The Case for Primary Health Care

It’s 4:30AM. The sun isn’t up yet but Miss Dee is already making her way up the rocky lane to the main road of her community where she will catch the first ride going into town. In her purse she carries enough money for taxi fare both ways, two mint balls and a wrapped up piece of plastic with her tattered clinic appointment card and her last prescription. She will reach the clinic by 6AM so that she can collect one of the first numbers. When she arrives she is the third person there. They settle in to wait until 7:30 when the first security guard will open the gate.

Forty-one years ago in the city of Almaty, Kazakhstan, when Miss Dee was still a bright young girl, leaders from all over the world gathered to make a decision about keeping people healthy. The Declaration of Alma Ata, as it would come to be known, states firmly that primary health care is the key to achieving ‘Health for All’ – the universally accepted goal that promotes the health of all people.

Before we get into the nitty gritty, let’s get a few definitions out of the way. What is health, exactly? The World Health Organization defines health as “a state of complete mental, physical and social well-being, not merely the absence of disease or infirmity”. And they should know. This sounds like something everyone should have, right?

Health is a state of complete mental, physical and social well-being, not merely the absence of disease or infirmity

World Health Organization

Health for All‘ is the slogan for universal health coverage: no person or population gets left behind. Women, LGBTQ+, disabled individuals, persons living with HIV – everyone is included! Unfortunately, in some places, not everyone gets included all the time.

Now what is primary healthcare? This is a way of thinking about and organizing the different aspects of health care. Definitions of primary healthcare often make reference to essential health care and primary care (not the same thing). A primary health care system has a few key characteristics.

  • It’s based on principles that are scientifically sound, and socially acceptable
  • Primary healthcare is universal – it includes every single person
  • Primary healthcare aims to provide improved access to health services, financial risk protection and improved health outcomes

And finally primary care refers to those services that are delivered in the community (usually at a clinic or health centre) by doctors, nurses and allied health workers (also called primary care providers). These services are often someone’s first point of contact with the health care system.

So if primary health care is the key to achieving #HealthforAll, and if healthy people live better, stronger lives then investing in a strong primary health care system is the best and most cost-effective way to ensure a healthy, productive population.

Investing in a strong primary health care system is the best and most cost-effective way to ensure a healthy, productive population.

Remember Miss Dee from earlier? She’s not real, but her story is. This clinic-before-daybreak sojourn is the reality for a majority of citizens who access services at health centres (clinics) in Jamaica. People leave home early hoping that they will get through the clinic quickly. But in reality reaching clinic by 6AM doesn’t guarantee that Miss Dee will be finished before 10AM or even before noon. Depending on the type of clinic, number of patients, availability of staff or occurrence of emergencies, Miss Dee may end up waiting until 3PM or later before she’s seen by a medical doctor (her primary reason for going to clinic in the first place). And remember she only brought enough money for transportation – not for lunch – and she left home too early to have a proper breakfast.

Public health care in Jamaica is a running joke. Meaning, the kind of joke people run from. Letters to editors, prime time news stories, and overheard conversations complain about common themes like long wait times, rude staff, lack of resources, lack of space and limited accessibility. The feeling of the man on the street (who only complains to overburdened health care staff and never to his chair-cushioned and air-conditioned MP) is that average people, poor people, who need and use these services are grossly neglected. Politicians and the well-to-do get private, highly resourced health care but the woman on the street gets what the duck got.

So what actually is the situation? The Layman’s Doctor recently posted a guide for people accessing care at their local health centres, in which she specifically addressed the notoriously long wait times and cautioned patients to prepare for it. For people who don’t work in or don’t access care in these clinics, it can seem like another world.

There are large crowds on days when a doctor is present at the clinic, and often the seating provided is inadequate. As we approach the summer months, there is no air conditioning, and clinics in the country don’t always have fans installed. The patient to staff ratio is usually high, which further prolongs the wait time, and to top it off most health centres do not have a pharmacy attached. This means that after seeing the physician patients have to get their medication at another (sometimes inaccessible) location, that may or may not have all the drugs they need.

If you’re frustrated just reading this, you aren’t alone. Experts the world over have agreed that accessible and universal primary care is critical to improving health outcomes. That means that people with diabetes won’t get their legs chopped off, and people diagnosed as obese can be prevented from getting diabetes in the first place.

Primary care providers save lives

WHO, 2018

In their technical series on primary health care the WHO reviewed systematic reviews and meta-analyses from a broad sweep of countries. The results were unanimous. When it comes to people dying (all-cause and specific-cause mortality), there is strong evidence that supplying primary care providers (ie clinic staff) leads to less people dying overall. Primary care providers save lives, y’all. And strong evidence that continuity of care (meaning the same doctor, same facility or strong linkages between doctors and facilities) also leads to less people dying.

For people who care more about the bottom line, the same review also examined health system efficiency (ie best bang for the buck). They found strong evidence that a supply of primary care providers reduces the number of avoidable hospitalizations, and evidence that case management programmes (think social workers) could reduce the number of total hospitalizations as well.

And for the social justice warriors (because health care is a human right), there is evidence that primary care, as compared with other types of health care, can improve access to health services, especially for disadvantaged adults.

Full disclosure – most of these studies took place in English-speaking high income countries but the evidence can be translated universally. Read the full 28-page review here: The Economic Case for Primary Care.

So if you were Minister of Health and you had to decide how to spend the meager Health budget, how would you allocate the funds? In Jamaica there are no user fees for nationals at public facilities (this does not mean health care is free!), so all the money comes from you (and a few donor agencies). You have to keep hospitals open, keep clinics running, pay your staff, provide medication, refurbish and maintain equipment, buy resources and develop media campaigns that remind people to “love yuh body, treat yuh body right“.

What’s your number one priority?

If you guessed hospitals – then you’d be right. . . Right on the side of our current Health Ministry, which is the wrong side.

Hospitals are undeniably important to the delivery of health care. Secondary and tertiary centres (smaller and larger hospitals) are vital and necessary, but they are vital and necessary in the way that having a spare tire is necessary. They’re super important if you get a flat tire, but it’s way simpler and easier to invest your time in avoiding a flat tire in the first place.

Now I know what you’re thinking – “But I can’t control when I get a flat tire!!”. And I hear you, shit happens. You drop into a pothole on the North South highway and pow! Yuh haffi draw fi di spare. But suppose you were using your spare tire every single day? If you had to choose between keeping your tires in good condition and avoiding potholes or buying a really expensive spare tire (complete with repairing the damaged tire, and the loss of work time that it’s going to take you to get the tires sorted out) which would you choose?

I really want to know, so leave a comment with your pick. And if you’re one of those brilliant minds out there thinking that this wouldn’t have happened if the roads were properly maintained in the first place then congratulations, you’ve just hit on another pillar of primary care – multi-sectoral policy and action. Because there are a lot of other things in the world that impact a person’s health, not just access to health services.

What I’m trying to say in my long rambling way is that investing the bulk of health budgets into hospitals isn’t going to yield any long-term improvement in the health of the population. Hospitals are necessary to deal with emergencies but, as we’ve shown, having a strong primary care system means there won’t be as many emergencies. A robust primary care system can handle minor emergencies and prevent major ones, reducing the burden on the hospitals and other referral centres.

So back to Miss Dee. By pouring more time and energy and investment into making primary care stronger, better and more effective Miss Dee won’t feel compelled to leave her house in the pitch-dark pre-dawn, risking ankle and foot injury on the uneven road. She could get to clinic at 8:30 or even 9 for her appointment, do her checks and see the doctor by 10, then get her medication (for free) at the same facility and return home in time for lunch. If we invested the right way, with the needs of the patient at the heart of our activities then even if Miss Dee was a 16 year old lesbian seeking advice on safe sex, or an 80 year old blind woman in a wheelchair she would have the same access, protection and positive outcome.

Health isn’t just for the good of the individual, it’s for the good of the country. Healthy people are more productive, and more healthy working people means more GDP. It’s time for all our leaders to make good on their promise – ‘Health for All’ is a human right.

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Women’s Bodies Make the News (again)

Lately I’ve been spending my time taking deep dives into the arena of gender analysis. Holed up in a small classroom for 3 hours a week in a recurring debate on the privileges of the penis may not sound like your idea of fun, but to me it’s absolute heaven. Feminist intellectual stimulation, stinging repartee and a whole bunch of new words to add to my vocabulary. It doesn’t get much better than this.

But the perspective comes with a shadow, cynicism. The niggling fear that the status quo (which is far more pervasive and sinister than I realized) won’t ever change because so many people are invested in keeping it the same. The concern that despite our promises as a country and despite our claims as a society, the day to day culture of Jamaica thrives on the subordination of women and other non-masculine groups.

Close to my heart, the topic of healthcare: reproductive rights and abortions. Recently in the news again thanks to MP Juliet Cuthbert-Flynn (In 2018 I learnt a bunch of useless US politician names, maybe 2019 is the year I learn Jamaican ones) who tabled a bill to decriminalize abortion.

Not a bill to let women kill their children.

Not a bill to give women an excuse to be promiscuous.

Not a bill to hasten the decay in Judeo-Christian morals and values.

(all points that were raised and shot down)

The bill was tabled to allow easier access to safe abortions – because women are literally dying.

As I read the discussions helpfully Tweeted out by groups in attendance (the revolution will not be televised because there is no revolution), the points raised by pro-lifers kept circling back to the idea that women do not own their bodies. Their bodies must be offered up for the greater good ie having babies and if they die in the process well it would have been a worthy sacrifice. The MPs who responded challenged the speakers to provide data to back up their claims (they couldn’t) and questioned the right of the Church to make decisions for a pluralist society.

I happen to follow mostly ‘woke’ people on Twitter: feminists, LGBTQ folks and advocates, pro-choice supporters. So my news feed lulls me into the false sense of feeling like maybe the progressive bunch scored a win.

But then I see pictures of the pro-choice stand/march that happened before the debate started – a handful of lovely women (and men, and I think maybe non-binary persons too) clad in black with shirts and placards bearing slogans like ‘NO WOMB FOR PATRIARCHY” and “MIND YOUR OWN UTERUS”. Catchy slogans, very clever, but not a big crowd.

And then I take note of the Members of Parliament who they Tweeteed about actively participating in the discussion. Again, lovely people, but only three maybe four names are repeated.

And then I realize something. It’s great to feel like a part of a movement. It’s great to have people who agree with your values and outlook on life. It’s nice to be included (I get such a thrill when WE-Change retweets me). But the shadow, cynicism, clouds the warm fuzzy feelings.

Culture, society, Parlimentarians in the majority aren’t ready to allow women full control over their own bodies. We might get ideas. The road to change is long and hard, and it will probably continue long after we’ve passed on the torch. This ‘gender thing’ is a huge obstacle to human rights, social development and nation building. We gotta start looking at these problems fully cognizant of the biases and privileges we bring to the table. We have to stop accepting the status quo and start challenging it.

I gotta get off woke Twitter and start changing the world around me.


Just in case anyone was wondering (I was) – the only news article that spoke about this debate was a brief piece in the Gleaner that basically recounted an emotional story from a Catholic nun about overriding women’s choices for the patriarchy. You can read it here.