In Support of Community-based Primary Health Care: Coping with the COVID-19 Crisis.

What impact will the Covid 19 pandemic have on reproductive health care in Africa and how should the health system ready itself? As primary health care clinicians and research collaborators in maternal health, we have some observations based on our experiences. While our clinical work is done in two very different settings: a rural Tanzanian district hospital (Chirangi) and an urban Canadian city (Webber), we have noted some commonalities in the response to the pandemic. Covid 19 has made people very afraid. The media images of over-run Italian hospitals with insufficient ventilators for very ill patients and exhausted staff has permeated all of our borders. People are avoiding getting health care, because they know that they are at risk of contracting this virus, with no cure or vaccine to help them. As a result, instead of being overwhelmed with sick patients, Canadian hospital emergency rooms are in fact quieter than usual. Elective surgeries have been postponed, and staff are being re-deployed. Our social distancing policies have appeared to flatten the epidemic curve in the general community (though unfortunately, not in longterm homes). Similarly, in rural Tanzania, people are avoiding getting health care services until they are very sick. Fear of leaving home to go to the more populated town, where there may be a greater risk of infection, is strong. We know from the Ebola epidemic in West Africa that women’s health suffered because either the health system was overwhelmed with Ebola patients, or the population believed they would be at risk of acquiring the virus when attending a health facility 1 . The outcome was the same - limited access to needed health care services and declines in maternal health. How can a primary health care system ensure that the population continues to have sound health care services during a pandemic? The first criteria are a close personal connection to the health care system. For example, in Canada most Canadians have a family physician who helps them navigate health care. The pandemic has changed how family physicians work; however, we have the benefit of a long-term relationship with our patients. Even during times of social distancing, we can use the telephone or video conferencing tools to help manage the health problems of our patients and choose who needs to be seen and whose health problems can be managed at a distance. With respect to reproductive health, we can ensure women have access to contraceptive services, and continue to see our pregnant patients in virus-free spaces (though we have learned that we may not need to see them as often as we once thought). We can make sure that newborns are growing well and that they receive their childhood vaccinations. Most importantly, as community-based, primary health care providers, we can keep our patients away from potentially infectious places such as emergency rooms. We are fortunate to have a strong public health system which has provided alternative clinics for those people who have Covid symptoms. Keeping the ill separate from mothers and babies is an important strategy that we will need to take forward into our future health care planning. In rural Africa, the primary health care system is built upon community health workers collaborating with dispensary nurses to attend to the health needs of the population. It is the relationships of the community health workers with local families which is key to maintaining the health of the community. This is particularly true for reproductive health care services such as family planning and antenatal care. In many regions in Africa, community health workers have been trained to assist women access family planning and prenatal services. We propose this relationship needs to be strengthened during a pandemic, when women are less likely to leave their communities for health care. The community health workers need more support at this time - both through phone supervision and through provision of supplies which they can distribute to community members. Community health workers must be trained and supported to refer women with danger signs for higher levels of care.  In our research in rural Tanzania, in addition to referring pregnant women with danger signs, trained community health workers can safely distribute condoms and oral contraception and educate women about more advanced family planning methods that can be obtained through a local health facility such as depoprovera injections, implants and intrauterine devices 2 . During a pandemic, it makes sense to train community health workers to provide injectable contraception to interested women in the villages, allowing the women to avoid a trip (and possible exposure) at a local clinic. Community health workers can also check on pregnant women and children, and screen them and refer for any serious health conditions, including symptoms of Covid 19. Supportive supervision is key to making this work. Finally, providing birth kits with misoprostol in rural settings is another strategy to ensure women have supplies they need at the time of delivery. While skilled birth attendance is always a goal for every woman, failures in supply chains, challenges with transportation and now fears of contagion may prevent women from accessing health care services. Having clean supplies and misoprostol tablets to take postpartum can help prevent postpartum hemorrhage and sepsis - two of the most common causes of maternal deaths 3 . Strengthening the provision of community-based care is one important strategy to address reproductive health for the women and infants living in rural Africa. Now is the time to invest in these services, to limit the impact of this global pandemic.

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