i. Introduction
John Fry
Although health care is rightly regarded as a human right, its implementation creates considerable dilemmas for the providers. Expectations and demands are almost infinite, but resources are definitely finite. The challenges facing us all are how to provide comprehensive, equitable and appropriate care within the limits of available resources.
What is āhealth?
The World Health Organizationās utopian definition of health, as āa state of complete physical, mental and social wellbeing and not merely an absence of diseaseā is a distant and elusive mirage. Although by this definition probably less than 10% of the population is āhealthyā at any time, nevertheless it must be a target to be aimed for.
In 1978, the World Health Organization promoted its policy ofāHealth for all: 2000ā, creating an equally impossible target. Translated into reality, the aim should be to achieve āHealth care for all by the year 2000ā.
Such a goal can be achieved only through strong and effective primary health-care services that are well conceived, well planned, well promoted and well supported.
What is ādiseaseā?
The dividing lines are blurred between health, disease, illness, sickness, dysphoria and general non-health. Whereas secondary hospital specialists are involved in the classification, diagnosis and treatment of more serious ādiseasesā, those in primary general care are involved more with minor and chronic diseases and undifferentiated collections of symptoms.
There are many ways in which non-health and disease can be measured and recorded; all have weaknesses and drawbacks because of inevitable difficulties of definition, precision, validity and reliability. Despite this, the available forms of data are important for comparisons and for highlighting problems and setting goals. Data are available on rates of:
Differences between countries and places depend on many factors beyond the medical services provided, but it is surprising how similar these indices are in SE Asia.
What is ācareā?
Good care has to be āthe art of the possibleā. Its limitations are as important as our optimistic expectations of the latest medical technologies. It has been said (somewhat ungrammatically) that doctors can only ācure sometimes, relieve often, comfort always and prevent hopefullyā.
The mortality of life is 100%. The objectives must be to prevent avoidable premature death and disabilities, to cure when possible, but always to remember that the primary roles of the family doctor are to relieve suffering and to support and comfort the sick and their families.
It is also necessary to accept the āinsoluble equation of health careā, which dictates that āwants will always be greater than proposed needs, which will always be greater than available resourcesā.
Faced with such dilemmas, the challenge for physicians, providers, planners and politicians must be to make the best use of what they have. This requires good data and information, and a critical evaluation of the usefulness of activities based on good cost-benefit measures. These activities apply to all levels of health care, from national policies right down to the work of a primary-care general practice or clinic. At each level, questions have to be posed.
Who requires care and who should provide it? Special at-risk groups should be defined and targeted. It should not be assumed that the primary physician has to do everything: a team approach is best, with shared care being allocated to nurses and others in a collaborative manner.
What care is possible and what has been shown to be effective? Constant review and reappraisal are essential.
How is care provided? It should not be assumed that present methods are the best, or that they are unchangeable. Constant experimentation and review are necessary.
Where is care provided? Many options and models are available, from the single-handed primary-care physician working alone, through partnerships and groups to large clinics or hospital units. Sensitive planning and political decisions are necessary to decide on the best ways and best places to provide primary care in the community. Again, the present systems must not be accepted as inviolable.
When to care? This relates to the possibilities for primary, secondary and tertiary forms of prevention. Immunization, screening, early diagnosis and treatment emphasize the community aspects of primary care, with its responsibilities beyond the doctorsā offices and the hospitals.
Why care? This question comes back to the issues of why particular promotional, clinical, diagnostic and therapeutic activities are carried out. There should be good positive reasons.
These questions and answers lead inevitably to further issues for consideration: what are the priorities and who should decide? What should the roles of consumers, patients and the public be in deciding what is possible within finite resources? How and where should rationing be applied? What checks and controls should be introduced to implement policies? How should outcomes and benefits be evaluated?
Current realities
We are at a crossroads: health care is no longer the sole province of the medical profession. In developed countries in SE Asia and elsewhere the total cost (if self-care is included) is almost 10% of the gross national product (GNP), and rising. Health-care provision, costs and organization can no longer be left to doctors and patients, but require increasing government involvement.
Primary health care is an essential keystone in all health services. It has to be recognized as such, since the rest of the health system depends on its quality and effectiveness.
ii. Social, Environmental and Economic Determinants
Anthony J Hedley
Chamberās Dictionary defines health as āa sound bodily or mental conditionā or āa condition of wholesomenessā. Dorlandās Medical Dictionary borrows from the World Health Organization definition (see page 2). The Encyclopaedia Brittanica adds to this very general statement the emphasis that our perception of personal health depends on the extent to which we can cope with our environment. In the late 19th century, Karl Marx put forward an economic definition of health as āthe capacity to do productive workā. In that sense our biological state of health might vary considerably depending on the demands which we make on our body in order to complete our activities of daily living, and our subjective feeling of health may have very little to do with the presence or absence of specific diseases. Many of us would regard a reasonable state of health as being a condition which allows us to eat, sleep, achieve normal bodily functions, enjoy freedom from pain and perform our expected quota of daily tasks. Some impairment of our health may result from a variety of symptoms, but whether we regard them collectively as a disease may depend on the type of symptoms and their severity. Teething trouble in infants, morning sickness in pregnant women, backache in building workers or headache in students might all be regarded quite differently from other problems such as chest pain requiring drugs for its relief or the need to take insulin to control blood sugar levels. The reader is invited to define what he or she would consider to be a minimum acceptable state of healthy living.
The personal characteristics and social circumstances of individuals often give rise to marked variations in subjective assessments of health and self-reported illness. For example in males in the United Kingdom (Table 1.ii.I)1 there are marked gradients, within different age groups, in the personal assessment of health by occupational groups. This type of patt...