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.

Reflections and Re-purposing

It’s officially a year since I left hospital medicine and ventured into the clinics and primary care. Like Lot’s daughters I never looked back to watch the world I once lived in burn, almost literally. I’ve wholeheartedly embraced this strange new territory and I’m coming to think of it as my home.

There’s a lot going on with primary care in Jamaica. One news story just a few months ago reported on the high level of dissatisfaction patients have with the way service is delivered. Primary care is plagued by low resources, for a number of unfortunate reasons. And primary care as a system is badly fragmented. There are many gaps in this new world.

When I walked sprinted out of secondary care I did it with a vow in my heart: I would try as hard as I could to prevent the untimely deaths and strokes and heart attacks that were caused by manageable chronic diseases. I was eager, I was willing and I was hopelessly naive. Stepping into clinic was like being splashed in the face with cold water; determination would only take me so far, about as far as the burnt out bridges of patient behaviour and system capacity. My sprint slowed when I realized this could not be the only direction I expended my efforts in. I needed to study the system to understand how to improve it.

So I began to learn, as much as I could and as often as anyone would let me. I didn’t just start to learn about holistic patient care, I started reaching for every training session that passed my way. The closer I got to the source, meaning the Ministry of Health, the more I was able to identify the gaps between protocol and reality. We play a hard-core game of Chinese telephone with our standards that usually ends with the front-line health care worker simply doing the best they can with what they have. This system was a mystery I was determined to unravel, and that curiosity illuminated an unexpected career goal.

I love organization. I love rules and protocols and standards and guidelines. It tickles my fancy to improve system efficiency, to find innovative and easier methods to meet goals and targets. And as it turns out, all those things that people in high school called me weird for liking are actually super important to the world of work. Those skills and interests can translate into actual jobs, with the right qualifications to back them up.

So it seems that after all these years of worry about a loveless career I am now falling, stumbling, eagerly crawling toward a purpose that resonates with my own ‘weird’ frequency. Hurrah.

“Senior” House Officer: Doc, where’s my steth?

Firmly in the category of Things No One Asked For (wedged between merchandising coffee mugs and your annual pelvic exam) this one is all about how I spent my Senior House Officer year. If anyone is still reading this to get some idea about medical life in Jamaica, you’re in luck. Everyone else, bear with me.

For my SHO year (the second year of relative supervision, coming after internship and before postgraduate study), I spent four months at the hospital in Internal Medicine and eight months in primary care bouncing around the clinics of St. James and Hanover. I had wanted an even six month split but the powers-that-be changed the schedule from two six-month rotations to three rotations of four months each, likely as an incentive for doctors to spend at least some of their time in primary care (which is woefully understaffed).

While I enjoy solving the diagnostic mysteries of Internal Medicine and relish the mental challenges of our limited resource setting, I did not particularly like my time at the hospital. One of the reasons is the aforementioned limited resources, which made it exponentially harder to get the job done (the job being getting the patient better and out of the hospital) but another more important reason was the unhealthy and sometimes toxic working atmosphere.

Doctors in hospitals across the world have to battle against so many barriers to effective patient care. Sure there are administrative and technical hurdles, but one of the most damaging and pervasive problems doctors face is other doctors. We can be unkind and unsympathetic toward our colleagues, we can be harsh and critical where kindness and compassion are needed. We can be overly competitive, deliberately misleading, and frankly aggressive. Specialties often argue instead of cooperating, departmental heads are sometimes overbearing and the support staff is at times less than supportive.

I frequently left work feeling like I spent the last 8-36 hours running a hamster wheel, exhausting myself and getting nowhere. For all my efforts I was yet to see any noticeable improvement in the quality of care being offered, and in fact quality of care was on the decline as Cornwall Regional was on the brink of a crisis by the time I had moved to my next rotation.

Unlike its older brother, primary care has no pretensions about the level of care it is able to offer. Clinics don’t promise CAT scans and then tell you the machine isn’t working; or promise urgent lab results that take hours to be processed. Primary care understands that its role is to prevent and screen, to catch the life-threatening emergencies before they become life-threatening. And that pace is so far suiting me just fine.

Hanover is the smallest parish in Jamaica, splitting its geography between enchanting sea vistas and rolling hills of green green bamboo. I spent my four months here really sharpening my clinical skills and patient interactions. I honed my management of chronic illnesses and developed some much-needed confidence (from all the time spent in clinic by myself because there weren’t enough senior doctors available). Hanover’s narrow, winding roads are where I learnt to drive and the country clinics reinforced all the stories I hear about the generosity of rural folk. I was sad to leave it behind.

(Spoiler alert: I’m stationed back in Hanover for the foreseeable future)

The camaraderie and team spirit were like a breath of fresh air after Cornwall’s sometimes hostile overtones. I felt more comfortable offering care at a less urgent pace (even though we had our fair share of emergencies!) and I appreciated the opportunity to effect behaviour change before it got to the stage where tertiary or secondary care was needed.

Despite challenges with patients’ educational level and access to care I still believe that primary care is where our efforts need to be concentrated if we are ever going to make our country truly healthy.

But enough about me. SHO year is all about testing the waters and seeing where your passion lies. It’s about picking up skills you think are important and spending time with physicians or surgeons or anesthetists who you think can teach you a thing or two. Internship is merely meant to be survived; SHO is where you thrive. Attack the smorgasbord of hospital specialties like an all-you-can-eat buffet, or settle down to dine at one specialty for the whole time – it’s up to you. Just remember that along the way you’re molding yourself into the medical officer or resident who will be the ‘senior’ by the start of the next year.

What kind of senior do you want to be?

Reframing Misconceptions

I make a habit of naivety.

Not always on purpose, but often enough that even my super-oblivious brain has recognized the trend. In his more romantic moments, my current partner says that my optimism is the perfect antithesis to his cynicism. In less romantic moments, he expresses great concern about my intelligence.

Running headlong and heedless from hospital medicine into primary care with the half-baked hopes of “fixing Jamaica’s healthcare problem at the source” will not rank highly in my self estimation. And it was silly of me to think for a second that the only thing broken was the almost universal lack of health education among Jamaican patients.

I will probably never know how wrong I was, because I will probably never fully comprehend the multiplicity of the flaws afflicting the delivery and reception of our healthcare. From patient contact to policy making, I think there are a myriad of ways for either the system or the client to fail each other.

This is where my optimism wanes. I doubt myself. It’s one thing to be exasperated by a  health illiterate patient in the emergency department, mentally berating primary care doctors for not taking the time to have proper dialogue with their clients. It is quite another thing to be confronted by climbing physician:patient ratios, dwindling consultation times, and perhaps the most frustrating of all: repeat offenders. The patients who, despite adequate counselling and interventions, persist in their unhealthy behaviours.

Cynicism rolls in like a dark cloud, closely followed by the lightning storm of burnout. The horizon of my imagined clinical nirvana (where patients and physicians work together to help patients live longer, better lives) all but disappears.

And yet.

The dream of an effective and efficient health care system isn’t inherently stupid. Yes, I was foolish to think I could effect change just by wishing for it hard enough, but the bottom line is that change needs to be effected. And the nugget of reality at the core of my fantasy is the desire to be a part of that process.

If I just re-frame my ideas of how exactly health care reform will happen (a lot more meetings and red tape, and a lot less glitter and fairy dust), the cloud of cynicism drifts out of sight. It will be longer, more tedious and may not turn out quite the way I expect (like most adult dreams) but that is okay. I don’t have to throw away the dream, I only have to take it down from that lofty shelf and actually work at it.

It would be easier to be cynical.