TABLE 1.
Health system risks posed by coronavirus disease 2019 and possible solutions to maintain essential services (according to the World Health Organization health systems framework).
| Possible health system risks posed by COVID-19 |
Proposed solutions to maintain essential health services whilst responding to the pandemic | |
|---|---|---|
| 1. | Service delivery (primary care level only) | |
| a. Essential services not prioritised because of competing interests,18 e.g., immunisation campaigns paused | World Health Organization proposes outreach mechanisms to ensure delivery of essential services,18 including immunisations and HIV services. For example, auxiliary nurses can do field-based immunisations (at rural health posts closer to community) rather than children crowding at clinics. Human immunodeficiency virus experts advise that male circumcision can be paused whilst harm reduction and condom distribution and HIV treatment services need to be maintained with modifications that will reduce contact with service providers.21 Currently, South Africa is implementing Central Chronic Medicines Dispensing and Distribution (CCMDD) programme whereby stable patients collect their chronic medications at different pick-up points near them outside the health facility. We recommend that CCMDD must be maximised to reduce physical contacts with service providers.22 Immunisation campaigns can be modified to reduce huge numbers at once. Consider integrated community-based outreach platforms offering immunisation services.23 |
|
| b. Covid-19 Physical distancing policy compels population to defer healthcare seeking for essential routine services like HIV and EPI14 | Integrate essential services with COVID-19 services at facility and community levels. For example, involve nurses delivering EPI and HIV services in screening for COVID-19 and reporting cases.23 Identify and prioritise vulnerable communities including infants, poor and the elderly for essential services. For example, maximise the use of social protection grants available during the emergency to promote access by the vulnerable groups. Generate a country-specific list of essential services for SA (based on context and supported by WHO guidance and tools). Prioritise current worse-performing provinces, districts and facilities, which need more attention and resources for delivery of essential services. Shift focus from conducting face-to-face, manual and paper-based routine operations and monitoring to utilising information technology and web-based platforms for maintaining services, for example, health promotion and prevention messages through mobile technology. Ensure positive health-seeking behaviour and adherence to care by maintaining population’s trust in the capacity of the health system, to safely meet essential needs and to control infection risk in health facilities. The communities should be sensitised and reassured through media, text messages and platforms like religious and other existing community structures. (WHO operational guidelines)18 |
|
| 2. | Human resources | |
| a. Health workers infected with COVID-19 | Intensive COVID-19 screening for health service providers. Prioritise and ensure adequate supply of personal protective equipment (PPE) for health workers. |
|
| Explore ways to support those needing self-isolation and quarantine whilst protecting their family/household. | ||
| b. Lack of COVID 19 training for health workers | Consider short, web-based training for health workers in COVID-19 screening, first-line treatment, referral guidelines, quarantine/isolation policies and personal protection through smart phones (based on videos/apps). They also need to be trained on how to assure/motivate/counsel the clients because they are the frontline contacts. | |
| c. Shortage of staff from essential services because of redeployment towards COVID-19 response | Consider task shifting and scope expansion where possible to improve access to care (24) – for example, enrolled nurses and enrolled assistant nurses could take up health prevention/promotion as well as curative tasks from professional nurses, for example, immunisation. Use of qualified health workforce resident in South Africa but not working, to be recruited. Part time health workforce to be asked to work full time. Utilise the senior health workforce students from training institutions to alleviate staff shortage pressures. Maximise health workforce from the non-governmental partners like provincial and district PEPFAR collaborations, defence, Red Cross, etc. Clinical associates, senior students from nursing colleges and interns can be deployed on a short-term basis and, if possible, accelerate early certification without compromising quality. Redistribute and redeploy staff from non-affected areas, or high-performing districts to low-performing districts. |
|
| d. Health workforce overwhelmed, at risk of resignations | Reassurance from department of health, small incentives for those health workers who contribute to both PHC and COVID-19 response. Explore ways of acknowledging and appreciating the health workforce. |
|
| 3. | Health information systems | |
| a Worsening of the quality of existing data in public health system25 | Minimise paper-based reporting and data collection considering physical distancing Strengthen online, web-based information systems for monitoring and progress of HIV and EPI programmes, which can be directly used by health workers and data can be submitted through smart phones to a centralised server, which is accessible to all project managers and decision-makers. |
|
| b. Competing interests leading to a shift in focus to monitor the COVID-19 data currently in greatest demand | During the emergency, ensure monitoring of ongoing delivery of essential health services to identify gaps and provide timely response. Prioritise, in this case, EPI, HIV and other critical indicators in the DHIS that need to be essentially monitored and leave out those indicators the monitoring of which can be delayed, such as male circumcision. |
|
| c. Lack of time for quarterly reviews to monitor progress on essential services to identify and address gaps, for example, health facility assessments, IMCI health worker supervision, etc. | Decentralise quarterly reviews at facility level – promote internal reviews of routine essential services (designate a team of nurses led by facility managers) if supervisors cannot visit the clinics and provide online feedback to managers. Web-based data reviews through Zoom/MS team/Skype/Google Meet, etc., and other platforms will save time without disturbing physical distancing. |
|
| d. Surveillance and reporting of AFP and vaccine preventable diseases might not be ensured | Maximise online tools for monitoring and reporting of cases of acute flaccid paralysis (AFP) for polio, measles, etc. (e.g. apps, web-based software) Involve private clinics and GPs in reporting and surveillance. |
|
| 4. | Access to essential medicines | |
| a. South Africa has existing ARV and vaccine stock-out challenges because of supply chain constraints.8,9,10,11 | Prioritise the worst-performing provinces on ARVs, vaccines and other essential medicines stock-outs. Collaborate with private health sector, pharmaceutical companies to maximise contribution and utilise their platforms. Use of advances in technology to improve supply chain management could be linked with current initiatives such as MomConnect. Stock-outs for medicines and vaccines can be reported by facilities or districts online through web-based platforms which are monitored by the district supply chain managers and supplies could be procured accordingly. For example, Blood Information and Management Application (BIMA) in Bangladesh takes online demand for blood and manages procurement.26 |
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| b. Shortage of COVID-19 essential protective wear for healthcare workers has already been reported27 as manufacturers fail to meet demands | Enhance and promote local manufacturing of PPEs. Capitalise on buffer system. |
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| 5. | Health financing | |
| Economy shrinking coupled with high financial constraints to cope with the pandemic may lead to fiscal constraints on essential health services spending for HIV and EPI28 | Presidency and department of finance need to coordinate with department of health and decide on diverting any funds available in contingency or from other non-essential departments, for example, tourism, and create extra budget heads for maintaining essential health services such as procuring ARVs or vaccines. Divert surplus funds under HIV and EPI heads towards poor performing districts and provinces for extra support (e.g. run a mobile unit for vaccination or conduct a community-based catch-up campaign). Strengthen private and public health sector partnership to ensure that the public health system taps from the available resources in the private sector. Initiate and promote COVID-19 fundraising activities at local, regional and national levels. For example, SA has introduced solidarity fund where individuals and firms are donating resources to meet the needs of the poor, and at the time of writing this article, R2.5 billion had been raised with a target of R4bn.29 |
|
| 6. | Leadership and governance | |
| a. Depleted leadership capacity for essential services as programme managers had been redeployed to COVID-19. | Inter-sectoral collaboration – human resources from other non-health departments need to be involved to provide the required leadership and coordinate with health department. These could include Department of Finance, Department of Agriculture, Department of Education, NGO and multi-national partner institutions, for example, UNICEF and WHO. The use of other ministerial departments to complement the containment of the pandemic. For example, the Ministry of Water and Sanitation to ensure that population including the hardest to reach ones have access to clean water and soap for handwashing. This can be accomplished in collaboration with the Ministry of Defence that can help in distribution. In addition, the Ministry of Information and Education can support free online education, the Ministry of Telecommunications can generate awareness by media campaigns and Telkom companies can be involved to provide mobile data free of cost to support information exchange and online management of health information, etc. Department of Health can also utilize senior students from medical, nursing and public health universities, clinical associates, interns and paediatrics registrars to assist with programme management and operations. They are better trained and equipped and can work in coordination with existing programme managers and leaders on a short-term voluntary basis to get a hands-on experience in public health and emergency response. |
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| b. Decisions to navigate and strike a balance between the emergency COVID-19 and essential services | Close collaboration between the COVID-19 and essential services teams at all levels of management (national, provincial, district, sub-district and below) to identify and agree on the priority essential services that must maintain continuity during emergency period. National coordinators for HIV and EPI need to adapt and implement WHO essential services guidelines to South African context and communicate with provincial and district-level programme managers on how to operationalise the modified guidelines in their respective areas. |
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Source: WHO 2007 and some ideas were adapted from Kumwenda-Nyasulu J. Pre-ART program service delivery at a PHC facility level: Access and retention of patients in care in the City of Johannesburg, South Africa [Monograph]. Johannesburg: The University of the Witwatersrand; 2016.
CCMDD, Central Chronic Medicines Dispensing and Distribution; COVID-19, coronavirus disease 2019; EPI, expanded programme on immunisation; PPE, personal protective equipment; BIMA, blood information and management application; AFP, acute flaccid paralysis; SA, South Africa; WHO, World Health Organization; PEPFAR; DHIS; PHC; IMCI; GPs; ARV; PPEs; UNICEF; NGO.