Primary Health Care / Universal Health Care Notes

Primary Health Care (PHC)

  • Definition: Essential health care based on practical, scientifically sound, and socially acceptable methods and technology. It should be universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford at every stage of development, in a spirit of self-reliance and self-determination (Alma Ata Declaration 1978).

  • What is it? A whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs as early as possible along the continuum:

    • Health promotion
    • Disease prevention
    • Treatment
    • Rehabilitation
    • Palliative care
    • Delivered as close as feasible to people’s everyday environment.

  • Components:

    1. Integrated health services to meet people’s health needs throughout their lives.
    2. Addressing the broader determinants of health through multisectoral policy and action.
    3. Empowering individuals, families, and communities to take charge of their own health.

  • Importance:

    • Cornerstone of a sustainable health system for Universal Health Coverage (UHC), health-related Sustainable Development Goals (SDGs), and health security.
    • Most inclusive, equitable, cost-effective, and efficient approach to enhance people’s physical and mental health, as well as social well-being.
    • Critical to make health systems more resilient to situations of crisis, more proactive in detecting early signs of epidemics, and more prepared to act early in response to surges in demand for services.

  • Financial risk: About 930 million people worldwide are at risk of falling into poverty due to out-of-pocket health spending of 10% or more of their household budget.

  • Impact of scaling up PHC: Scaling up primary health care (PHC) interventions across low and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030.

  • Proven results of health systems with a PHC-based foundation:

    • Improved clinical outcomes
    • Increased efficiency
    • Better quality of care
    • Enhanced patient satisfaction

  • Rationale for PHC:

    1. Greater access to needed services
    2. Better quality of care
    3. Greater focus on prevention
    4. Early management of health problems
    5. Cumulative effect of the main primary care delivery characteristics
    6. Role of primary care in reducing unnecessary and potentially harmful specialist care

  • Attributes of PHC:

    1. Accessible
    2. Affordable
    3. Acceptable
    4. Appropriate
    5. Adaptable

  • Principles of PHC:

    1. Multisectoral approach
    2. Community participation
    3. Focus on prevention
    4. Equitable distribution of health services
    5. Appropriate technology

Principles of PHC Explained

1. Multisectoral Approach

  • Involves all related sectors and aspects of national and community development, such as agriculture, animal husbandry, food, industry, education, housing, public works, communication, and other sectors.

  • Collaboration:

    • Between non-health agencies to improve oral health (e.g., water works and oral health)
    • Within the health sector to improve oral health (e.g., MCH and oral health)

  • Advantages:

    • Teamwork
    • Established structured system facilitates referrals
    • Working towards a common goal
    • Integration of oral health and general health, leading to networking
2. Community Participation

  • Continuous effort to secure meaningful involvement of the community in the planning, implementation, and maintenance of health services.

  • Maximum reliance on local resources such as manpower, money, and materials.

  • Built on the principles of community participation (or involvement).

  • Approaches:

    • Top-down approach
    • Mid-stream prevention
    • Bottom-up approach

  • Advantages of Community Participation:

    1. Increases program acceptance and leadership
    2. Ensures that the program meets the local needs
    3. Cost of implementing the program may be reduced by using local resources
    4. Uses local/familiar organizations, hence problem-solving is efficient
    5. Commitment to the decision is facilitated
    6. Key to sustainability
3. Focus on Prevention

  • Economical and best for developing countries.

  • Impact of prevention is in the long term compared to the immediate impact of curative measures.

  • Common-risk factor approach to prevention has a greater impact and is holistic.

  • Effects of dental caries and periodontal diseases are the two major oral diseases for prevention.

  • Oral Health Prevention in PHC:

    • Water Fluoridation
    • Fluoride toothpaste
    • Fluoride salt
    • Diet and Nutrition
    • Tobacco
4. Equitable Distribution of Health Services
  • Health services must be shared equally by all people, irrespective of their ability to pay, and all must have access to health services.
  • Addresses the inequality of care by shifting the center of gravity of the health care system from cities to rural areas and bringing these services as near people’s homes as possible.
  • The worst hit are the poor, needy, and vulnerable groups of the population in rural areas and slums; is termed as social injustice.
  • Commitment of the government is to provide care to all.
5. Appropriate Technology
  • Examples:
    • Availability of ART in areas not supplied by electricity
    • Affordable toothpaste to some countries
    • Village health workers to meet the demands of the community at minimal/no cost
    • Essential drugs for common problems (e.g., Panadol)
    • Basic oral health package for urgent dental treatment (e.g., dental extractions/temporary fillings)
    • Not to deprive the community from a standard and acceptable level of health.

Universal Health Care (UHC)

  • Definition: All people have access to the full range of quality health services they need, when and where they need them, without financial hardship.

  • Covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course.

  • Universal Coverage (UC) or Universal Health Coverage (UHC):

    • Ensuring all people have access to needed promotive, preventive, curative, and rehabilitative health services of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

  • Objectives of UC:

    1. Equity in access to health services
    2. Quality of health services is good enough to improve the health of those receiving the services
    3. Financial risk protection

  • WHO Definition of UHC: A health care system with a motive of equity in access through promotive, preventive, curative, and rehabilitative health interventions.

  • Achieving UHC is one of the targets the nations of the world set when they adopted the 2030 Sustainable Development Goals (SDGs) in 2015.

  • Includes financial risk protection, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.

  • The movement towards universal health coverage (UHC) is now one of the most prominent global health policies.

History of UHC

  • 1948 Universal Declaration of Human Rights:

    • “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family including food, clothing, housing and medical care and necessary social services.”

  • 1966, International Covenant on Economic, Social and Cultural Rights:

    • “The rights of everyone to the enjoyment of the highest attainable standard of physical and mental health.”

  • 1978, Alma Atta Declaration:

    • Signatories noted that “Health for All" would contribute to both a better quality of life and also to global peace and security.

  • 100 million people are pushed into poverty because of direct health payments.

  • 79 countries devote less than 10% of general government expenditure to health.

  • Health also frequently becomes a political issue as governments try to meet people’s expectations.

  • 2005, WHO Member States commitment:

    • To develop their financing systems so that all people have access to health services and do not suffer financial hardship paying for them.
    • This goal was defined as universal coverage or universal health.

  • 2010 World Health Report:

    • Builds on the 2005 WHA recommendations and aims at assisting countries in quickly moving towards Universal Health Coverage.

Approaches to Achieve UHC

  1. Equitable health services: Provide all population and people with equal access and availability of the health services.
  2. Quality health services: The services must contain good quality to enhance and promote services
  3. Multisectoral co-ordination: Including collaboration with the governmental, local, private and other sectors for effective outreach of health services.
  4. Health system reform: There should be a central change in the system mentioning UHC as its target of achievement.

Guiding Principles for UHC

  1. Universality: broader coverage all around.
  2. Equity: service for one who needs it.
  3. Non-exclusion and Non-discrimination
  4. Comprehensive care that is rational and of good quality: inclusion of all aspects of care.
  5. Financial protection
  6. Protection of patient’s rights that guarantee appropriateness of care, patient choice, portability and continuity of care.
  7. Consolidated and strengthened public health provision.
  8. Accountability and transparency
  9. Community participation
  10. Putting health in people’s hands.

Expected Outcomes of UHC

  • Improved health outcomes
  • Greater equity
  • Reduction poverty
  • Financial Protection
  • Greater productivity
  • Increased jobs
  • Efficient, accountable & transparent health system

Challenges for Developing Countries to Achieve UHC

  • Insufficient funds: In developing countries, the external funds are the main support for universal programs.
  • Financial risk protection: Access to all needed quality health services without financial hardship.
  • Reducing inefficiency: Attaining efficient provision of the services in all the sectors because of lack of efficient distribution of services.
  • Reduce inequity: There is a need to consider access to services to the poor, marginalized and vulnerable population which has not yet been able to be achieved due to financial hardships.
  • Mobilizing resources for health
  • Use of IT for better UHC and pre-payment systems
  • Improvising responsiveness, equity, and quality of healthcare services

Importance/Advantages of UHC

  • Promotion, prevention, treatment, rehabilitation, palliative care

  • Population-based and personal interventions

  • Interventions at different levels of the system: community, primary, secondary, tertiary.

  • Gives emphasis upon maintaining quality in the services of those who are getting it.

  • To ensure equitable services for all who needs it and not just ones who can pay for it.

  • To recognize that health depends not only on having access to medical services and a means of paying for these services but also on understanding the links between social factors, the environment, natural disasters, and health.

  • Millennium Development Goals, in alleviating poverty, and in achieving sustainable development.

  • Primary Health Care is the best way to achieve universal health coverage and the health-related development goals

PHC – UHC Partnership

  • Universal health coverage (UHC) depends on a strong primary health-care system.
  • For UHC to be successful, primary health care must be expanded at community and household levels as much of the world’s population still lacks access to health facilities for basic services.
  • Community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services.
  • Community involvement is the cornerstone of local, equitable, and integrated primary health care.
  • Policies and actions to improve primary health care must regard community members as more than passive recipients of health care.
  • Communities must become more involved in evaluating the success of efforts to expand primary health care.
  • Much of primary health care has taken place, and will continue to take place, outside health facilities.
  • Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care.
  • Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.
  • To reach universal health coverage (UHC), health systems must be oriented towards a primary health care (PHC) approach, which includes three essential components:
    • multisectoral policy and action
    • empowered people and communities
    • primary care and essential public health functions at the core of integrated health services
  • the PHC-UHC Partnership works to ensure healthy lives and promote well-being for all at all ages, leaving no one behind.
  • Because many of the factors that threaten health and well-being today lie beyond an individual’s control, the UHC Partnership is committed to promoting multisectoral actions to reduce risk factors and to prioritize health in all policies and healthy settings.