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 Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 1-3

Time to deliver: accelerating more equitable access to better quality primary health-care services in the WHO South-East Asia Region


1 WHO Regional Director for South-East Asia, New Delhi, India
2 Director, Department of Health Systems Development, WHO Regional Office for South-East Asia, New Delhi, India

Date of Web Publication4-Apr-2019

Correspondence Address:
Phyllida Travis
Director, Department of Health Systems Development, WHO Regional Office for South-East Asia, New Delhi
India
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DOI: 10.4103/2224-3151.255341

PMID: 30950422

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How to cite this article:
Khetrapal Singh P, Travis P. Time to deliver: accelerating more equitable access to better quality primary health-care services in the WHO South-East Asia Region. WHO South-East Asia J Public Health 2019;8:1-3

How to cite this URL:
Khetrapal Singh P, Travis P. Time to deliver: accelerating more equitable access to better quality primary health-care services in the WHO South-East Asia Region. WHO South-East Asia J Public Health [serial online] 2019 [cited 2019 Jun 15];8:1-3. Available from: http://www.who-seajph.org/text.asp?2019/8/1/1/255341



This issue of the WHO South-East Asia Journal of Public Health coincides with World Health Day 2019, which falls midway between the 2018 Global Conference on Primary Health Care and the forthcoming United Nations General Assembly High-Level Meeting on Universal Health Coverage in September 2019. The theme of this year’s World Health Day is again universal health coverage, this time with more focus on health equity and solidarity and on addressing gaps in health services through primary health care.



There is now a near-tsunami of global, regional and national political commitment to universal health coverage, which by definition is about equity.[1] This has been reinforced by the reaffirmation of the 1978 principles and values of primary health care of the Declaration of Alma-Ata,[2] in the 2018 Declaration of Astana.[3] There is also plenty of evidence that well-functioning primary care is equitable and efficient. Front-line services tend to be geographically closer to patients than hospitals, especially in more remote areas.[4] The majority of a person’s health needs throughout their life can be delivered by well-functioning primary care services,[5] and the economic case for primary health care is based on sound evidence.[6]

But the fact remains that in the World Health Organization (WHO) South-East Asia Region, while essential services coverage has improved in the last 10 years, major inequities remain.[7] Over 800 million people still do not have full coverage of essential health services. In-depth equity analyses in the region are limited but increasing, such as the 2017 study on health inequalities in Indonesia, which found significant inequalities on 11 health topics across eight dimensions of inequality, namely economic status, education, occupation, employment status, age, sex, place of residence and subnational region.[8]

One challenge is that use of front-line – or primary care – services is commonly quite low; it is often still associated with low-quality care, especially for women and children, and with services for the poor. Bypassing is common – even by the poor: the District Level Household and Facility Survey 2012–2014 in India found that 51% of households, poor as well as rich, bypassed their nearby public facility for usual care, with quality being a major concern.[9] Poor-quality care is now a bigger barrier to reducing mortality than insufficient access, according to the recent Lancet Commission report on high-quality health systems.[9] Improving access to poor-quality services is by any standard ineffective and wasteful, as well as unethical. The bottom line is that, to tackle inequities in health and health care, the quality of health care has to be addressed.

Given this situation, how should we see the future role of primary health care in South-East Asia, in the context of the 2030 Agenda for Sustainable Development[10] and the desire to “Leave no-one behind”?[11] How can the current political momentum around the Sustainable Development Goals, universal health coverage and primary health care be used to make more progress on reaching the most vulnerable? What should we be doing differently with existing and new resources, given the rapid changes in the region: in health needs, in people’s expectations, in available technologies, and for new vulnerable groups such as the urban poor and migrants, alongside the long-recognized vulnerable – those who are poor or less educated, those with stigmatizing health conditions and others? As always, this is both a political and a technical agenda. This editorial highlights four areas for action.


  Front-line services need to shift from episodic low-quality care to continuing, high-quality care Top


Front-line services need to respond both to new demographic and epidemiological challenges and to changing relations between service clients and service providers. They have to move beyond episodic care for women and children. Noncommunicable diseases and the multiple pathologies of ageing populations are increasingly part of the primary care case-load and require continuity of high-quality care. These tasks cannot just be added on to existing undertrained and underresourced front-line health workers. It is encouraging to see the growing number of new service-delivery models being introduced in countries in this region. It is imperative to begin now to document the difference these are making, to address access to needed, adequate-quality health care, especially for those “left furthest behind”.


  Front-line and hospital services need to be addressed together, along with managed engagement of private providers Top


Primary care can no longer be seen in isolation. Under-used front-line services and overcrowded hospitals are common across the region. A new look at ways to improve the quality and effectiveness of gate-keeping and referral by front-line services is needed, as are ways in which hospitals can better support the changing role of front-line facilities and staff. Indeed, a recent WHO paper on the transformative role of hospitals in the future of primary health care talks about “ending an outmoded dichotomy”.[12] Private providers should also not be ignored, given that they deliver a significant proportion of ambulatory care in this region. New approaches are needed to address the dual challenge of protecting patients from financial exploitation and poor-quality care on the one hand, while harnessing the extensive assets of the private sector for public health gains on the other.


  Fresh approaches to community engagement deserve to be nurtured Top


Today, individuals and community and local-government representatives, are increasingly well informed on health issues, with the rapid increase in access to information via mobile phones, etc. Ways to make them key – and empowered – allies in building healthy families and communities, not simply channels for transmitting health messages, need to be nurtured. This is an explicit pillar in the Astana Declaration on Primary Health Care.[3] Special efforts will be needed to actively engage vulnerable communities.


  Moving from political commitments to equity – implementing practical solutions and measuring results Top


Accelerating progress towards universal access to quality health care, with financial protection, will involve securing rights, overcoming exclusion, measuring the results of interventions and improving accountability. It will involve mobilizing societal and political support. Practical technical interventions may involve a combination of legislation on entitlements; campaigns to promote greater awareness of those entitlements; more transparent information on performance for the general public so they can see the extent to which access is improving; and the creation of institutions responsible for “remedy and redress” that are open to all, including the most marginalized. It is encouraging to see parliamentarians across the region increasingly becoming engaged in the agenda for universal health coverage.


  Conclusion Top


In conclusion, in the WHO South-East Asia Region, the technical legacy of primary health care needs a fundamental overhaul if there is to be real progress towards universal health coverage. Critically, front-line services still need to be seen as a priority if countries are to address new demographic and epidemiological challenges. They must not be seen in isolation, either from the broader health system of which they are part, or from issues such as health workers, financing and access to medicines, which are essential to their effectiveness.

Universal health coverage inherits the political mantle of primary health care: it maintains primary health care’s focus on equitable access, with equity further reinforced by adding financial protection to the agenda. The big challenge is to clearly recognize the many difficult and politically sensitive issues involved: securing rights and overcoming exclusion, as well as measuring the results of interventions, are integral to advancing universal health coverage.



 
  References Top

1.
Khetrapal Singh P, Travis P. Universal health coverage in the World Health Organization South-East Asia Region: how can we make it “business unusual”? WHO South-East Asia J Public Health. 2018;7(1):1–4. doi:10.4103/2224-3151.228420.  Back to cited text no. 1
    
2.
Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978 (https://www.who.int/publications/almaata_declaration_en.pdf?ua=1, accessed 18 February 2019).  Back to cited text no. 2
    
3.
Declaration of Astana. Global Conference on Primary Health Care, Astana, Kazakhstan, 25–26 October 2018 (https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf, accessed 18 February 2019).  Back to cited text no. 3
    
4.
Mahendradhata Y, Trisnantoro L, Listyadewi S, Soewondo P, Marthias T, Harimurti P et al. The Republic of Indonesia health system review. New Delhi: Asia Pacific Observatories on Health Systems and Policies; 2017 (Health Systems in Transition. 7(1); https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf, accessed 18 February 2019).  Back to cited text no. 4
    
5.
World Health Organization. Primary health care (https://www.who.int/news-room/fact-sheets/detail/primary-health-care, accessed 18 February 2019).  Back to cited text no. 5
    
6.
Building the economic case for primary health care: a scoping review. Technical series on primary health care. Geneva: World Health Organization; 2018 (WHO/HIS/SDS/2018.48; https://www.who.int/docs/default-source/primary-health-care-conference/phc---economic-case.pdf?sfvrsn=8d0105b8_2, accessed 18 February 2019).  Back to cited text no. 6
    
7.
Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the South-East Asia Region: 2018 update. New Delhi: World Health Organization Regional Office for South-East Asia; 2018 (https://apps.who.int/iris/bitstream/handle/10665/274313/9789290226628-eng.pdf?sequence=6&isAllowed=y, accessed 18 February 2019).  Back to cited text no. 7
    
8.
State of health inequality: Indonesia. Interactive visualization of health data. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/bitstream/handle/10665/259685/9789241513340-eng.pdf?sequence=1, accessed 18 February 2019).  Back to cited text no. 8
    
9.
Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S et al. High quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11):e1196–e1252. doi: 10.1016/S2214-109X(18)30386-3.  Back to cited text no. 9
    
10.
Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015 (A/RES/70/1; https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf, accessed 18 February 2019).  Back to cited text no. 10
    
11.
Khetrapal Singh P, Cassels A, Travis P. Primary health care at forty: reflections from South-East Asia. New Delhi: World Health Organization Regional Office for South-East Asia; 2018 (https://apps.who.int/iris/bitstream/handle/10665/275407/9789290226888-eng.pdf?sequence=1&isAllowed=y, accessed 18 February 2019).  Back to cited text no. 11
    
12.
The transformative role of hospitals in the future of primary health care. Technical series on primary health care. Geneva: World Health Organization; 2018 (WHO/HIS/SDS/2018.45; https://www.who.int/docs/default-source/primary-health-care-conference/hospitals.pdf?sfvrsn=5d7e8137_2, accessed 18 February 2019).  Back to cited text no. 12
    




 

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