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25 March, 2019 00:00 00 AM
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WHO on public health and primary care

WHO Report
WHO on public health and primary care

Modern primary health care emerged when gross health inequalities became a global concern. The Declaration of Alma-Ata, 40 years ago, endorsed primary health care as the means of attaining the World Health Organization’s goal of health for all. It was a global health milestone of the 20th century and, crucially, identified primary health care as a fundamental human right and a key factor in attaining equitable health for everyone.

Strong health systems founded on the primary health care approach have made substantial gains in population health. Coupled with improvements in living standards and socioeconomic development, people are living longer, with a more healthy life, and premature mortality has declined. However, such progress is in jeopardy as the burden of chronic conditions and associated risk factors are on the rise.

Many of these risk factors, such as smoking, obesity and diabetes, are linked closely to the social, economic, environmental and commercial determinants of health that, in turn, influence behaviour. An additional challenge to health is that the people most affected by these determinants are also more likely to have poor health literacy and are less likely to access health services.

Primary health care has three main elements: 1) primary care and essential public health functions as the core of integrated services, 2) multisectoral policy and action, 3) empowered people and communities.

In many settings, primary care, which is the first contact of people with health services that are continuous,  comprehensive and coordinated,  has, too often,  been focused on  treating illness as and when it arises rather than preventing disease in the first place.

Modern public health interventions at the individual and population levels aim to prevent disease, protect and promote health, and ensure the greatest threats to population health are addressed (including surveillance and monitoring).

Integrating a public health approach into primary care could be an effective way of preventing disease in local communities, thus reducing the demand on primary care and improving the health of the population.

Integrating public health functions into primary care involves many different actions including: enabling primary care to deliver more protective, promotive and preventive services to a defined population; improving communication and coordination between public health authorities and primary care providers and managers; sharing knowledge and data to evaluate the impact of both individual- and population- focused services on health; and strengthening the surveillance function of primary care and more effectively linking this to public health surveillance.

Key messages

Most primary health care services have focused on treating illnesses as and when they arise rather than on the prevention of disease.

Most health systems are based on an outdated “disease model” which cannot meet the individual and community health needs of the populations in today’s rapidly changing world.

With advances in interventional public health, personal and community services need to be provided through an integrated service.

Ageing, population growth, the rising burden of noncommunicable disease and technological advances are driving the transformation of primary care.

A comprehensive primary care that reaches everyone is the cornerstone of achieving universal  health  coverage:  “leave  no  one  behind”.

Securing the health of the whole population cannot be attained without universal coverage achieved through effective comprehensive primary health care that focuses not only on disease but also on health and how to improve it.

Strengthening public health with universal coverage and access to all, irrespective of their ability to pay for it, should be the aim of all modern health systems.

The six models of integration described in this report provide an opportunity to focus service around the population needs to improve health and longevity.

Primary care

Worldwide primary care has been shown to be associated with enhanced access to health services, better health outcomes, and a decrease in hospitalization and emergency department visits. Primary care can also help counteract the negative effect of poor economic conditions on health. Traditional primary care focuses on personal health care services and continuity of care.

The curative, “disease model” of the 1970s, which is still cpmmon today in many countries, is changing rapidly. Ageing, population growth, a rising burden of chronic, noncommunicable diseases and multi and technological advances are driving the transformation of primary care.

These demographic and epidemiological shifts require primary care to focus on prevention and quality of life, and encourage a proactive population management approach that targets individuals and groups that are most affected by the structural determinants of health. To do this effectively requires linking with public health. Proactive primary care means that radical changes need to be made to the current model of service, which include integrating key public health functions and interventions into primary care services.

In her definition of primary care, Barbara Starfield indicated the need to move to a health model that provides “the first level of contact with the health system to promote health, prevent illness, care  for  common  illnesses,  and  manage  on-going health problems”. With this comprehensive and holistic approach, over 95% of patient contact with the health service would take place in primary care.

It can therefore be argued that primary care is the backbone of a new effective health system that aims for better population health. In settings where primary care has been effectively deployed and supported with adequate training and resources, family physician only refer around 5% of patients from consultations onto secondary low care.

Patient satisfaction is high and at a decidedly cost to the health system. The evidence is very clear, a system that is not primary care-led is a weak and expensive system. Indeed, countries more oriented to primary care have populations health and services that are delivered at a lower cost.

Transforming primary care to have a proactive role in promoting health and preventing disease in addition to diagnosis, treatment and care is a logical step in primary care development.

Primary care, particularly when established with a clear responsibility for a population (empanelment or registration), is the building block of public health and is the appropriate location for the local public health interventions. This raises the question: what is public health in the context of primary care?  And, how can integration be  achieved?

Public health

Public health dscribed in some countries as public health medicine, or community medicine, is a multidisciplinary specialty, defined as “the science and preventing  disease,  prolonging  life  and  promoting  health through the organised efforts of society”. The multifaceted functionsof public health provide the necessary tools to improve health through health   promotion, protection and disease prevention at population and individual levels. Not all public health functions however can be delivered at the primary care level. In the WHO European Region, the five core essential public health operations are:

1. Surveillance

2. Monitoring preparedness for response

3. Health protection

4. Health promotion

5. Disease prevention.

There is enormous potential for primary care to take a more proactive role in contributing to tackling some of these essential public health operations, especially, promoting health and disease prevention.

Public health guidance from the United Kingdom’s National Institute for Health and Care Excellence advises primary care professionals such as family physicians to opportunistically and proactively carry out activities such as short interventions to identify, reduce and prevent problematic use, abuse and dependence on alcohol, tobacco and illicit drugs, among others.

However, in the case of smoking, for example, primary care professionals tend only to respond to requests for help with giving up smoking rather than proactively engaging with existing smokers. Such reactive approaches to health must become more proactive ones. Evidence of the benefits of health promotion within primary care is growing, and health professionals and academics are working together to expand the evidence base with a particular interest in return on investment.

Public health and primary care: the value of two natural allies

A health system is partly the product of a country’s culture and the way people are willing to fund it to ensure equity and fairness. There is no perfect health system, each has strengths and weaknesses. However, the most effective systems are those able to secure the health of the whole population.

This cannot be attained without universal health  coverage  achieved  through  effective  comprehensive primary care focusing not only on disease but also on  health and how to improve it. A strong proactive public health function, therefore, is required within primary care  to protect the health of the population and the individual, promote health, and prevent disease.

Proactive primary care saves lives, reduces the burden of disease and improves quality of life. It is also an important means to improve productivity and provide a seamless service.

Considerable overlap occurs in roles, responsibilities and functions between public health and primary care, especially in protection and promotion of health, and disease and injury prevention. There are numerous possible scenarios of  integration.  One  envisages  full  integration,  where  the structures, processes, and delivery of care for both public health and primary care are the responsibility of the same entity. A second is based on two separate organizational structures, where professionals work together and share the same aim and objectives.

A third sees integration fostered by a continuity of information and communication channels, supported by routine coordination mechanisms (collocation or scheduled meetings with clear delineation of roles and responsibilities). In any scenario, we need to take into account the fact that both primary care and public health services are in high demand and under resourced.

Mechanisms for integration, therefore, should look for mutual benefits and efficiency gains as well as opportunities to increase available resources to mutual benefit (e.g. seek grant funding for joint projects that are particularly effective).

However, evidence clearly shows that both primary care and public health would improve if their respective  strengths  were  augmented  through  partnership and  integration.

The real challenge to any health system is how to strengthen the relationship between public health and primary care to synergistically  enhance  both  functions.  Countries  such  as  Brazil, Canada, and the United Kingdom provide some excellent examples of strong relationships between these two specialties.

Public health achieves this through assessing health needs, defining        priorities, providing evidence of effectiveness, developing strategies for population-wide interventions in promoting health, protecting health, preventing disease and injury, and evaluating health impacts.

Primary care focuses on personal and family care interacting with the person in a holistic way. Through such personal and continuous care, primary care is able to implement public health strategies for healthy lifestyle (for example, smoking cessation, dietary advice, weight control, active living and control of stress), early recognition of disease (e.g. systematic and opportunistic screening), early intervention to tackle risk factors (e.g. hypertension, hyperlipidaemia and smoking), and health protection (e.g. immunization including the influenza vaccine and notifications of infectious disease).

With the decline of infectious disease and increase in lifestyle-related diseases and conditions, integration of public health and primary care is vital to reduce the burden of chronic conditions (noncommunicable diseases) on communities, reduce the costs to the health system and improve health equity.

In many settings primary care teams have moved beyond individual- level work to assess and tackle structural determinants of disease at the local population level, for instance housing, transport, and the availability of fruit and vegetables. Primary care holds extensive information about the health profile of the local community, and professionals often develop a deep understanding of local social issues that drive illness. By proactively analysing the leading causes of ill health at the practice population level, primary care is able to generate unique public health insights.

A proactive primary care approach has a crucial role in promoting healthier lifestyles through every contact with the public. Primary care professionals should  “make  every  contact  count”,  which  is  about  making  healthy  life a priority. Primary care physicians and nurses will need to be trained in public health to become proactive in promoting health and well-being.

Shifting to prevention could alter the shape of the workforce, with more people delivering early intervention and public health services rather than interventions for acute illness The six models described provide good opportunities to radically change health services to deliver a truly comprehensive service that can help achieve universal health coverage and fulfill the dream of the Declaration of Alma-Ata stated 40 years ago: health for all. Through integration alone, we can close the gap between primary care and public health, and move closer to that goal.

 

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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