Acceleration of Self-Care in the Time of COVID-19

This post was originally featured on Knowledge Success’ Blog.

Banner Image Photo: A woman holds a self-sample device for HPV. Credit: Jhpiego/Kate Holt


What is the context?
The need for fundamental transformation in our health systems has never been more apparent. Already the world faces a shortage of 13 million health workers. Now, in the context of COVID-19, our dependencies on a stretched health workforce are brought to the fore, demanding creative, urgent, and difficult solutions.

People are asked to steer clear of COVID-19 hotspots such as hospitals and clinics, to use telemedicine or hotlines where they exist, to self-diagnose using symptom guidelines, and to self-medicate. Preventative and curative care jostle together, both equally important, both challenged to be delivered in tandem. World over, millions volunteered almost overnight to support continuity of health services, with clinicians coming out of retirement, and others lending their non-clinical expertise and labor. At individual, community, and health system levels, we are witnessing an overnight transformation in how people use and organize healthcare.

As COVID-19 moved from outbreak to epidemic and now pandemic, and with the significant possibility that for the next 18 months we see episodic outbreaks of COVID-19, one immediate need—and potentially lasting health system transformation—will be learning what services and information can be provided with less dependency on health workers.

These measures are both to protect heroic frontline health workers, but also to ensure the most effective healthcare can be provided at scale. In this context, self-care is not only occurring, but has rapidly become a critical answer in the health system response to COVID-19.

What is self-care?
For the uninitiated, the World Health Organization (WHO) defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider,” and add in subsequent publications that “self-care interventions are among the most promising and exciting new approaches to improve health and well-being, both from a health systems perspective and for people who use these interventions.”

Figure 1. Self-care in the context of interventions linked to health systems.

Source: WHO Consolidated Guideline on Self-Care Interventions for Health

 

Prior to COVID-19, self-care was already increasing in relevance for health systems. This is not self-care focused on general physical and mental wellness, although self-care does incorporate those broader and important considerations. This is self-care in the form of drugs, diagnostics, devices, and digital health, that—paired with growing demand by individuals for participation in their healthcare—has led to a greater configuration of self-led health care possibilities than ever before. Information, products, and services previously requiring the full participation of health workers have seen individuals take greater responsibility for their health care. Examples of this abound across the range of self-management, self-testing, and self-awareness (see Figure 1). Prior to the outbreak of COVID-19, health systems from Uganda and Nigeria were working on plans to take the 2019 WHO Consolidated Guideline for Self-Care Interventions in Health for Sexual and Reproductive Health and Rights and other self-care interventions to scale. This specific WHO guideline recognizes that many evidence-based practices within the SRHR space could be promoted to enhance self-care, and recommends measures such as HIV self-testing, HPV self-sampling, and self-administered injectable contraception all be available at scale.

Photo: A woman holds a self-sample device for HPV. Credit: Jhpiego/Kate Holt

Why is self-care important in the context of COVID-19?
Within a COVID-19 response, self-care is how we help one another, and what keeps our health systems from complete collapse. It appears in our efforts to self-screen through AI-powered websites where we check how common our symptoms are in relation to COVID-19, or in those WHO WhatsApp alerts used to self-educate. It’s the promise of home self-testing (tantalizingly close), and all we do to care for ourselves and our household when someone falls ill.

This sudden and rapid reliance on self-care isn’t how we imagined it—haphazard and driven out of crisis rather than thoughtful health system design. There will be people now managing their health in ways that they should not, cannot, be expected to do alone. In this messiness exist dangers and pitfalls, such as the general public and physicians purchasing and using chloroquine and hydroxychloroquine after recent reports suggested they may be able to treat COVID-19, but with insufficient evidence or reflection on the consequences. The safeguards (financial protection, safe and quality care, adequate support from a health worker when needed) have not been fully established.

But crises don’t wait for us to get it right, as much as they reveal how previously we could have done things differently, better. This leaves us in a transitional moment, where the rapid transformation happening cannot be ignored. Within the lens of outbreak response itself, self-care plays an important function. Self-care will also remain important for the many healthcare needs that carry on regardless of COVID-19. And it will play a critical role in the health systems that exist once the pandemic has subsided.

Photo: An HIV self-test. Credit: Jhpiego/Karen Kasmauski

What does advancing self-care look like?
Self-care can mean better, more accessible, participatory, affordable, quality healthcare. In the case of the emergency contraceptive pill or acetaminophen when available over the counter, such self-care will require minimal or no interaction with a health worker. However, frequently, for COVID-19 and many health interventions, self-care requires a carefully choreographed set of interactions between health workers and individuals to enable people to take greater control over their healthcare. As the WHO guidelines also highlight, self-care is not a binary phenomenon of healthcare worker versus person-led healthcare, rather it’s far more dynamic. For example, the HIV self-test may be taken alone but requires referral into the health system for result verification and treatment, if needed. HPV DNA self-sampling allows a woman the control and privacy to collect her own specimens for screening for cervical cancer, but the health system will review the results and assist clients to interpret and act on them, including treatment when applicable. Self-injected DMPA-SC and oral PrEP for HIV prevention might require an initial contact with a pharmacist, clinician, or lay health worker, but are largely used autonomously thereafter—with support provided at intervals to counsel through any adverse effects and adapt regimens or switch methods as needed. The nature of these interactions will vary by intervention, by population, and across people’s lifetimes.

Photo: The DMPA-SC contraceptive method, which can be self-injected. Credit: PSI

What can we do?
During the COVID-19 outbreak and beyond, a health system that optimized self-care would therefore consider the following:

  • It would be designed around continuity of care, including self-care, acknowledging that connections to the health system will often remain and need to be fit for purpose: robust enough to ensure clients receive quality healthcare, yet flexible enough to ensure clients are not prevented from accessing the better healthcare that self-care can provide. Continuity might include use of digital health solutions, such as those being used now to support users at home while protecting healthcare workers from COVID-19.
  • In addition to a continuity of care approach, such self-care will keep a systematic approach to safety and quality of care front of mind, with processes to ensure technical competence of health workers and people in the delivery of self-care, of client safety and satisfaction, quality information and interpersonal exchanges. The unique role of credible and trusted information is also critical, to address rumors, myths, prevent dangerous practices, and promote good practices.
  • It would recognize the role of health system actors in promoting and advancing self-awareness—with healthcare workers and individuals not on parallel tracks towards health, but in partnership with one another. This requires healthcare workers take an active role championing health literacy, self-awareness, and promotion of self-care where appropriate. When we’ve been conditioned to view ourselves as recipients of healthcare, it will take healthcare workers to help us shift that paradigm.
  • Self-care should also keep universal health coverage top of mind, so that access, quality, and equity are not overly compromised amidst the rapid transformation health systems face with this pandemic. In particular, financing of self-care will require as extensive discipline as is applied to the financing of existing health systems, precisely because self-care is a health system solution.

Self-care, enabling people’s own capacity to do what once relied on healthcare workers, would have been one part of the future of healthcare regardless of COVID-19. But to navigate COVID-19 and come out with health systems and public health capacities that are stronger—not further fragmented—it’s increasingly important to find the balance between self-care and what we rely on healthcare workers and health systems to deliver. To the extent possible, documenting and reflecting on this rapid transformation will also be crucial to learning from this. And if there is one ray of hope in challenging times, it is that through necessity, quality self-care may become better organized, resourced, and applied. People, together, can do this.

About the authors
This work is co-authored by staff from PSI and Jhpiego. Both organizations are rapidly employing existing and new resources to respond to the COVID-19 pandemic, as well as ensure existing health system capacity is maintained in critical health areas. Through the Self Care Trailblazers Group, generously supported by the Children’s Investment Fund Foundation (UK) and the William and Flora Hewlett Foundation, both PSI and Jhpiego benefit from the collective wisdom and momentum of many organizations working in self-care at global and country level, from FHI 360, PATH, White Ribbon Alliance, IPPF, the Self Care Academic Research Unit at Imperial College London, Johns Hopkins University, SH:24, EngenderHealth, Aidsfonds, Voluntary Service Overseas (VSO) and many others. The technical leadership and support of the World Health Organization has also been vitally important to strengthening the emerging self-care movement, alongside the growing support from the USAID Office of Population & Reproductive Health, the Bill & Melinda Gates Foundation and the UK Department for International Development.

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Here’s what it looks like in practice.

In July 2020, PSI Angola, alongside the Angolan digital innovation company Appy People, launched Kassai, an eLearning platform that targets public sector health workers in Angola. Through funding from USAID and the President’s Malaria Initiatve (PMI), Kassai features 16 courses in malaria, family planning, and maternal and child health – with plans to expand learning topic areas through funding from ExxonMobil Foundation and private sector companies. A partnership with UNITEL, the largest telecommunication provider in Angola, provides all public health providers in Angola free internet access to use Kassai.

Kassai’s analytics system to follow learners’ success rate and to adjust the course content to learners’ performance and needs. Kassai analytics are integrated with DHIS2 – the Health Management Information System (HMIS) of Angolan MOH, to be able to link learners’ knowledge and performance with the health outcomes in the health facilities.  The analytics track learners’ performance by course and gives visibility by health provider, health facility, municipality, and province. Each course has pre-and post-evaluation tests to track progress of learning, too.

By the end of 2022, there were 6,600 unique users on the Kassai platform and 31,000 course enrollments. PSI Angola’s partnership with UNITEL, the largest telecommunication provider in Angola, allows for free internet access to learn on the Kassai for all public health providers in Angola. Building on its success for malaria training, Kassai now also provides courses in family planning, COVID-19, and maternal and child health. This reduces training silos and provides cross-cutting benefits beyond a single disease.

Implementing the SLPM digital ecosystem brings numerous benefits to health systems. It allows for more strategic and efficient workforce training and performance management, enabling ministries of health to track changes in health workers’ knowledge, quality of care, service utilization, and health outcomes in real time. The ecosystem also supports better stewardship of mixed health systems by facilitating engagement with the private sector, aligning training programs and standards of care, and integrating private sector data into national HMIS. Furthermore, it enables the integration of community health workers into the broader health system, maximizing their impact and contribution to improving health outcomes and strengthening primary healthcare.

OUR COMMITMENTS

WHISTLEBLOWER AND ANTI-RETALIATION

PSI does not tolerate retaliation or adverse employment action of any kind against anyone who in good faith reports a suspected violation or misconduct under this policy, provides information to an external investigator, a law enforcement official or agency, or assists in the investigation of a suspected violation, even if a subsequent investigation determines that no violation occurred, provided the employee report is made in good faith and with reasonable belief in its accuracy.

OUR COMMITMENTS

Global Code of Business Conduct And Ethics

PSI’s code sets out our basic expectations for conduct that is legal, honest, fair, transparent, ethical, honorable, and respectful. It is designed to guide the conduct of all PSI employees—regardless of location, function, or position—on ethical issues they face during the normal course of business. We also expect that our vendors, suppliers, and contractors will work ethically and honestly.

OUR COMMITMENTS

The Future of Work

With overarching commitments to flexibility in our work, and greater wellbeing for our employees, we want to ensure PSI is positioned for success with a global and holistic view of talent. Under our new “work from (almost) anywhere,” or “WFAA” philosophy, we are making the necessary investments to be an employer of record in more than half of U.S. states, and consider the U.S. as one single labor market for salary purposes. Globally, we recognize the need to compete for talent everywhere; we maintain a talent center in Nairobi and a mini-hub in Abidjan. PSI also already works with our Dutch-based European partner, PSI Europe, and we’re creating a virtual talent center in the UK.

OUR COMMITMENTS

Meaningful Youth Engagement

PSI is firmly committed to the meaningful engagement of young people in our work. As signatories of the Global Consensus Statement on Meaningful Adolescent & Youth Engagement, PSI affirms that young people have a fundamental right to actively and meaningfully engage in all matters that affect their lives. PSI’s commitments aim to serve and partner with diverse young people from 10-24 years, and we have prioritized ethics and integrity in our approach. Read more about our commitments to the three core principles of respect, justice and Do No Harm in the Commitment to Ethics in Youth-Powered Design. And read more about how we are bringing our words to action in our ICPD+25 commitment, Elevating Youth Voices, Building Youth Skills for Health Design.

OUR COMMITMENTS

Zero Tolerance for Modern-Day Slavery and Human Trafficking

PSI works to ensure that its operations and supply chains are free from slavery and human trafficking. Read more about this commitment in our policy statement, endorsed by the PSI Board of Directors.

OUR COMMITMENTS

UNITED NATIONS GLOBAL COMPACT

Since 2017, PSI has been a signatory to the United Nations Global Compact, a commitment to align strategies and operations with universal principles of human rights, labor, environment and anti-corruption. Read about PSI’s commitment to the UN Global Compact here.

OUR COMMITMENTS

Environmental Sustainability

The health of PSI’s consumers is inextricably linked to the health of our planet. That’s why we’ve joined the Climate Accountability in Development as part of our commitment to reducing our greenhouse gas emissions by 30 percent by 2030. Read about our commitment to environmental sustainability.

OUR COMMITMENTS

Affirmative Action and Equal Employment Opportunity

PSI does not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, protected veteran status or any other classification protected by applicable federal, state or local law. Read our full affirmative action and equal employment opportunity policy here.

OUR COMMITMENTS

Zero Tolerance for Discrimination and Harassment

PSI is committed to establishing and maintaining a work environment that fosters harmonious, productive working relationships and encourages mutual respect among team members. Read our policy against discrimination and harassment here.

PSI is committed to serving all health consumers with respect, and strives for the highest standards of ethical behavior. PSI is dedicated to complying with the letter and spirit of all laws, regulations and contractual obligations to which it is subject, and to ensuring that all funds with which it is entrusted are used to achieve maximum impact on its programs. PSI provides exceptionally strong financial, operational and program management systems to ensure rigorous internal controls are in place to prevent and detect fraud, waste and abuse and ensure compliance with the highest standards. Essential to this commitment is protecting the safety and well-being of our program consumers, including the most vulnerable, such as women and children. PSI maintains zero tolerance for child abuse, sexual abuse, or exploitative acts or threats by our employees, consultants, volunteers or anyone associated with the delivery of our programs and services, and takes seriously all complaints of misconduct brought to our attention.

OUR FOCUS

Diversity and Inclusion

PSI affirms its commitment to diversity and believes that when people feel respected and included they can be more honest, collaborative and successful. We believe that everyone deserves respect and equal treatment regardless of gender, race, ethnicity, age, disability, sexual orientation, gender identity, cultural background or religious beliefs. Read our commitment to diversity and inclusion here. Plus, we’ve signed the CREED Pledge for Racial and Ethnic Equity. Learn more.

OUR COMMITMENTS

Gender Equality

PSI affirms gender equality is a universal human right and the achievement of it is essential to PSI’s mission. Read about our commitment to gender equality here.

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01 #PeoplePowered

02 Breaking Taboos

03 Moving Care Closer to Consumers

04 Innovating on Investments

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