Primary Health Care's Role in Strengthening Health Systems - A Review

This essay critically examines the pivotal role of Primary Health Care (PHC) in strengthening health systems, providing a detailed overview of its significance. The essay begins by defining PHC according to the WHO and highlighting its comprehensive approach to healthcare, emphasizing its focus on the social, physical, and mental well-being of individuals. It then explores the importance of PHC in addressing health risks, reducing healthcare costs, and promoting health security. The discussion extends to the challenges faced in implementing PHC, including the gap between healthcare providers and the need for more professionals, and the issues of health care professionals' satisfaction with their jobs. The essay also examines the Alma Ata Declaration, its principles, and its impact on PHC, including the shift in global health policy. It assesses how attitudes towards PHC have evolved over time and considers the relevance of the declaration in relation to the Sustainable Development Goals (SDGs). The essay uses the case study of the United States to highlight the importance of primary health care in delivering healthcare at lower costs and improving health outcomes, emphasizing the need for nations to prioritize primary care to experience effective change in health care systems. The essay concludes by assessing whether and in what ways the relevance of PHC has been appropriately updated and reassessed since the original Declaration, over 40 years ago.

Running head: HEALTH CARE
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Title: Primary Health Care

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Introduction
According to the WHO (2019), primary health care is health centred approach on the
needs of the society. Primary health care focuses on the health determinants and the
comprehensive aspects of mental, social and physical wellbeing. Primary health care provides
a person’s health care needs throughout their life and not just for specific infections but all. It
ensures that a person receives quality and comprehensive health care from prevention and
promotion to rehabilitation, treatment and palliative health care. Primary health care is built
to uphold equity and social justice in the society as it I rooted on the human fundamental
rights (the right to one’s adequate health care together with his family, and also includes
social services housing food and clothing). There has been different interpretations and
definitions of primary health care by different scholars and researcher depending on different
contexts (De Maeseneer and Twagirumukiza, 2010). Some think it’s the provision of
ambulatory health care services. Some understand it as a priority health care for people with
low income (selective primary health care), while others take it as an integral part of human
development that focuses and embarks on the political, social and economic aspects of life.
Place of PHC strengthening
WHO defines primary health care as the act of empowering the society by perfecting
their health so as to meet and promote polices that advocate and promote the people’s health.
They also think primary health care as the systemic dealing with health determinants through
actions and policies in all relevant sectors. Primary health care is important in that is placed
that it should respond and take care of all types of changes (including social, technological,
demographic and economic changes) in health and wellbeing. It encompasses a varied range
of stakeholders who come together to look into, examine and change economic, commercial
and social police that determine health and well-being. It is the most appropriate, efficient

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and effective means of addressing health risks and handling challenges that emerge to
threaten health in the present and days to come (van Weel et al. 2016). Quality primary health
care is an investment as it reduces health care costs and increasing efficiency by reducing
costs incurred during hospital admissions. Primary health care helps improve and promote
health security. This is through preventing health threats such as antimicrobial resistance by
engaging the community in health education and setting public health functions. Strong
primary health care helps achieve goals beyond health such as reducing hunger and poverty
levels, upholding gender equality, increased dependence, work and economic growth,
attaining gender equality, sanitation and clean water (Kumar, 2018).
According to Bates (2010), primary health care in most nations is very expensive as
compared to the quality of the health care services delivered. With this expensive health care,
according to research my Sandy, Bodenheimer, Pawlson and Starfield (2009), US records the
highest death rates per 100 000 people, with this mortality rate being more than twice that of
France who spend almost half of what the United States spend. This case, which appears not
only in the United States but also in many other countries in the world, is associated to
governments failing to put more emphasis on primary health care within the primary health
care setting. Focusing on primary health care helps delver primary health care at lower costs.
Taking an example with the United States, their primary care rating is very low as compared
to other developed nations. The United States believes on a different theory on how the
primary health care works. They think that increasing the number of health care professionals
would reduce the mortality rate but Jeffe, Whelan and Andriole (2010) think that there exists
no such a relationship. Therefore, if nations have to experience an effective change in health
care systems in terms of low costs and high quality health services, they have to pay more
emphasis on primary care.

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Recently, health care systems are experiencing a large gap between health care
providers present and the number that should deliver primary health care in the society. The
key problem here is who is to deliver the primary health care. Most governments anticipate
that the midlevel health care professionals be part of the solution, however, due to the
complicated nature of primary health care especially for patients having chronic health
infections, physicians would be an integral part of the health care team. Family medicine,
general internal and pediatrics mostly form the health care team though in the recent days
medical students have been included in the team for a number of reasons. The gap existing in
primary health care make it more imperative to explain the issues surrounding the health care
arena. Issues like health care students would choose primary health care other than other
health care fields, how health care professionals are satisfied with their current practice and if
the health care providers are willing to continue offering primary health care (Bylsma,
Arnold, Fortna and Lipner, 2010). According to Bylsma et al. (2010), who researched on the
issue of more interns taking primary health care, found out that at midcareer, health providers
would leave the GIM than any other field and that most of the health care are not satisfied
with their role as compared to other health specialists. Their main reasons of leaving was due
to change of interests and to taking advantage of other preferred opportunities, though they
were not leaving for smaller practices.
It is now clear that if health care is to change in most nations, then there is need for
more primary health care organized in a way that those delivering the care service are
satisfied with their practice. This is because a few of the health care professionals are
satisfied with the practice or services they are offering. Efforts by most governments and
stakeholders including increasing the payment for primary health care providers and
promoting and supporting home demonstrations has been thought to increase nurses’
workforce, though Davis, Schoen and Stremikis (2010) argued that these strategies may not

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be enough to increase the health care professionals workforce. To revitalize primary health
care, according to Reid et al. (2009), there certain issues that must be addressed well. These
include giving a better pay for primary health providers than the health specialists and change
health care practice to a more rewarding primary health care. On the payment of primary
health care versus health care specialty, this could be handled by giving a more pay to health
care providers or giving less to health care specialists. Decreasing the specialty pay
(addressing the United States in particular) would seem inappropriate and unpopular with
most health care societies, where specialty pay is very high as compared to that of health care
providers. This could be achieved by allowing a gradual increase in the primary health care
pay, to a point relative to the medical price index. At more crucial levels, the primary health
care has to leave the free for service strategy, though could take time and face much
resistance (Reid et al. 2009).
Landon, Gill, Antonelli and Rich (2010) think that if primary health care is to be
made more satisfying and attractive, governments and relevant authorities must employ more
technology such as the electronic health records. This could face a couple of challenges as
transition do not go smooth due to different challenges according to Fernandopulle and Patel
(2010). However, regardless of the challenges that could come up these technologies make
the primary health care delivery easier. Taking for example the electronic health record, tasks
like making calls and giving prescriptions are made easier and also a health care provider can
deal with many clients other than just one patient. However, according to Bates and Bitton
(2010), the current ERMs are not installed with all that is needed for medical home, such as
registry roles and decision making support for chronic issues. This presents an opportunity
for the general health care interns who are thought to be more passionate in primary health
care. They would help build and evaluate these tools.

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The Alma Ata Declaration and how it has overseen change in PHC
Rafkin (2018) thinks that over centuries people did not recognize the importance of
health until the 20th century when people understood health as an important social
determinant by formalizing this in to a policy. This was done by the members of the WHO,
who came in to a conclusion that good and quality health care would lead to good access to
social services, better levels of education, economic and social stability and the ability to
make individual and political decisions and choices. According to the Alma Ata Declaration,
it the government’s responsibility to ensure that her people are healthy and this is achieved by
providing sufficient, adequate and quality health care and social measures. The declaration
gives the citizens the right to take part (either as a group or individually) in planning and
implementation of their health care. With support from the WHO member states, the
declaration put forward the Primary Health Care policy whose aim was scientifically,
practical and socially sensitive ways. Technology was to be made accessible to every member
of the community and at an affordable to maintain by every member state. The declaration
brought a new phase of health whereby quality health was now considered as a human right
supported by principles of community participation and equity (George, Mehra, Scott and
Sriram, 2015). Despite the challenges faced in implementing this policy in the early stages
due to some traditions among the member states and also due to neoliberal economics which
continued to be embraced by member states, it eventually took roots.
According to Rifkin (2010), the historical hierarchy of public health care has been
faced by challenges making it complex. The Alma Ata Declaration came in at a time when
many of the nations were dealing with the World War I and others were experiencing the
injustice of the prewar period after relinquishing their colonies. Due to this commitment the
United Nations was formed in search for justice, especially for the developing nations who
were just attaining their independence. The implementation and attainment of this policy was

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faced by challenges such as lack of capacity and the will to uphold equity and fair distribution
of existing resources. Tis was clearly manifest during the period of oil crisis. The IMF and
the World Bank showed concern with the developing nations and they gave loans on strict
conditions on the usage and payment of the loan (WHO, 2018). These loans were specifically
to be used in economic development. In 1993 they came up with a strategy of Investing in
Health whereby cost effectiveness was considered important to improve and promote health
care delivery. At the start of the 21st century, there was more focus on health as the focus was
now more directed to treatment, curing disease and preventive measures. There was a shift in
global health policy from comprehensive public health care which was associated with social
health determinants to a strategy that vertically focused on diseases. This recent approach did
not address equity, community participation and social justice.
In 2008 the WHO came up with two health agendas, one of them being the Primary
health care. This focused on reforms such as improving health equity, making health service
more patient centred, reforms that improved the accountability of health care authorities and
strategies to protect and uphold the health of the society (Labonte and Stuckler, 2016). The
second in these agendas claimed that social health determinants were important in improving
people’s health. This report focused on addressing health care inequalities (as they claimed it
was an ethical imperative) and social injustice, which led to mass killing of people. In 2010, a
financial crisis occurred that changed the orientation of pursue for primary health care and
focused on curative health care. This was influenced by different foundations who financed
this initiative and had more money than the WHO. This eroded the core agenda of the
primary health care as a human right and made the WHO major with a single agenda of
universal health care that focused on equity. Between 2010 and 2017, universal health care
became the slogan and mantra for WHO, which was built on respecting and maintaining
equity and human rights.

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The 4 decades of Alma Ata Declaration have been faced with failures and successes
in implementation of policies. These experiences have shown the complexity and challenges
in the growth and transition of a visionary policy to its practical application. In the early 190s
and 1980s the effort to expand primary health care was faced by different challenges
especially in the developing nations. These challenges according to Gillam (2009) included
economic crisis, political unrest and emergence of new diseases. In market oriented nations,
the declaration was not embraced as they claimed due to their political and social goals.
According to Bishai and Taylor (2018) the Alma Ata Declaration was a miracle that brought
in to the global health moments of transformation. Through this declaration individual
nations are able to appreciate and understand that health care is not just a simple transaction
between the patient and health care provider but involves total participation of the community
in addressing health care issues such as education, food and housing. This declaration has
been linked with a lot of benefits in the nations who applied the Alma Atta approach to
design and build their health care systems (Mubyazi and Hutton, 2012). The Cuba
government has been able finance health care home visits and organized forums and
committees who have helped health care providers in understanding the present and future
health care threats and coming up with ways to respond to these threats. In different member
countries, primary health care has helped in the selective distribution of health resources and
commodities including vaccines, antivirals and contraceptives.
Relevance of Alma Ata Declaration over the past 40 years
According to Birn (2018) much has changed and attained in the 4 decades of the
Declaration of Alma Atta and still the declaration remains a reference in terms of health
human right for both the developed and developing nations. Primary health care has been
largely appreciated in Europe and with the United States diluting the primary health care to
coordinated medical care. The declaration has helped developing nations to initiate

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privatization and liberalisation of health care. For some time now, these nations are
experiencing the entry of the private health sector as partners in the public health. Most
governments are also in support of the private health sector.
Despite many achievements, this declaration has faced many challenges. Primary
health care was the main vision for the Alma Ata declaration (WHO, 2017). This goal was
accepted by the member nations but with time there grew confusion on the implementation of
this initiative. This vision was understood and translated primarily as the provision of health
care in industrial nations. In the United States, it was understood as an entry that addressed
new issues and health needs by providing patient centred care. This initiative faced
challenges in the evaluation of health care interventions (Atkinson, Vallely, Fitzgerald,
Whittaker and Tanner, 2011). Policy makers and health care providers saw primary health
care as intervention designed to improve the world’s health status. For this reason the
successes and failures of the policy makers and health care providers was measured based on
the framework that accessed biomedical interventions. However researchers highlighted the
weaknesses of this assessment which include the approach defining a linear process which
could be generalized and predicted. Other challenges included difficulties in search for
equity, poor contribution towards community participation and difficulties in financing the
primary health policy.

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