I HAVE a broken record of writing on these pages about the importance of primary healthcare. Strengthening PHC is the only way to address our abysmal and many deteriorating vital health indicators related to family planning, maternal and child health, communicable and non-communicable diseases, and mental health. Readers are invited to read my article ‘Dubious distinctions’ published on these pages on Jan 13, 2023, to understand the tragic depth of the public health crises we are in. By not addressing these issues effectively we are endangering our future. Hence it is as much a national security issue as any traditional national security consideration.

Generally, people have a different and confused understanding of PHC and/or primary care. According to the World Health Organisation (WHO), PHC is an approach that combines three components. The first and central component consists of primary care, that is, first-contact accessibility, without any discrimination, to high-quality preventive, promotive, curative, rehabilitative and palliative health services and performance of essential public health functions, which are delivered in an integrated, comprehensive and continued manner. The second consists of the full participation of people in their healthcare. The third is multi-sectoral action to address the determinants of health that fall outside the health sector.

PHC is the lynchpin of Universal Health Coverage, as according to the WHO, the majority of essential interventions (90 per cent) for UHC can be delivered using the PHC approach. Our poor health indicators are a result of the lack of serious policy attention to PHC. Our state spending on health is among the lowest in the region, and whatever we spend, around 70pc goes on big hospitals. Tertiary-level hospitals are actually treating, at a very high cost, what we fail to prevent at the PHC level. We are not educating or training our doctors and other health professionals to serve at the PHC level nor we are providing enough incentives to them. An average medical graduate is never exposed to PHC settings. As a society with an elitist mindset, we have accepted PHC to mean poor healthcare for poor people.

Around 70pc of consultations and around 60pc of out-of-pocket expenditures are made in the private health sector. For most, these are catastrophic and impoverishing expenditures. Hence, any discussion about strengthening PHC in Pakistan has to include the private sector.

Boosting PHC would be solid advancement towards achieving UHC in Pakistan.

Where do poor people get healthcare in terms of the first point of contact in the public sector? Community health workers, BHUs, RHCs, public dispensaries, outpatient departments of tehsil, district and tertiary level hospitals. When they do not get satisfactory care at lower levels then they flood the OPDs of big hospitals. In the private sector, they go to homeopaths, hakeems, faith healers, GPs and OPDs of private hospitals.

Six critical steps that must be taken to strengthen quality PHC at the national level include the following:

First and foremost, we need to start educating and training our doctors and other health professionals about PHC. In the case of doctors, undergraduate curriculum reform is the need of the hour. Family medicine should be given due importance and properly taught to students. Our graduates should have a Bachelor’s degree in medicine, surgery and family medicine. Their hands-on training should take place in PHC facilities and community outreach programmes.

Second, all licensed medical and dentist colleges in Pakistan must establish PHC facilities of their own or adopt existing ones, in addition to their tertiary-level teaching hospitals. These teaching PHC facilities should not only act as PHC training facilities but also set standards of good practice and undertake research. It is crucial to link medical education and training to real healthcare needs on the ground by emphasising preventive and promotive health services. The recent PMDC decision to “play an active role in strengthening PHC in the country” is a long-awaited step in the right direction.

Third, each PHC facility should have a community outreach programme for a defined population for health education, prevention and promotion, including family planning support, with the help of community health workers.

Fourth, a well-thought-out incentive package, in cash and kind, should be developed for those serving in PHC facilities for a prescribed period of time.

Fifth, the Sehat Sahulat Programme now needs to be extended to GPs and not-for-profit healthcare providers at the PHC level in the country on a capitation basis. Certain minimal essential criteria will have to be developed for their empanelment. This is not only the best way to regulate private medical practice but also to ensure the implementation of minimum quality standards of practice through meticulous monitoring.

Sixth, digitisation of all health information and electronic medical records is a must to ensure the continuity of care with the benefit of hindsight, referrals and counter-referrals between different levels of healthcare and research.

Essential health service packages aligned with the burden of disease, telemedicine, a robust supply chain for essential medicines, vaccines and medical devices, diagnostics, and the supply of consumables, continuous training of staff, the appointment of a facility manager for each PHC centre and continued monitoring for quality are all critical elements of well-functioning PHC.

Imagine if all the above-mentioned six macro developments took place simultaneously and all elements were in place. We would be creating a quality ‘National Health Service’ in Pakistan, with full participation of the public and private sectors and quality PHC linked to the higher levels of healthcare, with a well-educated and trained health workforce, and with financial protection for those who cannot pay and other vulnerable people. This would be solid advancement towards UHC in Pakistan.

If we are genuinely concerned about the healthcare of the people of Pakistan then we need a paradigm shift on three fundamental issues: poor health indicators of Pakistan can never be changed through big hospitals; PHC does not and should not mean poor healthcare for poor people; and no national-level health reform is possible without the effective engagement of the private health sector, including the not-for-profit sector.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University, WHO adviser on UHC, and member of the Pakistan Mental Health Coalition.

zedefar@gmail.com

Published in Dawn, December 29th, 2023