Good primary care vital for health

THE importance of primary care was reinforced by the Declaration of Astana at the Global Conference on Primary Healthcare (PHC) held last month at Astana, Kazakhstan.

This conference was a follow-up to the Alma Atta Conference (also in Kazakhstan) in 1978 where, for the first time ever, an ambitious worldwide target of “health for all by the year two thousand” was set and the consensus then was that it was best achieved through primary care. Malaysia took part in both conferences.

At Alma Atta, primary care 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 to maintain.”

Primary care would be the first level of contact for individuals, their family and the community with the national health system, bringing healthcare as close as possible to where people live and work, and the first element of a continuous healthcare process.

This year, the World Health Organization (WHO), recognising that half of the people in the world are not getting the healthcare they need, set the theme for World Health Day as “Universal Health Coverage: Everyone, Everywhere”.

The Declaration of Astana reiterates that primary care is the most inclusive, effective and efficient approach to enhancing people’s physical and mental health as well as social well-being. Thus, PHC is the cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals from 2015 to 2030.

First contact occurs when individuals and families reach out to the formal healthcare system for help when ill or for advice. In Malaysia, this could be a general practitioner (GP) or family doctor, or a doctor at health clinics or outpatient departments of public hospitals. These are regarded as generalists. Others could be specialists, such as dermatologists or ophthalmologists, in the community.

For secondary or tertiary care (otherwise known as specialist care), one has to be admitted to a hospital.

The common local perception is that a generalist doctor just treats an illness. Actually, there are many other important roles for the generalist doctor, such as prevention of diseases and empowering of patients to self-manage their illness or health.

So do we have a healthcare system led by primary care? The answer is no, although it is a fact that in Malaysia, there is almost universal access to care provided by the public health system which is largely free.

But this is not primary care as this contact does not have many of its associated features. In a primary care-led healthcare system, every individual has an assigned family doctor to see when he is ill or for any advice on health. In its absence, the individual tends to hop between doctors.

More importantly, the family doctor functions as a gatekeeper, deciding who may require secondary or tertiary care in hospitals. This makes sense as studies have shown that about 80% of the complaints for which individuals seek a doctor can be managed by a family doctor.

Of course, any individual can access a hospital directly for acci- dents or emergencies. However, in Malaysia, a culture has developed where many directly seek specialist care thus bypassing the generalist doctor, resulting in overcrowded public hospitals.

In primary care, after being discharged from hospital, the individual is referred back to his doctor who will continue care in coordination with doctors at the hospital. This is important in the management of chronic illnesses, which is the pattern now with an ageing population and unhealthy behaviour, resulting in the rise of chronic diseases needing long-term care.

Also missing in Malaysia is domiciliary care, where nurses and other paramedics provide appropriate care at home after the patient is discharged from hospital. A good example is a stroke patient who would need physiotherapy at home.

The public also play an essential role in healthcare. Every individual must accept the idea that being healthy is primarily his responsibility. This means adopting a healthy lifestyle, having appropriate health screening and avoiding smoking and obesity to reduce the risk of many chronic diseases.

Looking again at our healthcare model, the reality is there was never a family doctor or GP system from the colonial times when public hospitals provided primary care (outpatients) besides inpatient care (specialist care) and there were a few health clinics and travelling dispensaries.

This is still basically the same now even though there is a growing number of health clinics providing care, notably via the Rural Health Services. In urban areas, 1Malaysia Clinics were introduced by the previous government but, sadly, GPs were left out.

In the private sector, this practice of primary care and specialist care is well established.

Currently, the delivery of public healthcare is fragmented and not coordinated between the different sites and levels of service, leading to a great deal of duplication and inefficient use of resources, and considerable patient dissatisfaction. With inadequate resources, the public sector is under immense pressure to deliver quality care both at the community level and at its hospitals.

The first call for all countries to accord primary care its rightful place in the healthcare system was made 40 years ago. The call from Astana is no different. If we want a truly people-orientated healthcare system with universal health coverage, this is the way forward for our country.