Hierarchical medical system in the COVID-19 pandemic era: A potential access to the management in disease control and medical resource sustainability--a commentary on “Health policy and leadership models during the COVID-19 pandemic: A review”

Dear Editor:

We read with great interest the article by Dr. Maria Nicola and colleagues [1]. The authors provided an inspiring discussion in pandemic-associated decision making. As mentioned by the authors, the leadership would face dilemma regarding the distribution of resources. During pandemic era, coping with the heavy burden on medical resources had become a critical issue in decision making. Thereby, we would like to report the current status of implementing hierarchical medical system in Taiwan. We fairly believe the development of hierarchical medical system could serve as backup in enhancing the efficiency in decision making of both authorities and policymakers and complement with the viewpoints proposed by the authors.

The critical aim of hierarchical medical system is to ultimately provide the publics with guaranteeing healthcare through emphasizing function of initial diagnosis and primary care of local clinics [2], which includes two essential concepts [3].

• 1)To share the burden of medical care by changing citizen's medical habits Patients will no longer rely on a single level of medical facilities to sort out their health problems, but gradually become accustomed to using local resources to share the burden of medical care in popular medical facilities [4].
• 2)To enhance the quality of health care by strengthening the connection between primary and superior medical institutions. The practice of bidirectional referral system among medical facilities can serve as a connection which provides patients with quality medical resources through the vertical flow of patients [3].

Take Taiwanese experience of developing hierarchical medical system as an example. Based on the NHI system in Taiwan, citizens could freely visit all medical facilities in different tiers, including General Practice Clinics, Regional Hospitals or Medical centers without any referral. As one of the consequences, people tended to seek care at medical facilities in higher levels because of its reputation and sufficient resources. Thereby, popular medical facilities in higher tiers became overcrowded [4]. Under such circumstances, call for development in hierarchical medical system had gradually been raised. To improve the quality of health care and to share the burden of medical resource, the government initiated the Family Doctors Integrated Care Initiative (FDICI) project in 2003, which also plays a key role in fighting against COVID-19. The project was expected to serve as the primary step in developing hierarchical medical system. The two mainstreams of the project were (1) to improve function of local medical facilities and (2) to enhance the connection between local clinics and medical facilities in higher tiers. Services for participated citizens, including case management delivering, 24hr-service line for medical consultation, integrated healthcare plan and medical education, were integrated and provided by local medical facilities. Bidirectional referral system between different tiers of medical facilities was set to ensure the vertical flow of patients. Moreover, shared care outpatient departments were held by all medical facilities in different tiers involved in FDICI to provide patients with both primary and further medical cares. Seminars were conducted in facilities participating in FDICI to evaluate the efficacy of the project [5].

The benefit of hierarchical medical system could become more significant especially under the pandemic era. First, when citizens found themselves appearing possible symptoms related to COVID-19, instead of directly turning to medical facilities in higher tiers for help, local medical facilities could provide citizens with primary diagnosis. If local physicians found a patient meeting the criteria for circular, the authorities could immediately be informed, and subsequent quarantine and tracking procedures could be performed. Treatment for non-Covid-19 related symptoms might also be provided if the criteria were not met.

Moreover, strengthened connections between primary care clinics, medical centers and authorities might help improve the accuracy and effectiveness of the disease reporting system. Once the bidirectional referral system is properly developed, authorities could more easily integrate pandemic-related information in communities and improve the quality of disease control. In this way, the stress and workload of the pandemic response will be eased and simplified.

Conclusion

Proper distribution of health care and enhanced partnerships among health institutions at all levels may enhance the sustainability of medical resources during the pandemic. As a supplement of the leadership models provided by the authors, we argue that promoting concepts of hierarchical medical system during the current and post-pandemic era could be a strong backup and could potentially serve as an effective intervention in enhancing the efficiency and performances in medical resource utilization.

Ethical approval

Not applicable.

Sources of funding

Not applicable.

Author contribution

Gau SY contributed to the original draft preparation and conception of the article.

Yang SC and Lu TI contributed to the original draft preparation.

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Guarantor

Mr. Shuo Yan Gau accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Statement

“Provenance and peer review Commentary, internally reviewed”.

Declaration of competing interest

No potential conflicts of interest exist.