Maintaining Essential Health Services During COVID-19 in Low Resource, Non-U.S. Settings

1. Background and Purpose

Globally, health systems have been challenged by the overwhelming demands of the COVID-19 pandemic. Resources and staff are being diverted to test and provide treatment for people with presumed or diagnosed COVID-19, and supplies are limited. Some healthcare services are being compromised in order to meet the demands of caring for COVID-19 patients, and many people fear accessing healthcare facilities due to fear of acquiring the virus.  These fears may be worsened by misinformation.¹ During the Ebola outbreak in West Africa in 2014–2015, increased morbidity and mortality in other diseases (e.g., measles, malaria, HIV/AIDS, and TB) were seen due to reduction in access to and utilization of healthcare services, and deaths from these diseases outnumbered deaths from Ebola.² It is important to ensure continuity of essential health services in order to prevent illness and death from non-COVID-19 illnesses.  This will likely require adaptations to service delivery models and settings.^3,4 In addition, infection prevention and control measures to reduce the risk of exposure to COVID-19 among patients and healthcare workers (HCW) should be integrated into all healthcare settings.⁵

The purpose of this document is to provide ministries of health, public health authorities, and implementing partners with a framework for implementing strategies to reduce preventable illness and death during the COVID-19 pandemic in persons with non-COVID-19 illness and injury, particularly in low-resource settings.

2. Activities to mitigate the impact of COVID-19 on health services

National and sub-national public health authorities play a critical role in determining how to mitigate the impact of COVID-19 on persons needing essential non-COVID-19 services in a variety of healthcare settings. Specific areas of focus for national and sub-national authorities could include:

• Prioritizing locations for targeted interventions to reduce the impact of COVID-19 on other diseases. This could be based on COVID-19 prevalence, as well as burden of non-COVID-19 diseases or the need for services (i.e. immunization services), and population size.
• Developing targeted communications and educational materials for use in all healthcare settings on:
  • COVID-19 symptoms, prevention, and transmission among patients and healthcare workers
  • Infection prevention and control (IPC) for both healthcare workers and patients
• Developing methods to facilitate access to facility and community-based healthcare services by service providers, patients, and their supporters during periods of movement restriction.
• Maintaining adequate supplies and commodities to provide services and reduce risk of exposure of patients and HCWs to COVID-19 at all service delivery points:
  • Ensuring adequate supply and use of personal protective equipment (PPE), hand hygiene supplies (soap and water or hand sanitizer with at least 60% alcohol), as well as cleaning and disinfecting supplies.
  • Forecasting and ordering for multi-month dispensing of medications (e.g., 3- or 6-month dispensing) for chronically ill patients who are stable to reduce length of time between clinic contacts. Use telehealth to monitor and support patients between in-person visits.
  • Establishing, staffing, and supplying community isolation centers for mild-to-moderately ill COVID-19 patients to isolate and recover.
  • Planning for and purchasing supplies needed to move essential non-COVID-19 services into makeshift clinics in areas most heavily affected by COVID-19. Coordinating with IPC focal persons for IPC considerations and requirements in such settings.

• Ensuring monitoring plans track service delivery occurring outside of healthcare facilities in order to track retention in health programs, including those for chronic disease, antenatal care (ANC), and immunization services.

3. Modification of service delivery to maintain essential non-COVID-19 services

Modify Service Access

• Determine which essential services will continue and which need to be paused or referred to another clinic due to burden of COVID-19 patients.
• Screen patients for symptoms of or exposure to COVID-19 before they get to the health facility; consider using telehealth platforms to screen patients before they come to the health facility and to make referrals, if needed.
• Triage and test patients for COVID-19, including, where possible, touchless temperature checks.
• Ensure hand hygiene (all people entering and exiting facility should wash hands with soap and water or use hand sanitizer with 60% alcohol), appropriate use of PPE, and regular cleaning and disinfection, especially of frequently touched surfaces and shared objects.
• Ensure use of a medical mask for all patients with respiratory symptoms or other symptoms suggestive of COVID-19 and encourage the use of masks for other patients.⁵

Modify Clinic Space:

• Separate patients by maintaining at least a distance of about 2 arm lengths (about 2 meters) when possible (e.g., move waiting areas outside) and limiting the number of people in the facility at a time, especially in small spaces such as pharmacies and hallway waiting areas.
• Consider altering and repurposing clinic space or designating certain facilities for COVID-19 care while others are designated for essential non-COVID-19 services.
• Modify underused spaces in facilities that have access to improved water sources (water supplied through a household connection, public standpipe, borehole well, protected dug well, protected spring, or rainwater collection) and good ventilation (e.g., operates properly and increases circulation of outdoor air as much as possible) for use as isolation areas for presumptive or positive COVID-19 patients.
• Ensure separate spaces that allow for physical distancing are available for assessment of acutely ill persons and delivery of essential non-COVID-19 services.

Modify Service Delivery:

• Minimize patient contacts with HCW and other patients to reduce risk of exposure or infection:
  • Lengthen time between appointments for stable, healthy patients.
  • Use telemedicine visits (either video, phone calls, SMS (short message service)) for screening, follow-up, and refilling prescriptions.
  • Implement 3- or 6-month dispensing of medication for healthy, stable patients.
• Provide staggered appointments to reduce the number of people in waiting areas and implement and enforce an appointment scheduling system to decongest clinics.
• Provide fast-track services for acute and chronic patients to reduce contact with multiple providers (e.g., charts pulled, medications ready, patient only sees provider if needed, one provider sees patient through all services).
• Limit number of visitors who may accompany patient to clinic or community-based services.
• Relocate services—each community and healthcare facility will need to determine which of the following options best fits their circumstances and available resources.^3,4,7 Decisions may vary based on the number of COVID-19 cases in the community.
  • Health facilities with few presumptive or positive COVID-19 patients may designate an area within the facility where COVID-19 patients can be isolated.
  • In sites where there is a higher burden of COVID-19 cases, the facility may consider:
    • Moving essential non-COVID-19 services outside of the facility into community spaces, (e.g., a vacant school, church, or community center) to reduce risk of exposure at facilities, ensure these patients remain in care and on treatment as some may fear getting sick if they return to the clinic, and reduce crowding at clinics so they are better able to care for COVID-19 patients.
    • Moving services for COVID-19 patients with mild or moderate symptoms to community isolation centers to maintain space in facilities for essential non-COVID-19 services.
  • Promoting home-based care for COVID-19 patients with mild or moderate symptoms who can safely isolate at home.
• Offer multiple “no-contact” drug pick-up options for patients with chronic illnesses:
  • Scheduled medicine pick-up at community or clinic pharmacies, or community pick-up points (e.g. houses of worship or schools). Consider adaptations to minimize in-person contact and exposure risk. Alternative modes of communication may include telemedicine calls, SMS, or social media.
  • Implement 3- or 6-month dispensing of medication for healthy, stable patients.
• Maintain routine contact with stable patients. Provide more frequent contact to new patients and patients at risk for loss to follow-up.
• Shift and share tasks as needed:
  • Re-assign staff from less busy services to assist with essential services.
  • Work with the Ministry of Health (MOH) and local HCW societies to determine how task shifting can best be used to provide essential services.
• Ensure HCWs are appropriately trained in provision of care for patients with COVID-19, and that clear guidance/ operating procedures exist for training on transmission of COVID-19, donning and doffing personal protective equipment, etc.

Links to Disease Specific Recommendations:

• Maternal, Newborn and Child Care
• Immunizations
• Malaria pdf icon[374 KB, 4 pages]
• HIV pdf icon[366 KB, 3 pages]
• Tuberculosis

Additional Resources:

https://www.jhpiego.org/wp-content/uploads/2020/06/Jhpiego-Operational-Guidance-for-Continuity-of-Essential-Services-Final.pdf pdf icon[1.57 MB, 37 pages]external icon

References:

1. WHO. Maintaining essential health services: operational guidance for the COVID-19 context, 1 June 2020. Geneva: World Health Organization. (https://www.who.int/publications/i/item/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreakexternal icon, accessed June 4, 2020).
2. Elston, JWT, et al. (2017). The health impact of the 2014-2015 Ebola outbreak. Public Health; 143; 2020: 60-70.
3. WHO. Operational considerations for case management of COVID-19 in health facility and community: interim guidance, 19 March 2020. Geneva: World Health Organization. (https://www.who.int/publications-detail/operational-considerations-for-case-management-of-covid-19-in-health-facility-and-communityexternal icon, accessed May 13, 2020).
4. WHO. Infection prevention and control during health care when novel corona virus is suspected, 19 March 2020. Geneva: World Health Organization. (https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125external icon, accessed May 13, 2020).
5. Operational Considerations for Infection Prevention and Control in Outpatient Facilities: non-U.S. Healthcare Settings.
6. WHO. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance, 5 May 2020. Geneva: World Health Organization. (https://www.who.int/publications-detail/community-based-health-care-including-outreach-and-campaigns-in-the-context-of-the-covid-19-pandemicexternal icon, accessed May 13, 2020).
7. Severe acute respiratory infections treatment: practical manual to set up and manage a SARI treatment centre and a SARI screening facility in health care facilities. 28 March 2020. Geneva: World Health Organization. (https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centreexternal icon, accessed May 13, 2020).