By Priya Balasubramaniam (Public Health Foundation of India & Centre for Sustainable Health Innovations), Birger C. Forsberg (Karolinska Institutet), Gerald Bloom (Institute of Development Studies), Phyllis Awor (Makerere University School of Public Health), Meenakshi Gautham, London School of Hygiene and Tropical Medicine), Desta, Lakew (Amref Health Africa) & Uranchimeg Tsevelvaanchig) and Fadi El Jardali (American University of Beirut)
This blog post is part of a series from Health Policy and Planning, which gives a voice to practitioners, implementers and policy-makers involved in national COVID-19 responses in low- and middle-income countries. The posts seek to facilitate timely cross-learning by sharing opinions, insights and lessons on the challenges and actions taken by those on the COVID-19 front line.
As the COVID-19 crisis unfolds across the globe, country health systems are being stretched to their limits. This blog calls for extraordinary measures to coordinate and engage with the ‘other half of the health sector’ – the informal health sector, private health professionals and non-state actors in low- and middle-income countries (LMICs) with weak health systems to start with, where the pressure from the current pandemic has been especially tough. When state capacity has failed, the unorganized sector and local private practitioners are often the first line of contact for many vulnerable populations.
Health systems in LMICs are being challenged on multiple fronts. This includes, grappling with disruptions in crucial health services for vulnerable populations with non-communicable, chronic and other infectious diseases, the distribution of necessary medicines to those who need them the most during national lockdowns, shortages in appropriate gear to protect frontline and community health workers exposed to community transmission in a timely manner and constraints in sanitation, isolation, surveillance and quarantine facilities for the poor and vulnerable in densely populated settings. Covid-19 has also exposed huge fault lines in underfunded primary care services that are struggling to cope with volume and the lack of evidence based protocols. These systemic cracks will be further stressed if the anticipated major economic downturn materializes.
In many countries, the private health sector consists of providers from a mix of professional backgrounds, who deliver an array of outpatient services in solo practices that include unlicensed providers, general practitioners, pharmacies, diagnostic-labs, small nursing homes and multispecialty polyclinics. In several countries, non-state actors are supplementing state response to COVID-19. Local NGOs in Nepal are offering to play a critical role in creating awareness and supporting the government in identifying and meeting unmet needs for outbreak response. Bangladesh’s largest NGO, BRAC, is raising campaigns in 61 districts, organise handwashing stations in urban slums and manufacture re-usable masks. In Iraq and Syria (pdf), local medical organizations are arranging tests, training health workers to screen communities and setting-up makeshift camps for quarantine. Non-state actors are also helping mitigate the collateral damage posed by COVID 19. In India, thousands of migrant workers displaced by national lockdowns, turned to local community organizations and non-state health networks for food, rations, shelter, essential medicines and treatment for chronic conditions and non-COVID emergencies.
More than 80% of slum and peri-urban populations in India seek health care from informal health providers and pharmacies. A national health survey in 2014 showed that 79% of the urban and 73% of the rural population used the private health sector for outpatient health care.
In Sub-Saharan Africa, commercial drug shops and pharmacies cover a large share of everyday health care needs. For example, in Nigeria, Uganda, Tanzania and Zambia, formal and informal drug vendors play a critical role in the diagnosis and management of malaria, diarrhoea and paediatric fevers. There is increasing evidence that integrating medicine vendors into the formal healthcare system could improve access to good quality healthcare and reduce the burden on state services.
WHO data from LMICs of the Eastern Mediterranean Region (EMR) (pdf) estimate that the private health sector provides between 33% and 86% of outpatient services. It also provides between 11% and 81% of the health services used by the poorest quintile in those countries. Yet, many non-state actors continue to remain disconnected from government health sector response and planning.
Diverse privately-run healthcare networks emerge when and where state capacity is absent or unable to cope, often within marginalized communities. As several communities use local small-size and informal private health providers as their first point of contact when falling ill, they represent an important bridge to the people. Rather than being inherently at odds with formal institutions, they fill a crucial gap in access to healthcare. Non-state networks can be a vital local resource for reaching vulnerable communities for COVID-19 control and mitigation now and beyond the pandemic. They do this by:
- Acting as first-responders: Non-state providers and private family doctors can be trained in first-level management, screening and triage of suspected corona cases. National or provincial guidelines can advise on testing, home care and isolation and assistance to go to quarantine hospitals if a patient becomes seriously ill.
- Reaching the marginalized faster: Integrating partners like drug shops, informal health-providers, local nursing homes and community- based clinics into the COVID 19 response teams that target slums and settlements that cannot self-isolate and lack water and sanitation adds valuable local knowledge and trust to state initiatives. Non-state actors must be used for communication and messaging around COVID control. Community based private networks in Vietnam for example have used social media to assist HIV positive patients with multi-month antiretroviral therapy refills and tuberculosis medicines during COVID-19 isolation.
- Supplementing health workforce: Sustaining COVID-19 mitigation and control measures after the lockdown will be vital as communities migrate across cities and borders to resume work. Non-state providers will be critical as point-of-care operators in monitoring community transmission, and preventing resurgence as well as an important source of treatment for those not admitted to hospital. In Africa private social enterprises are banding together to bridge capacity gaps in testing and triage for hard to reach communities.
- Maintaining essential health services: Finally, enlisting non-state actors to support non-COVID related health care is critical to prevent collateral health-damage faced by many people due to the outbreak. Maintaining necessary healthcare services and essential medicine supply at times of isolation and restricted movement particularly for the chronically ill, elderly and other vulnerable populations is critical. Governments can engage non-state actors to balance these competing demands based on local priorities, evidence and needs (pdf). Private primary care providers have been co-opted through telemedicine in Thailand and Indonesia to ensure health service continuity for non-COVID conditions.
Country health systems will never be the same after COVID-19, with many undergoing major design and operations overhaul. The current pandemic has taught us that governments have to anticipate, prepare and invest in local health resources more than ever before and integrate communities to form agile newer models of partnership in addressing health needs. We need to think outside conventional approaches and leadership models to find indigenous solutions that make use of even limited or evolving evidence to protect the most vulnerable in the absence of replicable models. Researchers need to ensure that their work supports rapid learning and adaptation to rapidly changing challenges.
COVID-19 presents governments of emerging economies with novel opportunities to make bold decisions and show the world how to deal with a pandemic. This is the time for these countries to ‘lean into’ and capacitate their local networks of non-state providers as resources for syndromic surveillance, awareness and management of mild symptoms. We call for governments to quickly develop a coordinated strategy for working with these providers for pandemic control as well as maintaining essential health services for those who need them them the most.
Image credit: Hindustan Times_pharmacy