Bob Mash
IF YOU were to ask anyone what the main health challenge is to the world in 2021, they would inevitably say the coronavirus pandemic.
Communities, families, health care workers and health systems have been traumatised and challenged by the loss of loved ones, economic hardship, fear of infection, overwhelming numbers of patients and continuous adaptation to the situation.
Much of the news coverage has focused on hospitals, intensive care units and critical care of severely ill people.
Much less has been said about the important role of primary health care and what we have learnt from the coronavirus pandemic to strengthen service delivery now and in the future.
The coronavirus has been a crisis, but also an opportunity to innovate and learn.
On World Health Day today, it’s important to point out that primary health care is the foundation of the healthcare system, where people go first when they are sick and where health services engage with communities and their health needs.
Because of its coverage and reach into every community, primary health care has the potential to improve the health of populations, respond to changing health needs, improve equitable access to health care, use resources more efficiently and enhance the resilience of health care systems.
In many African countries, however, primary health care is neglected and is often the Cinderella of the health care system in terms of funding, infrastructure, workforce and equipment.
In the Metro Health Services (MHS) of Cape Town, primary health care has five key roles to play in responding to the coronavirus pandemic.
These are community screening and testing for coronavirus, treatment of mild coronavirus disease, community engagement, maintenance of essential services, and roll out of vaccination.
Prior to the pandemic the MHS had pivoted towards a more community-oriented primary care approach and this proved invaluable in responding to coronavirus.
Fundamental to this approach were teams of community health workers in all vulnerable communities, with clearly delineated areas and households for which they were responsible.
These teams were linked to local primary care facilities and supported by professional nurses. Community health workers and professional nurses were employed by community-based organisations working under contract to the MHS.
Early in the pandemic community health workers were mobilised to assist with community screening and testing. This was mostly focused around known cases and hot spots to try and limit community spread and slow transmission of the virus.
People with symptoms of coronavirus were sent to the local primary care facility or a mobile facility for testing.
At the same time case investigation teams were formed in each substructure to telephonically follow up on all known cases and their contacts.
Unfortunately the potential impact of this work in primary health care was largely negated by the capacity of laboratories to test the samples and give a result quickly enough.
As laboratories were overwhelmed with samples, the time taken to provide a result far exceeded the incubation period of the disease, and transmission had already occurred by the time a result was available.
Testing had to be restricted to older people and those with co-morbidities in order to reduce the demand on laboratories.
However, case investigation teams provided much needed support and information to people, even though they were not able to significantly impact the spread of the disease.
Primary care facilities in the MHS were all re-organised to screen people into “hot” and “cold” streams at the entrance and to then keep the streams as separate as possible.
Patients with respiratory symptoms, typical of coronavirus, were seen and treated in the “hot” stream.
Many facilities had additional prefabricated coronavirus facilities built. Cases could be assessed, tested, treated and if mild, people could be advised on self-isolation and follow up at home.
People with more moderate or severe disease could be treated and referred on to hospital.
Despite the availability of primary care we saw that many patients presented directly to district hospitals. This may have been due to fears about the disease, the 24/7 availability of emergency hospital services as well as messaging in the community to avoid primary care facilities if possible.
This messaging was intended to decongest facilities in order to limit inadvertent spread of the coronavirus and free up capacity to respond.
One of the key aspects of responding to epidemics is community engagement and involvement in health services and health issues.
In Africa, the response to the Ebola virus had taught health services about the need to inform and educate communities on the disease, develop relationships of trust and to plan how public health measures can be made locally acceptable and feasible.
A lack of community engagement and participation can lead to misunderstanding, misinformation, resistance and even protest.
Primary health care services in the MHS have both formal and informal mechanisms for engaging with communities. Clinic committees and ward councillors offer more formal ways of engagement, while local community-based organisations and community health forums offer more informal ways.
When the pandemic struck many of these relationships were not yet formalised or fully engaged with and this was an aspect of the response that could be improved.
In many vulnerable communities the public health recommendations were not realistic, were not widely understood or locally adapted.
One of the challenges to primary care services was how to reduce unnecessary visits in order to decongest facilities and protect people from coronavirus, while at the same time maintaining essential services.
This was a particular issue for people with chronic diseases such as HIV or diabetes that put them at higher risk of severe coronavirus disease.
Again community health workers were enlisted, in this instance to deliver medication to people’s homes and to avoid visits to the facility.
Thousands of people benefited from this service, which undoubtedly also saved lives. People with diabetes who were poorly controlled or had complications such as kidney disease were at even higher risk and a special telemedicine service was set up to assist them.
People who had coronavirus and diabetes were followed up daily via telephone and quickly admitted to hospital if any problems arose.
A diabetes patient education initiative via WhatsApp was also developed and piloted. As a result of this experience, more attention is being paid to how people with chronic conditions can be assisted more in the community with less need to come to a primary care facility.
Innovation with technology has also been prominent in order to communicate with patients and health care teams. There is concern that some services may have deteriorated during the pandemic, for example, the identification of active TB might have suffered as well as services such as family planning.
Going forward we anticipate the roll out of vaccination for coronavirus. Primary health care, again, has a key role to play in reducing misinformation and vaccine hesitancy as well as in making vaccination accessible to all communities. How this will play out during the rest of this year is yet to be seen.
The coronavirus pandemic has demonstrated the benefit of a community-orientated primary care approach and the need for health services to continue implementing and strengthening this approach.
This approach shifts the focus from primary care facilities waiting to help sick people to primary health care looking at the whole population at risk. It also builds more collaboration between the health workers in the facility and those in the community.
Community health workers teams are clearly key with adequate support, supervision and resources. High quality and accessible primary care from motivated and competent primary care providers will remain a priority. As we go forward we will integrate learning about accessibility, the use of technology, alternative ways of collecting medication, community engagement and community-based services into improving service delivery.
* Professor Mash heads the Division of Family Medicine and Primary Care at Stellenbosch University.