In the context of the COVID-19 pandemic, the Peruvian Ministry of Health (MINSA) faces the challenge of ensuring the continuity of comprehensive health care for children at the first level of care. In view of the need to minimise the risks of contagion caused by close contact, the provision of health services was adapted from a fixed to a telehealth offer. This adapted form of integrated care is proposed as a strategy to meet the demands and improve access to health services, nutrition and development for children.
The webinar "Telehealth for the provision of comprehensive care solutions to children in the face of COVID-19", which took place on 20 October, was the fifth of the webinar series on early childhood development, organised by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ). The United Nations Children's Fund (UNICEF), the European Union (EU) and MINSA also participated in the development of this webinar. The panellists presented the progress and challenges of Peru, as well as the experiences of Colombia and Kyrgyzstan in the implementation of telehealth in integrated care services for children in the context of the current health crisis.
The speakers were Sandra Gallegos and Nathalia Munarth (Ministry of Health of Colombia), Dr Boris Verona Mesia (Ministry of Health of Peru), Bakyt Dzhangaziev (Ministry of Health of Kyrgyzstan), Tilek Nurdin Uulu (IT analyst of Socservice, Kyrgyzstan), Neha Verma (General Director of Intelehealth), Gerrit Maritz (Child Survival and Development programme for UNICEF, Kyrgyzstan) and Karin Källander (UNICEF senior health specialist). The session was moderated by Rosana Vargas, senior technical advisor of the Good Governance Programme, GIZ-Peru.
The application of telehealth for the integral care of children in the context of COVID 19: the Peruvian experience.
Speaker: Dr Boris Verona Mesia, Executive Director of the Directorate of Interventions for Life Course and Integrated Care, General Directorate of Strategic Interventions in Public Health.
The COVID-19 pandemic urged the Peruvian government to go beyond the model of face-to-face health service delivery to include other modalities of comprehensive care that would allow it to serve segments of the population at high risk, especially children. To this end, the Peruvian government identified the main problems faced by such group in the context of the pandemic: confinement, school absenteeism and lack of access to health services.
Considering these problems and the various service delivery scenarios (homes, public spaces, and health institutions, among others), the government defined as a central objective to invest in “comprehensive child care through quality telehealth, in an equitable, efficient and effective manner, using information and communication technologies in the context of COVID-19”. Dr Boris Verona Mesia listed the types of intervention that were prioritised:
- promotion and support of breastfeeding;
- closure of the vaccination gap;
- monitoring and evaluation of nutritional status;
- suitability for the control of growth and development;
- prevention of domestic violence;
- adaptation of public spaces.
Within the framework of Law No. 30421 ("Ley Marco Telesalud"), the National Telehealth Network is organised into four areas:
- Telemedicine: to provide remote health services (promotion, prevention, treatment, recovery, rehabilitation and palliative care). Its services are divided into five sub-areas: teleinterconsultation (relationship between professionals), telemedicalboard (when a group of specialists has to be assembled), teleconsultation (direct contact between professional and patient), telemonitoring and teleorientation.
- Telemanagement: to articulate the management of services in all regions of the country, as well as the cooperation between the system and other institutions.
- Teleinformation, education and communication: to disseminate healthy lifestyles and health care practices (such as COVID-19 prevention) from different digital platforms.
- Telecapacitation: to broaden the knowledge, skills, abilities and aptitudes of health personnel through online seminars and courses, focusing mainly on the aforementioned prioritised interventions and on the care and prevention of COVID-19.
Dr Verona Mesia also brought two concrete examples of telemedicine programmes developed and implemented in the pandemic period. The first was the creation of the “Programa tu Vacuna" (translated as “Your Vaccine Programme”), which allows parents and caregivers to schedule vaccination appointments without having to wait in line, and the other was the telemonitoring and teleconsultation programme, dedicated to the prevention and treatment of anaemia.
The panellist concluded his talk by presenting the main challenges that Peru faces in the process of adapting and extending telehealth, and by stressing the existing parallels with neighbouring countries, such as Colombia, that face similar adversities. He highlighted the "digital divide" and the connectivity problems that exist in Peru, the lack of adequate equipment for both professionals and patients, and the need for strengthening the human resources and unifying the digital platforms.
Telehealth for the integral attention to children during the COVID-19 pandemic: the Colombian experience.
Sandra Gallegos, advisor on service provision and primary care for the Colombian Ministry of Health;
Nathalia Munarth, paediatrician from the Promotion and Prevention Department of the Colombian Ministry of Health.
According to Gallegos, Colombia's general social security health system is made up of a group of institutions whose objective is to insure health risks and provide access to a minimum package of quality health services. The comprehensive health care system guarantees its services through collective and individual activities organised in a network. It is also divided into two comprehensive care routes: "health promotion and maintenance" and "specific risk groups and events".
The panellists presented some of the problems faced by children and adolescents (C&A), which represent 32% of the population in Colombia, as well as those faced by pregnant women. These were the barriers in access to health services in rural areas, availability of health professionals and specialists, late access to health services, and marked differences between the indicators of ethnic populations.
In 2010, Colombia responded to this scenario with the approval of a series of laws, decrees and resolutions that today compose the regulatory framework for telehealth in the country. Since then, its central objective has been to guarantee the effective fulfilment of the right to health. The regulation seeks to enhance and guarantee the quality of remote service provision. Such services constitute the structure of individual care for the C&A segment, and organize and regulate consultations at different stages of growth according to a logic of comprehensive and continuous care, including oral health, vaccination and nutrition.
The guiding principles of telehealth in the country are the free choice of the user, professional autonomy and responsibility, informed consent, information security and data confidentiality. In the image below, one can see the organization of the activities that compose the national system:
During the COVID-19 period, Colombia instituted regulations that facilitated the implementation of these services with the aim of reducing contact and contagion. According to the speaker, there has been a 117% increase in the number of centres that provide telemedicine services and a 192% increase in the number of offered services since January of this year (2020). At the time of the presentation, 3.5% of health service institutes in the country are entitled to provide such services. Among the authorised services, paediatrics represents 5%.
The experiences of three insurance companies that provide telehealth care in the Colombia were presented. One of the main highlights was the innovation in the use of artificial intelligence for certain stages of the service, such as pre-consultations and symptom identification.
The panellists emphasised the need to facilitate the advancement of telehealth in face of the persisting obstacles, including access to mobile and residential Internet service packages, lack of user adherence to processes and lack of training in the use of technologies. Some indications of the ways forward were: adapting care taking into account the particularities of the territories and the diversity of their populations, capacity building for both patients and professionals and the incorporation of teleorientation into risk management.
Improving maternal and child health services through standardisation of telemedicine services in Kyrgyzstan
Bakyt Dzhangaziev, Ministry of Health of Kyrgyzstan
Tilek Nurdin Uulu, Socservice (Kyrgyzstan)
Neha Verma, General Director of Intelehealth (Kyrgyzstan)
The last national experience presented in the webinar was that of Kyrgyzstan, whose C&A segment represents 38% of the population. With the aim of improving mother and child health services, Kyrgyzstan sought to facilitate and enhance the use of telemedicine, analysing the current context and mapping existing projects in this category. However, telehealth is an incipient modality in the country.
In addition to the effort of the Kyrgyz Ministry of Health, a situation analysis was also carried out with support from UNICEF to develop a set of recommendations and guidelines. The findings showed the existence of a plurality of projects that made it difficult to centralise support and scale-up efforts. From the analysis carried out, recommendations for policy guidelines were made, taking into consideration both the current state of telehealth and its development opportunities. One of the main conclusions was that, beyond technological advances, there is a need to ensure a legal basis for telehealth and telemedicine, as research indicates that many doctors preferred not to participate in such projects due to the lack of clear legislation on the subject. In addition to regulation and standardisation, funding also appeared to be a central issue, as before the State considered direct involvement in these types of initiatives, telehealth systems depended almost exclusively on donations. The recommendation favoured the creation of a reimbursement system.
Based on these recommendations, a legal framework was developed. Kyrgyzstan defined that the project would target children with disabilities to avoid the problems that could result from late identification and delays in attention. After multidisciplinary discussions between different institutions and partners, a programme was designed focusing on the provision of services through both telemedicine and home visits.
The project is still in the planning stage, but the panellists highlighted the fact that the system was based on a multiplicity of existing telemedicine experiences, which allowed it to overcome many of the common difficulties. The panellists also showed confidence that telemedicine will help promote equitable access to health services for children before the end of the COVID-19 crisis.
Telemedicine - Perspectives and recommendations
Commentator: Karin Källander, Senior Health Specialist, UNICEF
As Källander pointed out, there are a number of synergies between the different experiences, as well as common challenges. Among her recommendations, the following points were highlighted:
- Telemedicine has multiple expressions. Therefore it is necessary to define well what the objectives are before developing a project or system (it can be aimed at supporting the relationship between professionals, or between patients and professionals, for example).
- Not all solutions in telemedicine need to be complicated. There is a multiplicity of low-tech strategies that can help in a problem that was repeated in various national experiences: limited coverage.
After highlighting some of the central points in the development of a telemedicine system (such as the selection of suppliers, the technologies to be adopted and their demands, etc.) and presenting some examples of existing solutions, Källander made her final considerations. In her view, COVID-19 has changed the way we think about healthcare provision and has encouraged us to look for solutions that can help meet the needs of women and children in remote areas, from the most complex to the simplest and most low-tech.