Photo: Brent Stirton / Getty Images for the International Trachoma Initiative

The learnings we share in this brief emerge from the following experiences:

• April 20, 2020: Global Health Compassion Rounds: Compassion & COVID-19. This quarterly series, co-hosted with the WHO Global Learning Laboratory for Quality Universal Health Coverage, focused on how to cultivate  compassion in pandemic response at multiple levels.

• Internal conversations on racial equity and health. We cannot achieve  “health for all” if we do not understand racial inequities in health and take them  into account in designing and delivering health interventions, including  strategies for maintaining essential health services. Compassion is a catalyst  for social and racial justice.
  
  
• Self-care and resilience training for public health responders. In late 2020 and early 2021, FACE collaborated with the Compassion Institute  to offer compassionate self-care and resilience training for over 400 public  health COVID-19 responders. This helped address high levels of moral injury,  burnout, disengagement, and negative coping mechanisms as a result of the  compounding effects of navigating the pandemic.

• Teaching people about compassion works. In numerous studies, compassion cultivation interventions have measurably improved compassion, as reported by participants (Kirby, 2017). This can be applied swiftly to meet the challenging circumstances in maintaining essential health services.
  
  
• To become compassionate leaders, executives and managers must develop skills to notice various forms of pain that arise in their organization, cultivate a concern for the well-being of others, and then take action (Dutton, Workman & Hardin, 2014). Small actions can make a big difference. These skills improve organizational awareness of suffering during a pandemic, both for patients and staff, ensuring that essential health services are maintained and that an equitable recovery is achieved.
  

• Providing intentional opportunities for employee connection on a human level and for mutual care can impact the quality of work. For example, allocating time in meetings for team members to share non-work-related joys and challenges promotes psychological safety and feelings of solidarity and support (Duhigg, 2016). Studies have found that when compassionate practices like this exist in a healthcare environment, patient experience improves.
  
  
• Health systems that are supportive of its workers offer higher quality care (Shanafelt, et al., 2010; West., et al., 2006). Training and experiential opportunities are available. For example, the Compassion Institute offers a care package for frontline healthcare professionals and public health responders that focuses on how to incorporate compassion, self-care, resilience, trauma prevention, and steadiness of mind.
  
  
• Building networks of committed individuals and organizations (such as the community the Global Health Compassion Rounds promotes) helps cultivate cultures of compassion that nurture individual capacity for compassion and support its expression in healthcare and public health.
  
  
• Integrating compassion into clinical pre-service training and public health training curricula will make compassion a more explicit and valued part of clinical and public health practice. Palliative care offers insights about how to mainstream compassion in clinical care.
  
  
• Introducing the use of compassion metrics can promote accountability among health providers and service delivery organizations.
  
  
• Patient feedback on their care experience is critical for improving the compassionate quality of care. For example, compassion was assessed in customer satisfaction surveys administered to patients in quarantine centres in Zimbabwe. This strategy could be applied in essential health services, as well.

• Customer care training for healthcare workers in Zimbabwe teaches staff skills in counselling people and assuaging their fears about COVID-19. Such trainings could also include messaging about the importance of maintaining scheduled routine health services, like vaccinations, well-child check-ups, antenatal care, and chronic disease management.
  
  
• Inclusivity is a compassionate strategy. All people need to be involved in the development of pandemic response strategies, including those living in poverty for whom prevention strategies and access to essential health services may not be feasible.

• High-level institutional support for compassion-based learning, services, and outcomes ensures compassion is mainstreamed in clinical care and public health programming.
  
  
• Compassionate leadership is fundamental to compassionate healthcare. When employees believe they work in a compassionate healthcare environment, the quality of care and services increase. Leaders’ honest assessment of themselves and their organizations helps to build cultures of care that are compassionate both to patients and to staff, and that align healthcare organizations with their publicly stated values and services.
  
  
• Incorporating the language of compassion into our pandemic response and, in particular, in the maintenance of essential health services builds organizational cultures of compassion that support and sustain staff, provide higher quality health services, and promote more equitable recovery.
  
  
• Continuous attention to our shared humanity and a regular practice of compassion is necessary to maintain focus on the human dimension of healthcare services - not just the technical or procedural aspects of responding to the pandemic and maintaining essential health services.
  
  
• Relationships matter - within service delivery organizations and between patients and those who care for them. An abundance of evidence shows that compassion has powerful benefits for patients, caregivers, and quality of patient care because the human connection resulting from compassion confers distinct and powerful physiological and psychological benefits. Investing in and prioritizing caring relationships is critical to the ultimate success of healthcare and global public health.
  
  
• Compassion provides the courage and a framework for healthcare leaders to recognize and address the systemic inequities that have driven how the pandemic has affected the maintenance of essential health services.
  
  
• Mature compassion requires reflexivity - self-awareness of one’s positionality, privilege, and motivations, as well as the humility to acknowledge the limits of one’s knowledge and the courage to recognize when one’s well-intentioned efforts result in unintentional harm. As the COVID-19 pandemic has illustrated through neglect of essential health services and inequitable response strategies, a myopic pursuit of protecting health or ‘doing good’ for certain groups can exacerbate the suffering of others.
  
  
• Celebrating compassionate acts reinforces their value and promotes their proliferation. Examples of compassionate acts during the pandemic include community volunteerism, neighbourly support, and so-called ‘random acts of kindness’.
  
  
• Compassion flourishes most when it is cultivated and embodied at all levels - community, frontline providers, public health practitioners, health service delivery and public health organizations, and the health system at large.

• Even when leaders accept the scientific evidence and the desirability of compassionate leadership, they don’t know how to realize it (Hougaard, 2018) and they often lack self-compassion (you can’t give what you don’t have). They are also challenged by excessive demands on their time and a lack of emotional support in the workplace.
  
  
• Additional work is needed to clarify and evaluate practical steps to foster and sustain compassionate healthcare organizations.
  
  
• A global framework for the operationalization of compassionate care, including metrics and community accountability mechanisms, does not yet exist. Additionally, national-level guidelines are not clear about the role of compassionate care, despite the fact that the Sustainable Development Goals and the WHO 13th Programme of Work highlight people-centred approaches, which lie at the heart of quality care. Work is underway to develop and test such metrics and mechanisms.
  
  
• We are in the midst of a compassion crisis in health systems and clinical care. For example, physicians miss 60% to 90% of opportunities to respond to patients with compassion (Levinson, et al., 2000). The pandemic, as well as recent structural changes in healthcare, mean that physicians have fewer meaningful connections with patients. Burnout and moral injury have reached epidemic proportions among healthcare and public health workers, leading to historically high rates of mental illness and suicide.
  
  
• In global public health, professionals often work at great distances from the people whose health they are working to improve. They see population-level ‘numbers’ rather than individual ‘faces’. The need to focus on metrics, measures, and outcomes frequently leads to the neglect of relationships, process, and compassion. Without an intentional ‘remembering’ and prioritizing of the human ‘faces’, public health interventions can become bureaucratic and aloof and cause unintentional harm. Thus, cultivation of compassion is also a priority for public health agencies and organizations.
  
  
  Photo: Brent Stirton / Getty Images for the International Trachoma Initiative

• In what ways and to what extent can organizational cultures of compassion improve the maintenance of essential health services during emergencies and outbreaks/pandemics?
  
  
• Among the many possible ways to express compassion and embed it into the fabric of health systems and clinical care, what steps are most critical in emergency and outbreak situations to promote compassionate care?
  
  
• Most scientific evidence about the relationship between compassion and improved clinical health outcomes originates from the Global North. Additional evidence from the Global South is needed.
  
  
• Compassion may be understood or expressed differently in different contexts. More information is needed about patients’ experience of compassion cross-culturally.
  
  
• Randomized clinical trials document the effectiveness of compassion training in individuals. Less is known about the effectiveness of different strategies and approaches to effectively scale individual compassion to the organizational, community, and societal levels.