Primary Health Care: Module 1

Primary Health Care is the most significant force in world health. It provides both the goals and the methods, is both idealistic and practical, is integrative yet eclectic. In this first module you will explore the definition and the meaning of Primary Health Care to lay a foundation for your journey through this subject of the same name. As you move through the materials, try to keep the above objectives in mind. Don’t be afraid to take issue with what you read and to enter debate on anything here, since this is not propaganda and you are encouraged to think.

The World Health Organisation (WHO) is the official sponsor, as it were, for the PHC concept and it is defined as:

Essential health care 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 at every stage of their development in the spirit of self-reliance and self-determination. It is the first level of contact of individuals, the family and community with the national health systems bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. (WHO & UNICEF 1978, 6)

Now read the definition again as it is something with which you should become quite familiar. The WHO went on to state that PHC is the nucleus of the overall social and economic development of the community and addresses the main health problems, providing promotive, preventive, curative and rehabilitative services. Note too, that this definition was declared in 1978.

Consider this suggestion that PHC could be considered a threat to anyone with vested interests in the status quo (ie those who prefer the system to be left unchanged due to self-interest). Write a list below of those you think could be in this category.

The approach to health care proposed in the WHO definition represents a significant departure from the traditional model of so called "health" care delivery. Whilst all PHC practice should be sensitive to consumers’ needs and wants, it should always ultimately be empowering, that is, it is about increasing a client’s self-determination and enhancing cooperation. The traditional model did not support these goals. Instead, it tended to make client’s dependent on the health system and professionals within it.

Typically, a person went about the business of living until becoming sick, ill or injured, whereupon a visit was made to a local doctor or hospital or medical clinic. Treatment was dispensed and the person (who was called a patient, a term which itself implies passivity and dependence) was supposed to dutifully follow instructions in order to become cured. Once cured (indeed, if or supposedly cured would be more appropriate) the person was left to simply return to the business of living as before.

This did not empower the person. There was no attempt to examine lifestyle causes of the illness or injury, no attempt to educate the person in ways to avoid further problems. This system was certainly of benefit to the doctors, whose power, prestige and status (not to mention income) was magnified and secure. Whilst a large number of dependent patients was good for business for doctors, who typically hid this thought from public airing behind a great deal of rhetoric, it was not good for individuals, families (as units of economic consumption) or communities. Indeed, the economic cost alone to the nation became an intolerable burden, from which we in Australia have not yet recovered.

The need for a change was clear; the way is Primary Health Care. We shall now consider it in more detail.

According to NCEPH (1991, from which much of this section is adapted) the WHO concept of PHC may be understood to have three levels of meaning, as follow:

3.1 Level of service delivery

At the PHC level of service delivery there are several sub-sectors involved, including:

3.2 Approach to health care

I encourage you to refer to these principles in any assessments you undertake during this subject. Let’s explore them a little further.

PHC practitioners play a major role in helping people achieve self-reliance in relation to their health care. The principle of self-reliance applies at the three client levels of individual, family and community. This principle recognises the sovereignty and the priorities of the client. It is based on recognition of the fact that the vast majority of health problems are dealt with outside the formal health system. It is not about the paid health sector unloading health care responsibilities onto the voluntary health sectors but about supporting and promoting the work the latter do.

Community participation recognises on the one hand that there is a demand from communities to participate and on the other that such participation can be at the heart of professional practice strategies. The community based demand can be seen for example, in neighbourhood communities demanding to be included in planning decisions and industrial unions demanding to be included in decision making which effects the organisation of work. As a professional strategy it includes such programs as tackling specific disease prevention goals, such as the recent push to increase immunisation uptake rates.

The principle of intersectoral collaboration recognises that conditions for health are to a large degree determined by forces and condition which are beyond the health care system. For example, food production and distribution methods, building standards development and enforcement, and so on.

Integration of health services focuses on the program of care actually procured by the individual. Increasing specialisation has produced real dangers. The first is that a person with complex or chronic health problems may suffer if there is a breakdown in communication between the multiple providers typically consulted; a very real risk and common occurrence. The second is the tendency for the specialised system to provide services in institutions which remove the person from their normal context and tend towards routinised, technically categorised treatment, which can be quite depersonalising.

The principle of special attention to high-risk groups is a strategic imperative which seeks to address the inequalities in health status one finds between differing social groups and geographic areas. For example, Australia has been criticised for a failure to properly address the health needs of Aboriginals, we have a particularly high rate of youth suicide, and I am sure you can identify other vulnerable and high-risk groups.

Finally, use of appropriate technology at its simplest level involves ensuring that the use of any particular technology is always determined by the person’s need rather than some other factor. Too often, other factors such as marketing pressures (eg pharmaceuticals) or financial incentives associated with particular modes of remuneration, or the perceived need for frequently unnecessary exactitude in assessment data for diagnostic reasons, are actually what drives the use of technology.

3.3 Strategy for reorienting the health system

This way of understanding PHC views it as the leading edge in redirecting the development of the whole health system. The direction of change is along the lines suggested by the PHC approach and it seeks to reconcile this with the view of PHC as a level of service delivery.

We shall examine one important aspect of this concept of change associated with reorientation in section 3.0 below.

3.4 Minimum set of activities

The original Declaration of Alma Ata (WHO 1978) actually highlighted a minimum set of activities considered essential if PHC were to be implemented. These are:

Vouri (1984) was based in the WHO Regional Office for Europe when he published but his paper was a significant contribution to this topic. Further, his ideas are just as relevant in Australia today. His analysis of the reorientation addresses four dimensions, namely: focus, contents, organisation and responsibility. It is probably easier to consider these in the following table.

From		To
	Focus
illness		health
cure		prevention & care
	Contents
treatment		health promotion
episodic care		continuous care
specific problems		comprehensive care
	Organisation
specialists		generalist practitioners
physicians		other personnel
single handed practice		teams
	Responsibility
health sector alone		intersectoral collaboration
professional dominance		community participation
passive reception		self-responsibility

Think of our health care system in Australia (or in any state or territory if you prefer) and ask yourself where it presently stands in relation to its reorientation from a medically dominated condition to one which is concerned with PHC. It may be helpful if you think of it on a scale from 1 to 10. You might consider this overall or you might consider it in terms of each dimension in the table above.

Now that you have some idea of what PHC is, let’s sharpen the focus in the next section.

5.1 PHC is NOT only medical or medically dominated care.

In fact, you may be interested to know that there is a key role for nurses. Mahler (1985), the then Director General of the WHO, handed a mandate to nurses to literally "lead the way" in the shift towards health systems based on PHC in which the emphasis is on the promotion of health and the care of people wherever they live, work or play. He believed that the nurse’s role will change, with more nurses moving away from hospitals and other institutions to the everyday life of the community. He is credited with the now famous phrase that "nurses will become resources to people rather than resources to physicians". He suggested nurses would increasingly participate in program planning and evaluation, and in interprofessional and intersectoral teams for health and development.

The Australian Nurses’ Federation (ANF) published a Position Statement on Primary Health Care (ANF 1987) in which they acknowledged Australia’s position, stating "In 1979 the International Council of Nurses (ICN) confirmed the nursing profession’s commitment to the WHO goals. This, in turn, automatically committed RANF and the Australian nursing profession to action designed to meet these goals." The position statement states, in part:

The key role of nursing in implementing the essential changes in primary health care is clear. Nurses have the power to facilitate health for all by examining health promotion, cost effectiveness and policy over and above their role in clinical intervention.

Nurses thus have a responsibility to lead the change. They need to identify the strategies and actions that will be required to exercise their full leadership potential. They need to look beyond the expansion of traditional nursing roles of mere cosmetic changes in the educational programs to a deeper understanding of the philosophy of primary health care and a commitment to its values and goals. (ANF 1987)

Such a central role, or rather the recognition and acceptance of such a role, is unusual. Interestingly, no suggestion has been made by the WHO that leadership should be provided by the medical profession. It seems quite clear that the medical profession has been deliberately not identified as having a leadership role. The whole thrust of PHC is towards health and it is widely acknowledged that the medical profession, which has acknowledged expertise in illness and pathology, actually has little to do with health. As Gordon (1976, 43), who is Professor of Social and Preventive Medicine at the University of Queensland, put it:

Indeed, the contrast between medical care and health care is quite explicit in section 4.0 above.

5.2 PHC is NOT the same as primary care or primary nursing.

These terms frequently lead to confusion, and understandably so. Primary care is a much simpler concept and is subsumed by PHC as a very small component. Primary care is a term that can refer to any health profession, but usually refers to the medical care provided to individuals at their first point of contact with the health system. It could be more fully expressed as primary medical care. Members of the medical profession often confuse primary care with PHC.

Nurses on the other hand often confuse PHC with primary nursing. Krebbs (1983) drew attention to the need for nurses and the nursing profession to fully understand the concept of PHC and to differentiate it from primary nursing. That need still exists. Primary nursing is one mode of assigning nursing personnel to patient or client care. Stacy, Down and Donaghue (1986/1987) state that "Primary nursing is concerned with the one to one relationship between and patient/client for health maintenance and therapy of illness. Nursing in primary health care is concerned with the individual and family in the community, and stresses health as an integral part of the social and economic development of the community, and not something to be dealt with in isolation".

5.3 PHC is NOT concerned only or mainly with the first point of contact with a professional in the health care system.

I am sure you can see quite clearly that this is wrong, yet it is still a common misconception. It ignores some obvious facts. Firstly, PHC includes this but is much broader. The error here is to confuse a mere part with the whole. Secondly, perfectly legitimate and very important PHC is practiced by people who are not members of any profession or even perhaps paid for their services at all and by people who do not even operate within the health system. These points are what make this misconception dangerous. Subscribing to this mistaken view of PHC would disenfranchise the majority of PHC practitioners, all those who are not health care professionals.

5.4 PHC is NOT concerned to achieve health goals by employing the latest in high-technology.

This too is clearly a wrong view. Unfortunately there is a perceived association between use of high-technology and high levels of knowledge, skill and power (and of course, the status, prestige and hopefully income that go with these). This can mean that people who want to practice PHC still want to maintain the association and therefore promote the view that PHC is as much about high-technology as any other approach to health care.

Note here that PHC is not anti-technology, it merely requires that the above tests be applied before technological solutions are implemented. Frankly, a great deal of waste and harm could have been avoided if these tests were required for the use of technology generally in health care. Of course, this is one of the aims of reorienting the whole health care system.

5.5 PHC is NOT based on the belief that Western medicine is the best or in any sense necessarily superior to other medical traditions.

It is frequently the case that people who live in the developed nations suffer from a form of ethnocentrism whereby they regard their health care system/s as superior to the traditional medical systems of less developed nations. The notion of being "developed" in this context, we should remember, refers to economic and industrial development. Along with this development comes a large range of diseases which are not prevalent in less developed nations, which nevertheless have their own disease profiles. No set of diseases associated with a level of development can seriously be considered better or worse than another; they are all bad. We may not have the same health problems as The Republic of Congo on the African continent for example, but are we so much better off having one of the world’s highest rates of teenage suicide and our high mortality and morbidity rates associated with road traffic accidents?

The reality is that whatever actually achieves health goals within the principles of PHC in any given context is totally acceptable. According to Hope (1996) after carefully considering adopting western style pharmaceuticals just a few years ago, Fiji chose to maintain and develop its traditional medical system based on the cultivation of herbs. Nurses who provide health services through clinics distributed throughout the Fijian archipelago actually were trained in herb cultivation, harvesting and preparation to support their practice of herbal medicine. Western pharmaceuticals were considered too expensive, the cause of too much morbidity (side effects, reactions, etc) and unable to offer any improved efficacy over traditional medicines. This was probably a very wise choice; it was certainly consistent with PHC.

5.6 PHC is NOT an approach to health care which is only relevant to developing countries.

This too emanates from the mistaken view that the so called advanced health systems of developed nations are superior to the health systems in developing nations which would be better off using PHC. This is nonsense. The WHO is auspiced by the United Nations and its declarations, such as the one at Alma Ata, are intended for all nations on Earth, whether members or not. This is not meant as an infringement of the sovereignty of any nation but to reinforce the view that PHC should be applied to all nations. Indeed, PHC implementation is enhanced by international cooperation.

…it is true that the language of the Alma Ata Declaration was chosen with the developing countries primarily in mind. It can therefore be easily misinterpreted as a new orientation, specifically invented for developing countries. A keen observer will, however, quickly notice that the consumers of health services in the industrialised countries have been looking for something that would lessen their reliance on high-technology and hospitals. It suffices to look at the reception of Illich’s criticism of the ‘medical machine’ or the mushrooming alternative health care movements in industrialised countries to become convinced…

He goes on to point out that there is growing concern about the staggeringly high cost and marginal utility associated with high-technology medicine as found in the developed nations. Clearly, PHC is relevant in both developed and developing countries.

This will be a very brief review of some major developmental stages in health care services in Australia.

During the 1960s	There was growing awareness of the so- called "lifestyle diseases". Conditions such as heart disease, for example, were endemic.
Early 1970s	Mass public education programs, which are so commonplace today we take them for granted, were begun.
1973	The Community Health Program was instituted by the federal government. Community health as we see it today, with assorted programs and many Centres, grew from this beginning.
Then observed … (Alma Ata 1978)	Widening class differentials (people from the working class for example commonly presented with conditions rare in the middle and upper classes and vice versa). A knowledge-action gap (people knew appropriate health behaviours but didn’t put them into practice). Need for more recognition of the social environment to avoid victim blaming.(Eg suggesting to a patient that of course if they didn’t look after their children properly they would get sick - where there was an expectation that the patient represented the uneducated classes and naturally wouldn’t know, but no attempt was made to rectify this situation, just to blame them for having the problem)
Mid 1980s (Ottawa Charter 1986)	A federal government policy initiative called "Healthy Public Policy" was instituted to facilitate intersectorial collaboration.
1988	The federal Health Targets & Implementation Committee identified reasons for the health gap between rich and poor. Recommendation: Community development strategies aimed at teaching ways to increase self-reliance and mutual support. Release of the "Health for all Australians" report.
Since 1988	Further reorientation of all health services in line with the PHC agenda (albeit rather slowly).
1991	PHC Implementation Review (federal initiative)
Since 1991	Accelerated and more focused implementation (but significant resistance faced).

To place the above into a wider context you may care to read a brief paper by Jones (1990). In the meantime however, since you have probably noticed that there seems to be a gap between ideals or plans and actual outcomes, we shall now consider some of the problems faced when attempting to implement PHC.

Vouri (1984) identified a number of problems with the implementation of PHC in Europe. Even today, these problems can be identified in most developed countries to some degree. Perhaps as you read them you might reflect on the extent to which you think they apply in Australia. They include:

7.1 Conceptual problems

People tend to have difficulty understanding the concept of PHC as a result of one or more of the following.

7.1.3 Differing relevance of some important aspects of PHC such as technology, access model, degree of specialisation, etc.

7.2 Political and attitudinal problems

7.3 Organisational problems

7.4 Managerial problems

These are closely related to the previous problem. Without a well defined and operating PHC oriented health system, there has been little need to develop PHC management skills. This is something of a circular problem, not unlike the chicken or the egg dilemma.

7.5 Training problems

The current training of health care professionals is inadequate for PHC. The wrong knowledge, skills and attitudes are imparted by the wrong people in the wrong place.

Consider the following diagram carefully. Note that it shows nursing educational experience (ie preparation) exceeds requirements for practice in hospitals where nursing service coverage exceeds the need. As soon as we consider practice outside the hospitals the situation is reversed. Nurses are somewhat under prepared by their education and their service coverage does not meet the need.

To close this module on a more positive note, we should observe that a tremendous effort has been expended on the implementation of PHC around the globe as well as in Australia. There is a growing list of successful case studies. Indeed, over the last few years the students in this subject have had an important impact within our local region. The successful implementations around the world permit analysts to conclude that PHC is most successful within health systems committed to:

This definition is:	It could also be seen as:
powerful succinct comprehensive	revolutionary difficult to adjust to threatening to vested interests

Objectives