THE foundation of healthcare is primary healthcare. No country has been able to improve its health indicators without strengthening its PHC system. Universal health coverage, which has been our stated public policy for some time and is to be achieved by 2030 in the context of the Sustainable Development Goals, is not possible without an effectively functioning PHC. Pakistan has worrying health indicators. WHO considers PHC as the bedrock for advancing UHC. It is also not possible to put in place essential public health functions without a well-established PHC. The Covid-19 experience has unequivocally demonstrated this.
The historic Alma Ata declaration, an outcome of an international conference on PHC in 1978 in the then Soviet socialist republic of Kazakhstan, is considered among the most significant public health milestones of the last century and establishes PHC as the key to ‘health for all’. On the 40th anniversary of the Alma-Ata Declaration in 2018, WHO, Unicef and the Kazakhstan government again co-hosted a global conference on PHC and reaffirmed the importance of a strong PHC as an essential condition for achieving UHC.
PHC is a combination of community health services, ie at the household level provided through Lady Health Workers, midwives, vaccinators etc, and the health services provided at the PHC facility level to ambulatory patients. Currently in Pakistan, community health services are almost entirely provided by the public sector while facility-level services are provided by both public and private sectors. Public-sector facilities providing PHC services include Basic Health Units (BHUs), dispensaries, mother and child centres, rural health centres (RHCs) and outpatient departments of hospitals in cities. In the private sector, PHC is provided by general physicians and OPDs of private hospitals in the cities. People also seek primary care from homeopathic practitioners, hakims and practitioners of other systems of treatment in a weakly regulated private sector.
In the 1980s and 1990s, Pakistan built a national network of BHUs and RHCs with the idea that each union council with a population of 5,000 to 25,000 must have one BHU. In order to provide community health services, a national LHW programme was established. Currently, some 90,000 LHWs cater to some 115 million people. The 18th Amendment, however, has fragmented and politicised this vital national programme. This along with the private sector provides a good infrastructure for an effective PHC system in the country. The functioning of this system is, however, far from satisfactory.
Primary healthcare is as much for healthy individuals as it for those suffering from ill health.
PHC is not just for patients. It is as much for healthy individuals of all ages in terms of protecting them from disease and injury and risks to their health. The risks are chiefly environmental — quality of air, the water we consume, etc. — and behavioural — smoking, sedentary lifestyle, etc. Preventive and promotive health services hence are part of PHC. Likewise, rehabilitative services for disabled people and convalescents are part of PHC. Care of the terminally ill at home ie palliative services are also part of PHC. Research on health services has established that around 70 per cent of essential health services can be provided at the PHC level.
Apart from individual services, there are some essential public health functions including disease surveillance, health information collection, emergency preparedness, health communication and research. These functions are also performed at the PHC level. Lastly, since health is also affected by factors that are not directly in the control of the health ministries eg nutrition, safe drinking water, the sewerage system, education etc., collaboration with other sectors at the local level is also part of PHC. Timely cure of minor ailments and injuries, guidance on reproductive health to young women, antenatal care, family planning, essential vaccination, child growth monitoring, screening for diseases, nutritional guidance, home care for bedridden elders etc all take place at the PHC level.
PHC is not just a level of healthcare. It is also a philosophy of care and social well-being. It is a provision of healthcare at the household and community level in collaboration with other departments and with facilities that are easily accessible to the people. Ensuring the active involvement of people in the provision of healthcare, in its widest sense, is crucial. People must be informed, they must be consulted and they must monitor. Institutionalised community involvement through health committees in the context of local governments is the best and sustainable approach.
Despite its critical importance, somehow PHC in Pakistan is perceived as second-rate healthcare for the poor. The biggest hurdle in establishing a quality PHC system in the country is this elitist mindset. The rich and powerful go to big, expensive hospitals in large cities and BHUs and LHWs are for the rural peri-urban poor. Because of the weak PHC system, most patients go directly to tertiary-level hospitals even for minor ailments and hence the overcrowded and suffocating OPDs of big hospitals.
In a well-functioning health system, apart from emergency patients all other patients should be digitally referred to higher levels of healthcare. PHC in this sense is considered a gatekeeper for secondary- and tertiary-level care. Even our medical education system, both public and private, does not expose medical students to PHC settings. Until these perceptions and practices change, it is difficult to expect a vibrant and functional PHC.
The elitism in health also exists at the policy level. A review of our national and provincial budget documents has only a cursory, if any, mention of PHC. Even the periodic ‘National Health Accounts’ by the Pakistan Bureau of Statistics do not provide information about the expenditures on PHC, nor about the distribution of resources between the primary, secondary and tertiary levels of healthcare. An estimate is that the bulk of the health budget is spent on big hospitals rather than on PHC.
We have to make a drastic shift towards PHC if we are really interested in advancing UHC, improving the quality of healthcare and our health indicators in the country.
The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.
Published in Dawn, September 24th, 2021