Transforming Assistance in Primary Health Care: now or never!
Why was the “2018 Primary Health Care Now or Never” Campaign born
Universalistic healthcare systems consider health to be a an inherent right of each person, thus foster a continuous and free-of-charge access to healthcare; However, the social, demographic and epidemiologic transition* is undermining the sustainability of this model. Following recommendations by the World Health Organization (WHO), international literature, stresses the need for a radical transformation of all welfare systems along the lines of an integrated, multi-professional and multisector based perspective. These changes must be primarily enacted on a territorial level, involving an active participation by the communities.
To guarantee health as a right, and thus the sustainability of National Healthcare Systems in the twenty-first century, it is necessary to adopt a Primary Healthcare model focused on individuals, their family networks, on close relationships and be community-oriented. In the literature, this is called Comprehensive Primary Health Care, or C-PHC. In Italy, some of these recommendations have been adopted with the law creating the Case della Salute (House of Health), the development of documents such as the Piano Nazionale Cronicità (National Chronicity Plan), and the more recent Piano Nazionale della Prevenzione (National Prevention Plan). Even though there has been a positive reorganization of Primary Health Care in a few regions, the change in the mindset of operators and users, and in healthcare practices throughout the national territory, is slow and difficult. Perhaps, this might be the only possible way, since it entails a radical change in culture, shifting the Healthcare System’s focus from a hospital-centric model, to one based on territorial Primary Health Care.
One of the main obstacles lies in the training of health operators, which, throughout all of the steps before and after a degree, takes place almost exclusively in the great city hospitals; that is, places organized according to a specialized and ultra-specialized, highly technological approach. The professionals coming out of such training are thus culturally oriented toward acute pathology and competent in hospital healthcare.
The radical restructuring of programs and places dedicated to internships is a focal and unavoidable step. The twenty-first century society needs health operators who are trained to work in and with the territory, understanding its needs and complexities. Thus, the education of all healthcare operators must provide learning situations that involve both hospital and territorial services. This is the only possible way to understand the best multidisciplinary approach to each specific context, regarding the promotion of health, primary prevention of illness and complex management of chronicity and palliative cures.
Shifting to this new health and care paradigm, will require challenging the status quo and, most of all, a high quality creative action[8-9].
Who are we?
We are an independent group of healthcare operators from all over Italy and we are passionate about matters of health. We are young general practitioners and continuity of care operators, physicians studying to specialize as G.P.s, medical students, specialists in healthcare and other medical specializations, nurses and anthropologists. We are open to contaminations and the inclusion of everyone who appreciates the Comprehensive Primary Health Care (C-PHC) approach, or who wishes to better understand it.
Going back to the World Health Report “2008: Primary Health Care Now More Than Ever”, we reiterate the urgent need for a paradigm shift in primary health care which cannot be delayed further, and we launch the campaign “2018 Primary Health Care: Now or Never”, through these activities and principles:
- Field study and Exploration of Primary Health Care models which have already been adopted. We choose and visit some of the Primary Care situations which are considered excellent on a national and international level. Together with the local operators, we explore the various services and create on site dedicated spaces in which to analyze which practical measures are actually effective and desirable in supporting health and in globally taking charge of the population’s social and healthcare problems. This is carried out with an eye specifically on the role of the General Practitioner in the new epidemiologic context.
- Training and self-education: we create work and study groups on Primary Health Care and related themes, in order to collect and organize literature, and prepare educational material, considerations and summaries. We promote meetings on a national level in order to gain knowledge, empowerment and the necessary skills to work in the field of Primary Health Care. Shared learning and group work are aimed at acquiring the meta-expertise necessary to work in a multidisciplinary team. This is why we promote the renewal of undergraduate and graduate training (University and General Practitioner Specialized Training).
- Ethical and political orientation: We claim the right to health as one of the fundamental human rights to be achieved through a National Healthcare System, which must be universal, fair, public and committed to opposing social inequalities in matters of health. We promote initiatives (both local and not) which, by acknowledging the twenty-first century epidemiologic and social transition, will support, channel and foster a cultural shift in our NHS, toward a Comprehensive PHC.
We call upon and involve all interested parties.
For further information, subscribing to the campaign and giving your contribution:
List of campaign signatories: link
1. ISTAT. IL FUTURO DEMOGRAFICO DEL PAESE. Previsioni regionali della popolazione residente al 2065 . Statistiche Report. 2011
2. Starfield B, Leiyu S, James M. Contribution of primary care to health systems and health. Milbank Quarterly 2005
3. World Health Organization. The World Health Report 2008 – Primary Health Care (Now More Than Ever) 2008
4. Vilaça Mendes E. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família. Brasília-DF: Organização Pan-Americana da Saúde; 2012.
5. Legge 27 dicembre 2006 n. 296 (Legge finanziaria 2007)
6. Ministero della Salute. Piano Nazionale della Cronicità. 2016
7. Ministero della Salute. Piano Nazionale della Prevenzione 2014-2018
8. Frenk J, Chen L, Bhutta Z, Cohen J, Crisp N, Evans T et al. Health professionals for a new century: transforming education to strengthen health systems in an inter- dependent world. The Lancet. 2010; 376(9756):1923- 1958.
9. World Health Organization. Transforming and scaling up health professionals’ education and training. Guidelines 2013
What is meant by demographic transition is the rapid and constant ageing of the population which has been observed in Europe during the last decade. While in 2012 only 15% of the general population was over 65 years of age, by 2050 this group will represent over 25% of the total.
At the same time, it is expected that by 2065 the average life expectancy will grow to 86,1 for men and up to 90,2 years for women. This shift can be attributed to various causes, among which: an increasingly effective control of contagious diseases, a birth rate which is not high enough to compensate for deaths (by 2045 Italy will see a 2,1 million drop in population) and the decrease of child mortality. Another important instrument to measure this phenomenon is the old-age index, that is, the ratio of population over 65 years of age compared to that under 15, which has been in constant growth over the last 15 years.
From a sociological standpoint, we can look at the traditional family model which, especially in Italy, has always been a stabilizing factor. Its crisis (as is evidenced by indicators such as a decrease in marriages, an increase in divorces and a reduction in the average number of family members), will put more pressure on the NHS which will have to deal with a larger population of elderly living alone, who are fragile and have more complex welfare needs. This modification of the family structure and its consequences on welfare are the social transition taking place in our country.
Finally, what is meant by epidemiologic transition, is the change in health demand toward a constant and consistent increase of mortality caused by chronic disease, rather than communicable diseases. In Europe, in 2009, 80% of deaths have been caused by non-transmissible disease, which are related to multiple factors and are typified by a chronic progress. NHSs, which have been traditionally designed to respond mainly to acute diseases, must now cope with an epidemiological change, which mainly calls for the effective management of chronic problems, needing a completely different set of responses and service organization.