This blog is part of a series of blogs written by participants at HSR 2022 reflecting on some of the key messages and learnings emerging from the symposium.
The 7th Global Symposium on Health Systems Research had a major focus on primary health care (PHC) In many discussions at the conference, there was acknowledgment of what failed and what worked during the pandemic with PHC. An organized session on 3rd November where I was a panelist focused on PHC-related lessons from COVID-19 across Asia and the US.
Going into the session, my belief was that primary care could have done more to help in COVID-19 diagnosis and triage, and to provide therapeutic support for patients who did not require ventilation. Yet many health systems either could not or did not draw on their primary care systems. This is something high-income and developing countries need to address as institutions prepare to invest the $1.4 billion that the World Bank’s Pandemic Fund has mobilized.
The session and its Q&A confirmed my thoughts. There is a lot that the US and Asia can learn from each other – if we are listening.
During the session, moderated by Arin Dutta of the Asian Development Bank, Dr. Rajani Ved of the Gates Foundation India Office gave a hard-hitting summary of India’s PHC record during the pandemic. She discussed the significant gaps in health system functioning at the district/sub-district level, fragmented urban PHC, and a lack of public health training among PHC workers. While major investments are being made in India in PHC, such as more than 11,000 urban health and welfare centers, and apps developed during the pandemic are now finding new uses, the road to real public health competency at the PHC level is long. What role will your local clinic play in the next pandemic – this is something we will find out!
Dr. Piya Hanvoravongchai of Chulalongkorn University delivered a tribute to the role of the 1 million-plus village health volunteers (VHVs) in Thailand’s COVID-19 response. From household visits to case management and local surveillance, the VHVs were busy! One could see them as the Atlas on whose shoulders Thailand’s public health pyramid rested. As necessary in the 2020s, they even had a “SmartVHV” app – although not all VHVs were as digitally literate as the developers would have liked. Something to consider when thinking of digital silver bullets!
In a summative presentation, Dr Helena Legido-Quigley of the National University of Singapore reflected on PHC research from HSR2022. PHC was framed within the reconceptualization of health systems, where actions at the local level connect to the global. PHC is also critical in four target health system functions in the pandemic – partnering, coordinating, developing, and strengthening. As per Dr Legido-Quigley’s conference summary, and her own study of Singapore, PHC strengthening was linked to political economy and institutions (leadership and organizational routines). One lesson: to make sure it is not ignored, PHC should be integrated into broad reform packages. Interestingly, we heard that “researchers [must] become health diplomats!”
In my own presentation, I drew on primary care innovations from Montgomery County, Maryland (USA)–an attempt to link the hyperlocal to the global. This diverse county of one million residents has a sizable population of the uninsured and uninsurable–many of whom are undocumented. I highlighted the Montgomery Cares program, a public-private partnership between the county government, community-based clinics, and other non-profit service providers. The county’s rapid transition to flexible reimbursement allowed the clinics to keep their doors open throughout the pandemic, avoiding the financial crunch associated with output-linked payments in a period when PHC visits fell precipitously. The county also enabled reimbursement for telehealth visits for the first time, which demonstrated that telehealth works—including for low-income populations with limited digital literacy–but it’s not necessarily a cost-saving option to deliver care. This is especially true if you reimburse telehealth visits on an equitable basis as in-person care.
In the final presentation, Dr Hong Wang of the Gates Foundation summarized China’s gains under the rural primary healthcare improvement program. One of the many insights in his detailed talk was how PHC is viewed as essential to financial protection in China – distinct from the focus on catastrophic health expenses from specialized care elsewhere at HSR2022. The policy spotlight on disease as a driver of poverty in China left me with an uncomfortable feeling that such a view is missing in my own country. Dr Wang also highlighted how a focus on high-risk populations in the rural PHC system helped target resources and led to better outcomes.
Coming away from Bogota, I reflected on the energy and enthusiasm around PHC – and more broadly, on health as a human right – among the researchers and practitioners at HSR2022. Indeed, researchers and public health advocates must become diplomats. But equally, we need our actual diplomats and politicians to be public health advocates.
By Elizabeth Arend Dutta, DrPH Candidate, Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University.