Taking Action

Primary Health Care: Now or Never

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Diana Castro's profile picture
Diana Castro Sandoval
on
Nov 9, 2018

Dear Diary,

I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.

I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.

Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.

I disagreed with him.

I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.

This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.

No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.

I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.

I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.

Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.

As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I  provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.

Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.

Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.

Sincerely,
The elephant in the room

On the occasion of the 40th anniversary of the Alma Ata Declaration, leaders and representatives from all over the world met last week in Astana with the aim of reaffirming the principles of the original declaration.

The anniversary of this historic landmark in global health, renewed the commitment to primary health care (PHC) and to achieve universal health coverage (*UHC) and the Sustainable Development Goals (SDGs).

The declaration defined three essential principles. Firstly, PHC is an integral part and central function of robust health systems. Secondly, it plays a crucial role in achieving social and economic development. Thirdly, PHC must be universally accessible through full community participation and based on the practical, evidence-based, and socially acceptable methods and technologies (WHO, & UNICEF. 2018).


What is primary health care?

According to the World Health Organisation (WHO), primary health care is health care received in the community, usually from family doctors, community nurses, staff in local clinics or other health professionals. It should be universally accessible to individuals and families by means acceptable to them, with their full participation and at a cost that the community and country can afford.

The relation between PHC and health equity

According to the previous statements; would it be sensible to place PHC as the cornerstone for achieving UHC and decrease inequalities?

The answer is; absolutely yes. Primary care represents the entry point and cornerstone of many health systems. Experts consider that PHC is at the core of providing accessible person-centred, appropriate and equitable care from a population-based perspective (EXPN, 2017).

Extensive scientific evidence has shown a strong positive correlation between the strength of primary care dimensions and key health system performance indicators and outcomes variables, such as healthcare spending, patients perspectives, quality of care, potentially avoidable hospitalisations, population health and socioeconomic inequalities (Kringos DS.et al., 2013). Besides, the emphasis of PHC on community-based services is a meaningful way to ensure access, even in rural, remote and disadvantaged populations (Richard, L. et al.,2016).

So it's not nuts to say that nowadays, strategies to cope with challenges in the healthcare sector often include strengthening primary care systems.

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How can we strengthen PHC

The recently adopted Astana declaration (WHO, & UNICEF. 2018) stresses some of the main ones to strengthen PHC. At the core, we can find the need for sharing knowledge, build capacity and improve the delivery of health services and care. Investment in education, recruitment, and retention of the PHC workforce, with an appropriate skill mix. The need to increase the promotion of Health literacy and work to satisfy the expectations of individuals and communities for reliable information about health.

Aligning stakeholder support to national policies, strategies and plans and making sure that through digital and other technologies, individuals and communities are able to identify their health needs, allowing them to participate in the planning and delivery of services and play an active role in maintaining their own health and well-being.

But how do countries measure PHC performance and progress towards UHC?

Strong PHC does not emerge spontaneously. It requires appropriate conditions at the health care system level and in actual practice to make PHC providers able and willing to take responsibility for the health of the population under their care.

There is a strong need to collect and share information about what structures and strategies matter. To measure the performance and progress made towards PHC and UHC, systems need to monitor and evaluate through well-functioning health information systems that generate reliable data (Boerma T et al., 2014).

Proper health data collection systems are a critical source of information to improve decision-making at the local, subnational, national, and global levels (Nutley, T., & Reynolds, H. W. 2013).

In order to present conclusive information for decision making, the collected data needs to be accurate, valid, reliable, timely, relevant and complete.

The crucial role of proper data collection in decreasing health inequalities

Health policy decisions are fundamentally based on health specific data. Data can be a catalyst for improving community health and well-being. Collecting and understanding data can help to focus efforts to enhance community health.

Up to date, there are still remaining considerable gaps and challenges in health data coverage among many countries. To achieve real progress countries need quality data, this allows for comparison within and between countries and population groups. The equity element of existing systems needs to be reinforced, allowing for the correlation of health data with social, economic and environmental data (Sadana, R et al., 2011).

The collection of good quality data in PHC will make this possible. However, the potential will only be unlocked if staff in primary care understands why such data is valuable, have the resources available to support its collection and possess the appropriate tools and knowledge needed to use the information effectively.

Therefore, it's clear the crucial role that data plays in health. If it's unavailable, it means that policy and practice can't catch up with science.

I want to finish quoting Dr Tedros WHO general director statement in Astana: “Health is the right for all people, not a privilege for those who can afford it. We can take action now. Each of us can do everything to realise this vision”.

Definition:

UHC: This means ensuring that everyone, everywhere can access essential quality health services without facing financial hardship.

(WHO, 2018)


References:

  1. A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), 2018
  2. Boerma, T., Eozenou, P., Evans, D., Evans, T., Kieny, M. P., & Wagstaff, A. (2014). Monitoring progress towards universal health coverage at country and global levels. PLoS medicine, 11(9), e1001731. doi:10.1371/journal.pmed.1001731
  3. Expert Panel on effective ways of investing in Health (EXPH), Opinion on Tools and Methodologies for Assessing the Performance of Primary Care, 18 December 2017
  4. Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff (Millwood). 2013; 32(4):686-694.
  5. Nutley, T., & Reynolds, H. W. (2013). Improving the use of health data for health system strengthening. Global health action, 6, 20001. doi:10.3402/gha.v6i0.20001
  6. Richard, L., Furler, J., Densley, K., Haggerty, J., Russell, G., Levesque, J. F., & Gunn, J. (2016). Equity of access to primary healthcare for vulnerable populations: the IMPACT international online survey of innovations. International journal for equity in health, 15, 64. Doi: 10.1186/s12939-016-0351-7
  7. Sadana, R., & Harper, S. (2011). Data systems linking social determinants of health with health outcomes: advancing public goods to support research and evidence-based policy and programs. Public health reports (Washington, D.C.: 1974), 126 Suppl 3(Suppl 3), 6-13.

Dear Digital Diary,

I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.

This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.

Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.

Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.

The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.

Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.

Sincerely,
No more elephants in this room

Diana Castro's profile picture

Diana Castro Sandoval

I'm somebody passionate about international relations, public health, innovation and economic policy. Currently working at the European Forum For Primary Care while trying to shape the future of healthcare.

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