Malaysia is committed to attain the Sustainable Development Goals by 2030, of which goal three is to ensure healthy lives and ensure well-being for all at all ages.
Target 3.8 is to “achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all”.
The World Health Organization (WHO) states that “Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”.
Primary healthcare, primary care, general practice and family medicine are terms that have been used interchangeably.
Primary healthcare (PHC) was conceptualised in the 1978 Alma Ata declaration, and is defined as “essential healthcare based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford...
“It is the first level of contact of individuals, the family, and community with the national health system bringing healthcare as close as possible to where people live and work, and constitutes the first elements of a continuing health care process.”
Primary care (PC) is the care provided by a healthcare professional (HCP), for example, a doctor, dentist, nurse or pharmacist with whom a patient has initial contact and by whom a patient is referred to a specialist. In essence, PC is a subset of PHC.
General practice is a term that covers the general practitioner (GP) and other HCPs.
The GP is a doctor based in the community who manages patients with minor or chronic illness and refers those with serious conditions to a hospital.
Family medicine (FM) or primary care teams (PCT) comprise a core of GP(s) and nurse(s), but can be a multidisciplinary team comprising dentists, pharmacists, dieticians and so on.
The WHO defined a PCT in 2003 as a group of “fellow professionals with complementary contributions to make in patient care.
“This would be part of a broader social trend away from deference and hierarchy, and towards mutual respect and shared responsibility and cooperation”.
Primary healthcare and universal health coverage
The healthcare system involves more than human resource and financing considerations, which must be integrated into an overarching framework for the organisation and delivery of appropriate care for the population’s needs.
Such a framework is provided by PHC, which can be the foundation of an effective healthcare system that improves health, moderate increasing costs and lower inequality.
The interaction between PHC and UHC was stated succinctly by Thomas Hone et al in Revisiting Alma-Ata: What is the role of primary healthcare in achieving the Sustainable Development Goals?: “Firstly, with growing recognition that persistent health challenges require substantial health system reform, primary-care oriented health systems have become essential to increase appropriateness and efficiency, by focusing on people and their wellbeing.
“Strong primary care is essential to expand and sustain UHC, and UHC should promote equitable approaches to health system financing to support their reforms.
“Secondly, the importance of addressing the social and environmental determinants of health in relation to the UHC agenda has grown.
“There are concerns that UHC might focus too much on curative services, which disproportionately benefit wealthier populations. Embedding UHC within the broader vision of PHC is necessary to avoid such unintended consequences.
“Finally, PHC’s emphasis on equity and the right to health support UHC, and adopting and institutionalising these principles are prerequisites for maximising UHC.
“The benefits of reorienting systems to primary care will be dependent on coverage of the world’s most deprived and vulnerable populations. PHC is key to guaranteeing adequate and equitable coverage within UHC.”
The core principles of PHC, i.e. first contact, continuous, comprehensive and coordinated care, has been shown to be stable over time.
Lessons from many countries support the view that PHC is the route to UHC.
The Health Ministry participated in the UHC Primary Health Care Self-Assessment Tool jointly developed by the members of the Joint Learning Network for Universal Health Coverage Primary Health Care Initiative.
This was a multi-stakeholder survey to help countries assess whether their national, state or district health financing approaches are well aligned with primary care initiatives, efforts, and programs.
The salient findings of the report, published in June 2016 were:
• PHC is a main priority in national health policy and plans.
• Private sector facilities lack awareness and training on current national health priorities.
• Misalignment between PHC policy and service provision. Although private PHC facilities provide 51% of outpatient services, the type of services was not aligned with PHC priorities.
• Whereas PHC has a central focus in health policy documents, secondary and tertiary healthcare services receive the majority of health resources.
• Payment mechanisms in public and private facilities do not offer incentives for providers to deliver preventive care.
• Public health services have a good referral system, but not the private sector.
• Lack of human resources in public PHC clinics is a key barrier to achieving PHC objectives, particularly in rural areas.
• Insufficient training for PHC, particularly for private providers.
The recommendations included the creation of a communication strategy to engage the private sector and improve the integration between public and private sectors, and the provision of training and support to private primary care providers to strengthen their capacity and capability to deliver preventive services.
The tool was validated and found to be a useful instrument to identify key alignments and misalignments between UHC and PHC.
The study team presented its findings to the Health Ministry and the Government “is using the findings of this report to inform ongoing health financing and system reforms”.
However, there is a chasm between the words in an international report and the reality on the ground.
Although private registered medical practitioners (RMPs) provide more than half the primary care for the population, they are unaware of initiatives by the Health Ministry to address the PHC misalignments.
The private RMPs have provided and continue to provide cost-efficient and patient-centric services, usually in a one-stop patient-friendly facility, with choice, accessibility and affordability not a major issue.
Crucially, they have ongoing relationships with patients, as compared to their public sector counterparts.
The failure to seek the active involvement of private primary care providers is, at best, perplexing, and at worst, irresponsible, especially when Malaysia ranks 84th in the Global Health Quality and Access Index, behind Singapore (22nd), South Korea (15th), Brunei (53rd), Sri Lanka (71st) and Thailand (76th).