The 1978 Alma-Ata declaration announced global agreement that health is a “fundamental human right” and called for “urgent and effective national and international action to develop and implement primary healthcare throughout the world”.
Primary healthcare (PHC) was defined in the declaration as “essential healthcare based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford…
“It is the first level of contact of individuals, the family and community with the national health system, bringing healthcare as close as possible to where people live and work, and constitutes the first elements of a continuing healthcare process”.
It is universally accepted that about 90% of a person’s health needs across his or her lifetime can be covered by PHC.
PHC costs considerably less than hospital care, which provides secondary and tertiary care.
The Harvard group report to the Health Ministry stated: “There is a growing trend towards excessive spending on secondary and tertiary care services relative to primary care, a pattern which likely contributes to higher costs and worse health outcomes.”
Malaysia spends 49% of its total health expenditure on secondary and tertiary care, but only 17% on primary care.
The PHC approach is the foundation to the achievement of the shared global goals in Universal Health Coverage (UHC) and the health-related Sustainable Development Goals (SDGs).
The Declaration of Astana was announced at the Global Conference on Primary Health Care on Oct 25-26, 2018. The Health Ministry participated in the conference.
Some aspects of the Declaration would be helpful in helping increase Malaysians’ awareness of their right to health and healthcare:
Make bold political choices for health
“We reaffirm the primary role and responsibility of Governments at all levels in promoting and protecting the right of everyone to the enjoyment of the highest attainable standard of health.
“We will promote multisectoral action and UHC, engaging relevant stakeholders and empowering local communities to strengthen PHC.
“We will address economic, social and environmental determinants of health and aim to reduce risk factors by mainstreaming a Health in All Policies approach.
“We will involve more stakeholders in the achievement of Health for All, leaving no one behind, while addressing and managing conflicts of interest, promoting transparency and implementing participatory governance.
“We will strive to avoid or mitigate conflicts that undermine health systems and roll back health gains.
“We must use coherent and inclusive approaches to expand PHC as a pillar of UHC in emergencies, ensuring the continuum of care and the provision of essential health services in line with humanitarian principles.
“We will appropriately provide and allocate human and other resources to strengthen PHC.
“We applaud the leadership and example of Governments who have demonstrated strong support for PHC.”
Build sustainable primary healthcare
“PHC will be implemented in accordance with national legislation, contexts and priorities.
“We will strengthen health systems by investing in PHC. We will enhance capacity and infrastructure for primary care – the first contact with health services – prioritising essential public health functions.
“We will prioritise disease prevention and health promotion, and will aim to meet all people’s health needs across the life course through comprehensive preventive, promotive, curative, rehabilitative services and palliative care.
“PHC will provide a comprehensive range of services and care, including, but not limited to, vaccination; screenings; prevention, control and management of noncommunicable and communicable diseases; care and services that promote, maintain and improve maternal, newborn, child and adolescent health; and mental health, and sexual and reproductive health.
“PHC will also be accessible, equitable, safe, of high quality, comprehensive, efficient, acceptable, available and affordable, and will deliver continuous, integrated services that are people-centred and gender-sensitive.
“We will strive to avoid fragmentation and ensure a functional referral system between primary and other levels of care.
“We will benefit from sustainable PHC that enhances health systems’ resilience to prevent, detect and respond to infectious diseases and outbreaks.”
Align stakeholder support to national policies, strategies and plans
“We call on all stakeholders – health professionals, academia, patients, civil society, local and international partners, agencies and funds, the private sector, faith-based organisations and others – to align with national policies, strategies and plans across all sectors, including through people-centred, gender-sensitive approaches, and to take joint actions to build stronger and sustainable PHC towards achieving UHC.
“Stakeholder support can assist countries to direct sufficient human, technological, financial and information resources to PHC.
“In implementing this Declaration, countries and stakeholders will work together in a spirit of partnership and effective development cooperation, sharing knowledge and good practices while fully respecting national sovereignty and human rights.”
Ensuring PHC for all
The implementation of PHC for all will be dependent on knowledge and capacity building; human resources; technology; and financing.
The critical factors for the achievement of the Declaration of Astana will be learning from the past and building on its progress; explicit commitment about the task ahead; and bold political commitment.
Malaysia achieved much in health and healthcare when it was an Asian Tiger. Since then, its progress has lagged behind our neighbours in the past decade.
This is reflected in its 84th ranking in the Global Health Quality and Access Index, behind Singapore (22nd), South Korea (15th), Brunei (53rd), Sri Lanka (71st), and Thailand (76th).
According to the Harvard group, private registered medical practitioners (RMPs) account for 40% of utilisation and 65% of expenditure for PHC.
The private RMPs have provided and continue to provide cost-efficient and patient-centric services, usually in a one-stop patient-friendly facility, with choice, accessibility and affordability not a major issue.
Crucially, private RMPs have ongoing relationships with patients, a feature that has yet to be achieved by their public sector counterparts.
The Health Ministry’s commitment to PHC and its thinking on the role of the private RMPs, if any, have yet to find its way into the public domain.
Its silence on the political commitment to the Declaration of Astana is, to say the least, surprising. Anyone concerned about his or her health and healthcare would welcome some clarity on this essential issue.