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Research article

S.M. Abbas,¹ A.Y. Alam¹ and M.R. Malik ¹

الرعاية الصحية الأولية: ما هي وما ليس هي؟ آراء الهيئة التدريسيَّة في كلِّية طبية في المرحلة الجامعية الأولى في باكستان

سيد مسلم عباس، علي ياور عالم، محمد رئيس ملك

الخلاصة: بعد انقضاء ثلاثين عاماً على إعلان ألما آتا حول الرعاية الصحية الأولية في عام 1978، لانزال نصادف كثيراً من المفاهيم المغلوطة حول المفهوم الأساسي للرعاية الصحية الأولية. وقد استهدفت هذه الدراسة استكشافَ المعارف والآراء حول الجوانب المختلفة للرعاية الصحية الأولية والتنفيذ الملائم لها، وذلك لدى الهيئة التدريسيَّة في كلية الشفاء الطبية في إسلام أباد بباكستان. وقد أعد الباحثون استبياناً مُهَيْكَلاً أجاب عليه سبعون طبيباً ممن كانوا حاضرين في نهاية ندوة شهرية. وقد كان ثلثا الأطباء (%67.1) منهم يعتقد أن الرعاية الصحية الأولية لا تشتمل إلا على الرعاية الصحية الأساسية للأمراض الشائعة. وقد اقترح قلة من المستجيبين وجوب أن تكون البرامج المجتمعيَّة التوجُّه (%4.3)، وصحة الأمومة والطفولة (%2.9)، وتحري الأمراض غير السارية (%1.0) أو معالجتها (%2.9) من مكونات الرعاية الأولية. وخَلَص الباحثون إلى أن مفهوم الرعاية الصحية الأولية حسبَما تم تعريفه في ألما آتا عام 1978 لم يكن مُسْتَوْعباً من قِبَل أعضاء الهيئة التدريسية في مرحلتَيْ العلوم الأساسية والسريرية والأساسية في هذه الكلية الطبية.

ABSTRACT Over 30 years after the Alma-Ata declaration on primary health care in 1978 there are still misconceptions about the basic concept of primary health care. This study aimed to investigate the knowledge and opinions about various aspects of primary health care and its appropriate implementation among the teaching faculty at Shifa College of Medicine in Islamabad, Pakistan. A structured questionnaire was answered by 70 physicians present at the end of the month seminar. Two-thirds of the doctors (67.1%) believed that primary health care involved only basic health care for common illnesses. Few respondents suggested that community-oriented programmes (4.3%), maternal and child health (2.9%), screening (1.0%) or treatment of noncommunicable diseases (2.9%) should be components of primary care. The concepts to primary health care as defined at Alma-Ata in 1978 were not well understood by teaching faculty from the basic and clinical health sciences in this medical college.

Soins de santé primaires : comparaison entre les concepts et les croyances du corps enseignant dans une faculté de médecine de premier cycle au Pakistan

RÉSUMÉ Trente ans après la Déclaration d'Alma-Ata sur les soins de santé primaires en 1978, des idées erronées subsistent encore au sujet du concept de base des soins de santé primaires. La présente étude avait pour objectif d'évaluer les connaissances et les opinions du corps enseignant de la faculté de médecine de Shifa, à Islamabad (Pakistan), sur différents aspects des soins de santé primaires et leur mise en œuvre appropriée. Un questionnaire structuré a été rempli par 70 médecins présents au séminaire de fin de mois. Deux tiers des médecins (67,1 %) pensaient que les soins de santé primaires comprenaient uniquement les soins de santé de base des affections les plus communes. Peu de répondants ont indiqué que les programmes communautaires (4,3 %), la santé de la mère et de l'enfant (2,9 %), le dépistage (1,0 %) ou le traitement des maladies non transmissibles (2,9 %) devaient être des composantes des soins primaires. Les concepts de soins de santé primaires tels que définis à Alma-Ata en 1978 n'ont pas été bien compris par les enseignants en sciences fondamentales et en sciences cliniques de la santé de cette faculté de médecine.

¹Department of Community Health Sciences, Shifa College of Medicine, Islamabad, Pakistan (Correspondence to S.M. Abbas: This e-mail address is being protected from spambots. You need JavaScript enabled to view it )

Received: 11/03/10; accepted: 29/06/10

EMHJ, 2012, 18(3): 261-264

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Introduction

Primary health care (PHC) was defined at the First International Conference on Primary Care at Alma-Ata in 1978 as “essential health care 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 the country can afford to maintain at every stage of their development in the spirit of self-determination” [1]. Before Alma-Ata, PHC was regarded as synonymous with concepts such as basic services, first contact care, easily accessible care and services provided by generalists. The Alma-Ata conference reaffirmed the World Health Organization policy of “health for all” as the major social goal of governments [2], and stated that the best approach to achieve the global goal of health for all was by providing PHC, especially to the vast majority of underprivileged rural and urban people [1,3,4].

Despite the promotion of PHC as a worldwide, long-term plan for ensuring basic health care for all people [5], there are sometimes misconceptions about the fundamental concept of primary health care, even among experts [6]. It is critical that PHC be understood as a community focus in health care that differs from a focus on individuals. The greater understanding there is of PHC, the better it can be implemented, especially in less developed nations [7,8].

This study aimed to investigate the knowledge and opinions about various aspects of PHC and its appropriate implementation among the teaching faculty at Shifa College of Medicine in Islamabad, Pakistan. It was hoped that the results from this study would give some insight into misconceptions relating to PHC.

Methods

This was a cross-sectional survey of physicians teaching or practising in basic or clinical health sciences at Shifa College of Medicine, an undergraduate medical college in Islamabad, Pakistan. Using the WHO sample size calculator and using an estimated the knowledge of physicians about PHC to be 20% and with 95% confidence interval and precision of ± 10%, the sample size was estimated as 62. This was rounded to 70. Questionnaires were distributed to 70 physicians who were present at the end of the month seminar in November 2009 (i.e. every third physician out of 200 attending). Medical students, nurses and paramedical staff were excluded.

A structured questionnaire was designed based on a literature review of the subject to assess the respondents’ knowledge and opinions about various aspects of PHC and its appropriate implementation. The questionnaire had 2 sections: respondents’ knowledge about the definition of PHC and where it was best practised (5 multiple choice questions); and respondents’ opinions about what services/programmes should be included in PHC (3 open-ended questions). Questionnaires were anonymous and no demographic data were collected from respondents except for their job description at Shifa College of Medicine.

The physicians were initially given an explanation about the purpose of the research and the content of the questionnaire and ample time was given to the participants to complete the forms. Ethical approval for the research proposal was obtained from the institutional review board committee.

Descriptive data are presented as frequencies and percentages.

Results

A total of 70 physicians participated in this survey: 13 house officers, 5 senior instructors, 10 instructors, 13 assistant professors, 12 senior registrars, 6 professors, 4 associate professors, 2 registrars, 2 consultants, 2 community liaison officers and 1 medical officer.

Only one-third of the physicians (32.9%) agreed that PHC was defined as comprehensive health care whereas the remainder thought that it was basic health care of common ailments only (Table 1). Almost all the doctors (97.1%) agreed that PHC was “good quality” health care. Almost three-quarters of physicians believed that PHC included all aspects of health services, i.e. health prevention and promotion, curative care, diagnosis and referral.

The great majority of respondents (92.9%) indicated that PHC was best practised in the community. The remainder believed that it should be based in a tertiary health care facility, in both the community and tertiary care or in another place. When asked to give at least one reason in support of their answer, those who supported PHC in the community indicated that this was the best place to practise and implement PHC (48.6%) and that it was easily accessible to people (35.7%), while only a minority mentioned cost-effectiveness (5.7%). Reasons for practising PHC in tertiary care were the availability of more facilities (4.3%) or because people visit clinics only when they are sick and not for preventive care (5.7%).

In the open-ended question about which services/programmes should be a part of PHC respondents suggested that the main preventive services should be good sanitation, health education and hygiene (32.9%) and vaccination (27.1%) (Table 2). Few respondents mentioned community-oriented programmes (4.3%), maternal and child health programmes (2.9%) or screening (1.0%). Most of the physicians responded that diagnostic facilities in PHC should include only baseline investigations (72.9%). Facilities for curative care should include outpatient facilities (42.9%), inpatient facilities (25.7%), availability of common medicines and minor surgery (22.9%) and treatment of communicable and noncommunicable diseases (18.6%).

Discussion

The principle of PHC as defined at Alma-Ata is essential health care that is universally accessible to all in the community at affordable cost [1]. The different health services that form a part of PHC in Pakistan need to be better utilized [9] and this can only be achieved through proper knowledge of its domains and boundaries. Efforts to develop more effective PHC need a better balance across the different elements of primary health care [8,10,11].

The physicians who participated in this survey, who are practising and teaching at a college of medicine, displayed an incomplete understanding of the principles of PHC. A high proportion of the respondents (67.1%) were of the view that PHC included only basic health care of common ailments and did not recognize that it should be comprehensive health care. Primary health care covers not only treatment of common diseases and injuries and provision of essential drugs but also a wide range of services such as health education about disease prevention, proper nutrition, safe water and sanitation; maternal and child health care including family planning; immunization; and prevention and control of locally endemic diseases [4]. Only half of our respondents believed that the full range of services—health prevention and promotion, curative care, diagnosis and referral—should be covered in PHC. When questioned about the preventive services/programmes that should be offered in PHC the main focus was on sanitation, health education and vaccination. An important aspect such as maternal and child health (which would include family planning) was only mentioned by 2 of the 70 doctors and only 1 respondent suggested prevention and control of locally endemic diseases.

A majority of doctors believed that only baseline investigations should be part of the diagnostic services offered in PHC. Our study shows that 68.6% of the health workers thought inpatient and outpatient facilities should a part of the curative services in PHC whereas only 22.9% thought medicines and minor surgeries should be provided.

The ideal location for PHC is in the community, as it should be as close the beneficiaries as possible. In our study 92.9% of the respondents were of the same view and 35.7% mentioned ease of accessibility for people as the justification.

More than 30 years after Alma-Ata’s paradigm shift in thinking about health there is growing recognition that the health of populations in some countries are becoming left behind and a sense of lost opportunities [12]. Our research shows that the concept of PHC, despite being promulgated worldwide for the last 3 decades, is still not clear to the physicians in this medical college. More efforts are needed to educate those who are responsible for teaching the medical students of the future.

Acknowledgements

Sincere thanks to Dr Ali Yawar Alam for designing the questionnaire and providing important information and references relating to primary health care. Dr Raees Malik is greatly appreciated for advising on the analysis.

References

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