primary healthcare

What Determines our Well-being?

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She is blind. Cataracts, or maybe glaucoma. Maybe diabetic retinopathy or some other word she will never be able to pronounce or even see. Her prescriptions are filled by a relative, at a pharmacy that only provides half the medication she needs, and brought home to her fumbling fingers. She makes her way to clinic unaccompanied, navigating footpaths and public transportation by memory if not sight. Arrives to hear that her blood pressure is elevated, and her sugar is out of control. Insulin, the doctor says. Never mind that she has not been able to get her Metformin pills for weeks and weeks. Never mind that she has no refrigerator. Never mind that she cannot see. Your sugar is too high and there are no more pills we can prescribe for you. Insulin.

He has HIV. Contracted from some faceless sexual contact long ago; he rages at the diagnosis, a short-sighted anger that settles on his most recent partner. But CD4 cells are warriors, and do not drop to 50 overnight. How could this happen to him? He disappears for months. Changes his number. Skips town. Grows a beard to hide the tattoos. Loses himself in alcohol and cannabis. Cannot forget. He returns on a hospital gurney, face drawn, spiking fevers. Newly diagnosed, the internist says. Never linked to care, the social worker corrects him. If he lives, he will join the clinic. Fire spent, bitter and resigned. If he lives.

What are the social determinants of health?

According to the World Health Organization, these are the conditions into which people are born, grow, work, live and age and the wider set of forces and systems that shape daily life.

In other words, everything. Your world as you know it determines how healthy you can or cannot be. If we were fish, social determinants would be our fish tank and everything in it. Which would be great, because we could just upgrade to a bigger tank with better water and a more efficient pump/filtration system and most of our problems would be solved. Except for food, I guess. I don’t know, I’m getting out of my depth.

Social determinants of health can be thought of as any feature of life that supports people being well or makes it more likely for them to get sick. Things like employment, finances, food supply, housing, education, clean air and water, transportation, and access to healthcare. The list goes on. If we take a curative approach and think of health as treating disease then the social determinants are all the things that get in the way of someone reaching the doctor, getting an accurate diagnosis, getting the right treatment and recuperating successfully. If you stop to think about it, there are a million ways this process can be thwarted.

As a field of significance, social determinants have been on the health agenda for decades, since the 1940s. But they were relegated to the back burner in favour of alternative (read: neo-liberal) approaches to public health. Finally in the early 2000s they were revived and examined more closely, giving us hard science on health inequalities across the globe. This is a prime example of the gap between people who make health policies and the people who live with them. I’m sure the man or woman walking into a doctor’s office could easily have easily told you that the reason they ignored that suspicious lump for so long was that they couldn’t get time off work to visit the doctor and they were trying to save up money to buy the medication but the children had to go to school. Social determinants impact health in real time.

When we think about our roles as medical practitioners (and here I can only speak for doctors) we imagine waving a stethoscope and pen to make people healthy. With the right investigations and the right remedies blood pressures will be controlled, diabetic feet will heal and that infection will clear up in no time. But the reality is that our ten-minute consultation is merely a blip in the busy lives of the people who access healthcare. Our brief contact can only do so much and no more. In medical school we are told in not so many words that you can lead a horse to water, but you can’t make him drink. But our patients are nowhere near the pond. They are on the other side of the hill, separated by hot coals, barbed wire and quicksand.

There just isn’t much exposure to the social determinants in medical school. Public health and primary care docs try to explain this complex and layered concept on two short Community Health rotations to students who care more about cramming for exams than pondering the barriers to care for Miss Ivy in rural St. Mary. But this feels like a failure of the medical education system. I’ve mentioned before that we can’t all be paediatric neuro-oncologists, yet medical schools consistently emphasize the rote memorization of esoterica as the most important part of being a doctor. We graduate into hospitals that perpetuate this idea of health as a binary: either you are ill (in the hospital) or well (not in the hospital), failing to recognize that health exists on a continuum that is constantly shifting in relation to the environment.

We have to shift our thinking to come up with new and better ways to preserve and promote wellness. We have to train new generations of physicians and allied health workers to look beyond the confines of their facilities to the communities where people live and work. Meaning the places where health actually happens (or doesn’t). We have to ask hard questions and be open to the answers. Until we are ready to grapple with the consequences of our societal systems and structures, we will never be able to reach our vision of “Health People, Healthy Environment”, not in 2030 or ever at all.

The Case for Primary Health Care

Robyn, , , , , , , 3 Comments

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.