PRIMARY CARE

The challenges of a changing world

Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical Health Sciences, Hiroshima University

Sajeda Chowdhury, Graduate School of Biomedical Health Sciences Hiroshima University

Primary care is the day-to-day healthcare by a healthcare provider in comprehensive first contact. In this changing world, we are facing unprecedented demographic and epidemiologic transitions. Urbanisation, aging and globalised lifestyle changes lead to increase noncommunicable diseases with multimorbidity. The ultimate aim of primary care is better health for all.

Primary healthcare is the first level of contact of individuals and communities with the healthcare system. The Alma-Ata Declaration ‘Health For All’ is broadly accepted to be a precise statement of the principles of primary healthcare. With a few exceptions, it was observed that a number of countries adopted targets and expressed their commitments to primary health in order to improve the health services. This commitment has been assimilated into practice in various ways such as ‘Healthy People 2000’ in the USA, 'Targets for Health for all’ in the European countries, the ‘New Perspectives on the Health of Canadians’, and the ‘African Health Development Framework’ in the African countries. Regrettably many countries, particularly the poor ones have given marginal importance to the safety aspect of food production and supply chain, although the declaration of Alma-Ata recognised that the provision of food and proper nutrition are essential elements of primary healthcare. It has been observed that a number of issues like the environment, urban growth and rapid population growth that were not appropriately dealt with have since received considerable attention by the Alma-Ata Conference in 1978. Other relevant concerns are unmet needs of water supply and basic sanitation, and special needs of women and elderly people. However, 2.5 billion men, women, and children still lack access to basic sanitation services around the world. About 1 billion people continue to perform open defecation. An additional 748 million people do not have ready access to an improved source of drinking water, and hundreds of millions of people live without clean water and sanitisers that could facilitate the spread of diarrheal disease, the second leading cause of death among children under five. The major problem is inequality between and within countries in ensuring the uniform healthcare practices.

This article explains the challenges and changing nature of primary healthcare due to the changing global context. The world population trend is changing and increasing ageing rapidly. At present, the aged population is at the highest level in the human history. The proportion of the world's population over 60 years will be nearly double from 12 per cent to 22 per cent between 2015 and 2050. Ageing is the major cause of mortality in the developed world. In 2050, 80 per cent of older people will be living in low- and middle-income countries. A compounding factor of poverty will be the highest prevalence of disability among elderly in a population. The increase in the number of people with multi-morbidity is being recognised as a greater risk of adverse health outcomes with two or more chronic conditions. Countries facing these major challenges need to ensure that their health and social systems are capable of addressing this demographic shift. The growing urbanissation of this world’s population is projected to accelerate following increase in city slums and degradation of the environment. Therefore, special attention is needed to several critical issues, such as population growth, ageing, urbanisation, and the environment changes.

Undoubtedly, globalisation can be termed as an important factor in disease transmission around the world. Among infectious diseases, Human Immunodeficiency Virus (HIV) remains as the world's most significant public health challenge, particularly in low- and middle-income countries. Globally, an estimated 36.7 million people were living with HIV in 2015 with the vast majority in low- and middle-income countries. Although we are fighting for a Tuberculosis (TB)-free world, it is still one of the top 10 causes of worldwide death while HIV poses the greatest risk for developing active TB. Thus, TB is a leading killer of HIV-positive people causing a 40 per cent mortality in 2016. The alarming emergence of multidrug-resistant TB may ultimately advance toward the threat of an incurable epidemic. The current challenge is to end the TB epidemic by 2030, which is one of the health targets of the Sustainable Development Goals. In 2016, nearly half of the world population was at risk of malaria, causing huge burden and death, mostly in sub-Saharan Africa. The malaria situation has been stagnant in many countries; however, drug resistance of parasites and vectors to insecticides is becoming a major challenge. An increasing tension remains in developing countries between the promotion of primary healthcare and vertical diseaseorientation programs focusing on HIV, TB, and malaria.

Following the continued epidemiological transition, Noncommunicable Diseases (NCDs) are progressively replacing infectious and communicable diseases. Every year globally, 70 per cent deaths are caused by NCDs where Cardiovascular Diseases (CVDs) and Cancer remain as the number one and second cause of death, respectively. Most CVDs can be prevented by addressing risky behavioural attributes such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol by utilising robust strategies. To reduce the significant disability, suffering and deaths caused by cancer worldwide, effective and affordable programmes in early diagnosis, screening, treatment, and palliative care are prerequisites. NCDs are being recognised as an increasingly important problem for public health both in developing and developed countries. The prevalence of Diabetes Mellitus (DM) is known to be highest in some developing countries and among disadvantaged population groups and minorities in developed countries. As the treatment and management of DM cases are costly, the developing countries have to assess the feasibility of national control programmes seriously. Alcohol-borne diseases, mental illness, and drug addiction have also become a major concern. Early detection and management could reduce the risk and cost by providing primary healthcare. Prevention being better than cure, the emphasis should urge communities to promote healthy lifestyles and behaviour.

Lower literacy rate among women folks is another serious obstacle to health development. Numerous studies have reported the clear relationship between literacy, family planning, and falling infant mortality. The global average of immunisation coverage has remained stalled at 86 per cent with no significant changes during the past year. Widespread activities are needed to accelerate coverage to 95 per cent, such as availability of vaccines, weekend management of vaccination programs, and strongly motivating the health workers. Maternal, neonatal and child health is facing various challenges in many developing countries. Pneumonia and diarrhoea are still the leading causes of death among children under-five. A failure to breastfeed, malnutrition, measles, and HIV are related risk factors for frequent, severe or prolong episodes. Most of the maternal and under-five child mortality and morbidity could be prevented through the access of firstlevel care including immunisation, good nutrition, provision of safe water supplies and sanitation facilities. In industrial countries over the last three decades, the fall in the prevalence of breastfeeding, especially after three months has been becoming a threatening issue for child health as well as maternal health. Genital mutilation is traditional and cultural practices harmful to the health of women and children remain an important problem in a number of developing countries. A need for more integration between healthcare programs has been recognised, however, incorporating primary healthcare into development programs has never been easy.

Moreover, inequalities in health and healthcare between different ethnic, gender, social, and occupational groups remain a serious problem. Unemployment is increasing in most of the countries. Injury, violence, and crime are also increasing in some areas. War and conflicts in many parts of the world have spurred up migration and mobility, causing excessive suffering, disease induction, disability, and death. The threat of natural and man-made disasters such as floods, tsunamis, earthquakes, droughts, and the outbreak of new diseases also possess devastating effects on health. All of these factors contribute to the increasing social insecurity and stress around the world. Global attention to occupational health safety is also needed to mitigate the risk of diseases and injuries in the vulnerable and high-risk groups.

Another challenge for primary healthcare is resource allocation. A large portion of health budget with few exceptions goes to staff salaries, very little money remaining for medicine and operating costs. The cost of firstlevel care in Africa is nearly double in comparison to Asia, as well as hospital care is also higher. The maldistribution of health staffs and disproportions between various types of health staffs is the main problem in human resources. Huge variation in the ratio of nurses to doctors is striking in different countries. There is a great involvement of traditional health practitioners in the health system in many countries. Community health workers and volunteers are also engaged in primary healthcare services in several countries. The role of health personnel needs to be more precisely defined. There are limited funding, limited capacity and capability of healthcare providers ultimately leading to inadequate services. Training, incentive, motivation, improved remuneration demand necessary attention. More attention to teamwork, collaboration, and appropriate manpower mix can bring higher achievement.

Access to medical technology varies greatly; therefore, availability of qualified and reliable laboratory services is essential for diagnosis and treatment. One of the greatest challenges is to invent rapid diagnosis facilities in health centres of developing countries for lifethreatening diseases like AIDS, malaria, typhoid, Ebola, etc. Approximately more than half of people lack access to the basic radiological diagnostic services, although radiotherapy and nuclear medicine exist in many developing countries. There is still limited access to diagnostic techniques of Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scanners compared to developed countries. Many countries need to develop the institutional bodies for technology assessment.

The social determinants of increased health risk, such as poverty, unemployment, landlessness, remoteness, and urban slum environments, have been largely neglected. Health improvement for vulnerable and high-risk groups requires the approaches that designed to tackle the complex web of economic and political marginality. An integrated multi-sectoral approach is a prerequisite to obtaining access to health services, clean water and food for the empowerment of mass populations. Many projects have been reported with considerable success in this direction, supported by nongovernmental organisations. Technical cooperation in primary healthcare is a continued effort among developing countries that need seamless supports from multilateral and bilateral agencies.

Behavioural and health system research remains relatively weak in terms of investment in developing countries, which reflected in the poor planning and management. There are enormous problems in logistics management for health services. Along with haphazard operations, weak communications impose an additional constraint on logistics in the developing world. People in hardto-reach areas, have limited access to healthcare and often suffer from lack of resources, including trained health personnel. Quality assurance remains a major problem in many developing countries because of malpractice in disobedience and non-compliance with the standard operating procedures, poor commitment and inadequate capacity ultimately causing huge death and disability tolls. The future challenge will be to develop applied methods for solving with real problems and for improving health.

The term ‘health promotion’ has been used since the 1920s that incorporates both individual and societal action to ensure improved health. Health education is an essential element of primary healthcare and to comply with the promotion of healthy behaviour. However, health promotion strategies are still very challenging to implement, especially during crisis or disaster period such as Ebola outbreak or any form of natural disaster.

At the international level, primary healthcare is inevitably linked with concerns of economic equity, balanced world development, and international peace. Four basic principles are underlying the primary healthcare: 1) universal accessibility and coverage on the basis of need; 2) community and individual involvement and selfreliance; 3) intersectoral action for health, and; 4) appropriate technology and cost-effectiveness in relation to the available resources. Efficient and effective primary healthcare provides the best contribution to greater social justice and equity by reducing the gap between people with and without access to an appropriate level of healthcare. The appropriate level of information dissemination and motivation is the key to enhance community involvement in primary healthcare, for greater self-reliance. Health workers must be trained to acquire a better understanding of approaches that promote community participation. As per the practical implication of the primary healthcare approach, the healthcare system must be enabled to coordinate actions with other sectors at the appropriate level. The primary healthcare approach recognizes the value of technology, particularly when it can contribute cost-effective solutions to common problems (such as the cold chain temperature indicators). Increasing the cost-effectiveness and efficiency of health services is also required to make a positive transition in public resource allocation. The primary healthcare approach, which calls for greater community involvement, intersectoral collaboration, and the application of alternative technologies, will need more flexibility and a certain degree of decentralisation through new institutional arrangements.

Substantial progress has been created in the accomplishment of a number of the elements of primary healthcare. Globally as a whole, ageing population, increasing urbanisation, and the emergence of diseases and technologies are creating new demand on the healthcare system. The growing economies are impacting the rising cost of healthcare expenditure, which ultimately increases the concern of national economic competitiveness. Strong political commitment, community-participation, skilled providers, evidence-based medicine, and sound research are needed to tackle these challenges of the changing world through accessible, affordable, comprehensive and quality primary healthcare. It is high time to get prepared for systematic and scientific addressing of the upcoming primary healthcare challenges.

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--Issue 40--

Author Bio

Md Moshiur Rahman

Md Moshiur Rahman is an Associate Professor of International Health and Medical Care, Hiroshima University, Japan. He has outstanding academic credentials combined with experiences in public health, population and health science, research, administration, and leadership. He has more than 15-year experiences in health-related programs and researches in Bangladesh, Africa, and Japan.

Sajeda Chowdhury

Sajeda Chowdhury is a multidisciplinary Researcher at Hiroshima University, Japan. She has research experiences both in molecular biology and epidemiological field. Formerly, she worked as Lecturer of undergraduate medical students and Trainer of nursing students in Bangladesh. Her research interest included Hepatitis-B virus and antiviral candidates along with public health issues.