Coronavirus disease (COVID-19) has exposed long-standing fragmentation in health systems strengthening efforts for health security and universal health coverage while these objectives are largely interdependent and complementary. In this prevailing background, we reviewed countries’ COVID-19 Preparedness and Response Plans (CPRPs) to assess the extent of integration of non-COVID-19 essential health service continuity considerations alongside emergency response activities. We searched for COVID-19 planning documents from governments and ministries of health, World Health Organization (WHO) country offices and United Nations (UN) country teams. We developed document review protocols using global guidance from the WHO and UN and the health systems resilience literature. After screening, we analysed 154 CPRPs from 106 countries. The majority of plans had a high degree of alignment with pillars of emergency response such as surveillance (99%), laboratory systems (96%) and COVID-19-specific case management (97%). Less than half considered maintaining essential health services (47%); 41% designated a mechanism for health system–wide participation in emergency planning; 34% considered subnational service delivery; 95% contained infection prevention and control (IPC) activities and 29% considered quality of care; and 24% were budgeted for and 7% contained monitoring and evaluation of essential health services. To improve, ongoing and future emergency planning should proactively include proportionate activities, resources and monitoring for essential health services to reduce excess mortality and morbidity. Specifically, this entails strengthening subnational health services with local stakeholder engagement in planning; ensuring a dedicated focus in emergency operations structures to maintain health systems resilience for non-emergency health services; considering all domains of quality in health services along with IPC; and building resilient monitoring capacity for timely and reliable tracking of health systems functionality including service utilization and health outcomes. An integrated approach to planning should be pursued as health systems recover from COVID-19 disruptions and take actions to build back better.

Simulation Exercises (SimEx) are an established tool in defence and allied security sectors, applied extensively in health security initiatives under national or international legislative requirements, particularly the International Health Regulations (2005). There is, however, a paucity of information on SimEx application to test the functionality of health systems alongside emergency preparedness, response and recovery. Given the important implications health services resilience has for the protection and improvement of human life, this scoping review was undertaken to determine how the publicly available body of existing global SimEx materials considers health systems, together with health security functions in the event of disruptive emergencies.The global review identified 668 articles from literature and 73 products from institutional sources. Relevant screening identified 51 materials suitable to examine from a health system lens using the six health system building blocks as per the WHO Health System Framework. Eight materials were identified for further examination of their ability to test health system functionality from a resilience perspective.SimEx are an effective approach used extensively within health security and emergency response sectors but is not yet adequately used to test health system resilience. Currently available SimEx materials lack an integrated health system perspective and have a limited focus on the quality of services delivered within the context of response to a public health emergency. The materials do not focus on the ability of systems to effectively maintain core services during response.Without adjustment of the scope and focus, currently available SimEx materials do not have the capacity to test health systems to support the development of resilient health systems. Dedicated SimEx materials are urgently needed to fill this gap and harness their potential as an operational tool to contribute to improvements in health systems. They can act as effective global goods to allow testing of different functional aspects of health systems and service delivery alongside emergency preparedness and response.The work was conducted within the scope of the Tackling Deadly Diseases in Africa Programme, funded by the UK Department for International Development, which seeks to strengthen collaboration between the health system and health security clusters to promote health security and build resilient health systems.