{"id":45963,"date":"2019-10-29T13:53:43","date_gmt":"2019-10-29T12:53:43","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=45963"},"modified":"2019-11-11T09:42:09","modified_gmt":"2019-11-11T08:42:09","slug":"dainius-puras-empowering-primary-care-is-only-way-to-achieve-universal-health-coverage","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/29\/dainius-puras-empowering-primary-care-is-only-way-to-achieve-universal-health-coverage\/","title":{"rendered":"Dainius P\u016bras: Empowering primary care is only way to achieve universal health coverage"},"content":{"rendered":"<p><span style=\"font-weight: 400\">Medical education needs a drastic overhaul if we are serious about meeting the 2030 Sustainable Development Goals to achieve universal health coverage and health for all. It is now 41 years since the Alma Ata declaration sought <\/span><span style=\"font-weight: 400\">\u201c<\/span><a href=\"https:\/\/www.who.int\/publications\/almaata_declaration_en.pdf\"><span style=\"font-weight: 400\">an acceptable level of health for all the people of the world by the year 2000,<\/span><\/a>&#8221;\u00a0<span style=\"font-weight: 400\">through primary care, and 33 years since the <\/span><a href=\"https:\/\/www.who.int\/healthpromotion\/conferences\/previous\/ottawa\/en\/\"><span style=\"font-weight: 400\">Ottawa Charter<\/span><\/a><span style=\"font-weight: 400\"> for health promotion outlined prerequisites for health that extended beyond medical care. But regardless, medical education has remained firmly focused on producing physicians for secondary or higher level healthcare. This comes at a cost to primary healthcare, and global health.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The <\/span><a href=\"http:\/\/www.who.int\/workforcealliance\/knowledge\/resources\/mlp2013\/en\/\"><span style=\"font-weight: 400\">Global Health Workforce Alliance report<\/span><\/a><span style=\"font-weight: 400\"> in 2013 advocated for greater use of &#8220;mid level healthcare workers&#8221; (those trained for 2\u20135 years to acquire basic skills in diagnosing, managing common conditions and preventing disease.)\u00a0 The Alliance found mid level care is as effective as physicians\u2019 in many situations, so re-allocating funding into mid level training, employment, and support, makes economic sense as it costs at least twice as much to train a doctor than a nurse or other mid-level workers. The resulting increase in the number of health workers could have a big impact on achieving UHC. But the real challenge in making mid level workers (including nurses) effective goes beyond funding allocations, and numbers of workers, and here I return to medical education.\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Traditional medical education is grounded in a hierarchy that values specialists over all other health workers, including other doctors. The hierarchy both determines and reinforces what is taught in medical school, which is an excessive focus on the diagnosis and cure of diseases and biomedical pathologies. Yet it is long known that social determinants contribute far more to a population\u2019s health status than individual disease.<\/span><span style=\"font-weight: 400\"> The hierarchy privileges the work and views of specialists who wield power at all levels of the health system, including management, and this cycle maintains the emphasis on disease and secondary or tertiary care, rather than primary and public health. This creates imbalances and exacerbates serious problems in the performance of health systems, including excessive medicalization, fragmentation in the provision of healthcare, and it undermines the principle of \u201cfirst do no harm.\u201d Power imbalances ingrained from medical training enable systems of corruption to emerge and persist, and these have a damaging impact on the right to health, with <a href=\"https:\/\/undocs.org\/A\/72\/137\">money being directed away from primary healthcare and promotion<\/a><\/span><span style=\"font-weight: 400\">. Users of services, and less valued health workers including primary care doctors, and non-medical health professionals, are denied the opportunities to participate in the planning, implementation and accountability of health systems, which leaves health services weaker and less responsive to people\u2019s broad health needs.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Primary healthcare contributes the most to health systems when it provides services to 80 per cent of people needing care. Overemphasis on specialist services is expensive and it effectively reduces funding available to train and employ primary health workers, which denies the possibility of universal health coverage being achieved.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">However, if medical schools adopted human rights-based approaches to education, the value of primary care workers and services would be recognized. Human rights principles include equality, dignity, interdependence of all human rights, transparency, and participation. Curricula grounded in these principles emphasize the importance of social determinants and promote an understanding in medical students that more participatory and inclusive processes, giving a voice to all health workers, and all users of services, is not only a human right, but provides better and more available care.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Medicine is not an exact science and there is nearly always some uncertainty about the most appropriate way to manage any condition. However, medical training builds the expectation in doctors and users of services that doctors have the knowledge and power to make all decisions, including non-clinical ones, with certainty and confidence. This places physicians under constant stress and leads to burnout. There are many decisions made within healthcare services, including on policy, managerial, diagnostic, preventive and therapeutic issues, which can be led by nurses and non-medical workers.\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Efficient use of mid level healthcare workers occurs in health systems that are not overly dependent on specialist physicians and which recognize that ill health does not always require a physician-led response. Where there is greater equality and power shared between primary and secondary care workers, it becomes easier to attract, train, fund and retain primary healthcare workers. When these conditions are met, the attainment of universal health coverage and primary healthcare is more achievable. Low- and middle-income countries, experiencing vast workforce shortages, should value primary healthcare and take great care not to emulate the education systems of high-income countries that are not based on equality, dignity, and other fundamentals of human rights.<\/span><\/p>\n<p><span style=\"font-weight: 400\">For these reasons, <a href=\"https:\/\/undocs.org\/A\/74\/174\">my new report &#8220;Right of everyone to the enjoyment of the highest attainable standard of physical and mental health,&#8221; and <\/a><\/span><span style=\"font-weight: 400\">delivered to the UN General Assembly today, urges states and medical schools to adopt human rights approaches in medical education to overcome medical hierarchies that privilege specialization and undervalue primary healthcare.\u00a0<\/span><\/p>\n<p><em><span style=\"font-weight: 400\"><strong><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2019\/10\/dainius-1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-45965\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2019\/10\/dainius-1-150x150.jpg\" alt=\"\" width=\"150\" height=\"150\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2019\/10\/dainius-1-150x150.jpg 150w, https:\/\/blogs.bmj.com\/bmj\/files\/2019\/10\/dainius-1.jpg 160w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a>Dainius P\u016bras<\/strong>, UN Special Rapporteur on the right to health.<\/span><\/em><\/p>\n<p><em><strong>Competing interests<\/strong>: None declared<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Medical education needs a drastic overhaul if we are serious about meeting the 2030 Sustainable Development Goals to achieve universal health coverage and health for all. It is now 41 [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/29\/dainius-puras-empowering-primary-care-is-only-way-to-achieve-universal-health-coverage\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":45966,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[263],"tags":[],"class_list":["post-45963","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-global-health"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Dainius P\u016bras: Empowering primary care is only way to achieve universal health coverage - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/29\/dainius-puras-empowering-primary-care-is-only-way-to-achieve-universal-health-coverage\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Dainius P\u016bras: Empowering primary care is only way to achieve universal health coverage - The BMJ\" \/>\n<meta property=\"og:description\" content=\"Medical education needs a drastic overhaul if we are serious about meeting the 2030 Sustainable Development Goals to achieve universal health coverage and health for all. 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