The world Health Organization asserts that a strategic purchaser prioritizes primary healthcare (PHC) and protects funding for those services. In the wake of COVID-19, it appeared that primary healthcare services were taking a back seat as countries mounted an appropriate response to COVID-19. This was not surprising, given that this same scenario played out with the Ebola crisis. Data from Liberia showed that childhood vaccinations, malaria treatments and antenatal visits decreased in the first four months of the Ebola outbreak and it took more than one year to get back to pre-Ebola levels .
So, in the month of May, we set out to find out what countries were doing to ensure the prioritization of primary healthcare. We invited two countries – Rwanda and Nigeria to our Twitter chat (SPARCchat) to share their thoughts on the prioritization of primary healthcare services in these difficult times. These two countries were symbolic of some of the concepts we wished to explore: 1) the use of technology to improve access to primary healthcare as seen in Rwanda and 2) how experience with a previous epidemic (Ebola) in Nigeria could be utilized to improve health system resilience and ensure service continuity during health system shocks as being seen with the COVID-19 pandemic.
What did we learn from these two countries?
- Make comprehensive, flexible plans to protect essential services. Nigeria built on experience from the Ebola outbreak to develop an integrated action plan to ensure coordination and zero service disruptions with room for course correction as the pandemic unfolds
- Build on existing strengths. Rwanda is relying on community health workers to be a link between the community, local leaders and health providers to share information, and make sure that ambulance services are reaching everyone who needs immediate attention
- Innovate. Rwanda’s experience shows that the use of online/virtual consultation clinics can help address barriers to access due to lockdowns and fear of contracting COVID-19 in health facilities. Although not all conditions qualify for this kind of care, this can help increase the chances of primary healthcare continuity
- Ensure that COVID-19 services are covered and providers are paid to deliver them. Both countries ensure people have explicit coverage for COVID-19 services at no cost to beneficiaries.
- Fully engage frontline providers to be a part of the response. Some budget reallocations may be necessary in the short-term but if the providers understand the shared responsibility of getting funds to where they are needed for both the COVID-19 response and routine services, they will give their full support
- Motivate and protect the healthcare workers as they carry out their work. This may not apply to only primary healthcare but across board for all levels of care. In Nigeria, this has taken the form of insurance plans and special passes for ease of movement, but could also involve mental health support, provision of PPEs and consistent communication
Our technical partner in Republic of Benin, CERRHUD, hosted at the Force community webinar, shared similar PHC service continuity concerns. Panelists confirmed that COVID-19 has reduced access to PHC due to shift of public resources to the pandemic response and changes in health seeking behavior as people avoid health facilities for fear of contracting the virus. They provided additional recommendations to ensure service continuity during these difficult times
- Separate health facilities providing COVID-19 care from those providing other essential services
- Ring-fence funds for other essential services to avoid service disruption
To round off our month of learning on this subject, we invited Professor John Ataguba of the University of Cape Town (SPARC’s technical partner in South Africa) to guest-write a blog post on this same subject. His post raises an interesting point – that primary healthcare has always struggled for ‘its own share of the pie’ in Africa when compared with secondary, tertiary and quaternary care, due to the continent’s focus on hospi-centric care. Therefore, COVID-19 has only just exacerbated a bad situation, disproportionately affecting the poor and vulnerable who depend on these ‘lower level’ services. This is in keeping with the findings of WHO in the wake of the Ebola crises in 2014.
Professor Ataguba adds two additional recommendations to our list:
- Continually track and monitor spending on COVID-19-related activities to ensure that it does not crowd-out primary health care spending or spending on other public health issues facing countries
- Countries in Africa must strive to build resilient health systems, described as those ‘prepared to handle shocks and evolvingly adapt to changes by ensuring that people receive the needed quality health services timeously without suffering financial hardship.’
As we pause and reflect on these key messages form our partner countries, technical partners and network of regional coaches this month, I leave you with a few thoughts.
Does COVID-19 provide an opportunity to turn the tide in favour of PHC, not just for this pandemic response, but thereafter – moving the continent from hospi-centric care to a greater focus on PHC?
As we continue to battle this pandemic, what early warning signs can alert policy makers of potential crowding out of PHC? Some indicators used in Liberia to track this disruption pre, during and post-Ebola crisis include change in numbers of first antenatal care visits, measles vaccinations, Artemisinin-based combination therapy (ACT) treatments for malaria etc. Are these being used in other countries and if not, can they be used? What other indicators are useful here?
How can we track funds flow to PHC to ensure that other essential services are not overlooked in the bid to address an epidemic/pandemic?
What tangible actions can policy makers take to address fear of contracting the virus in health facilities at times like this? Is this an opportunity to explore/expand innovations in technology or perhaps, leverage community health workers?
Will the COVID-19 experience prove to be the catalyst for an increased focus on health system resilience?
As you reflect on these, please feel free to drop us a line and let us know your thoughts
 Wagener, B.H. et al (2018). The 2014–2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010–2016. . Available online at https://doi.org/10.1371/journal.pmed.1002508 (Accessed: 28 May, 2020)
 WHO (2014). High level meeting on building resilient systems for health in Ebola-affected countries. Available online at https://www.who.int/csr/resources/publications/ebola/hs-meeting.pdf?ua=1 (Accessed: 28 May, 2020)