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Reimagining Delivery of Essential Health Care

By Koki Agarwal. Originally posted on jhpiego.org.  

Director of MOMENTUM Country and Global Leadership urges a renewed focus on decentralized, community-based, client-centered services

With the prospect of delivering an effective COVID-19 vaccine ever changing, public health professionals have a responsibility to ensure uninterrupted access to essential health care to women and their families. At the same time, we must protect clients and the health workers who serve them from infection. In a profession noted for person-to-person contact and compassionate, person-centered care, we have an opportunity—some may say an imperative—to reimagine service delivery. Already, health systems have pivoted to reconfigure waiting areas, offer virtual visits and deliver refills to people in their homes. But reimagining care requires more than “keeping the doors open.” We must take this opportunity to reinvigorate health systems strengthening efforts that prioritize decentralized, community-based and client-focused mechanisms for accessing health products, services and information.In the months since the World Health Organization declared COVID-19 a pandemic, and with infection rates still climbing, we are beginning to see the damage the coronavirus is having on efforts to advance the health and survival of women and children around the world. We’re also seeing a devastating increase in health worker deaths, with the loss of more than 600 nurses worldwide to COVID-19, which has infected more than 450,000 health care workers. Beyond the disease itself, efforts to mitigate it are creating a gap in available essential health care for communities. Global health experts estimate that more than 56,000 women and 1.1 million young children in 118 low- and middle-income countries could die of reduced access to high-quality health care—an indirect effect of COVID-19.

As countries emerge from lockdown, we must rededicate ourselves to meeting the Sustainable Development Goals. Despite progress made before the onset of the pandemic, more than half of the world’s population still lacks access to essential health care. The health system and infrastructure gaps that impeded progress before COVID-19 continue to impact countries’ capacity to implement lasting change in health service delivery. As we reimagine delivery of essential health care in the COVID-19 era, with a steadfast focus on supporting countries’ journeys to self-reliance, we must prioritize country-level coordination, planning and monitoring; community engagement; infection prevention and control; and person-centered, competent and respectful care.

Maintaining Respectful, Competent Care for Women and Children

Self-care will play a critical role in ensuring that women have access to the care they need, while developing them as advocates for their own and their families’ health. Telemedicine and telehealth platforms allow us to move some aspects of service delivery, such as client histories, screening for sexually transmitted infections and triage for women in labor, to a virtual setting. Various apps can support patient flow in facilities and help anticipate stock-outs of vital medications. In India, for example, telehealth platforms are helping community health officers to identify high-risk pregnancies, and apps are being used to support facility readiness assessments. Social media campaigns can raise awareness of COVID-19 and infection prevention practices. Helplines and hotlines can provide support to survivors of gender-based violence as well as frontline health workers.

Of course, some services, such as childbirth and immunization, have no virtual option. Women must have access to respectful, skilled care before, during and after pregnancy. Researchers at the Guttmacher Institute note that even a 10% decline in service coverage for women during pregnancy could result in an additional 28,000 maternal deaths and 168,000 newborn deaths. We must continue to advocate for the recommended eight antenatal care contacts, although how these contacts are offered may change. In India, community health officers—the country’s “corona warriors”—are offering home-based antenatal care and delivering folic acid and iron to pregnant women. It’s also critical that we regain, maintain and continue to accelerate the progress we have made in facility-based births and deliveries by skilled birth attendants, as unattended childbirth holds greater risks for women and newborns than the potential for infection with COVID-19 at a health facility. In all cases, a woman’s right to respectful care must be protected and the gains made in engaging birth companions maintained as per country guidelines.

And while protecting our clients is critical, I cannot stress enough how important it is to support our frontline health workers. We must ensure they have personal protective equipment (PPE) to keep them safe. Tanzania, for example, makes sure all community health workers are well equipped with PPE—about 90% of which is locally made—and handwashing supplies. Equally important is offering counseling to help health workers cope with their own and their clients’ fears, and providing social support, such as transportation, to allow them to do their jobs. Continuity of high-quality care depends on their well-being!

Safeguarding Access to Family Planning and Reproductive Health Care

As we have seen in countries such as Kenya, where voluntary family planning care dropped to about 30% of the average in March, COVID-19 and the resulting disruptions in care and supplies threaten gains in contraceptive use. Guttmacher Institute researchers estimate that a mere 10% reduction in access to short- and long-acting contraceptives could result in an estimated 49 million women with unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the next 12 months. We need leadership and commitment at the country level to operationalize and institutionalize creative solutions to making voluntary family planning and supplies available, while keeping lines of communication open with the women and families we serve.

With contacts between clients and the health system limited due to the pandemic, integration of services takes on a new urgency. We must optimize every opportunity to screen, inform and provide voluntary family planning and reproductive health care to women and families. Facilities should plan for future commodity needs to avoid disruptions in the supply chain, anticipating breakdowns in transportation and availability of various methods. Stronger data monitoring systems will allow facilities to identify trends, troubleshoot bottlenecks and reduce stock-outs and waste. Coordinating data collection and analysis at the country level, as Ethiopia’s Federal Ministry of Health is doing, helps ensure timely, accurate and actionable information. For clients, multimonth dispensing through doorstep delivery by community health workers or new social enterprises reduces health facility visits and ensures uninterrupted supply. Keeping informed and voluntary choice at the forefront of our messaging, we should continue to educate about self-care family planning methods, such as injectables, condoms and fertility awareness methods, and ensure clients can get support from a health worker on demand—giving them the tools to take control of their health.

The Journey Ahead

All programs must recognize the particular vulnerability of adolescent girls and youth to changes brought on by the pandemic. Teenagers may have more difficulty accessing information and care, and are at increased risk of sexual exploitation, gender-based violence and early pregnancy. Even temporary school closures can lead to poor educational outcomes, compromising the health and futures of girls and young women. We must keep the connection between these vulnerable populations and the health system open. In Tanzania, for example, community health workers make regular household visits, bringing information about COVID-19 and infection prevention, and offering other support where needed.

As we move forward to address not only the essential health needs of women and children in low-resource settings but also the challenges of the novel coronavirus, we must be innovative in our reimagining of how we deliver care—and brave enough to take advantage of the current situation to create the resilient health systems of the future. As we support health systems and health providers, we must also support all women to become advocates for their own health and care. Women form the foundation of communities; strong, healthy and informed women can transform societies, leading countries on their journeys to self-reliance.

Koki Agarwal, MD, MPH, DrPH, is the Director, MOMENTUM Country and Global Leadership, and Vice President, DC Operations, Jhpiego