WHO South-East Asia Journal of Public Health
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   Table of Contents - Current issue
February 2021
Volume 10 | Issue 3 (Supplement)
Page Nos. -

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Message from Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia, on International Universal Health Coverage Day (12 December 2020) p. 1
Poonam Khetrapal Singh
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Foreword p. 2
Manoj Jhalani
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The significance of primary health care for building back better: lessons from COVID-19 p. 3
Alaka Singh, Stephanie M Topp
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Strengthening primary health care in the COVID-19 era: a review of best practices to inform health system responses in low- and middle-income countries Highly accessed article p. 6
David Peiris, Manushi Sharma, Devarsetty Praveen, Asaf Bitton, Graham Bresick, Megan Coffman, Rebecca Dodd, Fadi El-Jardali, Racha Fadlallah, Maaike Flinkenflögel, Felicity Goodyear-Smith, Lisa R Hirschhorn, Wolfgang Munar, Anna Palagyi, KM Saif-Ur-Rahman, Robert Mash
Amid massive health system disruption induced by the coronavirus disease 2019 (COVID-19) pandemic, the need to maintain and improve essential health services is greater than ever. This situation underscores the importance of the primary health care (PHC) revitalization agenda articulated in the 2018 Astana Declaration. The objective was to synthesize what was already known about strengthening PHC in low- and middle- income countries prior to COVID-19. We conducted a secondary analysis of eleven reviews and seven evidence gap maps published by the Primary Health Care Research Consortium in 2019. The 2020 World Health Organization Operational framework for primary health care was used to synthesize key learnings and determine areas of best practice. A total of 238 articles that described beneficial outcomes were analysed (17 descriptive studies, 71 programme evaluations, 90 experimental intervention studies and 60 literature reviews). Successful PHC strengthening initiatives required substantial reform across all four of the framework’s strategic levers – political commitment and leadership, governance and policy, funding and allocation of resources, and engagement of communities and other stakeholders. Importantly, strategic reforms must be accompanied by operational reforms; the strongest evidence of improvements in access, coverage and quality related to service delivery models that promote integrated services, workforce strengthening and use of digital technologies. Strengthening PHC is a “hard grind” challenge involving multiple and disparate actors often taking years or even decades to implement successful reforms. Despite major health system adaptation during the pandemic, change is unlikely to be lasting if underlying factors that foster health system robustness are not addressed.
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Emerging good practices and lessons learnt to maintain essential health services during the COVID-19 pandemic p. 26
Masahiro Zakoji, T Sundararaman
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Unpacking the service delivery function: COVID-19 provides an opportunity for some reverse thinking p. 30
Ann-Lise Guisset, Phyllida Travis, Sepideh Bagheri Nejad, Rajani Ved, Katherine Rouleau
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Impact of the COVID-19 pandemic on immunization and surveillance of vaccine-preventable diseases in the WHO South-East Asia Region p. 33
Sunil Bahl, Sudhir Khanal, Mohammad Sharifuzzaman, Jayantha Liyanage
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Redesigning routine antenatal care in low-resource settings during the COVID-19 pandemic p. 36
Rinchen Zangmo, Archana Kumari, Deepali Garg, K Aparna Sharma
Obstetric care, because of the unique and varying needs specific to different patients, requires special consideration in times of a pandemic such as the coronavirus disease 2019 (COVID-19) pandemic. Health care facilities providing obstetric care need to develop contingency plans for minimizing antenatal visits to limit the exposure of both healthy pregnant women and care providers to the virus. However, to mitigate any potential adverse effects of reduced antenatal visits, intelligent use of evolving telemedicine capabilities can protect the continuum of care despite the overwhelming burden caused by the pandemic. A collaborative work model involving health workers in the community and regional-level health centres also has the potential to prevent the catastrophic collapse of obstetric care services during a pandemic such as the COVID-19 pandemic.
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Roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region p. 41
Supriya Bezbaruah, Polly Wallace, Masahiro Zakoji, Wagawatta Liyanage Sugandhika Padmini Perera, Masaya Kato
To enhance public health emergency preparedness, countries have strengthened core capacities required by the International Health Regulations (2005). In addition, recent major public health emergencies, including the coronavirus disease 2019 (COVID-19) pandemic, have reiterated the critical importance of underlying health systems and their resilience, including the roles of community health workers (CHWs). The aim of this study was to summarize the situation of CHWs in the World Health Organization South-East Asia Region, including their roles and the challenges they have faced during the COVID-19 pandemic response. We reviewed journal articles, policy documents, national guidelines, reports and online publications from development agencies, governments and media houses. Our review results, including three identified case studies, suggest that CHWs in the region have expanded their usual roles to meet the need for both maintenance of regular health services and demand for COVID-19 response activities. During the response, the regular role of a CHW in health education and promotion focused on awareness-raising and the promotion of “new normal” behaviours; CHWs also played critical roles in assisting in surveillance and contact tracing, and in ensuring that people followed isolation and quarantine guidelines. Concurrently, CHWs ensured continuity of essential health services. However, there were challenges, such as stigma, a lack of adequate training or protective equipment, and limited levels of incentives and recognition. Based on these findings, we recommend the development and implementation of long-term plans across the region to strengthen and support CHWs and recognize CHWs as an integral component of resilient health systems. Planning for CHWs as part of the primary health care system will enable local authorities to ensure that an adequate level of resources (including capacity-building, incentives, necessary equipment and consumables) is allocated to CHWs.
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Decentralization of India Hypertension Control Initiative services to maintain continuum of care for hypertensive patients during COVID-19 pandemic in Telangana p. 49
T Sravan Kumar Reddy, Abhishek Kunwar, Kiran Durgad, Fikru Tesfaye Tullu, Chintala Sreedhar, Abdul Wassey, Anupam Pathni, Leimapokpam Swasticharan, Meenakshi Sharma, Mallela Madhavi
The India Hypertension Control Initiative (IHCI) was launched in Telangana, India, with the vision of maintaining the continuum of care for hypertensive patients and improving treatment outcomes through provision of free hypertension medication. Decentralization of the IHCI towards more patient-centred services was undertaken to bring free medication and follow-up services closer to the community in the hopes of improving follow-up and control rates for hypertensive patients. To determine if decentralization of hypertension follow-up services and free medication to peripheral health centres improved continuity of care and treatment outcomes in hypertensive patients and helped to mitigate disruption during the coronavirus disease 2019 (COVID-19) pandemic, hypertension outcomes were reviewed before and during the COVID-19 pandemic, for patients registered in health centres that decentralized free medication and follow-up services to subcentres – the intervention group – and in health centres that did not decentralize these services – the non-intervention group. Hypertensive patients had higher rates of monthly follow-up and controlled blood pressure in the decentralized facilities than in the non-decentralized facilities, where these services were limited to primary and secondary health centres. Comparing follow-up rates and blood pressure control rates before and during the COVID-19 pandemic, these were maintained for patients in the decentralized facilities whereas they were significantly lower for patients in the non-decentralized facilities. The IHCI decentralized model appears to have contributed to continuity of care for people with hypertension and to have maintained this continuity against system shocks such as that of the COVID-19 pandemic. Decentralization of free medicines and follow-up services to the first and most peripheral point of contact in the primary health care system brings these essential services closer to home, which can encourage patients to seek services from the public sector – capturing a strong case for a primary health care foundation to the strengthening of systems for universal health coverage.
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Pandemic preparedness requires better regulation and stewardship of private providers that dominate provision of primary health care p. 59
Mishal S Khan, Afifah Rahman-Shepherd, Nina van der Mark, Osman Dar, Rumina Hasan
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Financing health in the new normal: issues and opportunities p. 61
Soonman Kwon
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Financing health care in the WHO South-East Asia Region: time for a reset p. 63
Ajay Tandon, Valeria Oliveira Cruz, Aarushi Bhatnagar, Hui Wang, Trina Haque, Manoj Jhalani
The coronavirus disease 2019 (COVID-19) pandemic is having a devastating impact and continues to take its toll in the World Health Organization South-East Asia Region. In addition to its direct impact on morbidity and mortality, the pandemic is adversely affecting economic activity as a result of lockdowns and voluntary social distancing. The average per capita economic contraction among South-East Asia Region countries is currently projected to be 5.3% in 2020, suggesting severe consequences for financing for health and sustaining progress towards universal health coverage. Health financing systems in many countries of the region – characterized by extremely low levels of public financing and a predominance of out-of-pocket spending – have contributed to weaknesses in primary health care (PHC), including in relation to pandemic preparedness and containing COVID-19. Without sustained countercyclical public spending and an increased priority for health in government budgets, countries will be likely to see a slowdown or even reversal in growth in public financing for health, which is already at a low level in several countries of the region. In the face of this economic adversity and fiscal tightening, efforts to improve the efficiency and equity of public spending on health will be key, especially for strengthening PHC and enhancing cost-effectiveness in terms of the choice and delivery of interventions. To this end, countries must emphasize the public health focus, improve targeting of public financing towards the poor and vulnerable, reduce fragmentation and duplication of financing flows, leverage strategic purchasing and cut wasteful spending. The COVID-19 pandemic also presents an opportunity to reset how health systems and PHC are prioritized and adequately financed in the countries of the South-East Asia Region, as areas of core public investment that not only contribute to better health outcomes but also are critical for ensuring a sustained economic recovery.
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Deep impacts of COVID-19: overcoming challenges in strengthening primary health care by targeting the health workforce p. 73
Viroj Tangcharoensathien
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Implementing a decade of strengthening the health workforce in the WHO South-East Asia Region: achievements and way forward for primary health care p. 76
Tomas Zapata, Masahiro Zakoji, Mikiko Kanda, Phyllida Travis, Viroj Tangcharoensathien, James Buchan, Manoj Jhalani
Background Health workers are the cornerstone of primary health care (PHC) services, the delivery of an effective coronavirus disease 2019 (COVID-19) response and progress towards universal health coverage (UHC). In 2014, the World Health Organization (WHO) South-East Asia Region committed to the Decade for Health Workforce Strengthening 2015–2024, and UHC became a regional flagship with a focus on strengthening the health workforce. Since its inception, three rounds of monitoring with standardized indicators have been completed. Methods In 2019, data on human resources for health were collected through the National Health Workforce Accounts online platform by the country focal points; this was complemented by a regional online consultation in June 2020. A mid-term review report on the Decade for Health Workforce Strengthening was launched during the 73rd session of the Regional Committee in September 2020. Results The availability of doctors, nurses and midwives in the South-East Asia Region has increased by 21% since the decade began in 2014. Nine countries of the region are now above the 2006 WHO threshold of 22.8 doctors, nurses and midwives per 10 000 population, compared with only six countries in 2014. However, only two countries are above the 2016 revised WHO threshold of 44.5 doctors, nurses and midwives per 10 000 population, the density estimated to be needed to achieve the Sustainable Development Goals. Countries of the WHO South-East Asia Region have made progress to different extents during the past 5 years on strengthening governance of human resources for health, data, rural retention and health professional education. Discussion Addressing broader health workforce challenges and particularly PHC workforce challenges will require extra commitment and prioritization by governments for the second half of the decade. COVID-19 presents the necessity and an opportunity to increase long-term investment in the health workforce and in strengthening PHC in the South-East Asia Region.
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Using the SCORE for Health Data Technical Package to strengthen primary health care p. 87
Ruchita Rajbhandary, Preeti Negandhi, Anjali Sharma, Sanjay Zodpey
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Shift to digital during the pandemic could enable universal health coverage p. 91
David Walcott, Sofiat Akinola
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Maintaining essential health services during the pandemic in Bangladesh: the role of primary health care supported by routine health information system p. 93
Sangay Wangmo, Shila Sarkar, Tasmia Islam, Md Habibur Rahman, Mark Landry
In the initial phase of the coronavirus disease 2019 crisis, Bangladesh’s health systems faced competing demands to respond to the pandemic and concurrently maintain the continuity of essential health service delivery, particularly at the primary care level. Bangladesh’s established network of primary care health facilities, the country’s backbone for delivering essential health services, routinely feed data into the national health information system, the District Health Information Software 2 platform, which provides near real-time data on the utilization of essential health services, visualized through user-friendly integrated dashboards. Trend analyses of these data showed that by April and May 2020 there had been sharp reductions in the utilization of key essential health services across all levels of care. Early and continuous monitoring and analysis of these data informed public health policy-makers and health facility managers on rapid response strategies to restore the availability and use of essential health services. Through corrective policy measures and targeted interventions, Bangladesh’s primary health care network provided a critical platform for Bangladesh to build back most of its essential health services by October 2020. Bangladesh’s experience highlights the critical role of primary-level health facilities as a touchpoint for monitoring population access to services and as a staging point for implementation of strategies and interventions that rebuild and strengthen health service delivery towards achieving universal health coverage and more resilient health systems.
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