The Primary Goal of a Health System

The best health system would be one where as few people as possible would need hospital services

By Dr R Neerunjun Gopee

Most people think hospitals are places where they go to regain their health, in other words they tend to associate health with hospitals. In general they are not really conscious that they have a responsibility to maintain themselves in good health, unless egged on by the medical professionals when they fall sick and seek treatment. In the system of allopathic or western scientific medicine as it has evolved from its beginnings over the past couple of centuries, the ruling model has been the treatment of disease. This has been so despite some spectacular early historical successes in the prevention of disease – such as supplying clean potable water when a cholera outbreak was found to be due to sewage contaminating drinking water by Dr John Snow (London, 1854), or antiseptic measures introduced by Dr Semmelweiss (Budapest, 1860s) to control childbirth infections and reduce mortality.

“The best health system would be one where as few people as possible would need hospital services, which in fact should be the main goal of any health system. It can only be achieved if people make more effective use of Primary Health Care and take greater care of their own health and quality of life by following the whole range of advice that the PHC outlets as well as the Health Promotion Unit dispenses. Of course we will still need hospitals, because in spite of taking all the preventative and promotive measures, one can still fall sick and need hospital care…”

All doctors trained in modern medicine, who constitute the majority of practitioners in practically all countries aspiring towards modernity in today’s world, are overwhelmingly driven by this mindset of treating disease rather than preventing illness – and I plead guilty. As we pass out of medical school, we look forward to eventually find a position in a hospital, the bigger the better, or if this does not happen then to set up in private practice on our own. Either way we have access to an armamentarium of equipments and drugs to propose to our patients.

And they too are fed on the same paradigm, believing that there is a pill for every ill. Thus, it is only when they fall ill that they first come in contact with the health system, in the form of a doctor, who by virtue of his training then resorts to dispensing treatment which will almost invariably include drugs. And once they feel well, even if it means taking medicines long-term for a chronic condition, they equate that to being in good health: the absence of a physical ailment.

Mostly we doctors too go along with this perception, although during the medical course we learn the definition of health according to the World Health Organisation when studying Public Health: ‘Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.’ However, we memorise this as we do so much else only for clearing the exams, after which – especially when we specialize – it is relegated to the backburner. But I must also admit that those who taught us the subject – known then as Preventive and Social Medicine – didn’t manage to make it sound as sexy as other subjects that we had to pursue. Maybe it was different for others and elsewhere, but as far as I know only a handful of doctors passing out from any cohort would go on to specialize in Public Health, which is a low down option.

But we are reminded of its importance, nay its significance, most visibly and dramatically when there is a sudden and explosive health crisis, such as food poisoning or, as we are going through now, an epidemic or a pandemic.

Unbeknown to their populations at large, national authorities had for ages been taking steps to ensure their health. This is seen as far back as in ancient civilizations, such the Harappa-Mohenjodaro one, often referenced for its geometrically laid out buildings and a system of drains for both water collection and disposal of wastes among other things. But in recent historical times too, there was growing awareness about the need for clean water, clean air, hygiene and sanitation, proper nutrition and so on as being necessary for good health as science and medicine advanced, with the adoption of vaccination as an important preventive factor.

But still, the focus continued to be the cure of disease, the model being: prevention-treatment-rehabilitation (preventive-curative-rehabilitative), and again, with the hospital being given pride of place. We had to wait for nearly 30 years after the founding of WHO, in 1978, to include the concept of promotion in a bid to inculcate the idea of quality of life, thus in a way enjoining the individual to assume responsibility for his health. This meant that they had a more active role to play in ensuring their good health, which is the very basis of quality of life, instead of being passive recipients of treatments dispensed only when ill-health was diagnosed.

This dimension was highlighted and captured during the first ever International Conference on Primary Health Care which was held at Alma-Ata in September 1978, jointly sponsored by WHO and the United Nations Children’s Fund. It came up with a now famous document on Primary Health Care known as the Alma-Ata Declaration, whose opening paragraph drew attention to the ‘need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all people of the world…’

While governments have a responsibility to provide adequate health and social measures, Para IV of the Declaration emphasises the role of the people: ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.’

By then, the accelerated industrialization that was taking place after the second World War, the education and emancipation (including development of the contraceptive pill) allowing women to join the workforce and an increasing world population were some of the main factors that were driving levels of stress and change in family structure and human relationships. Food habits changed too as a result, with the rising consumption of fast food. Along with a host of other factors such as pollution, lack of adequate physical exercise, abuse of tobacco and alcohol, the conditions were leading to a rise in what are today known as the non-communicable diseases, first in the more developed and industrialized countries which had controlled infectious diseases, before spreading to other less developed countries as well, imposing on them a ‘double burden’ of disease (infectious and non-infectious).

Primary Health Care (PHC) was to address this problem in a novel way, as being ‘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…It forms an integral part of the country’s health system, of which it is the central function and main focus…the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.’

Thus was set up locally the network of Community and Area Health Centres (140 +) to which were later added the Mediclinics. And at the central level (ministry) a Health Promotion Unit (HPU) which has been upgraded.

Has PHC been a success? Alas, no. Because people are still stuck to the pill-for-every-ill paradigm as they continue to pursue habits of consumption and lifestyles that are more conducive to sickness than to good health. And continue to flock to hospitals.

The best health system would be one where as few people as possible would need hospital services, which in fact should be the main goal of any health system. It can only be achieved if people make more effective use of PHC and take greater care of their own health and quality of life by following the whole range of advice that the PHC outlets as well as the HPU dispenses.

Of course we will still need hospitals, because in spite of taking all the preventative and promotive measures, one can still fall sick and need hospital care. Just as using a pedestrian crossing does not mean that you will never be hit by a car – but at least you considerably reduce the chances.

Similarly for your own health, reducing significantly the possibility of needing hospital care.

All of us: choose good health and quality of life through self-health promotion so as to push back hospital care the farthest possible, if ever.

* Published in print edition on 11 June 2021