Integrating public health and primary care: the response of six Asia–Pacific countries to the COVID-19 pandemic

CHARACTERISTICS OF PRIMARY CARE IN THE SIX COUNTRIES BEFORE COVID-19

Key characteristics of PHC in the six countries are outlined in Table 1. Gatekeeping was well established in NZ, Macao, Thailand, and Fiji. In Thailand and Macao, this was largely through the public sector, whereas private GP clinics generally provided this role in NZ and Fiji. In all countries, governments funded PH, but there were different funding arrangements for PC services that range from out-of-pocket through blended to government-funded models. PC services were largely delivered by interdisciplinary teams in coordination with other community-based providers in Thailand, Macao, NZ, Philippines, and Fiji. In Japan, care managers were responsible for coordinating social services for long-term care; however, there was little coordination between them and community-based doctors.

REORGANISATION OF PRIMARY HEALTH CARE DURING THE COVID-19 PANDEMIC

Table 2 outlines the various responses to COVID-19 in the six countries. In NZ, GPs and practice nurses have been staffing COVID-19 community-based testing clinics as well as separating their practice for patients with respiratory symptoms and those with regular consultation teams. In Thailand, as well as rearranging their practices, PC teams had village health volunteers (VHVs) implementing community surveillance and preventive measures. Macao benefited from experience with the SARS epidemic in instigating fever clinics, physically isolated from other parts of community health centres, contributing to a timely response. In NZ, Philippines, and Thailand, PC and PH professionals worked together at the borders to provide care at community and state quarantine facilities.

In Japan and the Philippines, where there was no gatekeeping, hospitals that accepted suspected COVID-19 patients had to deal with everything from PC to secondary and tertiary care, saturating finite resources. Similarly, in Fiji, PH facilities were challenged with greater workload, necessitating collaboration between public and private sectors. In the Philippines the situation has helped the government focus on strategies for PH and community interventions against the spread of infection, with the development of health professional alliances urging the government to establish COVID-19 referral networks to enable people to access diagnostic centres, clinics, and hospitals according to their need.

In some countries the private sector has significantly contributed to PH measures. In the Philippines, the private sector has supported implementation of the plans in the provision of mass testing, setting up of community quarantine sites, and procurement of personal protective equipment (PPE). Private PC providers in Fiji procure their own PPE without government support. In Thailand, other sectors have stepped in to assist, such as engineering providing construction of negative pressure testing booths, as well as offering amenities for community quarantine.

Most of the countries have used telehealth to help mitigate risk of COVID-19 infection. In the Philippines, the Academy of Family Physicians collaborated with the government in supporting free PC telemedicine consults. In Fiji, with the shortage of PPE and need to maintain routine care, GP private practices largely moved to telemedicine. However, digital information systems were not fully operated in the public sector, hence the health information linkage remained fragmented. Private clinics have found challenges in getting patient payments for telehealth services. In NZ and Thailand, the use of telecommunication during the pandemic has highlighted disparities and inequities through the lack of Information technologies (IT) literacy or lack of internet access.

None of the six countries had large first waves that overwhelmed their health systems. NZ and Macao managed to eliminate COVID-19. NZ had occasional small community outbreaks that were soon under control. However, the other countries have had further waves. Fiji and the Philippines are having a second surge with the emergence of COVID-19 variants, the third wave is on the rise in Thailand, and the fourth in Japan.¹⁶

The countries report different degrees of involvement and coordination of PC and PH. In NZ and Thailand, there is generally a collaborative approach with both dedicated community-based centres and general practices delivering testing and now vaccination, whereas, in Thailand, the government’s involvement of private PC needs to be improved, and in Japan there has been poor coordination, with family doctors needing to ask the local PH centre to test, impeding prompt triage and referral.

All countries have introduced vaccination programmes, with vaccines generally free to all. In Macao, families of workers on visas pay a subsided fee with all other residents free. In NZ, Thailand, and Fiji, the vaccination target is 100% of the adult population by the end of 2021. The Philippines hopes to vaccinate two-thirds of the population by the end of this year. Macao aims to vaccinate 100% of adults and Japan 100% of those aged ≥65 by the end of July. All countries have a mixture of vaccination sites with dedicated centres. In NZ, vaccination is community based in dedicated centres and general practices. In all the other countries there are also hospital-based vaccination programmes.

LESSONS LEARNT

In NZ, closing borders early and sharp lockdown eliminated community spread. Good science and strong leadership working together engendered trust in the measures applied. In Fiji, lack of public support for restrictions is making the second wave hard to get under control. In Thailand, the whole society recognised the urgency for collaboration, hence contributed to preventive and control measures. The private and public sectors and the community stepped up for a coordinated response. There has been a similar PPP in the Philippines, although the involvement of PC was lacking. Poor PC and PH coordination in Japan is hindering effective detection and early management.