Major challenges to health system performances in the aftermath of COVID-19 with a focus on longer waiting time for elective surgery and vaccine hesitancy in health care staff

  • Rathnayake Mudiyanselage Rathnayake

Student thesis: Doctoral ThesisDoctor of Medicine


Waiting times for elective surgery have grown steadily over time in many countries and were recently heightened by the COVID-19 pandemic. The overall aim of this thesis is to identify opportunities to improve the efficiency of health systems, in particular to minimise major bottle necks that hinder patient throughput over the elective surgical care pathways. The health systems research in this thesis uses two research methodologies relevant to each of the two research elements. These are a portfolio of systematic reviews and a descriptive study. First, a portfolio of systematic reviews was completed to synthesise and collate global evidence on policy strategies and interventions to reduce long waiting times for elective surgeries. The second component investigated concerns of HCW towards COVID-19 vaccination using a descriptive study methodology. In the first component, the electronic search in the five bibliographic databases yielded 7543 records and 92 eligible articles were identified with the updated search as 21 quasi-experimental, 61 cohort, 7 systematic reviews, and 3 experimental studies. Considering the relevance and validity of evidence presented for numerous interventions, this component of the thesis presented as seven sub-reviews listed for seven major strategic areas namely; referral management, patient prioritisation, prevent surgery cancellations, perioperative time management, public private partnership, quality improvement methods, waiting time targets. In the second component, the overall results confirmed that a majority (93.5%) of the HCW were vaccinated and only 6.5% declined the vaccine. Among the vaccine declined group, primary level education was the single socio-demographic barrier associated with not receiving the COVID-19 vaccine and most of this group were health assistants. Combining these two elements shows that the ongoing problem of long waiting times for elective surgeries could be minimised by strong vaccination policies and systematic implementation of effective waiting time strategies into surgical care pathways that cause delays.

Thesis is embargoed until 31 December 2023.
Date of AwardDec 2022
Original languageEnglish
Awarding Institution
  • Queen's University Belfast
SupervisorFinian Bannon (Supervisor) & Mike Clarke (Supervisor)


  • Waiting time
  • elective surgery
  • COVID-19
  • vaccine hesitancy
  • health care staff
  • systematic review

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