Non-communicable diseases (NCDs), a leading cause of global morbidity and mortality,
are key challenges to achieving the 2030 Sustainable Development Goals. Looking at
trends over the years, the surge in NCDs is anticipated to continue, with the greatest
impact on the poor and marginalized groups, mainly from low- and middle-income countries
(LMICs) [1]. During the COVID-19 pandemic, people with one or more underlying NCDs
were particularly vulnerable given the increased risk of severe disease and death
[2]. Despite being vulnerable, people living with NCDs (PLWNCDs) faced challenges
meeting their health care needs, attributed to the preventive measures against COVID-19
such as physical distancing and nationwide lockdowns and restrictions, which further
exacerbated their physical and mental health outcomes [1]. COVID-19 disrupted the
regular health services as the demand for acute care surged and strained the already
weak public health system of many countries, especially in those hardest-hit by COVID-19,
such as India, Nepal, Bangladesh, Brazil, Iran, and some other LMICs, stretching them
beyond their capacity. In fact, the pandemic in some LMICs contributed to a near collapse
of health service delivery [1]. Given their increased vulnerability to COVID-19, although
PLWNCDs required greater support and care to manage their conditions than ever before,
overwhelmed health care systems failed to meet their needs.
Recalling the old truism constructed by Winston Churchill, “one should never let a
crisis go to waste,” there is an opportunity to learn from COVID-19, specifically
with regards to the prevention and control of NCDs. In this paper, we first highlight
the challenges faced by PLWNCDs during the COVID-19 pandemic, then discuss how primary
health care (PHC) can act as a critical foundation for strategies to meet the health
needs of the PLWNCDs during current and future outbreaks and emergencies.
Photo: Peripheral health system of Nepal captured by Uday N Yadav in 2019 (used with
permission).
CHALLENGES FACED BY PEOPLE WITH NCDS IN THE COVID-19 PANDEMIC
As NCDs and COVID-19 are highly correlated, they cannot be addressed in siloes. Further,
during outbreaks, health systems have dual responsibilities to respond to acute system
demand as well as continuing to provide essential health services. However, a rapid
assessment by the World Health Organization (WHO) on the impact of COVID-19 on NCD
resources and services revealed a considerable disruption to NCD services in many
LMICs due of a lack of budget allocation for NCDs by governments or relocation of
funds from NCDs to COVID-19 management [3]. Additionally, LMICs were much less likely
than high-income countries to include NCDs in their COVID-19 response plans [4].
Despite the importance of prevention and control of NCDs during the pandemic [5],
preventive measures such as lockdowns have made health care almost inaccessible [6].
Public transport, the main means of transport for low-socioeconomic groups, ceased
in many LMICs such as Nepal, India, Bangladesh during the COVID-19 pandemic. As private
transport is accessible only to the wealthier groups in many of these countries [7,8],
these restrictions disrupted visits to health facilities and/or seeking health care
for acute care and essential services related to NCDs. Several studies from LMICs
also revealed severe disruption of health services for PLWNCDs, and consequently,
the need for alternative delivery methods to face-to-face consultations [9-11]. Moreover,
fear of contracting COVID-19 while seeking treatment also jeopardized their access
to care [12].
Emerging evidence from LMICs also shows that PLWNCDs, particularly from marginalized
populations, experience myriad challenges in accessing health services, and procuring
medication for pre-existing conditions, missed follow-up visits, and experienced worsening
of their pre-existing conditions [4]. The lockdown measures also aggravated risk factors
for NCDs such as a sedentary lifestyle, unhealthy diet/less access to nutritional
foods as well as increased smoking, alcohol and tobacco use [1,11].
PRIMARY HEALTH CARE AND ITS ROLE IN PREVENTION AND CONTROL OF NCDS IN LMICS
Recognizing the global burden and impact of NCDs on individuals and societies, WHO
developed the Global Strategy for Prevention and Control of NCDs (2013-2020) and Package
of Essential Noncommunicable (PEN) Disease Interventions for integration and management
of NCDs into PHC in low-resource settings, which has been endorsed by 193 member states
[13]. In any public health emergency, PHC can play a crucial role in addressing the
emergency-introduced local public health needs within the limit of available resources.
However, a survey conducted by WHO reported that NCDs were not prioritized in the
COVID-19 response plans of many LMICs [3]. In the current pandemic, many health leaders
and policymakers of LMICs have failed to consider PHC as an essential part of the
COVID-19 response, which created constraints on secondary and tertiary health facilities.
Despite the need to establish a strong PHC at the community/population level, LMICs,
often with the assistance of donor nations/organizations, have focused on establishing
teaching hospitals, medical and nursing schools, and disease-specific vertical programs
[14,15]. LMICs do have the concept of strong PHC incorporated in their plans and policies.
However, in reality, their PHC services are not in a position to deliver comprehensive
health care services. Often a major portion of the budget is invested in secondary
and tertiary hospitals and there is a lack of linkage between the overall health plan
and its actual implementation in LMICs. Tertiary-level health services are expensive
and concentrated in urban areas, making access to comprehensive health care challenging
for rural populations.
WAYS FORWARD
During and beyond the pandemic, continuity of comprehensive care for PLWNCDs can be
delivered through a strong PHC system by engaging community health workers in promoting
self-management of NCDs, expanding digital innovation at the PHC level, and introducing
policies, advocacy, and research to broaden the scope and our knowledge of NCDs management
through PHC.
Figure 1
demonstrates the essential components/elements of PHC required for required for addressing
health needs of PLWNCDs during pandemic and beyond.
Figure 1
Comprehensive care framework for people with noncommunicable diseases using primary
health care (PHC) approach. White circle: Pillars of PHC. Purple circle: Elements
of PHC. Green circle: Benefits of comprehensive preventive and promotive health care
services for people with non-communicable disease.
Revitalization of PHC
Strong PHC systems are essential to maintaining essential health care services in
communities, but the workforce shortages and absenteeism have hindered the provision
of care through PHC. Specifically, in LMICs, the availability of a health workforce
at the PHC level is substantially below the level recommended by WHO [16]. Mixed interventions,
such as free or subsidized educational and training opportunities for students from
rural, indigenous tribes and marginalized communities, providing incentives to health
care staff to move to rural areas of shortage, and re-locating staffs in their own
local bodies or province have been adopted by various countries to address the issues
of health workforce shortage [17,18]. During COVID-19 pandemic, PHC has been mobilized
in LMICs for continuity of care for PLWNCDs by re-organizing service delivery for
better access (eg, expanding home-based care and provision of virtual counseling),
operating NCD clinics [12], involving community health workers in delivery of medicines,
extending the operation of pharmacies and PHC to 24 hours to maintain essential services
and operating teleconsultation services [19,20]. In Thailand, access to medicines
for PLWNCDs was maintained through village health volunteers or postal services (17).
Drawing upon these leanings, it is vital to involve PHC in emergency preparedness
and developing strategies to provide health services to vulnerable people like PLWNCDS.
The pandemic had demonstrated that clear lines of responsibility should be given to
PHC for ensuring continuity of care for vulnerable groups such as PLWNCDs.
Self-management support and engagement of community health workers
As treatment of NCDs can be expensive, it may pose major economic challenges to health
care systems in many LMICs. Hence, comprehensive self-management that can reduce health
care expenses [21], should be prioritized and expanded in LMICs. Community health
workers (CHWs) are a well-established, effective, and relatively inexpensive human
health resource in many LMICs for delivering self-management support for chronic disease
patients [22]. CHW’s involvement in PHC delivery saves time and financial cost without
compromising the quality of care or health outcomes for patients [23]. In this context,
CHWs can be trained to empower and engage PLWNCDs to prevent and manage NCDs in LMICs
during the COVID-19 pandemic and beyond.
Opportunity for digital innovation at the level of PHC
Although telemedicine existed pre-pandemic, it received significant attention in the
COVID-19 era as an effective alternative for health service delivery when face-to-face
consultations are not feasible [24]. Some LMICs such as Egypt, Pakistan, India, Philippines,
Sri Lanka, China etc. have leveraged telemedicine to deliver health care services
for people with NCDs during COVID-19 pandemic. For example, the “e-sanjeevani” initiative
by the Government of India has been used to monitor symptoms and provide advice on
self-care for PLWNCDs [19,25]. The COVID-19 pandemic is a wake-up call for policy
makers of LMICs to frame regulations and standards to support the adoption of telemedicine
to help and alleviate the pressure on health care systems during and beyond the pandemic.
Policy, advocacy, and research
In general, and specifically during this pandemic, emergency management policies were
often centered on hospitals rather than PHC. This highlights the need to incorporate
PHC in all policies, strategies, and services developed to manage emergencies. During
the current and future pandemics, PHC could be leveraged as a critical foundation
and the first line of defense for direct surveillance and management of outbreaks
through community testing, contact tracing, outbreak communication, isolation, and
other public health and social measures that have been crucial in slowing down disease
transmission as well as a service delivery mechanism for the vulnerable population
such as PLWNCDS. Policymakers and health care leaders also need to prioritize investment
in human health resources in PHC as well as the essential diagnostic and medical supplies
required for PHC to deliver comprehensive PHC services.
Researchers working in LMICs have the opportunity to undertake studies on: (i) documenting
their experience of implementing PEN package at PHC during the pandemic (ii) design
and evaluate the acceptability and effectiveness of digital health technologies in
the management of NCDs within PHC, and (ii) design and test models of care with PHC
at the frontline of holistic care for PLWNCDs.
CONCLUSION
The COVID-19 pandemic has impacted the lives of all, including PLWNCDs. The public
health actions implemented by the governments of LMICs during the COVID-19 pandemic
have been largely directed towards strengthening secondary and tertiary care and containment
strategies for COVID-19 while continuity of care for PLWNCDs did not receive enough
attention. PHC could be strengthened to blunt the impact of the current and future
pandemics and emergencies on public health by providing continuity of care and essential
health services to vulnerable and disadvantage groups. Some ideas to strengthen PHC
includes delivering comprehensive preventive and treatment services linked to other
levels of care, innovating PHC delivery through the use of digital technology, mobilization
of CHWs to provide to localized health care both during the COVID-19 pandemic and
beyond.