The webinar on Universal Health Coverage (UHC) and the Coronavirus Crisis – Challenges and Responses: maintaining essential health services while responding to COVID-19 held on May 12th, 2020 was the 10th event in the webinar series on Social protection responses to COVID-19. It was co-organized by the United Nations Children’s Fund (UNICEF), the Pan American Health Organization / World Health Organization (PAHO/WHO) and the International Policy Centre for Inclusive Growth (IPC-IG), in collaboration with GIZ, on behalf of the German Federal Ministry of Economic Development and Cooperation (BMZ), and the Australia Government’s Department of Foreign Affairs and Trade (DFAT).
With emerging examples around the world of governments responding and continuously adapting their measures to ease the impacts of the COVID-19 pandemic, the aim of the webinar was to contribute to the global exchange of experiences to increase the understanding of challenges and solutions, improve the effectiveness of cross-disciplinary responses, and promote country-to-country learning and cooperation amongst countries, including through South-South and triangular cooperation.
The event was moderated by Dr. James Fitzgerald, Director of Health Systems and Services, PAHO/WHO, and featured presentations from:
- Dr. Choe Young June, MD, PhD, Department of Social and Preventive Medicine, University College of Medicine, Republic of Korea
- Dr. Robin Nandy, Principal Advisor & Chief of Immunizations, UNICEF
- Dr. Yu Wenzhou, National Immunization Center of China, Center for Disease Control, People’s Republic of China
After welcoming the participants, introducing the panellists and outlining the structure of the webinar, Dr. James Fitzgerald gave an overview of the current COVID-19 context, and its implications in the maintenance of essential health services. Dr. Fitzgerald recalled that the disease has resulted in enormous loss of life and livelihoods throughout the world, thus impacting our health and our economies. He highlighted the enormous impact on the first level of care, particularly the high levels of transmission amongst health workers, and the resources being taken from the first level of care and being assigned to the secondary, tertiary level of care, or even within specialized hospitals.
As a result, Dr. James Fitzgerald noted the interdependency between health, social protection and economic development, pointing to the need of resilient health systems that have the capacity to respond to surges and address essential health services at the same time. When referring to the provision of essential health services, he stressed the false dichotomy between the response to COVID-19 and the provision of essential health services throughout the health care network, not only the first level of care. He underlined various alternatives to deliver essential services through the first level of care, such as telehealth, teleconsulting, mobile clinics and other innovative mechanisms such as community health workers.
The capacity of health systems to respond to COVID-19 and at the same time deliver essential health services: The Experience of South Korea
Dr. Choe Young June shared some experiences from South Korea in regard to the response to COVID-19 from the perspective of universal health coverage. With respect to the current situation in the country, South Korea seems to have flattened the curve in the period of late March to April, and discussions have been ongoing for reopening, but unfortunately, these have been postponed as cases have surged in the past few days. Dr. Choe Young June explained the structure of the health system in South Korea, noting the existence of a national health insurance service as a unique single payer social insurance system that covers, 100% of the population in Korea (see slide below). He also noted that the private providers are major suppliers and that the public sector is less than 10%, therefore the default payment system is based on service basis fees. In detailing the UHC approach in Korea, Dr. Choe Young June showcased how the government opted to include the community-wide social health insurance, together with the government-issued social insurance, to form a comprehensive national health insurance service. He also underlined the fact that the system is not only universal, but it strives to ensure access to the population.
In terms of the response to COVID-19, Dr. Choe Young June detailed the South Korea experience in testing and rapid introduction of the PCR kits, which has been expanded throughout the country in a very rapid manner. The national health insurance has allowed for free testing if there is an epidemiological link or suspicion of COVID-19. Similarly, he showed the increase in hospital beds in the country for the past 15 years and the availability of isolation units in health facilities (See slide below).
Dr. Choe Young June further outlined the role of the National Health Insurance in the response to COVID-19 and explained that policies were put in place to cushion the financial impact on vulnerable populations and in geographical hotspots. Additionally, the Government extended this policy to the foreigners residing in Korea.
A few challenges were also discussed, particularly the bottleneck in the triage system and the diversion of the role of community health centers to the response to COVID-19. These challenges also resulted in halting immunization services (adult pneumococcal vaccines), routine NCD treatment, among others.
Finally, it was recognized that the Korean UHC model provided a robust response to COVID-19 in terms of efficiency and equity, particularly through testing and treatment. Public-private partnerships were also highlighted as successful endeavors in facing these challenges.
Delivering essential health services including immunization during COVID-19 and links to health system capacities and Universal Health Coverage
Dr. Robin Nandy, approached the subject from a broader global perspective and focused on one particular aspect of essential services within the primary health care universe universal health care package: immunization. The presentation started by outlining the status of immunization prior to the pandemic, noting that the global immunization coverage in DTP3 remained in the mid-80s, remaining stagnated over the last decade and highlighting that prior to COVID-19 approximately 20 million children were under or unvaccinated, with more than 13 millions of children lacking access to vaccine services (see slide below). He stressed that within the global immunization partnership, the emphasis has been on addressing these inequities, reaching the proverbial fifth child in the most underserved communities.
UNICEF, along with the Bill and Melinda Gates Foundation, chair the Equity Reference Group for Immunization and serves as a think tank to drill down on various immunization related issues. The data shows that most of the so-called “zero-dose children” have not received any vaccines, and very likely don't receive any other health services either. This is compounded by their living situations: remote rural areas, urban slums and areas in chronic conflict. So, as the challenge of the COVID-19 pandemic continues, it exacerbates these inequities, and it impacts service delivery and other essential health services.
Dr. Robin Nandy, explained how WHO and UNICEF, along other global partners, have developed guidance to address immunization services in the context of COVID-19, reaffirming immunization as an integral part of primary health care and therefore universal healthcare as well. The guidance notes that there might be constraints, and also adjusts delivery modalities, so as to ensure the prevention of the further spread of COVID-19 while delivering immunization services, hence the guidance also recommends temporarily suspending the campaign-style delivery of vaccines. A key aspect of the guidance is continuing immunization surveillance and more importantly to monitor the disruption of services.
In an attempt to collect data on the impact of immunization services, a survey was conducted as a joint effort between the World Health Organization, GAVI and the Sabin Institute, along with UNICEF, collecting data from 800 respondents from various parts of the world. Dr. Robin Nandy recounted that 74 countries across different regions of the world, have reported some sort of disruption in immunization services, but cautioned that even those countries that are not reporting disruptions in service delivery, are unable to get people to these services because of lockdowns and physical distancing measures. This is compounded by fear of coming in contact with COVID-19 infections at health facilities, which is reflected by the qualitative aspects of the survey which reveals that parents are not taking the children to be vaccinated. UNICEF is also coordinating modeling scenarios on the impacts with key collaborators (School of Tropical Medicine, Penn State University Institute).
The challenge of supplies and supply chains was also addressed, as there has been a huge disruption with commercial flights particularly on the African continent, which in turn has hindered UNICEF’s ability to move supplies and vaccines to countries, resulting in a reduction down to a fifth of what normally would be expected for this period. In this context, it is really important to engage suppliers and prioritize shipments, to ensure they go to the right places to avoid vaccine stock-outs.
In terms of next steps, Dr. Robin Nandy reassured collaboration with partners in the Coordination Group, and to continue tracking the impacts on the immunization programs, to the likings of the essential obstetric care and neonatal childcare programs. Support and guidance will continue to be provided with case by case adaptations due to contextual and risk factors of the country. The relevance of events such as these webinars was highlighted as platforms for the exchange of good practices and knowledge dissemination. He reiterated the message to countries to initiate planning, ensure supply availability and resources for an early resumption of immunization services to catch up missed doses, avoiding an outbreak of vaccine preventable diseases. He stressed the importance of immunization services, in a post COVID-19 context, where countries are going to have less disposable resources, and are looking for efficiencies.
The capacity of health systems to respond to COVID-19 and at the same time deliver essential health services: The Experience of China
Dr. Yu Wenzhou, introduced the Chinese experience on the impacts in immunization services due to the pandemic and the strategies during the epidemic. He noted that, with regards to COVID-19, the majority of cases are in Eastern and Central China. Compared with December 2019, the doses vaccinated in January accounted for 70%, in February they accounted for only 26% (see slide below). In March, most provinces restarted vaccination services, so the doses number almost recovered to normal levels. In China, Hepatitis B and tuberculosis are the priorities of infectious diseases to be controlled, thus the need to provide the vaccine as early as possible. Rabies vaccine and tetanus toxoid, were also prioritized. The government also conducted a risk assessment, were: (i) low-risk areas would conduct routine immunization services at the vaccination clinic; (ii) middle risk areas delivered vaccination services with caution, and; (iii) in high-risk areas the EPI clinics stopped the vaccination services.
It is estimated that 59.8 million vaccination doses have been delayed or missed due to the epidemic from January 22 to April 8, 2020. As a result, the government is starting a catch-up to be completed in the next 2 months. The strategy to achieve is this is three-fold: (i) sorting out vaccination status through Immunization Information System (IIS) with children accurately located; (ii) By mobilizing community staff and vaccination doctors to find unvaccinated children through house visits; (iii) By telephoning parents or WeChat to check vaccination status.
Dr. Yu Wenzhou, commented on the progress of the catch-up vaccination efforts, and outlined that overall the progress is at 69%, with the Hubei province being the most affected by COVID-19 at 45% as of 12 May. Finally, he summarized his intervention by recalling that 80% clinics suspended vaccination services for a 1-2 months period during the epidemic, and that all clinics were asked to provide service for the first dose of hepatitis B vaccine and BCG, as well as rabies vaccine and tetanus toxoid. Additionally, all counties were asked to conduct risk assessments before providing immunization service and had to balance catch-up vaccination and routine immunization services. In China, strong immunization system helped to ensure that despite the pandemic, a catch-up vaccination campaign and routine immunization service could be managed.
The panellists also addressed some specific questions:
Q1: With resources being limited for COVID-19 in the developing world, what are we putting in place to ensure delivery of primary health services without more exposure to COVID 19? How do we restore trust with communities during and post COVID-19?
Dr. Choe Young June, mentioned that vaccination coverages had dropped both in child and elderly immunizations, and outlined the challenges to maintain services during the pandemic. He highlighted successful public-private partnerships as well.
Dr. Yu Wenzhou, highlighted the importance of community health workers and their role not only in controlling the epidemic, but also in the delivery of essential health services.
Dr. Robin Nandy, recalled the complexity of the situation, and the need for the guidance to issue guidance in a pragmatic way, taking into consideration the current context. Hence the guidance seeks to balance the trade-offs, with the possibility to review and adapt based on risk assessment. He called for unity among the various initiatives in order to build back better with a comprehensive package of services.
Q2: In terms of the lessons that we are learning from this in relation to our health systems response capacity, how do we use this experience to ensure that health systems move towards universal health coverage in the future?
Dr. Choe Young June, recalled the reform process in Korea over the last 15 years, and the transition to a single payer system. He also highlighted some of the challenges, like the elevated levels out-of-pocket expenditure, as well as the disproportionate impact on the economically vulnerable population. The complementarity of the public and the private system was also addressed.
Dr. Yu Wenzhou, made reference to the lessons learned of the SARS outbreak, and noted the need to regain the public trust in the health system. The need for more resources for the health system was also underlined.
Dr. Robin Nandy, pointed out the impact in vulnerable population and the need to identify health coverage gaps, that could be abridged by complimentary sectors like health and social protection. The importance of primary health care for this and future pandemics was also stressed, as well as the challenges that the PHC strategy faces.
As part of the concluding remarks Dr. James Fitzgerald thanked the panelists for their valuable contributions and summarized the following takeaway points from the interventions:
- health systems need to be able to respond to the pandemic, and reconfigure/reorganize so as to be able to ensure the provision of all essential health services;
- it's not just an issue of coverage, ensuring the inputs necessary for health systems, it's really about breaking down the access barriers to health and removing issues associated with financial, geographical, cultural barriers, so that we reach all the populations that we need to reach in terms of essential health services;
- primary health care is an important strategy, that should have a strong resolutive capacity at the first level of care that meets the needs of populations;
- health financing, in a sustained global financial recession, needs to be protected and increased, otherwise, we would have not learned the lesson from this pandemic.
UNICEF (2020): Coronavirus (COVID-19) Global Response
WHO (2020): COVID-19: Operational guidance for maintaining essential health services during and outbreak
WHO and UNICEF (2020): FAQ: Immunization in the context of COVID-19 pandemic
WHO, UNICEF and IFRC (2020): Community based health care including outreach and campaigns in the context of the COVID 19 pandemic
This blog post is part of the Social protection responses to COVID-19 webinar series. The series is a joint effort initiated by the IPC-IG, GIZ on behalf of the German Federal Ministry of Economic Development and Cooperation (BMZ), and the Australia Government's Department of Foreign Affairs and Trade (DFAT) collaboration with the socialprotection.org platform, and in cooperation with partners from different organisations. Join our online community ''Social protection responses to COVID-10 [Task force]" to learn more about the initiative and future webinars.