“Covid-19 will be a great leveller – it will affect us all!” some proclaimed early in 2020. How empty these words proved to be. Covid-19 is exposing entrenched inequities across and within countries and forcing us to reckon with that.
It is clear that there are intimate links between social determinants of health, multiple chronic conditions and susceptibility to death from Covid-19. We are witnessing tragic disparities in mortality depending on whether these risk factors are present or not. Indeed the burden of chronic physical conditions (or non-communicable diseases (NCDs)) such as diabetes and heart conditions is rising and was already augmenting existing burdens of infectious diseases, maternal and child health problems, and nutritional conditions in health systems which are poorly oriented towards managing and preventing multiple health conditions.
Covid-19, NCDs and poverty, recently described as a perfect storm, represent a global health emergency on a scale which is difficult to comprehend let alone respond to. Indeed, the demands that will be placed on weaker health systems will be felt for many years to come on a scale yet to be imagined.
Whilst we scramble for solutions to contain this horrible disease, we must also recognise that Covid-19 joins a long, grim list of urgent societal challenges. Alongside a multitude of health challenges sit conflict, climate change, food insecurity and poverty. COVID-19 is exposing vulnerabilities within and across health, food, and economic systems.
It has particularly exposed fragility across highly varied health systems and led to a realisation that strong, proactive primary health care and public health systems are critical. An account from Ghana reminds us that the frontline of every robust health system is primary health care and it must be protected at all times.
Vertical programmes designed to tackle diseases in isolation – even in a pandemic – do not correlate with healthcare workers daily experience of treating people. Not diseases, but people. With our complex lives, our individual and societal behaviours, our belief systems all impacting on our health and health care needs.
Providing integrated, equitable access to promotive, preventive and curative healthcare close to people’s homes is a central pillar to any Universal Health Coverage initiative, and indeed central to pandemic planning. Primary health care is inherently universalist in approach, striving to be effectively all things to all people; 90% of the care to 90% of the people over 90% of their lifetime. Strengthening primary health care in planning and preparation for a pandemic response can allow health systems to pivot and respond to repeated shocks as well as provide for ongoing health needs in the recovery phases.
Yet under-resourced primary healthcare workforces pose a particular challenge to resilient health systems. Back in March this year, the George Institute India published a rapid evidence synthesis highlighting the opportunities to enhance the well-being and contribution of frontline health workers in primary healthcare systems tackling the Covid-19 pandemic.
It is absolutely critical that primary healthcare workers, an oft-neglected cadre within the health system, are equipped with the skills to safely screen, triage and care for people with Covid-19 whilst simultaneously looking after other health needs and ensuring continuity of routine healthcare services which keep their populations healthy.
The international responses to Covid-19 have clearly demonstrated that a ‘Global North teaches Global South’ attitude is inappropriate. This pandemic has shown that even the best resourced countries, cushioned by strong health systems and armies of scientific advisors, can still respond in deeply inadequate ways to public health emergencies. Many low-income and middle-income countries, in comparison, have substantial experience in managing infectious disease outbreaks and have deployed context-specific containment strategies in a highly effective manner. Strategies such as effective contact tracing and the value of community health workers in controlling pandemics (when deployed effectively) are two such examples of excellence in pandemic control that have been led by Global South nations. And around the world, exemplary political and technical leadership combined with sufficiently integrated primary care and public health systems seem to be critical success factors.
But there is a long way to go before we will see the primary health care sector being sufficiently supported to fulfil its potential. Despite the momentum generated by the Astana Declaration, the global monitoring report on UHC 2030 demonstrates significantly delayed progress in realising Universal Health Coverage through primary care systems. We need only look at per capita expenditure on health to understand, that failure to prioritise investment in primary healthcare has created fragmented systems.
The consequences of this under-investment are strained capacity, inefficient linkages to care, limited facility capability, inadequate prevention and promotion activities and large access barriers to high quality care (with attendant effect on DALYs and on mortality). This is fertile ground for the (accidental or intentional) neglect of economically and socially marginalised groups, fundamentally violating the UHC principle of leaving no one behind.
As a primary health care champion, PCI is quickly adapting its offerings to meet current needs, much in the way that a strong primary health care system must. We are responding to requests from front-line healthcare workers across the globe by providing open access to newly created Covid-19 e-learning resources for those working in resource-limited settings, tackling a range of topics from screening and triage, clinic operations, health workforce planning through to continuity of essential services including mental health. These have been co-created by our own networks in partnership with guest writers and partners, drawing from a wide pool of knowledge and expertise, and have now been accessed in more than 75 countries. We are also providing technical and clinical support to new and existing partners as they pivot and re-align health services. We are particularly glad to partner with humanitarian organisations for whom the challenges are multiplied, including supporting the WHO Covid-19 response in Syria. Looking ahead, many more of PCI’s primary healthcare resources and services will be moving online as we adjust to some kind of ‘new normal’.
It’s clear that we all need to learn to live with risk and precarity – for the more privileged among us this is a steep learning curve. For a great many more, this is unfortunately business as usual. We must surely recognise that we are in this together. But will our leaders find the moral courage to work collaboratively and build back better?
In the coming months, PCI will be further developing and sharing this Primary Care Perspectives series: exploring a range of themes relevant to primary care in a time of Covid-19 and beyond. We will be partnering with authors from within our own network as well as our partners to publish a collection of opinion pieces drawing on our collective experience as primary care practitioners, as social justice advocates and as global citizens.
- Julia Beart. Julia is Chief Executive of Primary Care International.
- Professor David Peiris. David is Director of the Global Primary Health Care Program (Better Care) at the George Institute for Global Health. He also works clinically as a GP in Sydney.
- Dr Mamsallah Faal Omisore. Mamsallah is a Senior Clinical Advisor at Primary Care International. She is also Faculty for the Healthcare Leadership Academy in Lagos, Nigeria, and is a family physician practising in both the UK and Nigeria.