|Year : 2021 | Volume
| Issue : 3 | Page : 73-75
Deep impacts of COVID-19: overcoming challenges in strengthening primary health care by targeting the health workforce
International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand
|Date of Web Publication||26-Feb-2021|
Dr Viroj Tangcharoensathien
International Health Policy Program, Ministry of Public Health, Nonthaburi
|How to cite this article:|
Tangcharoensathien V. Deep impacts of COVID-19: overcoming challenges in strengthening primary health care by targeting the health workforce. WHO South-East Asia J Public Health 2021;10, Suppl S1:73-5
|How to cite this URL:|
Tangcharoensathien V. Deep impacts of COVID-19: overcoming challenges in strengthening primary health care by targeting the health workforce. WHO South-East Asia J Public Health [serial online] 2021 [cited 2022 Jan 20];10, Suppl S1:73-5. Available from: http://www.who-seajph.org/text.asp?2021/10/3/73/309880
The coronavirus disease 2019 (COVID-19) pandemic has had unprecedented negative impacts on the health, well-being and livelihoods of people worldwide. The crisis has triggered the deepest global recession in decades, with global gross domestic product (GDP) projected to fall by 5.2% in 2020. Economic recovery is uncertain if the pandemic persists and restrictions on movement and disruption to economic activity continue. Furthermore, a significant increase in the public debt burden and a reduction in governments’ fiscal space, especially for health, may jeopardize countries’ progress towards achieving the health-related Sustainable Development Goals (SDGs).
Variations by country in the extent to which policy-makers have taken timely multisectoral action and in the effectiveness of their social measures and public health interventions have affected the outcomes of pandemic control in terms of caseload, morbidity, mortality, burden on the health system and capacity to maintain essential health services. A study of eight European countries estimated that, across those eight countries, a further delay of 1 week in imposing lockdown would have cost more than half a million lives. Substantially more lives were saved in countries that acted promptly than in those that did not. Effective management of COVID-19 responses through a whole-of-government approach – notably through collaborative public health and social measures – in conjunction with resilient health systems can contain infection, prevent health system disruption and maintain essential health services.
The pandemic has profoundly shaped how countries deliver health services. Prior to the pandemic, countries in the World Health Organization (WHO) South-East Asia Region were steadily progressing on essential health services coverage. Efforts to strengthen primary health care (PHC) and improve health systems’ resilience in these countries supported the public health response to the pandemic. For example, in Thailand, to prevent the spread of coronavirus infection in hospitals, non-urgent ambulatory care was transferred to PHC or delivered through telehealth consultations, while access to medicines was maintained through deliveries by village health volunteers or postal services. In Sri Lanka, PHC was one of the key response mechanisms for implementing infection prevention and control amid the COVID-19 crisis, through strengthened capacity of primary care providers, who also ensured continued provision of essential health services through telemedicine. In one district in Telangana, India, during the lockdown imposed as a result of COVID-19, transferring follow-up services for hypertensive patients to the lowest-level PHC facility, the subcentre, led to significantly lower patient attrition rates than in a district with no transfer of services.
Despite the South-East Asia Region’s increased health service delivery capacity in the face of the pandemic, one enduring challenge remains to achieving universal health coverage (UHC): adequate capacity in terms of human resources for health (HRH) at PHC level. There has been progress; between 2014 and 2019, the region experienced a 21% increase in the average density of doctors, nurses and midwives, with 9 of the 11 countries of the region having surpassed the WHO threshold, set in 2006, of 22.8 health workers per 10 000 population. However, only two countries are above the revised WHO threshold, set in 2016, of 44.5 health workers per 10 000 population, the density estimated to be required to achieve the SDGs. Continued progress will rely on good HRH governance. Except for one, all countries of the region have established HRH coordination units in their ministries of health, which facilitate multisectoral action to be taken by, for example, health professional education and training institutes, public and private employers and professional councils. Yet many of these HRH coordination units struggle with fragmented oversight, planning and management, and require targeted capacity strengthening.
HRH strategies must link directly to strategies for improving health service delivery, and more policy attention needs to be paid to frontline PHC workers. Historically, the PHC health workforces in South-East Asia Region countries have focused on providing maternal and child health services, gradually extending coverage to screening and treatment for noncommunicable diseases and other acute conditions. However, most of the PHC workforces in the region have limited capacity to perform other critical public health functions, notably surveillance of and response to health threats. This limited capacity on public health, compounded by the rural retention issues that most countries struggle with, reveals significant gaps in the PHC workforce when it comes to effectively addressing public health emergencies.
If these gaps are not addressed, countries will fall short of the HRH required to implement the imminent large-scale COVID-19 vaccination campaign targeting priority and high-risk populations, as recommended by the WHO Strategic Advisory Group of Experts on Immunization. In the South-East Asia Region, the sheer population size – 2 billion people in 11 Member States – means vaccinating 400 million people to cover 20% of the population and vaccinating 1 billion people to cover 50% of the population. To achieve this vital undertaking, the region’s PHC workforce will need to be significantly scaled up and their skills and roles expanded. Some countries of the region have had success in improving rural retention through “bundles” of interventions that include a mix of educational interventions (e.g. recruitment of students from rural backgrounds and ethnic minorities, home-town placements once students graduate, and pre-service curricula that reflect rural health services and provide exposure to PHC early on) and financial and non-financial incentives. There has been less progress in developing new skills and cadres of frontline health workers.
The United Nations Member States have committed to invest at least an additional 1% of GDP in PHC. However, the methodology for producing national health accounts (NHAs) has yet to capture expenditure on PHC. The lack of evidence in NHAs on the true size of investment in PHC and, within that, in HRH inhibits useful monitoring of HRH spending. Furthermore, the emerging national health workforce accounts for the region do not capture all cadres of the PHC workforce. This will impede the kind of planning that underpins responsiveness and adaptability in the face of public health emergencies such as the COVID-19 pandemic.
Over the past 2 years, health workforce strengthening has been in the global political spotlight thanks to the 2018 Astana Declaration on PHC and the 2019 United Nations Political Declaration of the High-level Meeting on Universal Health Coverage. Building on the steps needed to respond to the pandemic and achieve UHC by strengthening PHC, the following are policy recommendations for South-East Asia Region countries.
First, accelerate increased coverage of functional PHC. WHO proposes three functions defining adequate PHC: (i) provision of comprehensive health services as the first contact point with the health service throughout the life course, (ii) multisectoral actions to address determinants of health and (iii) empowering citizens and communities to lead healthy lives. Evidence shows that, while provision of comprehensive health services to the population is more developed in the region than the other two functions, even there gaps remain.
Achieving UHC targets will require not only the scaling up of the health workforce through incentives and education strategies but also investment in effective and integrated health workforce databases that enable real-time tracking of the skills mix and geographical distribution of the health workforce. In addition, more policy attention needs to be paid to expanding the roles of health workers. The transformations in the education of health professionals that are under way in most South-East Asia Region countries must address instructional and institutional aspects to ensure that new cadres of health professionals are able to respond appropriately to the emerging health needs of the population.
Second, strengthen PHC to enable better responses to emergencies and outbreaks. In this regard, PHC has two functions: first, identifying and managing emergencies, and, second, providing surge capacity for hospitals. For the first, strengthening the capacity of PHC health workers to conduct case-based and event-based surveillance, followed by outbreak investigation and containment of small daily health threats, is a platform that can be built on to respond to large public health emergencies. This requires immediate policy attention.
For the second, a well-functioning PHC sector can relieve the pressure on the hospital sector during public health emergencies. To achieve this, the PHC workforce needed to be adaptable, take on additional skills and roles to support new models of service provision, and implement innovative approaches to service delivery. As illustrated earlier, routine noncommunicable disease services, including dispensing of medicines to well-controlled patients, can be transferred from hospitals to PHC. Innovative approaches using telecommunications (e.g. smartphones) need to be more widely integrated into PHC and incorporated into the transformative education agenda. Use of technology and changes in service delivery design can also contribute to alleviating rural retention issues.
Third, mobilize adequate resources for PHC. Despite fiscal challenges, governments need to make bold decisions and commit politically to investing in the health of their populations through PHC. Including PHC-related HRH data in 5- and 10-year sector-wide planning would enable the integration of PHC into the whole continuum of health workforce planning and corresponding resource allocation, making it possible to target improvements in terms of education, recruitment, the absorptive capacity of the public sector, desired skills mix, posting, retention and continued professional development. As building these capacities will need lead time, countries need to act now.
Source of support: Thailand Science Research and Innovation under the Senior Research Scholar on Health Policy and System Research (Contract No. RTA6280007)
Conflict of interest: None declared.
Authorship: VT conceptualized and wrote this commentary.
| References|| |
Barach P, Fisher SD, Adams MJ, Burstein GR, Brophy PD, Kuo DZ, Lipshultz SE. Disruption of healthcare: will the COVID pandemic worsen non-COVID outcomes and disease outbreaks? Prog Pediatr Cardiol. 2020;59:101254. https://doi.org/10.1016/j. ppedcard.2020.101254
Reddy TSK, Kunwar A, Durgad K, Tullu FT, Sreedhar C, Wassey A et al. Decentralization of India Hypertension Control Initiative services to maintain continuum of care for hypertensive patients during COVID-19 pandemic in Telangana. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S49–S58. doi:10.4103/2224-3151.309873.
Zapata T, Zakoji M, Kanda M, Travis P, Tangcharoensathien V, Buchan J, Jhalani M. Implementing a decade of strengthening the health workforce in the WHO South-East Asia Region: achievements and way forward for primary health care. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S76–S86. doi:10.4103/2224- 3151.309881.
The Decade for Health Workforce Strengthening in the SEA Region 2015–2024: mid-term review of progress, 2020. New Delhi: World Health Organization Regional Office for South-East Asia; 2018.
WHO SAGE roadmap for prioritizing uses of COVID-19 vaccines in the context of limited supply, version 1.1. Geneva: World Health Organization; 13 November 2020 (https://bit.ly/37f20x9
, accessed 28 November 2020).
Vande Maele N, Xu K, Soucat A, Fleisher L, Aranguren M, Wang H. Measuring primary healthcare expenditure in low-income and lower middle-income countries. BMJ Glob Health. 2019;4(1):e001497. http:// dx.doi.org/10.1136/bmjgh-2019-001497
A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization and the United Nations Children’s Fund; 2018.
Chotchoungchatchai S, Marshall AI, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, and Tangcharoensathien V. Primary health care and sustainable development goals. Bulletin of the World Health Organization. 2020;98:792–800. https://dx.doi. org/10.2471/BLT.19.245613