By guest contributors Carmino Antonio De Souza, Clarissa Vasconcellos De Souza, Giuliano Dimarzio, Adail de Almeida Rollo, Aguinaldo Gonçalves, Rubens Bedrikow, and…
By guest contributors Steve Murigi, Dr Sentayehu Tsegaye, and Dr Matthew Harris
What is Primary Care?
Simply put, primary care (PC) is first contact care. Its principal function is to bring continuous, integrated, comprehensive and accessible health services as close as possible to the people. For many of us, and under usual circumstances, this is how we interact with the healthcare system for most of our lives. It will meet 90-95 percent of our health needs.
In the narrower sense, PC is ‘designed’ to treat and manage illness. In the wider sense, PC is a crucial part of the primary health care system (PHC) which extends to public health promotion, disease prevention, and safeguarding of good health and well-being in communities and at home. To draw on a more comprehensive understanding, we will follow the Organisation for Economic Co-operation and Development’s (OECD) description of PC as care that “addresses the main health problems in the community, providing preventive, curative and rehabilitative services. This account expands the meaning of primary from ‘first’ to ‘principal’.
While primary care, particularly for countries in the Global North, is usually provided at a located facility, and by a general practitioner (GP) or nurse, PC can be provided anywhere. In many parts of the world, PC practitioners will include other health professionals such as pharmacists and community-based networks of health workers. The physical bricks and mortar infrastructure is important but what makes PC effective is its foundation, connection, and trust with the community. It is this trust that enables primary care providers to support public health efforts in keeping people healthy outside of health facilities. Hence, PC is about caring for the health needs of people in places where they live, work, learn and relax.
The mechanics of PC also means that triaging patients and tackling a majority of the health conditions presented at the community level ensures that valuable time and resources are saved, safeguarding the entire health system and individuals from high/er costs.
According to the World Health Organisation (WHO), PC is a cost-effective model of care that aims to drive equity and reduce disparities among populations. This is a critical component for driving and achieving UHC.
Impact of the pandemic on Primary Care
The COVID-19 pandemic has had a significant impact on PC in particular and on the PHC system in general. Already stretched systems and PC providers had to scramble to provide care to surging numbers of COVID-19 patients, while simultaneously providing other essential and routine health services to other patients.
Without the availability of PPE for staff, and without spaces that supported the recommended transmission precautionary measures, such as distancing, reducing non-urgent hospital admissions was fitting as a temporary crisis measure. The biggest challenge, of course, was the knock-on effect on wider health-seeking behaviours and health utilisation. According to a study published by the BMJ, utilisation of healthcare services reduced variably by about a third during the pandemic. A study by the WHO affirms that disruption to essential health services was greater in lower-income settings. Patients who had to travel long distances, and at a cost, could not afford to be turned away or to wait for extended periods. Additionally, government lockdowns made it much more challenging for many, particularly those who relied on public transportation, to get themselves to health posts and clinics.
Whilst the full extent to which this disruption is yet to be established, a few emerging themes are of note. Firstly, the pandemic was more than a health crisis. It is/was a social and economic one too. Because of it, the global economy shrunk by 3.9% from 2019 to 2020. According to the International Monetary Fund (IMF), the economic cost of covid-19 is estimated to be $13.8tn from 2020 to 2024.
Secondly, not enough investment has gone into PC for a majority of countries. Even the most ‘advanced’ healthcare systems were caught out, lacking the appropriate tools and platforms to withstand the shock of the pandemic. An already underpaid health workforce was expected to do more, with less, as the rest of us cheered them on – virtually of course. From this, we have observed a universal problem of chronic burnout and demotivation in the PC workforce. – a physically and mentally exhausted workforce whose commitment was undermined by a lack of resources.
Thirdly, the pandemic exposed the inequity that exists within global health more widely. PC providers from lower-income settings were expected to be more resilient, and bare themselves for longer without the vaccine and without the PPE that would have allowed them to do their job more effectively, and safely. This while higher-income countries vaccinated their populations fully and rolled out booster programmes against the WHO call for a moratorium on COVID -19 booster shots. As of November 22, three in four people (72.79%) in high-income countries have received at least one dose of the COVID vaccine compared to one in four (27.18%) in lower-income countries.
Lastly, and positively, we saw an accelerated adoption of technology to provide care through telemedicine although there is limited evidence to suggest that this has broken economic and social barriers to care, particularly in low-income settings.
PC providers have had to reorient themselves to provide care and to maintain trusting patient-carer relationships remotely. Triaging of patients is increasingly conducted via a hotline, and preventive messaging rolled out in mass via mobile phones. Many countries including the UK, Kenya, and South Africa availed telemedicine abortion care under emergency COVID-19 procedures. A few, including England and Wales, made this provision permanent.
Support to healthcare providers was also done digitally. Providing them with real-time data and information, and creating platforms that allow transnational peer support, learning and collaboration.
What do we learn from this?
Future pandemics are inevitable. But we can prepare. We can save more lives and reduce the economic disruption that leads to poor health outcomes. Primary care is the proven thread that connects disease surveillance and response: facilitating detection, care and vaccinations.
There is a need for resilient health systems anchored in PC to meet unanticipated surges in demand while maintaining ongoing demand for essential services. This requires cross-cutting, multisectoral-sectoral effort and investment in health.
Health spending should be efficient, prioritising PC as a people-centred, biggest “bang for the buck” intervention, addressing the most challenges for the majority of the population and for the longest period of their lives.
To attract, retain and incentivise quality PC providers, investment in PC should prioritise increasing their numbers and the numbers of the community network teams that support them such as community health workers, availing tools and equipment, providing training, better compensation, and improving the conditions in which they work.
In addition, vaccine equity is not only the ethical and sensible thing to do from a health security perspective, it is the prudent thing to do from a global economic recovery standpoint. According to the WHO, “low-income countries could have added $38 billion to their GDP forecast for 2021 if they had similar vaccination rates as high-income countries.” By supporting WHO-recommended mechanisms and partnerships such as the Access to COVID -19 Tools Accelerator (ACTA), a global effort to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines, we can increase vaccination rates globally as our first line of defence for future variants and facilitate global economic recovery.
Finally, we should cautiously lean into remote and digital models of training PC providers and of providing care – to increase the number of providers and people accessing quality services. This however must consider existing and emerging access barriers to digital infrastructure and capabilities to not perpetuate and exacerbate existing inequalities. Only an inclusive digital transformation can lead to positive health outcomes. Implementation of the move to digital should centre those left behind the most, leveraging and fortifying conventional models of primary care.
About the authors:
Steve Murigi, Head of Programmes & Strategic Partnerships, Amref Health Africa UK (Incoming CEO for Primary Care International)
Dr Sentayehu Tsegaye, (MD + MPH + MBA-IB) Deputy Country Director, Amref Health Africa Ethiopia
Dr Matthew Harris, DPhil MBBS MSc PGCE FFPH, Clinical Senior Lecturer in Public Health Medicine, Hon Consultant in Public Health Medicine, Imperial College NHS Trust, Department of Primary Care and Public Health, School of Public Health