Community-led COVID-19 responses:
filling in gaps of urban public health system
Thailand reported its first case of coronavirus disease 2019 (COVID-19) on 13 January 2020. Country’s first wave was contained relatively quickly due to measures like the closing of all schools, all Bangkok public and business areas and the declaration of a state of emergency with enforced curfew. The second wave, starting in December 2020, was again quickly contained through these restrictive measures. However, Thailand has entered its third wave of COVID-19 outbreak since April 2021, with daily new infections rising from 26 cases on 1 April 2021 to 2,070 cases on 23 April 2021.
Since all people with confirmed COVID-19, even those without symptoms, were requested by the government to be hospitalized, the number of people needing hospitalization rapidly exceeded available hospital beds. Furthermore, major COVID-19 testing units, including in private hospitals, reduced daily testing slots to limit influx of new cases into their hospitals. Non-Thai individuals suffered another layer of discriminative actions by service providers due to the lack of government’s clear and official commitment to reimburse costs of COVID-19 testing and treatment to these providers. By late April 2021, an overwhelmed public healthcare system resulted in people in Bangkok dying at home while waiting to be hospitalized or tested.
Isolation efforts were seriously impeded by the lack of basic livelihood provision for individuals who need to undergo home isolation. There was a severe lack of community’s capacity and skill building, based on fact not fear, on how to triage and provide initial care for COVID-19 cases while waiting for hospital beds to become available. The enforcement of fear-based containment measures had little effect during the third COVID-19 wave, with more than 5,000 new infections per day at the end of June 2021. By then, with imminent failing of hospital healthcare system, the immediate need to bring COVID-19 treatment and care to individuals at home and in community has become obvious.
From Community to Community
In response to Thailand’s third wave of COVID-19, the Institute of HIV Research and Innovation (IHRI) together with civil society organizations (CSO) and other non-governmental organizations (NGO) have established the Community-led COVID-19 Support Workforce (ComCOVID-19) on 23 April 2021 to rapidly identify community needs and immediately respond to them.
The initial client-centered and holistic service was delivered virtually by physicians, nurses and counselors from IHRI to provide clinical assessment and triaging of COVID-19 cases and their contacts. In parallel, key population (KP)-lay providers and community leaders were trained to provide assessment of basic clinical conditions, livelihood needs, mental health, stigma, and human rights violation needs.
In July 2021, ComCOVID-19 has been requested by the National Health Security Office (NHSO) and Department of Medical Sciences to expand its scope to provide quality COVID-19 care at home or in community for majority of COVID-19 cases who had no to mild symptoms while the government was trying to free up hospital beds for those with severe diseases who really needed them. This turned out to be country’s comprehensive community-led COVID-19 service delivery model which included risk screening, rapid/self-testing, and immediate antiviral treatment and supportive care delivered to cases and contacts at home and in community, by family/community members together with virtual consultation provided by healthcare professionals.
From July-November 2021, IHRI has worked hand-in-hand with the community-led troop including Human Settlement Foundation, TNP+, ACCESS, SWING and RSAT, together with the Royal College of Family Physicians of Thailand, to bring COVID-19 testing and treatment to almost 30,000 people in Bangkok and its vicinity – 10% being non-Thai.
The invaluable contribution of ComCOVID-19 to mitigate COVID-19 crisis can happen as it was built on a decade long investment and experience of community-led responses to HIV that IHRI and its partners have established to fill in service gaps of the mainstream public healthcare system by ensuring a client-centered and holistic approach. Convincing government stakeholders and healthcare specialists in accepting and endorsing the leadership and roles of communities in designing and co-delivering the most appropriate healthcare to their people have been challenging but achievable. Support from Thailand Ministry of Public Health’s Department of Medical Services and the NHSO have been instrumental in the success of ComCOVID-19. Community-led primary healthcare system, with adequate investment for sustainability, has huge potential as an efficient service delivery model for other health conditions in urban settings in Thailand.
Fight Stigma and Discrimination with Facts
Over the past two years, COVID-19 stigma and discrimination have been pervasive in Thai society. The effects of being stigmatized may have an impact on the mental health of individuals. IHRI rapidly launched a mixed methods study to explore the types of stigma and discrimination prevalent, and associated factors.
By making members of public come to an understanding of COVID-19 with hope to reduce stigma and discrimination, surveys were conducted among a wide range of people including 280 people affected by the COVID-19 pandemic and people under investigation, 300 people co-living with COVID-19 patients, 271 healthcare providers, and 1,200 online respondents. A participatory learning and sharing workshop was conducted among those affected by the COVID-19 pandemics, people under investigations and online respondents to learn about their concerns and fears, and finally come up with the set of untold facts made ready for public communications. Some of the facts will help foster the ideas that COVID-19 can be coexisting and mental care for COVID-19 patients is essential to self-manage stigma and discrimination.
We have emphasized these messages with our community representatives as they are key to COVID-19 primary management and care. This has been made possible through several trainings built upon our hands-on experience and expertise.
Moreover, through this study, we hope to explore the effects of preparing communities prior to the return of COVID-19 patients and launch public fact-based campaigns to reduce this unnecessary health burden.
Mass Vaccination in Solidarity
Realizing how bad COVID-19 situation in Bangkok could be and the urgent need for many more community lay providers to address the crisis, IHRI sought and fought for opportunities to get access to COVID-19 vaccines which at that time were prioritized only for healthcare providers working in hospitals and to essential workers in transportation and education sectors. IHRI volunteered more than 30 staff to daily serve registration, health screening, and vaccine injection stations at the two mass vaccination sites of Chulalongkorn University during May-June 2021. This brought IHRI an opportunity to secure some COVID-19 vaccination slots for our key population and community lay providers who have subsequently become one of our crucial workforces of ComCOVID19 – those who care for thousands of COVID-19 cases and families in their communities.