By K Srinath Reddy
As India moves the G-20 deliberations to a grand finale of its presidency at the summit meeting in September, health must feature high on the agreed agenda of accelerated, equitable and sustainable global development. Rude shocks administered by the Covid-19 pandemic reminded all nations that economic development and social stability can be held hostage by public health emergencies. Even when there is no acute emergency, the engines of economic growth will be corroded by a multitude of deadly or disabling chronic conditions that afflict unhealthy populations.
There is greater political commitment in the post-pandemic mindsets of policymakers, for strengthening health systems. This is mostly devoted to measures for pandemic prevention, prediction, preparation and prompt response. There is a strong push for integrated microbial surveillance (One Health), data sharing on outbreaks and emerging pathogens, medical countermeasures (vaccines, diagnostics and drugs) and creation of stronger platforms for a concerted global response (pandemic treaty, revised international health regulations) and scaled up capacity for critical care. Innovative digital technologies are viewed as efficient enablers of an effective response to pandemic threats.
With the world now free from the chokehold of the pandemic, thanks to the long reign of the less threatening Omicron variant, our march towards the 2030 targets set by the Sustainable Development Goals (2030) must gather pace. Progress in this direction slowed when countries fully committed their health systems to battling the rampaging virus. SDG targets for health cover a broad spectrum of health needs, with universal health coverage (UHC) providing the platform for energetically advancing actions to achieve them.
In all of these endeavours, whether directed at pandemics or devoted to SDGs, primary health care (PHC) has a pivotal role. If we neglect it, an unsteady health system will shakily sway on weak foundations and will be unable to deliver either routine or emergency services with competence or confidence. Yet, primary care has not received the attention it deserves in the deliberations of G7 or G20. Their view is still fixed on the rear view mirror images of a receding pandemic.
We must recognise that the best defence against pandemics comes from a strong primary healthcare system. Early alerts of outbreaks will come from primary care teams, when family or neighbourhood clusters emerge. ‘Case’ detection, by symptom based syndromic surveillance and home based testing, is a function of primary care. Contact tracing, isolation and quarantine are set in primary care. Triage of infected persons, for home based care or hospital referral, is also a task that primary care must perform. Even long term post-hospitalisation care (as for Long Covid) needs home based primary care.
Detection and care of co-morbidities, like diabetes and hypertension, will achieve success only if primary care systems are actively engaged. Vaccination programmes depend on community connected primary care teams. If ventilators became the visage of vulnerability in the early phase of Covid-19 in India, the frontline ASHA (Accredited Social Health Activist) emerged as the WHO hailed heroine of our success in the latter half of the pandemic.
UHC too requires well functioning primary health services. Progressive universalisation is portrayed as a cube by WHO—with population coverage, service coverage and cost coverage as the three quantifiable dimensions. Primary healthcare performs best on each of these metrics. Everyone in the population needs some form of primary care at some time in life. Comprehensive primary care offers the broadest range of health services for a variety of common health needs. It is also most resource optimising. It reduces out of pocket expenditure by providing care at home or close to home, assuring continuity in chronic care. It protects from devastating catastrophic expenditure for hospitalised care of severe illness, by preventing disease or detecting it early and providing effective treatments which stall disease progression and prevent complications. Both ways, it protects people from being pushed into poverty. Even enabling digital technologies (like point of care diagnostics, clinical decision support systems on hand held devices and tele-health services) find their best use and maximum impact in primary care.
Transition from Millennium Development Goals (MDGs) to SDGs resurrected commitment to ‘comprehensive primary care’, liberating health systems from the thrall of ‘selective’ primary care imposed by donor driven vertical programmes which fragmented health services by disease and segmented them by age. Apart from the inclusion of non-communicable diseases (NCDs) and mental health disorders, comprehensive primary care includes adolescent health and women’s health across the whole life course. Earlier, the MDGs restricted their attention only to children under 5 years of age and women who were pregnant. The vital period of risk prone adolescence was missed and women too were viewed as reproductive machines whose child bearing functions must be protected.
Women have a variety of health needs, from menstrual hygiene to mental health and from correction of anaemia to care of NCDs. From cancers, strokes diabetes and heart attacks, women have a high burden of disease which demand attention in primary care. Even in pregnancy, it is not just the reduction of mortality that matters but also the prevention of morbidity in many forms. Post-partum depression, for example, can find needed support and solace only in a primary care setting.
Women have greater economic and social constraints than men in seeking care and also in getting respectful attention from hospital based healthcare providers. An efficient and empathetic primary health care system can correct that. Investments in primary care will also boost employment opportunities for women in the health sector.
While G-20 nations must indeed prioritise actions based on learnings from the pandemic, they will be repeating past errors if they adopt reductionist solutions to segmented problems. Unless primary healthcare is accorded the highest priority while reconfiguring our health systems, we will risk failure in responding to future pandemic threats and in achieving the SDG targets. This calls for co-investments in developing a multi-layered, multi-skilled, motivated health workforce capable of delivering comprehensive, competent, continuous and compassionate community based primary healthcare. Will the G-20 make that commitment?
The writer is cardiologist, epidemiologist and distinguished professor of public health, PHFI