Primary health care has an important role to improve the health status of the entire community. (Image source: Doc. PUSPA)

Jakarta, 25 May 2022 - The COVID-19 pandemic showed primary health care (PHC) played a substantial role in reducing the pressure on the health system, one of which is preventing mortality. Thus, the focus of PHC needs to be addressed directly to the community in order to optimize the prevention and treatment to COVID-19 patients.

Introduction to PHC

Health care is an effort to maintain and restore physical, mental and emotional health through professional health workers. While primary health care is health services that are closest to and easily accessible to the community. There are many forms of PHC in Indonesia, namely primary clinics, practicing midwives, and puskesmas (community healthcare).

WHO defines primary health care as essential health services that are practical and scientific. Methods and technology in service are also socially acceptable and easily accessible to individuals and society.

Every person and community has the right to live a healthy life that includes physical, mental and social well-being. To build a healthy life, it has to follow a whole-of-society approach where health services are expected to provide health promotion facilities, disease prevention, treatment, rehabilitation, to palliative services when a person can no longer be cured.

First PHC in the world

WHO first proposed the concept of primary health care in January 1975. (Image source: Reuters)

The WHO Executive Council first proposed the concept of primary health care through a study in January 1975 which outlined seven principles that governments should follow to improve the quality of healthcare:

1. Providing healthcare that are easily accessible in the community
2. Involving local communities in health efforts
3. Optimizing local community resilience in health issues
4. Ensuring the availability of health promotive, preventive and curative efforts in a health service
5. Providing human resources who are trained to provide health services closest to the community
6. Providing an environment that supports health efforts closest to the community
7. Integrating public healthcare with other sectors of life.

In 1978, the concept of primary health care was officially declared through the Alma Ata Declaration in Kazakhstan. There are 134 members of the World Health Assembly (WHA) and the World Health Organization (WHO) who have ratified the declaration.

For the first time the world acknowledges inequality in access to health, which later agreed on the concept of "health for all" as the main principle and goal of creating a healthy society in member countries.

After the Alma Ata Declaration, in 1986 the Ottawa Charter for Health Promotion, Canada, was signed. The Charter agrees on achieving health for all through health promotion or non-medical measures, where individuals are expected to be able to identify, make ends meet, and change the environment to avoid all forms of health problems.

The response by world society

The Alma Ata Declaration, the beginning of the concept of strengthening primary health care, has often been criticized. Although this declaration describes steps to strengthen health care at the closest level of society, the approach is considered too idealistic and unrealistic.

Facilitating access to public health worldwide is extremely difficult, let alone to achieve it by 2000. Some say that strengthening primary health care should first focus on the situation of certain diseases in developing countries that can be controlled, not just focusing on equal access. 

Moreover, there is also political resistance. The Investing in Health World Bank (1993), reported that the state should focus on effective and economical services with a minimal role. The aim is to form competition for health care providers. According to the document, the government does not need to focus on providing easy access to health care. Instead, they need to promote competition in financing services and health insurance so that health services run optimally.

Our Primary Health Care, how is it that we have now?

Puskesmas is one form of primary health service in Indonesia. (Image source: PN PRIMA)

On the 30th anniversary of the 2008 Alma Ata Declaration, WHO launched The World Health Report: Primary Health Care: Now More Than Ever (WHO, 2008) to encourage the improvement of health care. The document outlines 4 important things:

1. Ensuring equal access to health. The state is expected to ensure that all members of society can enjoy access to the best health regardless of personal or financial background.
2. Ensuring a human-focused health system. The state must ensure that every member of society achieves a state of mental, physical or social health. In addition to improving the quality of human resources or medical devices.
3. Increasing the responsibility of those who manage health care. The state needs to ensure that all health service providers provide equal access to all members of society without exception.
4. Facilitating public policies to promote and protect public health. The state needs to facilitate appropriate public policies and support public health by upholding the spirit of equality and human rights.

Two years after the launch of this report, WHO launched the World Health Report: Health System Financing: The Path to Universal Coverage. Universal health coverage (UHC) is a health service system that guarantees that all people have access to quality health care without any cost barriers. The UHC concept is WHO's commitment to strengthen primary health care and protect the public.

Why is primary health care so important?

Primary health care, such as puskesmas, emphasize the importance of promotive and preventive efforts. These two efforts aim to prevent the number of hospitalizations and reduce various forms of costs, especially those included in the national health insurance system through BPJS Kesehatan. Thus, it benefits people with middle and low socio-economic levels. It also promotes equal access to quality health care so as not to discriminate against the community financially.

In recent decades, investment in primary health caree has also focused on improving health care. Countries are expected to increase investment in human resources and health technology. PHC is expected to be easily accessible, but of high quality for the public.

Which countries have succeeded in strengthening primary health care?

Strengthening PHC takes the government's work to fix various aspects, such as political commitment or infrastructure. Even so, the following two countries succeeded in increasing their public health level through strengthening PHC.

First, Thailand.

The land of white elephants mentions “primary health care” in their constitution. The government of this country allocates a large budget for their primary healthcare to reduce the burden of hospital care.

The government has also trained more than one million health cadres to collect data, educate and assist the community in health efforts. The government also conducts collaborations between ministries and universities to develop curricula for health workers, research, and policy evaluation. As a result, Thailand has succeeded in improving various health indicators. From 1990 to 2006, the country managed to reduce the mortality rate of five year olds by 8.5% each year.

In 2002, this country was recognized as successful in facilitating access to health for the whole community. They also became the first Asian country to successfully eliminate mother-to-child transmission of HIV in 2016.

The Saúde da Família program is one of the Brazilian government's efforts to strengthen primary health care. (Image source: PN PRIMA)

Second, Brazil.

Brazil optimizes the role of health cadres through a program called Saúde da Família or Family Health Program. The family health team consists of doctors, nurses and four to five health cadres.

These teams are organized in district-level facilities equivalent to puskesmas and serve between 3,000 and 4,000 people in each area and have successfully assisted 65% of the Brazilian population. 

Several agendas were carried out, such as recording the community's routine health history, carrying out health education, and in an outbreak, tracing cases. This agenda contributed to increasing the achievement of antenatal care for pregnant women, the achievement of immunization of pregnant women, and reducing the number of hospitalizations for diabetes patients.

What should the government do to strengthen primary health care?

It is time for Indonesia to strengthen PHC as those carried out by the governments of Thailand and Brazil. Given that Indonesia has more than 10,000 puskesmas, strengthening them is a meaningful investment in public health.

CISDI as a non-profit organization that focuses on health policy issues consistently implements various efforts to strengthen PHC. Through the Pencerah Nusantara (PN) and Puskesmas Terpadu dan Juara (PUSPA) programs, CISDI seeks to improve puskesmas services by sending multi-professional health workers.

CISDI was also involved in compiling a research report on the future of primary health care in Indonesia through collaboration with AIPI for policy advocacy.

The government is expected to be able to implement good practices in strengthening PHC through research, program implementation, and optimizing available puskesmas resources. Moreover, it can be initiated by strengthening political commitment to increasing the allocation of the health budget for PHC.

About CISDI

The Center for Indonesia's Strategic Development Initiatives (CISDI) is a non-profit organization that encourages the implementation of scientific evidence-based health policies to create an empowered, equal and prosperous Indonesian society with a healthy paradigm. CISDI carries out advocacy, research and program management to achieve transparent, adequate and equitable governance, financing, human resources and health services.