Reflections on Primary Healthcare and Health Equity
Community health center… Community nurse… Dispensary… Growing up, health care to me was synonymous with these words. These were the places and people we would turn to to receive immunizations for preventable diseases like polio, tetanus, measles and to be treated for flu and malaria. For most people, this type of healthcare — known as primary healthcare— is their first point of contact with a country’s health system. Primary healthcare (PHC) practitioners and providers are thus an integral part in this system and when they fail, things start to fall apart. One advantage of PHC is the intimate understanding of the specific issues that the target population experience, which enables establishing trusting relationships. A strong, easily accessible and effective PHC is essential to achieving health equity.
We cannot talk about health equity without talking about PHC and its interactions with individuals who have complex health and social needs. The traditional healthcare model was not established to handle these complexities. Many health systems focus primarily on treating diseases. Now more than ever, however, we need to start thinking about how the full spectrum of human needs are considered (or not) in healthcare delivery. Social determinants of health and their effects have been discussed at length in epidemiological research. The effects can be summarized in one simple statement: where we live, work, learn and play dramatically affects our health, for better or for worse.
Spending on Healthcare in the U.S.
When we think about investments, we envision that the expected return will be proportional to the principal amount invested. No one puts money aside expecting to lose it. You would expect the same with healthcare, i.e. the more resources spent on healthcare, the better the outcomes and the greater the savings. The story is a bit different in the U.S., however. Compared to other Organization for Economic and Co-operative Development (OECD) countries, the U.S. government spends considerably more in health care. In 2016 alone, the total amount spent was $3.3 trillion, which translates to an approximate average cost of $10,300 per person. This spending did not necessarily result in better health outcomes in comparison to the other OECD counterparts who spend much less on healthcare. Even with this spending, disparities in health persist and one issue that remains unchanged in this widening gap is differences in income. The American poor are the most hit by the stark reality of the country’s health system.
This begs a question: Given the high cost of care, what is happening to individuals in low resource settings? What happens to individuals who earn a median annual income of $33,025 when the average income for the state is $73,702? What happens to an individual who cannot find a job on release from prison yet has diabetes, is living in homelessness, and is fighting substance abuse? Who is responsible for this individual and what does health equity mean for him/her? Why is it that even with increased spending we have not seen improved outcomes, especially in low resource settings? What can we learn from the countries who are performing much better than the U.S.?
One approach we can focus on is strengthening primary healthcare and improving social safety nets. Research has shown that people who undergo regular physician checkups tend to have better health outcomes. Treating diseases before they become severe, investing in prevention, and training more primary care providers can greatly reduce costs and improve outcomes. Aptly put, prevention is better than cure. Two specific strategies we can use to strengthen primary healthcare systems are practice transformation and partner collaborations.
Practice Transformation
As currently constituted, PHC does not take into account the complexities that some patients have. It’s not uncommon to encounter an individual experiencing a combination of medical, behavioral, and social needs at a given time. Ensuring that there is an established way of handling such cases is helpful. This is not to say that PHC providers need to have solutions for social problems like homelessness. The focus here would be for them to have clear, comprehensive guidelines on how to handle such cases, including making referrals to social services where needed.
Many providers do have various services under one roof such as ambulatory care, behavioral health, specialties, and more. However as long as communication between these services is not streamlined, there is a high chance that the quality of services delivered will be negatively impacted. To understand how this disintegration manifests itself, imagine going to a car manufacturing store to buy a car, but instead of getting a fully assembled car, different parts are given to you separately without concern for how they work (or don’t work) with the other parts. It’s ridiculous, isn’t it? We can all agree that it’s not the role of the buyer to assemble the car, but when it comes to healthcare, this is what most of us are getting. Acknowledging that this disintegration exists is a big step towards developing strategies that ensure effective care coordination.
Unless there is accountability and proper transitions of care, say from discharge to ensuring the individual attends follow up appointments, then people will continue to fall through the cracks. You can treat a person for a given disease, but if the root cause is not dealt with, then it’s just a matter of time until they come back and the cycle continues.
Partner Collaborations
Kidole kimoja hakivunji chawa. This is a Swahili proverb that loosely translates to one finger cannot kill a lice. When it comes to strengthening PHC, collaboration is extremely important. Imagine a system where in a given city, all social service providers, hospitals, community health centers, policymakers, advocates, and other stakeholders come together regularly and discuss the challenges of serving target populations and find innovative ways of working together to overcome such challenges.
“Complete transformation of our primary healthcare systems will require a significant shift in how we think about healthcare delivery and strong political support. I am hopeful that with strong leadership, collaboration, and willing partners, we can achieve it. After all, dawn is ever the hope of humankind.”
It is through nurturing such collaborations that providers can establish data sharing strategies that provide a complete picture of the populations they serve and help identify the most pressing issues in their communities. A doctor can only provide comprehensive treatment based on the information that he/she has about the patient. Information sharing among various providers allows for real-time treatment and ensures the ‘care team’ knows what is happening to a given individual at any given time and any crisis can easily be abated.
Complete transformation of our primary healthcare systems will require a significant shift in how we think about healthcare delivery and strong political support. I am hopeful that with strong leadership, collaboration, and willing partners, we can achieve it. After all, dawn is ever the hope of humankind.
Sarah Mulwa is a 2017–2018 Global Health Corps fellow at the Greater Newark Healthcare Coalition.
