides a shared blueprint for peace and prosperity for people and the
planet, now and into the future. And achieving the goals of the United Nations’ Sustainable
Development Goals by 2030 depends on nurses leaders exerting their influence in communities
and health care systems worldwide. The COVID-19 pandemic exemplifies the importance of
considering the broad social, political and economic implications of healthcare.

The United Nations’ Sustainable Development Goals. (Click to expand)

Data from around the world have identified highly variable approaches to dealing with the
COVID-19 pandemic, from intensive case tracing in South Korea through to a less intensive
approach in Sweden. Many of the decisions around healthcare strategies are based on an
understanding of population size, resilience of the health system and available resources.
Understanding the social, political and economic dimensions of health systems is important in
formulating healthcare strategies. So, taking the time to understand the health care system in
your country and available resources will help you understand strategies.

Some scientists have suggested considering the COVID-19 pandemic as a series of distinct local
epidemics. The impact of COVID-19 in different settings has been dependent on the
characteristics of health systems and strategies implemented to halt the virus.

Over to you

Read through this additional article on responses to managing the pandemic in six different
regions.

6 countries, 6 curves: how nations that moved fast against COVID-19 avoided disaster (The
Conversation, April 2020)

Are you from one of these countries or regions? If not, how does your local setting compare to
those cited in the study?

Answer

The Philippines, my homeland, is absent from the mentioned list. I find the government's
reaction to the pandemic to be both sluggish and insufficient. Stringent quarantine measures were
only enforced when the virus had already widely proliferated. The decisions regarding the
closure of borders to foreigners and returning Filipinos from high-caseload countries were not
promptly executed. Moreover, I am of the opinion that the management of the initial surge of the
virus in the country could have been more effective had accurate data from reliable sources been
utilized.

Health systems: meeting current and future need

1143 comments
The State of the World Nursing report provides an important record on where we are and
what we need to achieve to move towards the Sustainable Development Goals and
achieving universal health care coverage.

Developed by the World Health Organization with the International Council of Nurses and the
global Nursing Now Campaign, this new, real-time snapshot of nursing across the globe
challenges all of us to shape our profession for the future, and identify opportunities to achieve
healthcare for all.

What it highlights, however, is a huge shortfall in nurses. Of an estimated needs-based shortage

of 17.4 million health workers, more than 9 million are nurses and midwives. By 2030, the WHO
Global Health Observatory forecasts the need for 32.3 million nurses and midwives.

You can download a summary slide for your own country by visiting the SOWN 2020 report. We
have included a sample on Kenya in the See Also section below. As you can see, this summary
provides some important information on health systems strengthening.

Ensuring we have a confident, competent and credentialed nursing workforce is critically

important in building robust health systems. Without greater and more effective investment in
health systems and the nursing workforce, it will be impossible to achieve national and
international goals and address current pandemics and future health crises.

Take your learning further

Use these additional examples to help you reflect on your experience.

 Rural America
Although the numbers of cases may be low, access to health care services may also be
limited. Could telehealth help augment access?

 Germany
The response to COVID-19 has been better than many other countries. One of the reasons
postulated is that there is a higher nurse to patient ratio in the country.

Over to you
  To what extent do you see the pillars of effective healthcare systems present in your local
and national context?

 Where do you see the gaps: are they in information systems, financing, leadership and
governance, or staffing?

 How confident are you that you can find out more information about the decisions
driving your local healthcare strategy?

Answer

 Health service delivery

 Health workforce

 Health information systems

 Access to essential medicines

 Health systems financing

 Leadership and governance

Answer

In the Philippines, the three essential components of healthcare—health service delivery, health
workforce, and health information systems—are present but exhibit deficiencies. The health
service delivery in my country is notably lacking, primarily attributable to the government's
sluggish response to the COVID-19 pandemic. The health workforce has also been adversely
affected, facing shortages and inadequate compensation due to unjust work schedules.
Furthermore, the health information system is inadequate for disseminating updates to all regions
of the country, hindered by poor technology and information management. Despite the evident
need for improvement in these three pillars, there has been no discernible progress.