The WHO (World Health Organization) published on 2008 a very important report on “Primary Heath Care” which in our view should be an essential reading and reference for every primary heath care decision-makers. This is why we will review some of its essential parts. It was also published on the year which marked both the 60th birthday of the WHO and the 30th anniversary of the Declaration of Alma-Ata on Primary Health Care in 1978.
Few health providers have been trained for person-centred care. Lack of proper preparation is compounded by cross-cultural conflicts, social stratification, discrimination and stigma. As a consequence, the considerable potential of people to contribute to their own health through lifestyle, behaviour and self-care, and by adapting professional advice optimally to their life circumstances is underutilized. There are numerous, albeit often missed, opportunities to empower people to participate in decisions that affect their own health and that of their families
They require health-care providers who can relate to people and assist them in making informed choices. The current payment systems and incentives in community health-care delivery often work against establishing this type of dialogue.
Conflicts of interest between provider and patient, particularly in unregulated commercial settings, are a major disincentive to person centred care. Commercial providers may be more courteous and client-friendly than in the average health centre, but this is no substitute for person centeredness.
The diversity of health needs and challenges that people face does not fit neatly into the discrete diagnostic categories of textbook primitive, preventive, curative or rehabilitative care. They call for the mobilization of a comprehensive range of resources that may include health promotion and prevention interventions as well as diagnosis and treatment or referral, chronic or long-term home care, and, in some models, social services.
It is at the entry point of the system, where people first present their problem, that the need for a comprehensive and integrated offer of care is most critical.
Comprehensiveness makes managerial and operational sense and adds value.
People take up services more readily if they know a comprehensive spectrum of care is on offer.
Moreover, it maximizes opportunities for preventive care and health promotion while reducing unnecessary reliance on specialized or hospital care. Specialization has its comforts, but the fragmentation it induces is often visibly counterproductive and inefficient: it makes no sense to monitor the growth of children and neglect the health of their mothers (and vice versa), or to treat someone’s tuberculosis without considering their HIV status or whether they smoke.
That does not mean that entry-point health workers should solve all the health problems that arepresented there, nor that all health programmes always need to be delivered through a single integrated service-delivery point. Nevertheless, the primary-care team has to be able to respond to the bulk of health problems in the community. When it cannot do so, it has to be able to mobilize other resources, by referring or by calling for support from specialists, hospitals, specialized diagnostic and treatment centres, public-health programmes, long-term care services, home-care or social services, or self-help and other community organizations. This cannot mean giving up responsibility: the primary-care team remains responsible for helping people to navigate this complex environment.
Comprehensive and integrated care for the bulk of the assorted health problems in the community is more efficient than relying on separate services for selected problems, partly because it leads to a better knowledge of the population and builds greater trust. One activity reinforces the other. Health services that offer a comprehensive range of services increase the uptake and coverage of, for example, preventive programmes, such as cancer screening or vaccination. They prevent complications and improve health outcomes.
Comprehensive services also facilitate early detection and prevention of problems, even in the absence of explicit demand. There are individuals and groups who could benefit from care even if they express no explicit spontaneous demand, as in the case of women attending the health centres in Ouallam district, Niger, or people with undiagnosed high blood pressure or depression. Early detection of disease, preventive care to reduce the incidence of poor health, health promotion to reduce risky behaviour, and addressing social and other determinants of health all require the health service to take the initiative. For many problems, local health workers are the only ones who are in a position to effectively address problems in the community: they are the only ones, for example, in a position to assist parents with care in early childhood development, itself an important determinant of later health, well-being and productivity. Such interventions require proactive health teams offering a comprehensive range of services. They depend on a close and trusting relationship between the health services and the communities they serve, and, thus, on health workers who know the people in their community.