COVID control: Gazette to enforce tough guidelines
A Gazette giving legal teeth to measures to prevent the spread of COVID-19 is due to be issued this weekend, as Colombo and a few other districts open under a controlled mechanism, a high-level health official said.
The Gazette to be issued under the Quarantine and Prevention of Diseases Ordinance would ensure social distancing and other measures such as adequate facilities for hand-hygiene, as the country is opened up after the lockdown, Health Services Director-General Dr. Anil Jasinghe told the Sunday Times.
“We cannot afford to keep the country closed for a long period,” he said, pointing out that the Gazette would allow for legal action to be taken if social distancing and hand-hygiene facilities are not in place.
He said that in addition to the guidelines already developed for the country to adhere to after the lockdown was eased, more specific guidelines which would go “very deep” were also in the pipeline. This is while the legal empowerment through the latest Gazette would help maintain the gains achieved during the lockdown.
“Legal power would be vested in me as DG of Health Services and I would be able to delegate some of these powers to the police to act on my behalf and also seek the assistance of the armed forces,” he said.
A seven-member operational and monitoring cell headed by Dr. Hemantha Herath, the National Coordinator for Disaster Management, has been established to work closely with different levels of healthcare staff. These levels are the Medical Officers of Health (MOHs), the Regional Directors of Health (RDHS) and the Provincial Directors of Health (PDHS) and also the hospitals to support OPD and triaging protocols, it is learnt.
This cell would be in constant touch with the divisional health units, Dr. Jasinghe added.
The Quarantine and Prevention of Diseases Ordinance of 1897 makes provision for “preventing the introduction into Sri Lanka of the plague and all contagious or infectious diseases and for preventing the spread of such diseases in and outside Sri Lanka”.
Under this ordinance, the Minister may, from time to time, make and when made revoke or vary, such regulations as may seem necessary or expedient for the purpose of preventing the introduction into Sri Lanka of any disease.
“All regulations made under this ordinance shall be published in the Gazette and shall from the date of such publication have the same force as if they had been enacted in this ordinance,” it adds.
Amother with a five- year- old child who has fever, cold and cough goes to the Outpatients’ Department (OPD) of a state hospital on a Monday morning. The child has been ill for a day, the OPD doctor examines the child, prescribes some medicine and the mother and child go home.
By Tuesday evening, the cough is worse, so the mother consults a private General Practitioner (GP) as she feels that the OPD doctor did not pay much attention to the child. The GP examines the child and orders a Full Blood Count (FBC), if the fever does not clear and gives some medicine.
By the next day, the fever is higher and by evening the mother channels a specialist at a private hospital. The specialist recommends that if the fever has not settled by evening the next day, the child should be admitted to hospital. The child is admitted to a state hospital. When the illness worsens with vomiting and the presence of a rash, the child is diagnosed as having Dengue Haemorrhagic Fever (DHF), admitted to the Intensive Care Unit (ICU), treated and discharged.
It is through this simple tale – a reality enacted daily across the country – that Prof. Kumara Mendis, Chair Professor of Family Medicine of the Faculty of Medicine, University of Kelaniya, explains how ‘primary’, ‘secondary’ and ‘tertiary’ care is administered to people.
This is also why Primary Medical Care Units ( PMCUs) which are at the very grassroots need strengthening to meet future challenges such as COVID-19, it is learnt.
The health structure is as follows:
Primary care – this is what the mother had with the OPD doctor and the GP. Prof. Mendis explains that when people consult doctors in the ‘ambulatory’ (outside a state hospital) setting, they get ‘first contact care’ through a GP or at an OPD. If they are to be referred to secondary care, there should be a referral system in place.
Secondary care – this is provided in state hospitals under different specialities such as general medicine; surgery; obstetrics & gynaecology; paediatrics and psychiatry.
Tertiary care – all the niche specialities such as intensive care, neurology and cardiology etc., fall under this category.
Delving into the situation created by the COVID-19 outbreak, Prof. Mendis stresses that most of the guidelines Sri Lanka has for COVID are for hospital doctors.
Regrettably, these guidelines are issued on the assumption that they would cover both the OPD and the wards, but he points out that in some recent 47-page guidelines, there is less than one page specifically for the OPD, where COVID-19 or non-COVID-19 patients have first contact.
“The successes with regard to curbing the spread of COVID-19 up to this point are mainly due to the preventive arm of the public health state system. The primary healthcare (PHC) system has two arms, with ‘prevention’ being carried out by the Medical Officers of Health (MOHs) and their staff and the ‘curative’ arm being handled by primary medical care units at the very grassroots,” he says.
Commending the PHC system, Prof. Mendis heaps appreciation on MOHs and Public Health Inspectors ( PHIs) who have performed their duties “beyond” expectations. “Even now, I am 90% sure that there is no community spread.”
The Assistant Registrar of the Sri Lanka Medical Council ( SLMC), Dr. Chandana Atapattu adds his voice to the plea to strengthen primary care, while looking at the small- time GPs who at grass-root level conduct their practice in a
small space which consists of a tight waiting, consultation and dispensary area.
There are three key features in the provision of primary care – ‘ first contact care’ (a person walks from his/her home to the closest doctor, who is sometimes referred to as the ‘family doctor’); ‘continuity of care’ (this too is provided by the family doctor); and ‘holistic care’, he says.
Citing the differences between the care given by a family doctor and a specialist when seeing a person with asthma, Dr. Atapattu says the family doctor would know the patient and his/ her history well, whereas a specialist would prescribe some inhalers for the specific problem. Therefore, it is the family doctor who provides holistic care.
Next the Sunday Times gets a view of the primary healthcare facilities available in the country. In the government sector, the main providers of primary
healthcare are 499 PMCUs (earlier called central dispensaries) with each staffed by a doctor. The next level is the 472 Divisional Hospitals (earlier called rural hospitals, peripheral units or district hospitals). There are also Base Hospitals, General Hospitals and Teaching Hospitals which have OPDs which also provide primary care.
In the private sector, there are GPs, family doctors and family physicians, all tallying up to about 250 full-time, while more than 10,000 doctors work in the state sector during office hours and engage in private practice after hours, who provide primary care, says Dr. Atapattu, pointing out that then there are also specialists providing channel consultations as first contact care.
According to the annual health bulletin, there are 100 million visits to primary care doctors, says Prof. Mendis, ana
lyzing this figure as one person ( when taking a 20 million population) seeking such treatment five times per year on average.
Of these 100 million visits, 55% are private primary care consultations and 45% in the government sector. It is estimated that by 2027, the 100 million visits will increase to 200 million. “The sad plight is that there is simply no medical record, not even a small slip, of all these visits except a prescription given to the patient which most probably gets misplaced after a few days. Only the GPs would have a file of their patients, maybe for about 5-10%, and those will not be computerized records,” he adds.
Their urgent plea is that in view of the dangers that the world and Sri Lanka are facing due to COVID-19, there is a need to strengthen what the country already has in place in the primary care setting.