My contribution to COVID-19 pandemic management in the country as a Public Health Specialty Program Resident in the University of Chile

by Jorge Vilches Apablaza
General Public Health . School of Public Health, University of Chile

The Public Health Medical Specialty Program in the University of Chile

The Public Health Medical Specialty Program (Residency) in the University of Chile has a learning methodology focused on metacognition and mentoring. This proposal  emphasizes a theoretical-practical framework to create learning proper environments to favor knowledge. The length of the program is 3 year.

The theoretical component is developed in class courses in the School of Public Health of University of Chile, like epidemiology, politics and system, biostatistics, health management, and others. The practical component is particular to the specialty program and considers intramural practice rotations in School of Public Health of University of Chile, and extramural practice rotations in different institutions in the Chilean health system. This configuration is similar to clinical specialty programs because focus is professional career development, above the academic career oriented more to investigation development. 

In the first year, intramural practice rotations in the School of Public Health prepare me to utilise the knowledge acquired in courses related to epidemiology, biostatistics, policy and health system, and management at aggregated form. 

In second and third years, the extramural practice rotations consider a progressive increment in complex activities in institutions of chilean health system, in order:  health services management in Health Metropolitan Area (Servicio de Salud Metropolitano Oriente) managing a health services network with population assigned in area, health provider in north area of Santiago city (Hospital Clínico de la Universidad de Chile) a universitary hospital with public-private function, metropolitan health authority (Secretaría Regional Ministerial de Salud Metropolitana) accomplish a regulatory activities, Ministry of Health (Ministerio de Salud) and his stewardship role, health public insurance (Fondo Nacional de Salud) accomplish a financing role in health system, and in the last five months of third year an elective practice rotation linked with personal interests. 

How to influence the COVID-19 pandemic in the Specialty Program

The COVID-19 pandemic changed the way of life as it was understood to this day, and obviously in the Public Health Specialty Program, transforming face-to-face activities into remote activities, pushing the academic program team to apply “emergency remote teaching”. This approach prioritized essential topics in the disciplinary areas of interest, centered in the first moment in assuring general conditions for students and professors and then in an essential matter “decision-making” as a public health specialist.

On the other hand, the preferent new format of activities in the practice rotations was a synchronic remote sessions and asynchronous remote sessions, and occasional pressential activities in institutions dependence.

In this context, I experienced an elevated uncertainty as to whether the emergency formative activities contribute for two principal aims: to learn effectively above the accepted limit for specialty program, and for the effective pandemic management at different levels of institutions where I was a practitioner. Looking around now, my experience was better than my expectative.

My contribution in COVID-19 pandemic context in different institutions of Chilean Health System

Now I will share with you some experiences about my work in the different institutions where I was a practitioner at COVID-19 pandemic times. Also, an important issue was the collaborative work process and report elaboration with my cohort partners of specialty program, Rodrigo and Jean Claude, under the tracing of academic program team, specifically, Prof Marcelo.

Servicio de Salud Metropolitano Oriente (Western Metropolitan Health Services)

As a management health services institution, in a regional metropolitan level. There we elaborated a mixed case study (quali-quantitative) about the implementation of “Residencias Sanitarias” (health facilities to institutionalized COVID-19 quarentine). This strategy was implemented in march 2020 and our case study characterized its first three month of function, reviewed how to adapt the normative guide to a particular territorial context, and how networks were built at the regional and national level, considering that these facilities were the first in the metropolitan region. The characteristics of this work were focused on the management principles: formulation, implementation and evaluation framework, generating improvement proposals. 

At the same time, we developed intermediate products like abbreviated evidence reviews, one of these about measures in older adults long-term residentials on COVID-19 context, scaling from local level to national level (Ministry of Health) because it was recognized as a potential contribution to a national normative guide. This is so gratifying for me because I see indirectly that my effort contributes to elevate people’s health level, one of the aims pushed me to enter in the specialty program. 

Hospital Clínico de la Universidad de Chile (University of Chile Clinical Hospital)

As a university hospital, health provider in the north area of Santiago city. In this practice rotation we conducted as a team a qualitative case study about how institutional health workers perceived the directive team strategy to approach COVID-19 pandemic, related to an ICU bed transformation and health services prioritization. Using focus group methodology and qualitative analysis with ATLAS-TI platform, we could systematize the experience of the transformations carried out. This process was participative with directive and based workers, collecting the assessment of interest parts and encouraging continuous improvement in clinical-administrative management. This product will allow, in the next institutional transformation related to any health emergency, to consider an institutional perspective of the workers, achieving a better adherence to the strategy and work performance.

Moreover, this approach would be considered as a useful methodology in other health providers to optimize their strategies in the emergency context, and really practical in management knowledge to our professional performance. 

Secretaria Regional Ministerial de Salud Metropolitana (Metropolitan Regional Health Ministerial Secretary) 

As a health authority in a metropolitan area. The institution aims to oversee regulatory compliance in the public-private health providers. In this context, the contribution of a technical perspective is more hard to nail down, considering the predominant political component in the directive team and central supervision in the ministry of health about the institutional performance. In this context, we used our relational resources to approach the management style of the directive team, with support of  workers in mid-level like secretary of the department or field epidemiologist. 

With the intention to optimize the testing, tracing and isolation COVID-19 activities – entrusted to the institution – we developed a 4-steps strategy: diagnostic, design, implementation and evaluation, elaborating abbreviated memorandums about a tracer case. We discover improvement points, most important related to case definitions and how that influenced the continuous tracing and isolation services. When our practices activities were over, the case definitions act was modified according to our proposals reaching the national regulatory level. This reinforced to me the relevant role of the Public Health Specialty and our presence in practice rotation. 

Ministerio de Salud (Ministry of Health)

Ministry of Health: this institution was the only one where my practice activities resulted in individual products. Here, in a coordinated action between the Public Health Subsecretary and the program academic team,  we were received in the epidemiology department for the division chief and topic sentences were immediately suggested to develop our rotation. I decided to work on the international travelers strategy.

I identified that the international travelers strategy in my country was reactive to demand, and it wasn’t elaborated in prospective form with the best evidence available. In this context, I proposed elaborate measures related to international travelers strategy with a human rights perspective. 

For this, I utilized a World Health Organization international travelers framework by 3 steps: risk estimation, risk mitigation and risk communication. Doing abbreviated evidence reviews and comparative policy analysis I suggested a particular risk estimation tool, identified general and specific measures to mitigate risk with human rights approach, and a collaborative risk communication in travel related institutions (ie: airlines, civil aeronautic direction, an other). 

Once my practice was finished, some criterias present in my report were considered in a modification on strategy by Ministry of Health authorities, like a shortened on length isolation times in international travelers to strengthen performance or home isolation in international travelers with citizens category to have economic protection, but not considering all elements proposed to these dimensions. This was to be expected, because at the central level represented by the Ministry of Health the pandemic management has shown a strong tension between technical and political criterias.

The Public Health Medical Specialty profile

In the formative program, the academic team presented to us the spanish acronym MAPA to define a Public Health Medical Specialty profile. Each word means: “M” for Medical and its  disciplinary dimension, “A” for actor, but in english it is best understood as a player or performer, “P” for the politics skills that we should  acquired in our professional performance in health sector; and the last “A” for administrative skills, representing agency or advocacy capacities needed to better results in our working process. In perspective, during my experience shared in, I’m working on developing all these profile skills recently viewed.