Cambodia
Direct impact
Concerning the amount of visits for NCD care provided at PHC facilities during COVID-19, some practitioners stated that the quantity of NCD care decreased, where others mainly focussed on the fact that the provision of NCD care was already limited within PHC in Cambodia.
“Before COVID, we had a lot of patients. Now because of COVID, the number of patients declined.” (Practitioner)
“NCDs at public services are not very popular. So the reason that people didn’t come to health centres is not due to COVID, but before COVID they also didn’t come for NCDs.” (Macro-level stakeholder)
On the demand side, respondents noted that patients delayed health care seeking, the main reason being fear of contracting COVID-19 at the facility. In addition, the lockdown reduced access to care because people needed a proof of evidence of the healthcare visit. On the supply side, respondents noted a difference between the public and private sector facilities. In many places, the private sector frequently closed their doors (or shut down their services), whereas the public sector remained open. Respondents explained this by saying that the staff felt responsible towards keeping the public facilities open, as their duty to provide care for the population. The reasons for closure of private health facilities was explained by regulations, but also by the fear for COVID infection. Private providers are often located in cabinets (private consultation rooms without inpatient capacity) close to the physician’s residence, which means that by seeing patients, they would also expose their families to the risk.
“The truth is, we’re always scared, all the time, everywhere. But our private cabinet, we don’t want people coming in and out infecting our family. Here at the hospital, it’s our duty as a government servant. The government did not close offices during COVID. Doctors everywhere have to come to work if they’re in the public sector. It’s a must for every ministry. Especially in the health sector, we are like the soldier for this battle.” (PHC practitioner)
Even if the facilities remained open, staff was often reallocated from the facility to (outside) COVID-19-related services, such as treatment centres and vaccination campaigns. To continue services, some PHC practitioners started to use their phone to communicate with patients. Community health workers have a role in screening and in self-management support for people with chronic diseases in Cambodia. When COVID regulations prohibited visiting patients at home, some community-based health workers adopted their community-based approach and provided their support and care in the health centre. Some CHWs expanded their scope of work and included advise and support in COVID-19 prevention measures.
Respondents also mentioned other areas of impact, such as economic and political. COVID-19 reduces budget at all levels, from the government level (more expenses), the health care facilities (less patients) and at the household level (reduction of employment or labour), which led to austerity in the entire society. For patients, it meant postponement of expenditures on chronic care first, because of the less-urgent nature. The political impact was immense, in the sense that COVID-19-related issues usurped the attention from all other issues, which was visible in the time dedicated by politicians, but also trickled down in all other domains, for instance, in research.
Strengths of the health care system
Respondents recognised that the COVID-19 crisis revealed the strong sense of responsibility in staff as a strong asset of the public health facilities. Health care providers noted that they perceived the public to have trust in their services, when available, illustrated by the observation that people were willing to get vaccinated. Respondents assessed the public vaccination campaign as a big success, reaching high coverage across the entire country.
In catchment areas of MoPoTsyo, respondents also noted the value of a strong community-based support system through that non-government organisation, because they were able to maintain access to chronic care during the pandemic well compared to other areas.
“Before the existence of MoPoTsyo here, the diabetes patients had to travel so far to Phnom Penh to get treatment. Some people could not afford to travel that far so they avoided treatment. So with MoPoTsyo nearby, it helps a great deal. It's near their home and every month they only spend 10 000 or 20 000 riel. They do not have to spend on travelling far. Blood check is cheap, and medicine is also cheap. Even those who are not well off, they can get the care they need.” (PHC practitioner)
Weaknesses of the health care system
The main issue in Cambodia is the quality of NCD care in public health care facilities. Respondents mention the two major and interrelating factors being the lack of material and the competences of health care providers. Continuous medicine supply is the core constraint. PHC practitioners explained that they receive a very limited amount and range of medication and diagnostic materials such as test kits offered to deliver to patients. This was worse during the crisis.
“There are a lot of issues with the medication because we have not been supplied with enough medicines. Generally, the medicines we receive account for just about 30%. The other 70% are bought by us.” (PHC practitioner)
In the hospitals, the supply is often better, but these are further away for most patients. As a consequence, most people with NCDs prefer to visit private practitioners who are widespread, and more accessible than the public health care providers. The capacity of staff in public primary health care facilities is also limited. Health centre personnel - often nurses - have received little training, largely on screening and diagnosis, but less on the treatment and support related and chronic nature of these NCDs. The shift of patients to private facilities reduces the exposure of staff in the health centres to patients with NCD, and makes it difficult to develop and maintain NCD competences.
Some respondents said that also the number of staff was not sufficient for the number and type of patients. This is partly exacerbated by the fact that some health care staff also have a private practice during other hours in the day. This practice was less frequent during COVID-19 pandemic.
Opportunities due to the COVID-19 crisis
The COVID-19 crisis led to an increased focus on health and the health care system. People realised that being healthy is valuable and high-ranked politicians were forced to focus on the health sector, whereas in prepandemic times this was not much a priority. The government expressed the intention to maintain access to essential health care services even in the crisis context, and explicitly recognised that care for NCDs are essential. The successful vaccination campaign also led to many people having a first-ever contact with the public primary health care services. This exposure creates opportunities to increase the utilisation of these services, creating incentives to invest in the public primary health care sector.
“I think one of the things COVID has highlighted is that even during health emergencies, essential services need to be maintained and NCDs is definitely part of essential services. So in that sense, the Cambodian government has several times emphasised that they want to maintain essential services during this and even future health emergencies. So NCDs will be part of it.” (Macro-level stakeholder)
This sudden spotlight on health and health care allowed a discussion on structural problems in the primary health care system. The issue of supply of medication towards primary health care level became part of the political agenda. This translated into an increase of permanent staff capacity at the Ministry of Health, with the assignment to address this issue.
Slovenia
Direct impact
Also in Slovenia, the direct impact of the COVID-19 epidemic on the primary care system and chronic care in particular related to a shift of staff, reduced availability of services, and a reduction in capacity. Some core staff members in the primary care teams—the registered nurses and health promotion nurses—that used to take up the bulk of integrated are for chronic diseases, such as screening, prevention and routine management were all required to take up new duties in the COVID-19 response, such as manning of swab units. This put their regular jobs on hold. Since registered nurses were responsible for most patients with stable chronic diseases (e.g. by inviting them to visit the health care facility), the regular follow-up abruptly halted. The interruption of the routine integrated care system may have long-lasting effects, since the experience and the routine of these registered nurses got lost in some places.
“Care was delayed. That is one of the problems because we mainly dealt with acute problems and these chronic patients didn’t come for their annual review and consultation and they even weren’t called by their physicians. But of course, also the chronic patients had the fear of coming to us and that is why they also delayed care.” (PHC practitioner)
Although patients could theoretically go to a GP instead, the crisis context made it quite difficult to access primary health care providers in general. In the initial phase, the government forbade PHC practices to open. A major observation was that all GPs were overloaded with the extra COVID-19-related tasks mainly consisting of e-mail and phone consultations. Health care providers experienced this as additional burden, and but also noted that this way of working lowered their quality of work. Also, telephone lines and email channels became overloaded and sometimes blocked. For chronic care related tasks, most GPs are poorly reachable.
“And we had an increase, like the emails were increasing plus three to five. It was an increase that was impossible to answer them. And also, the younger patients as well, they saw an opportunity to do something through email and this sounded very easy at the beginning of COVID. But, after a year, we actually saw that this was something we don’t want to do because you need to see the patients. There are some health care problems that you can do it through email or through phone.” (Practitioner)
Cooperation with the hospital was difficult during COVID-19 times, as some outpatient clinics were closed too, or they demanded a negative COVID-19 swab to accept patients. Larger-scale and lasting consequences of this crisis were that the additional burden of work and the change in way of working led to quite a number of physicians leaving the profession, respondents said. The pre-existing shortage of GPs was thus further aggravated.
Similar to Cambodia, the COVID-19 crisis affected health-seeking behaviour as well. Even after reopening of PHC services, many people assumed it not possible to visit. Some, especially people with chronic conditions, also feared contracting COVID-19.
Strengths of the health care system
The crisis made respondents aware of the strengths of the primary health care system. First, access to PHC in Slovenia is mostly good. The interruption of the routine work of registered PHC nurses made their function in routine integrated care for stable NCD visible, and showed their role in access to chronic care. Second, the Slovenian health care system is strongly regulated, with clear guidelines and protocols across the system. This standardises care and facilitates effective processes for integrated chronic care, thereby contributing to consistency in quality. Third, respondents said the current situation made them aware of the importance of prevention and proactive care.
“But all in all, I must say that it is exactly this cooperation between public health [health promotion and disease prevention] and primary health care that keeps the focus on health promotion and disease prevention also at primary health care. Without the strong role of public health, primary health care services would be much more medicalised and disease oriented. So it’s quite a strength in Slovenia that you have so much focus on the health promotion especially in primary care.” (Macro-level stakeholder)
Fourth, opinions differed about teamwork. Some said nurses and physicians cooperate well in primary care, facilitating integrated care for many patients. However, others said that nurses and physicians work much too separately, with physicians being consulted only when patient’s health deviates or deteriorates. Due to their relocation to COVID-19 facilities such as swab and emergency care settings, some doctors and nurses learnt to collaborate in new ways, increasing mutual understanding. On the other hand, routine collaboration practice for chronic care was severely affected. Lastly, Slovenia has a strong tradition of community engagement and recognises volunteering as a valuable activity that contributes to the well-being of society. The crisis catalysed this potential, with many volunteers who took up health care related tasks in their communities.
Weaknesses of the health care system
According to respondents, the major constraints in the PHC in Slovenia are the shortage of personnel, of both doctors and nurses, which was further exacerbated by the COVID-19 crisis. The shortage of GPs was attributed to both low instream and high attrition. Relatively few medical students opt for a profession as GP, partly because of the lower status and remuneration of the PHC sector in comparison to hospitals. Working in the community health centres, which make up a large part of the primary health care sector in Slovenia, GPs experience a high administrative burden and long working hours. Quite a number of doctors resign, to search employment in private practice or in companies, contributing to a vicious circle. This makes the shortage of PHC staff an urgent problem.
“So there is a very serious lack of primary health care physicians. We are seeing that some of them are leaving community health centres and prefer operating as concessioners or even as freelance physicians, working on the contract basis either with community health centres or concessioners. Which means that they don’t operate their own registered list of patients, which is a problem.” (Primary care practitioner)
Consequences of the shortage of GPs are that not all people are able to register with any of them, that waiting times for consultations are increasing, and that quality is declining. Respondents note a lack of attention for, and stimulation of, quality of care. Despite the integrated chronic care organisation, health care provider respondents noted that some patients with chronic diseases have a high frequency of consultations and that the routine of self-management is underdeveloped. This puts a high burden on the limited time of health care workers (HCWs).
Another weakness of the PHC system that was illuminated by the COVID-19 crisis was the inflexible financing system of community health centres. They are largely paid for face-to-face consultation, and not for additional tasks. This makes, especially the larger organisations with many staff members, vulnerable to times of reduced consultations such as in the COVID-19 crises.
Opportunities due to the COVID-19 crisis
Respondents said both the public and the politicians began to value the importance of PHC as essential to the health system, as PHC practitioners were successful in triaging COVID-19 patients and preventing the hospital system from overflooding. This has led to additional resources and innovations in PHC organisation. The government decided to increase wages for PHC physicians and to add an additional staff member to the primary care teams, the administrator, with the intention to lower the administrative burden.
Consultations without appointment were abolished. HCWs appreciated this change, not only because of the improvement of patient flows, but also because they perceived that physicians feel more valued, because the appointments make patients feel that the physician’s time is precious. The high burden of phone consultations and e-mail consultations also led to innovations. A platform was created to streamline these requests, and in one region a new educational program was created to support patients with long COVID. To improve the quality of care, health centres introduced experimental remote care models that included pulse oximetry and consultations for patients with COVID. A national COVID telemonitoring centre was also established.
Health care workers noted that working in a different way during the crisis was enriching, because people had to do other tasks, and they got to know other people in a different way. Working on common goals towards overcoming the crisis was good for the team spirit, respondents said.
“But this situation showed them [patients] that they can get appointment time. It means when the process will go further, they will understand that we are not on the market. And they have to claim their visits and they have to think about their problems, what will they present to the doctors. Not just a call ‘Oh, I have a problem, what [...]’ That they have to become more organised.” (Macro-level stakeholder)
Belgium
Direct impact
The direct impact on the supply of PHC related to the availability of services, the change of working mode, and the income for GPs. In Belgium, at the start of the COVID-19 crisis, the government required PHC practices to restrict opening to urgent cases, in order to contain the virus. Thus, there were fewer consultations for patients with chronic diseases. As a result, HCWs switched to alternative modes of consultations. Teleconsultations were implemented, and as the crisis progressed, they were also reimbursed. Like in the other countries, the drop of patients led to a drop of income for GPs. Some GPs needed to temporarily discharge their staff. The government’s decision to allow primary care facilities to fully open again coincided with COVID-19 testing becoming widely available. The latter imposed a huge administrative burden on PHC practices to follow up on testing, on results and to explain the consecutive quarantine measures to patients. As in Slovenia, it made some GPs deciding to leave the profession and a number of older professionals to decide on early retirement.
“Yes, I think there is a huge fatigue. Yes, people feel they can’t take anything on right now.” (PHC practitioner)
Strengths of the health care system
The COVID-19 crisis revealed three characteristics of the Belgium PHC system and society that proved to be strong assets. Firstly, many people got engaged to help in providing support to public services, from volunteers, to practitioners, and people on regional or national governmental levels, such as in vaccination and triage centres. Secondly, patients perceive the care of PHC providers as very patient-centred and of high quality. Thirdly the entrepreneurship of PHC practitioners in Belgium, leaving enough freedom to take useful initiatives is an important strength. Practitioners have been flexible in providing care, such as working many more hours to serve their population.
“We come very much from a liberal, unregulated health care system, which is why we see that we can achieve a lot from personal initiatives. And I think that is something we actually need to preserve. We don't want to move towards an over-regulated system where personal initiative is no longer possible.” (Macro-level stakeholder)
Weaknesses of the health care system
Despite the recognition of the general high quality of care by patients, the potential of PHC for good quality integrated chronic care has not yet been realised. Whereas chronic care requires pro-active management, many primary health care are organised to provide reactive care. Respondents noted that the current PHC organisation is not yet good enough from that perspective. The majority of PHC practitioners work in monodisciplinary practices and have few options for multidisciplinary care for their patients, for instance due to lack of space or budget for nurses that could be hired. Moreover, the current fee-for-service payment system does not stimulate physicians to delegate tasks. Most PHC practitioners have no routine to assess the status of and needs of their patient group as a whole for instance by analyses the data of the health information system built up by the electronic medical files. This also reduces their capacity to organise proactive care management for people with chronic diseases. All primary healthcare workers became usurped in the COVID-19 crisis by the increasing health care demands. But practices that have proactive systems in place were better able to reorganise and adapt to the crisis context.
“So through COVID it became even clearer what was already dormant, that how we currently organise general practice, that that is not sustainable to deliver resilient care. That within the fee-for-service system you have no incentive to proactively organise your care because people know that you end up seeing people less often and so you earn less.” (Macro-level stakeholder)
Like in Slovenia, the relative shortage of GPs was aggravated during the COVID-19 crisis. The increased medical and administrative burden led to higher attrition rates. The PHC sector is comprised of small-scale entrepreneurs, with little intrasectoral organisation. This lack of organisation, especially when compared with hospitals, makes it more difficult for the government to guide and coordinate actions efficiently.
Opportunities due to the COVID-19 crisis
Respondents said they believed the crisis changed something in the mind of the GPs, which might provide opportunities for more integrated care. GPs realise that they have to change their organisation in order to be crisis- and future-proof.
“Because I am sure that the COVID pandemic has led to some kind of existential crisis in many practices. Where that a lot of practices have asked themselves the question of ‘what on earth are we all doing?’ There was a lot of administration involved as well. A lot of GPs felt like they were a walking stamping pad. And I think that, especially in light of the chronic care pandemic, we really need to look at how we can give those GP practices the necessary tools to be able to transform into a different care model where chronic care is given an important place with population management and towards integrated care.” (PHC practitioner)
The growing awareness GPs in the field also gave a push to the discussion of reform of PHC at higher level. Since teleconsultations turned out to be vital to continue consultations with patients during the crisis, so the health financing organisation decided upon a mode for reimbursement, which was otherwise not foreseen in the short term. Respondents also pointed out that the discussion on how the integration of nurses into primary care practice can be made possible got new impetus. The ministry of health started a reform process to develop an alternative model of primary care practice organisations that would allow for multidisciplinary working and integrated chronic care supported by a provider payment system based on a mix of capitation fees and services delivered. In Flanders, the newly erected primary care zones had been started to develop their thinking about population management for chronic diseases, when the COVID-19 crisis gave them new tasks (vaccination) which increased their visibility and agency. COVID-19 also led to the accelerated development of tools to monitor population health. For instance, the COVID-barometer allowed primary care practices to easily extract data on COVID-19 infections and vaccinations, which could then fed into the development of COVID-19 dashboards at multiple levels. This development is widening in scope towards other mainly chronic diseases. Like in Slovenia, the pandemic led to increased recognition of the importance of a strong primary health care system which supported political decisions to invest in these developments.