A New Focus and Challenge for Nursing

The Thirtieth World Health Assembly resolved in May 1977 that the main health organisations in the coming decade: "...should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life."¹ Realisation of the WHO goal requires international and intersectoral collaboration and redirection of national health policies and strategies to ensure every individual has access to primary health care, and through it access to all levels of a comprehensive health care system

Primary health care as defined by WHO is:...essential care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part, both of the country’s health system of which it is the nucleus, and of the overall social and economic development of the community.²

Despite the financial resources invested in the present health system and the development of new drugs, technologies and medical sciences in the last 30 years, people’s level of health in industrialised countries is far lower than it could be. Further, irrespective of the high level of economic, scientific, and educational development, inequalities in health still exist.

The WHO European Region recently has called for fundamental changes to health developments in industrialised countries, and outlined four main areas of concern:

Of the required changes in health policies a much higher priority should be given to health promotion and disease prevention. Not only the health service but all sectors having an impact on health should take positive steps to maintain and improve it. Much more stress should be laid on the role that individuals, families and communities can play in health development, and primary health care should be the major approach used to bring about these changes.³

In 1979 the International Council of Nurses (ICN) confirmed the nursing profession’s commitment to the goal of health for all by the year 2000, through primary health care.⁴ In recognising primary health care as the key to achieving health for all, ICN recommended that national nursing organisations study the implications in terms of their respective health care and nursing systems, and community participation in health issues. Attention was directed to the need for changes in relation to:

The ICN recognition of primary health care as the key to achieving health for all automatically commits RANF and the Australian nursing profession to action designed to meet these goals. The Australian government is similarly committed by its 1979 endorsement of the WHO Global Strategy Health for A11/2000. However to date the major thrust of activities concerning health for all through primary health care has occurred in non industrialised countries, with an emphasis on preventing and treating disease. Industrialised nations have been slow to respond to the ? implications of their explicit commitment to WHO’s strategy.

The health needs of many Australians are not met by the existing health care system with its focus on illness, diagnosis and treatment. The existence of a strong medical infra structure means that only medical aspects of primary health care receive attention. On the other hand primary health care is a multi faceted approach which acknowledges health care as much more than simply medical care. This broader view of health is reflected in the value that is placed on health promotion and disease prevention, the adaption of technology to help people stay in familiar surroundings for as long as possible, and the integration of all aspects of care. The primary health care approach improves the availability and accessibility of health care, especially for isolated, deprived, and needy segments of the population. Its relevance is clear in the opportunity it presents to reduce inequalities in health by making better use of existing resources, and by improving the coordination, planning, delivery and assessment of health care services. In so doing the concept of social justice underlying WHO goals is realised. It should be noted that ‘JUSTICE’ was the watchword chosen by the President of ICN in 1985, towards which nurses should strive.

Although differences in political, economic, geographic and socio-demographic features lead to a wide variety of approaches ? implementation, the principles of primary health care remain the same wherever applied Primary health care incorporates recognise the relationship between all health professionals, as well as between professionals and lay people.

Explicit within the primary health care philosophy and approach is the realisation that individuals and families, through community participation, can become increasingly involved in planning, organising, delivering and processing health care. Primary health care has been viewed as one way to control costs of health and illness, costs largely attributed to the growth of highly specialised and technical services which are increasing exponentially. The need to find ways of cost containment is well recognised and emphasis on health rather than illness, and on community involvement within the primary health care approach rather than reliance on medical and other health professionals, is seen to provide one means of cost containment. However innovative projects, educational reforms and financial and legislative changes undertaken in piecemeal fashion will not by themselves lead to well established health systems based on primary health care.

The achievement of health for all through primary health care essentially requires restructuring of the health care essentially requires restructuring of the health care system and professional education and practice to correct the imbalance between secondary, tertiary and primary health care that currently exists in Australia. It means a redistribution of health resources so that essential health care will be accessible to all individuals and families in an acceptable and affordable way, and with their full involvement.

Health professionals will need to change their attitudes and expectations and be prepared to share knowledge and responsibility with consumers. These changes will not occur unless there are changes in the structure of the present health system, in the education of health professionals and in their general working conditions and professional practice approaches.

The introduction of a primary health care approach means a redistribution of resources and opportunities within society. It necessitates a redistribution of power within both health and local systems which inevitably threaten established practice within the present structure, possibly resulting in resistance to required changes.

A brief examination of the present Australian health and nursing system indicates the need for the above mentioned changes if Health For All/2000 is to become a reality in Australia. Secondary and tertiary structures are highly technological areas of treatment and support, with minimal development and integration of the primary health care structure. This system perpetuates the illness approach, resourcing the treatment of symptoms rather than illness prevention and health promotion measures, and its acceptance by a relatively passive consumer population further complicates the situation. Even in the area of domiciliary care, services are frequently restricted to those in ill health and without family support. For those with social and other human needs the rehabilitative and illness prevention functions of domiciliary services is largely ignored.

Government initiatives in Australia bear little resemblance to WHO’s global strategy which provides a framework for international and national action in pursuit of health for all goals through primary health care.

The Director General of WHO, Dr H Mahler, has stated that nurses lead the way in the shift towards health systems based on primary health care in which the accent is on the promotion of health and the care of people wherever they live, work, or play. He foresees the nurse’s role changing, with more nurses moving away from hospitals and other institutions to the everyday life of the community. In Mahler’s view, nurses will become resources to physicians. He believes nurses will increasingly participate in program planning and evaluation, and in interprofessional and intersectorial teams for health and development.⁶

Doris Krebs of ICN draws attention to the need for the nursing profession and individual nurses to fully understand the concept and approach, and to differentiate between such terms as primary nursing and nursing in primary health care.⁷ Primary nursing is concerned with the one to one relationship between nurse 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. ICN’s statement on the role of nursing in primary health care suggests the changes required in nursing education, practice and management to enable nurses to participate fully in health for all goals:

Nursing initiatives in support of Health for All/2000 goals in Australia similarly lack cohesion and a comprehensive framework for the development of nursing in primary health care. On the whole, nursing education and practice continue to support the secondary and tertiary care structures and to be dominated by the medical model of health care.

In some nursing education and community nursing programs, nursing models with an emphasis on primary health care have been developed. In some, the community is actively involved and various conditions contained in the WHO definition of primary health care are met. However, it is unrealistic to think that a few schools of nursing and some isolated nurses working in environments that favour the application of primary health care principles will have a significant impact on the development of a primary health care structure, or on nursing in primary health care in Australia.

Australian nurses now have a significant opportunity to assume a leadership role in pressuring for a changed approach at the national government level, and to demonstrate within their own system the nurse’s role in primary health care.

In the past, nursing personnel have contributed significantly to the care provided in the Australian health care system. Nurses need to ensure they have the ability to maintain this responsibility within a changed health care system. They need to be in the forefront of developments that will change the focus of care and integrate primary, secondary and tertiary care structures within an effective health care system that meets today’s community needs.