The Astana Declaration of 2018 examined the dire need to strengthen primary healthcare (PHC) to achieve universal health coverage (UHC). The declaration laid emphasis on an inclusive, effective, and efficient primary health system driven by political commitment, research, and innovation.[1]
A health system built on a robust primary health care system, enables communities to respond to health needs of its people and nurture’s their trust in health workers. During crises, an efficient PHC system adds to the resilience of the larger health system and facilitates a swifter, more effective response.[2] In view of the current Covid-19 pandemic, the role of a strong and integrated health system cannot be underemphasized. The pandemic impacted people across several countries with physical, mental, economic and social travesties. People with chronic conditions faced a double threat, firstly by being more vulnerable to the disease and secondly by the lack of regular care and care in case of acute exacerbations of their conditions. For patients with acute conditions, dependent on higher levels of care in the absence of a strong PHC, seeking care was a challenge.[3]
It is hence intuitive that a strong primary care system is necessary as opposed to a ‘virus to hospital’ strategy. A comprehensive PHC system is indispensable to effectively dealing with the shocks that patients face during and illness and the mental trauma that follows.[4]In a pandemic scenario where people cannot travel to access healthcare, frontline health systems needs to be strong to ensure that the delivery of care is not disrupted.
Global evidence during the pandemic has highlighted a few elements and features of a strong primary healthcare system and its role in ensuring health systems resilience. These include:
- Access. A resilient primary health system can dismantle all barriers to access during a crisis situation. A resilient health system ensures that people have access to care, medicines and other supplies as needed, and that the the system has access to financing and resources with limited bureaucratic hurdles. A prominent example of seamless access to healthcare via the primary healthcare systemare the Public Health Preparedness Clinics (PHPC) in Singapore. These clinics were setup during the outbreak of the SARS pandemic. These clinics consolidate the response of primary health care to public health emergencies and outbreaks into a single scheme for better management. The government ensures access to supplies(like drugs, protective gear etc.) during emergencies. During non-emergencies, training is imparted to the personnel at the PHPCs to prepare them to perform their roles during public health emergencies.[5]
- A resilient workforce. Strong PHC systems have a motivated and well-supported workforce which can meet the surge in demand for care as and when needed. A resilient workforce can shift responsibilities during a crisis. Countries like France[6], Ireland and Jordan[7] have designated community pharmacists to prescribe long term NCD medicines. Such initiatives have been welcomed by the public as pharmacists are close to the community. In the US, community health workers integrated in the PHC services were involved deeply in spreading information related to protection, raising awareness, countering social stigma as well as self-management of chronic conditions. Further the recent strengthening of Home Community Based Services under the American Rescue Plan Act (2021) has released significant funding to strengthen home care services. The intent is to provide dignified home and community based care, by training of primary care professionals.[8] Finally, the role of primary care physicians, staff nurses and frontline workers has been highlighted during the Severe Acute Respiratory Syndrome, H1N1 and more recently the COVID – 19 pandemic, especially in Hong Kong. PHC workers need to be well trained to detect the earliest spike in an infectious disease. In Hong Kong,many PHC workers have been observed to discharge their duties even during the peak of the SARS pandemic.[9]
- Surveillance Systems. A strong data driven surveillance system is the backbone of a resilient health system. Countries like Singapore and South Korea, have used various methods for active surveillance. Singapore leveraged its public health infrastructure, innovative diagnostics and PHC physicians trained during SARS to handleoutbreaks for early screening, testing, and treatment. This helped in containing the disease early on. 900 such General Practitioners were actively trained for early detection and prompt referral. The usage of a healthcare cloud (known as H-Cloud) helped further. Singapore developed an app called TraceTogether which has a secure system to save patient data. Unlike other countries where people need to download an app, Singapore also gives an option of physical token which does not need permission to be synced with the phone.[10] South Korea with its strong PHC system and strong data infrastructureis another country which could contain the pandemic. To facilitate epidemiological investigations, the government introduced the COVID-19 Epidemiological Investigation Support System which was set up as a centralized data collection and multi-agency coordination platform, speeding up the procedure for data request from the primary care providers. Korea’s Global Epidemic Prevention Platform was developed duringthe MERS outbreak of 2016. The platform uses primary care physicians for the trace-test-treat strategy with AI and data analytics.[11]
- Telehealth.Many countries realised the importance of telemedicine and connecting primary care physicians via telemedicine. COVID-19 has led to leapfrogging of telemedicine guidelines in several low constraint countries. MyDoctor is a Colombo-based digital health solution provider, who has partnered with the Ministry of Health and Indigenous Medical Services (MOH) to enable the Government’s eHealth system to offer free telemedicine services via the app.[12]In early 2020, Vietnam started remote healthcare, connecting primary care doctors in majors cities with sub-urban and rural areas.[13]The Indian government’s Telemedicine Practice Guidelines enable Registered Medical Practitioners to provide healthcare to bridge the gap in access to primary healthcare during the pandemic.
- Commitment to Quality Improvement.Continuous improvement of quality measures of primary health systems are needed to tackle a crisis effectively. Firstly, it ensures that people have access to high quality services and do not have to suffer from secondary ailments during a crisis. Secondly, quality improvement “Plan-do-show-act” models are necessary to enable a dynamic rapid recycle to the care provided by the PHC facilities. In these models there is a continuous process of evaluating the outcome, improving on it, and testing again. In a situation like COVID these cycles have helped to manage the patients in emergency settings.[14]In a study conducted in the US, since the load on the primary care settings increased during the COVID, treatment for paediatric primary care practices faced increased challenges. The application of plan-do-act helped to address the gaps in care that led to the loss of safe and secure primary care access.[15]During crises, existing quality protocols ensure better documentation and improved response to other diseases as well.[16] The Vietnamese government also stresses on the quality of care delivered by primary care physicians, epidemiologists and nurses and the need to measure this on an ongoing basis to tackle a pandemic.[17]
To conclude, health systems continue to learn and unlearn new things during the ongoing COVID 19 pandemic. The focus has largely been on scaling up the services at hospitals and tertiary care. However, the pandemic has also affected the health of people who have not been infected with Covid. A more sustainable approach is to place primary healthcare at the core of the health system. A strong primary health care – with inter-disciplinary human resources whose services are well-integrated with community and preventive health, armed with digital technologies and a well-designed financial system can help deliver an effective health system response in a crisis.
Dr.Anuradha Katyal
[1] https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf
[2]https://www.euro.who.int/en/health-topics/Health-systems/primary-health-care/primary-health-care/questions-and-answers-understanding-primary-health-care#384499
[3]https://www.oecd.org/coronavirus/policy-responses/strengthening-the-frontline-how-primary-health-care-helps-health-systems-adapt-during-the-covid-19-pandemic-9a5ae6da/
[4] https://www.oecd.org/coronavirus/policy-responses/strengthening-the-frontline-how-primary-health-care-helps-health-systems-adapt-during-the-covid-19-pandemic-9a5ae6da/
[5] https://www.primarycarepages.sg/practice-management/moh-national-schemes/public-health-preparedness-clinic-(phpc)
[6]https://www.euro.who.int/en/health-topics/Health-systems/pages/news/news/2020/5/community-pharmacists-are-key-players-in-covid-19-response-and-must-stay-up-to-date-on-guidance
[7]https://pubmed.ncbi.nlm.nih.gov/33280210/
[8]https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/hcbs
[9]https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-10-661
[10]https://www.tracetogether.gov.sg/
[11]https://www.annfammed.org/content/applications-artificial-intelligence-primary-care-research-practice
[12]https://www.ha-asia.com/sri-lanka-riding-the-telemedicine-wave/
[13]http://www3.weforum.org/docs/WEF_PHSSR_Vietnam_Report.pdf
[14]https://apm.amegroups.com/article/view/43455/html
[15]https://journals.lww.com/pqs/Fulltext/2021/05000/Managing_the_COVID_19_Pandemic_Using_Quality.5.aspx
[16]https://www.ccjm.org/content/early/2020/06/01/ccjm.87a.ccc041#:~:text=CONCLUSION,during%20disasters%20such%20as%20pandemics.
[17]http://www3.weforum.org/docs/WEF_PHSSR_Vietnam_Report.pdf
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