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Performance of Healthcare Systems During and After the COVID-19 Pandemic

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A special issue of Healthcare (ISSN 2227-9032). This special issue belongs to the section "Healthcare in Epidemics and Pandemics".

Deadline for manuscript submissions: 29 June 2026 | Viewed by 14937

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Dr. Dimitris Zavras

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Department of Public Health Policy, School of Public Health, University of West Attica, 196 Alexandras Avenue, 11521 Athens, Greece
Interests: socioeconomic impact of COVID-19; access to healthcare; utilization of healthcare services; healthcare provider choice; unmet healthcare needs; catastrophic health spending; health status measurement; research on health services; impact of economic crises on healthcare; research on health systems
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Special Issue Information

Dear Colleagues,

The COVID-19 pandemic found most health systems worldwide unprepared to respond to this overwhelming public health crisis. Their weaknesses became particularly evident during the first and second waves of the pandemic, affecting primary, secondary, and tertiary care. The resulting reactions of health systems involved all aspects of care in an attempt to meet the needs of both emergent COVID-19 and non-COVID-19 patients. The question now is how health systems worldwide are functioning today having returned to normalcy, given the changes that took place during the pandemic.

The evaluation of health systems is more relevant and important today than ever, as it reveals whether the lessons learned from the pandemic have transformed operations within the framework of upgrades. The purpose of this Special Issue is to examine the changes that have taken place and their outcomes. Research areas may include (but are not limited to) the following: crisis management, operations research (medical prioritization, capacity planning, staffing, patient scheduling, etc.), systems research, healthcare management and decision making, health policy, and the assessment of health system performance through the presentation of health system evaluation indicators.

Based on the previous points, this Special Issue attempts to highlight the performance of healthcare systems after the COVID-19 pandemic, emphasizing patient care and healthcare delivery.

High-quality scientific and policy papers, both empirical and theoretical, from academics and researchers are welcome.

I look forward to receiving your contributions.

Dr. Dimitris Zavras
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Healthcare is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

COVID-19
performance of health systems
healthcare delivery
performance indicators
health policy
decision making
healthcare management
crisis management
operations research
systems research

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Published Papers (7 papers)

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Research

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20 pages, 734 KB

Open AccessArticle

Increased Experiences of Multiple Forms of Discrimination in Healthcare Settings During the COVID-19 Pandemic Among African, Caribbean, and Black (ACB) People Across Canada: A Cross-Sectional Survey

by Josephine Etowa, Amos Buh, Angela Kaida, Shamara Baidoobonso, Joseph Osuji, Judith Apondi Odhiambo, Lilian Ndongmo, Egbe Etowa, Bishwajit Ghose and David Este

Healthcare 2026, 14(10), 1332; https://doi.org/10.3390/healthcare14101332 - 13 May 2026

Viewed by 128

Abstract

Background: In Canada, racialized communities, including African, Caribbean, and Black (ACB) people, are disproportionately affected by HIV and COVID-19. Experiencing multiple forms of discrimination in healthcare settings compromises care engagement and health outcomes. The objective of this study was to assess the forms of discrimination ACB people experienced during the COVID-19 pandemic, discrimination levels experienced before and during the pandemic and the demographic factors associated with the increased experiences of discrimination among ACB people when accessing healthcare services during the pandemic. Methods: Data were collected via an online survey co-led by the Public Health Agency of Canada, University of Ottawa, ACB community leaders and researchers across Canada. Participants were recruited via email contact. To be eligible, a participant had to be living in Canada, be aged 18 years or older, be able to read English or French, and self-identify as an ACB individual. The survey captured information on access to health services and experiences of multiple forms of discrimination before and during the pandemic. We used multivariable logistic regression to identify factors associated with discrimination. Results: Of 1556 participants, 39.6% were aged 25–39, 42.7% were resident in Ontario, and 63.2% were of African origin. Prior to the COVID-19 pandemic, 62.1% reported having experienced at least one form of discrimination in a healthcare setting. During the COVID-19 pandemic, over 66% reported having experienced at least a form of discrimination, with 25% reporting a perceived increase in the frequency with which they experienced discrimination. The perceived increase in the frequency of discrimination was 10.8%, 15.3%, 15.9%, 17.0%, 18.1%, 18.7%, and 31.2% among participants who reported having experienced sexual orientation-, gender-, substance use-, disability-, age-, economic status-, and race-based discrimination, respectively. In the multivariate logistic regression, the odds of reporting increased experiences of discrimination in participants aged 50 and above were 0.38 times (95%CI: 0.21, 0.69) those in participants who were 31–40 years of age. Conclusions: The proportion of participants who reported an increased experience of discrimination during the pandemic was high. Although there is variation in levels of experienced discrimination, the different forms of discrimination (race-, gender-, sexual orientation-, substance use-, economic status-, disability- and age-based discrimination) that participants experienced are alarming. This underscores the need for concerted efforts to address multiple forms of discrimination in healthcare settings to improve care engagement and health equity among ACB communities. There was a significant association between perceived increased experience of discrimination and only one sociodemographic factor—older age (50 and above); other factors contributing to participants’ perceived increased experience of discrimination when accessing healthcare services need to be explored. Full article

(This article belongs to the Special Issue Performance of Healthcare Systems During and After the COVID-19 Pandemic)

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13 pages, 260 KB

Open AccessArticle

Changes in Disease Severity and Outcomes Among Electively Admitted Cirrhosis Patients During the COVID-19 Era

by Melania Veronica Ardelean, Dana Roxana Buzas, Alin Viorel Istodor, Paul Ciubotaru, Vlad Ivan, Norina Simona Basa, Daniel Florin Lighezan, Dan Iliescu and Ovidiu Florin Ardelean

Healthcare 2026, 14(9), 1255; https://doi.org/10.3390/healthcare14091255 - 6 May 2026

Viewed by 292

Abstract

Background: Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, had profound primary effects on global health and secondary effects through widespread disruption of healthcare systems, limiting access to elective medical services essential for the management of chronic diseases such as liver cirrhosis. Elective hospitalizations play a key role in disease monitoring, prevention of complications, and therapeutic optimization. This study aimed to evaluate the impact of the pandemic on the clinical profile, disease severity, and outcomes of patients electively admitted with liver cirrhosis across three periods: pre-pandemic, pandemic, and post-pandemic. Methods: This retrospective, single-center cohort study included 248 adult patients electively admitted with a primary diagnosis of liver cirrhosis between February 2018 and February 2024. Patients were stratified according to admission period. Data on demographics, clinical presentation, etiology, decompensation markers, severity scores (Child–Pugh, Baveno), procedures, and hospitalization outcomes were analyzed. Results: A total of 248 patients were included, with a significant reduction in elective admissions during the pandemic (23.0% vs. 46.4% pre-pandemic), followed by partial recovery post-pandemic (30.6%) (p = 0.031). A higher proportion of urban patients was observed during the pandemic (70.2%, p = 0.004). Disease severity increased during the pandemic, with a higher prevalence of Child–Pugh C (17.5%) and Baveno stage 6 (10.5%), whereas post-pandemic data showed improvement (Child–Pugh C: 6.57%; no Baveno stage 6; p = 0.004). Ascites (47.4%) and paracentesis (21.1%) peaked post-pandemic (p = 0.012; p = 0.003). Endoscopic activity decreased during the pandemic (22.8%, p = 0.017), while interventional procedures were more frequent (8.8%, p = 0.045). Transfusion requirements (17.5%, p = 0.001) and hospitalization costs (€467.08, p = 0.01) were highest during the pandemic, while no deaths were recorded post-pandemic. In-hospital mortality was observed in 1.7% of patients during the pre-pandemic period and increased to 3.5% during the pandemic period, while no deaths were recorded post-pandemic. Conclusions: The COVID-19 pandemic significantly altered elective cirrhosis care, leading to reduced admissions, increased disease severity, and higher resource utilization. Although partial recovery was observed post-pandemic, persistent evidence of delayed decompensation underscores the importance of maintaining continuity in elective hepatology services. Full article

(This article belongs to the Special Issue Performance of Healthcare Systems During and After the COVID-19 Pandemic)

13 pages, 458 KB

Open AccessArticle

Quality of Life and Financial Burden in Duchenne Muscular Dystrophy in Greece: Insights into Health System Performance in the Post-Pandemic Context

by Eleni Katsomiti, Catherine Kastanioti, Elisabeth Chroni, George Mavridoglou and Evangelos Pavlou

Healthcare 2025, 13(22), 2835; https://doi.org/10.3390/healthcare13222835 - 8 Nov 2025

Viewed by 1234

Abstract

Background: The COVID-19 pandemic disrupted healthcare systems, disproportionately affecting individuals with rare diseases. This study explores the health-related quality of life and financial burden in the post-pandemic context among children with Duchenne Muscular Dystrophy and their families in Greece, providing insights into health system performance. Methods: A multicenter, cross-sectional study was conducted in two neuromuscular clinics in Greece. Fifty families (response rate 67%) completed standardized quality of life instruments (PedsQL™ 4.0 Generic Core Scale; PedsQL™ 3.0 DMD Module) and a socioeconomic questionnaire. Descriptive and correlation analyses assessed associations between functional status, financial strain, and psychosocial indicators. Results: Children with Duchenne Muscular Dystrophy reported moderate-to-severe reductions in physical and emotional well-being, and substantial out-of-pocket expenditures. Families with greater financial strain or wheelchair-dependent children had significantly lower health-related quality of life scores. Insurance coverage was positively associated with emotional and psychosocial functioning. Conclusions: Greek families living with Duchenne Muscular Dystrophy continue to face significant financial and psychosocial challenges in the post-pandemic period. While the cross-sectional design does not allow causal attribute to COVID-19 pandemic, the results underscore the need to strengthen financial protection, coordinated multidisciplinary care, and equitable access to support services for rare disease management. Full article

(This article belongs to the Special Issue Performance of Healthcare Systems During and After the COVID-19 Pandemic)

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22 pages, 305 KB

Open AccessArticle

Public Perceptions on the Efficiency of National Healthcare Systems Before and After the COVID-19 Pandemic

by Athina Economou

Healthcare 2025, 13(17), 2146; https://doi.org/10.3390/healthcare13172146 - 28 Aug 2025

Cited by 2 | Viewed by 1099

Abstract

Background/Objectives: This study examines individual perceptions of national healthcare system efficiency before and after the COVID-19 pandemic across 18 countries grouped into three clusters (the Anglo-world, Europe, East Asia). This paper aims to identify the demographic, socioeconomic, health-related, and macroeconomic healthcare drivers of public assessments, and explain changes in attitudes between 2011–2013 and 2021–2023. Methods: Using individual-level data from the International Social Survey Programme (ISSP) for 2011–2013 and 2021–2023, logistic regression models of perceived healthcare inefficiency are estimated. In addition, the Oaxaca–Blinder decomposition model is adopted in order to decompose the assessment gap between the two periods. Models include a range of individual demographic and socioeconomic characteristics and national healthcare controls (healthcare expenditure, potential years of life lost). Results: Health-related factors, especially self-assessed health and trust in doctors, consistently emerge as predictors of more favourable evaluations across regions and periods. Higher national healthcare expenditure is associated with more positive public views and is the single largest contributor to the improved assessments in 2021–2023. Demographic and socioeconomic variables show smaller regionally and temporally heterogeneous effects. Decomposition indicates that both changes in observed characteristics (notably, expenditure and trust) and unobserved behavioural, cultural, or institutional shifts account for the gap in public healthcare assessments between the two time periods. Conclusions: Public assessments of healthcare systems are primarily shaped by individual health status, trust in providers, and national spending rather than differential demographic and socioeconomic traits. Therefore, policymakers should couple targeted investments in the healthcare sector in order to address adequately public healthcare needs, and strengthen doctor–patient relationships in order to sustain public support. Future research should focus on disentangling the cultural and behavioural pathways influencing healthcare attitudes. Full article

(This article belongs to the Special Issue Performance of Healthcare Systems During and After the COVID-19 Pandemic)

14 pages, 779 KB

Open AccessArticle

Barriers in Access to Healthcare Services in Greece Post-COVID-19: Persisting Challenges for Health Policy

by Kyriakos Souliotis, Christina Golna, Agni Baka, Aikaterini Ntokou and Dimitris Zavras

Healthcare 2025, 13(15), 1867; https://doi.org/10.3390/healthcare13151867 - 30 Jul 2025

Cited by 4 | Viewed by 3797

Abstract

Background/Objectives: Access to health services is often limited due to socio-economic and organizational determinants of health systems, which lead to increased unmet healthcare needs. This study aimed to identify access barriers for the general population in Greece, including those that may have emerged following the COVID-19 pandemic. Methods: This was a cross-sectional survey of 1002 Greek citizens. A questionnaire regarding socio-demographics, healthcare utilization, and access to health services was used. Interviews took place between October and November 2022. Results: Of 837 participants who used health services in 2022, 82.6% had a medical consultation, 80.6% took diagnostic tests, and 63.6% visited a pharmacy for pharmaceuticals. Of those having a medical consultation, 33.1% did so at an NHS health unit, while 75% of the participants taking diagnostic tests visited a contracted private laboratory. Out of the 135 participants requiring hospitalization, 62% were hospitalized in a public hospital, while 85% of the participants requiring pharmaceuticals visited a private pharmacy. Access barriers in the past year were reported by 48% of the participants requiring a medical consultation, 34% of the participants requiring diagnostic tests, and 40% of the participants requiring hospitalization. The most common barriers were long waiting times and financial constraints. The main barrier to accessing pharmaceuticals was the availability and administration of the product. Conclusions: The identified healthcare access barriers highlight the vulnerabilities of the current health system in Greece, which were further exposed during the COVID-19 pandemic crisis. Addressing socioeconomic factors that are considered key access indicators should be the focus of future health policy initiatives. Full article

(This article belongs to the Special Issue Performance of Healthcare Systems During and After the COVID-19 Pandemic)

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26 pages, 362 KB

Open AccessArticle

Performance of Greek Public Hospitals Before and After the Economic Recession and the Pandemic: Application of a Novel Cost Malmquist Index for Comparing Productivity Across Multiple Groups

by Argyro Fourlopoulou, Panos Xenos, George Messinios and Nikolaos Maniadakis

Healthcare 2025, 13(11), 1253; https://doi.org/10.3390/healthcare13111253 - 26 May 2025

Cited by 2 | Viewed by 2827

Abstract

Background/Objectives: This study introduces the Multi Group Cost Malmquist Index (

C M g_{m}

), a novel tool for comparing and ranking the cost efficiency of multiple groups of similar decision-making units operating in different contexts. It was applied to Greek public [...] Read more.

Background/Objectives: This study introduces the Multi Group Cost Malmquist Index (

C M g_{m}

), a novel tool for comparing and ranking the cost efficiency of multiple groups of similar decision-making units operating in different contexts. It was applied to Greek public hospitals to assess productivity change between 2009 and 2021, covering the period before the economic recession and after the second lockdown during the COVID-19 pandemic. The study aimed to determine the impact of these external shocks on hospital efficiency and to identify differences in cost productivity based on hospital size and regional location. Methods: Data envelopment analysis was employed to compute the Malmquist indices for productivity change and ranking. Overall, 109 Greek public hospitals were analysed using three models: as a single group, classified by bed capacity, and classified by regional health authority (RHA). Cost productivity was decomposed into its core measures. Results: During the economic crisis, hospitals improved their cost productivity by 13.2%, whereas during the pandemic, it declined by 32.1%, primarily due to cost frontier deterioration resulting from increased healthcare demand and strained resources. Medium-sized hospitals exhibited higher cost efficiency than small and large hospitals. Regional disparities were also observed, with hospitals in the 5^th and 7^th RHAs outperforming those in 1^st and 2^nd RHAs. Conclusions: The findings highlight the pandemic’s disruptive impact on hospital cost productivity compared to the efficiency gains during the economic crisis. It is encouraging, though, that hospitals are recovering again after the lifting of strict lockdown measures. The

C M g_{m}

is a valuable tool for policymakers, offering insights into hospital performance across multiple groups. Future healthcare policies should prioritise resource optimisation and address regional disparities to enhance system-wide efficiency and resilience in times of crisis. Full article

(This article belongs to the Special Issue Performance of Healthcare Systems During and After the COVID-19 Pandemic)

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20 pages, 433 KB

Open AccessReview

Mental Health Impacts of the COVID-19 Pandemic on College Students: A Literature Review with Emphasis on Vulnerable and Minority Populations

by Anna-Koralia Sakaretsanou, Maria Bakola, Taxiarchoula Chatzeli, Georgios Charalambous and Eleni Jelastopulu

Healthcare 2025, 13(13), 1572; https://doi.org/10.3390/healthcare13131572 - 30 Jun 2025

Cited by 7 | Viewed by 3760

Abstract

The COVID-19 pandemic significantly disrupted higher education worldwide, imposing strict isolation measures, transitioning learning online, and exacerbating existing social and economic inequalities. This literature review examines the pandemic’s impact on the mental health of college students, with a focus on those belonging to minority groups, including racial, ethnic, migrant, gender, sexuality-based, and low-income populations. While elevated levels of anxiety, depression, and loneliness were observed across all students, findings indicate that LGBTQ+ and low-income students faced the highest levels of psychological distress, due to compounded stressors such as family rejection, unsafe home environments, and financial insecurity. Racial and ethnic minority students reported increased experiences of discrimination and reduced access to culturally competent mental healthcare. International and migrant students were disproportionately affected by travel restrictions, legal uncertainties, and social disconnection. These disparities underscore the need for higher education institutions to implement targeted, inclusive mental health policies that account for the unique needs of at-risk student populations during health crises. Full article

(This article belongs to the Special Issue Performance of Healthcare Systems During and After the COVID-19 Pandemic)

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