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Adjusting Primary Health Care to respond to COVID-19: Lessons from Colombia

As the world faces the COVID-19 pandemic and health care systems are strained by its effects, countries continue to be responsible for ensuring access to routine, high quality health care services. We have seen how disease outbreaks can disrupt traditional health care delivery models, leaving the most vulnerable populations without access to essential health services. How can we adapt our health care delivery models to ensure access to care during COVID-19 and beyond?  
Over the last 25 years, Colombia has invested steadily in the development of its health care system, currently covering over 96% of its legal residents with comprehensive health insurance. One of the strengths of the Colombian insurance system is that it entails having comprehensive lists of patients, including information on their age, underlying chronic conditions, and pregnancies (an empaneled population). The information available to the insurance system coupled with long-term investments in telecommunication infrastructure have been critical to our pandemic response efforts.
Since the first confirmed case of COVID-19 reached Colombia in early March of this year, the country has implemented an innovative service delivery model to improve access to primary health care services. The Colombian model makes extensive use of telecare and homecare to guarantee the continuity of services and protect the most vulnerable, while protecting patients, providers, and communities from possible transmission.
On March 28, the Ministry of Health and Social Protection passed a resolution that outlines how primary health care services must be delivered to people in preventive isolation. If a person seeks medical assistance for general or respiratory symptoms during the COVID-19 emergency, she/he will receive a telecare consultation, which includes self-care and safety guidance, the ability to order medications to the home, or referral to either homecare or hospital care, where appropriate. Patients who are referred to homecare are visited by a provider who can conduct laboratory tests, provide medications, or issue a referral to hospital care, if it is deemed necessary. These health care facilities are working to ensure that physicians and nurses are trained to employ a family approach and use telemedicine, meaning other family members in the home can also receive a consultation, regardless of symptom status. Training efforts have followed a multi-pronged approach where the facilities are the first responsible to ensure health workers have the knowledge to implement the new care model but receive the support of insurance companies, Departmental-level Ministries of Health and the National Ministry of Health through guidance and short courses that include the use of technologies, aspects of data confidentiality and adequate use of telemedicine tools for the delivery of care as per defined standards. This is critical because the treatment and prevention of COVID-19 requires the attention, care, and cooperation of more than just those who contract the illness – engaging families and offering support and guidance is a key component of combatting this pandemic.
It is important to highlight that the Colombian delivery model, defined in the resolution, aimed to make the best use of limited human resources by drawing on multidisciplinary teams with the appropriate skill-mix and allocation of roles and tasks. These teams are composed of general physicians, nurses, and technicians, where lower cadre health workers support in the provision of health care services.  This includes community health workers who are instrumental to increasing health care access, especially to hard-to-reach communities. The multidisciplinary teams must develop a basic customized health maintenance plan for the person and family unit, negotiated in agreement with them, which contains the basic health care activities to be performed over the time, according to the life course and identified risk factors. This tool helps ensure good follow up, delivering comprehensiveness and continuity of care.
Telecare and homecare are particularly beneficial for populations most at risk from COVID-19, such as older adults and people with chronic conditions or immunosuppression. Indeed, the model includes specific delivery processes for patients with pre-existing and chronic conditions at varying degrees of risk, as well as pregnant women; in essence, all patients who face a greater need for continuous access to essential and routing health services.
While the Colombian delivery model can be used for COVID-19 testing and treatment, it also supports access to general primary health care services to treat diabetes, hypertension, and mental health as examples. Past experiences showed us how access to basic health care services can be jeopardized by an epidemic, causing more deaths than the epidemic itself. During the Ebola outbreak in Sierra Leone, for example, antenatal care coverage, post-natal care, and facility delivery decreased by 22, 13, and 8 percentage points, respectively. This led to an estimated increase of 3,600 deaths, a higher toll than Ebola was directly responsible for. Developing innovative delivery mechanisms during epidemics is crucial to guaranteeing the provision of routine health care services.
The implementation of the above-mentioned service delivery model to improve access to primary health care services during the pandemic in Colombia is an ongoing and heterogeneous process. This implementation has faced a variety of challenges in the diverse regions of the country, particularly related to the current insurance model, and the differential access and models of care delivered by public and private health care providers. Nonetheless, we have identified three key takeaways that we believe are crucial considerations in times of health emergencies, and in the promotion of strong primary health care systems generally. First, there must be systems in place that protect the comprehensiveness and continuity of essential and routine health services during times of crisis. Second, robust telecare and homecare services are key components of a strong primary health care system, especially during pandemics. With telecare and homecare, we have been able to maintain patient access to key health services while mitigating the possibility of person-to-person transmission when accessing services. Finally, the health of the most vulnerable needs to be made a top priority. Both the development of ad hoc delivery processes in primary health care and the explicit prioritization of services are instruments that promote health system resiliency and protect the most vulnerable during emergencies. Improving (and adapting) primary health care is the smartest way to reduce health inequalities.
As countries study the Colombian example and look to draw lessons from it, it is important to note that the country’s delivery model was made possible by long-term, sustained investment in building primary health care infrastructure. Colombia’s past investments in telecommunication networks and equipment, and the focus on improving coordination between stakeholders in our health and social sectors during the current emergency, allowed the rapid deployment of an innovative delivery model that protects the country’s most vulnerable populations. Though future challenges remain for the continued adoption of this healthcare delivery model that relies on telecare and homecare, in the post-pandemic period, undoubtedly, efforts should continue to better position primary health care and its core strategies of outreach and team-based care, over the long term in the Colombian health system.  It is never too late to begin investing in the health systems—and people—that have made this response possible for Colombia.