The focus of the World Health Organization’s (WHO) World Health Day held on Apr 7, 2019, was Universal Health Coverage (UHC).
UHC means that “all people have access to the quality health services they need, when and where they need them, without financial hardship”.
The goals of World Health Day 2019 were “to improve understanding of UHC and the importance of primary healthcare as its foundation; and to spur action from individuals, policymakers and healthcare workers to make universal healthcare a reality for everyone”.
Primary health care (PHC) was conceptualised in the 1978 Alma Ata declaration and was defined 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.”
Primary care is the care provided by a healthcare professional (HCP), e.g. doctor, dentist, nurse or pharmacist, with whom a patient has initial contact and by whom a patient is referred to a specialist.
In essence, primary care is a subset of PHC.
General practice is a term that covers the general practitioner (GP) and other HCPs. The GP is a doctor based in the community who manages patients with minor or chronic illness, and refers those with serious conditions to a hospital.
PHC can meet the majority of an individual’s health needs throughout their life, including screening for health problems, vaccination, information on prevention of disease, family planning, treatment for long- and short-term conditions, coordination with other levels of care, and rehabilitation.
In essence, PHC is about caring for the person, and not the specific disease or condition. It is a cost-effective, cost-efficient and equitable mode of healthcare delivery.
The core principles of PHC, i.e. first contact, continuous, comprehensive and coordinated care, has been shown to be stable over time.
There are lessons from many countries that support the view that quality PHC is the foundation of UHC.
Quality PHC needed
Everyone has different perceptions of quality, which may not be easy to quantify at times.
Quality of care has been defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.
The characteristics of quality health services are effectiveness, safety, people-centric, timeliness, integration, efficiency, fairness and impartiality.
High-performing primary care systems act as people’s first contact and are comprehensive, coordinated, people-centred, continuous and accessible.
The question is, who defines quality PHC?
The easy approach is that quality should be defined by patients and not policymakers, politicians or healthcare professionals, but then who are the representative patients?
While recognising that the link between PHC and quality is the foundation for UHC, it has to be acknowledged that quality does not occur on its own.
Leadership is the primary requirement of any quality improvement effort, without which all other efforts risk failure.
Transparency about performance and errors, accountability and system-based learning are critical.
The alignment of professional values, particularly compassionate care and the empowerment of individuals, are central to a culture of quality and safety.
Finally, all quality improvement and safety efforts have to be coherent and coordinated.
Some information of how primary care in Malaysia is faring can be found in the report by the Harvard group titled Malaysian Health Systems Research Volume 1 2016, for example:
• Primary care doctors were not identified as the first point of contact for many common conditions, especially for mental illness, addictions and substance abuse, with only one-quarter or less of public clinic doctors indicated they were (almost) always or usually consulted on a first contact basis for mental illness (page 77).
• Doctors in public clinics were also not deeply involved in the comprehensive follow-up of a wide range of primary care-sensitive conditions, especially mental illness and other non-communicable diseases (p78-79).
• Continuity of care between specialists and primary care providers is weak, as clinic doctors are seldom or never (50%), or only occasionally (31%), informed after a patient has been treated or diagnosed by a specialist (p79).
• Medical officers do not regularly carry out many medical and surgical procedures that a well-functioning primary care facility with a comprehensive set of services would typically provide (p79).
• Forty-nine percent of total health expenditure is on secondary care, but only 17% on primary care and very little on long-term care (p87).
• The shifting of expenditure further toward secondary and tertiary care between 1997 and 2013 – real expenditure per capita on secondary and tertiary care increased by 130%, while expenditure per capita on primary care increased by only 73% (p87).
• There is a high share of hospital admissions for ambulatory care-sensitive conditions, or conditions that could have been managed – with fewer resources and better health outcomes – in ambulatory care settings (p89).
• There is a very high rate of admissions to hospital for long-term complications of diabetes mellitus (p89).
The road to achieving UHC founded on quality PHC is long and fraught with the challenges of underinvestment in PHC, uncertain political will, parochial policies, and even misconceptions about the role and benefits of PHC.
Yet, if Malaysia is to attain the health-related Sustainable Development Goals (SDGs) by 2030, it has to have a health system with a strong PHC as its core.
The global experience is that such a system delivers better health outcomes, efficiency, improved quality of care and safety.
The alternative is unsafe and low-quality health care that, in the words of WHO, “ruins lives and costs the world trillions of dollars every year”.