How PHC/PC is Conceptualized

The terms Primary Health Care and Primary Care are very often used interchangeably in almost all of these articles. Only 7% (8/119) clearly defined the term primary health care or primary care in the context of the paper.

Fifty percent (59/119) of the papers use the term primary health care and primary care to mean the care provided by certain clinicians, most commonly physicians in high income countries (89%). Forty four percent describe primary health care and primary care by the actual activities that were done such as act as gatekeeper, immunizations, prescriptions, and provision of basic medical services. Twenty one percent describe a set of attributes that the system would provide like accessibility, continuity, utilization and also level of care. Community oriented care as a concept was only discussed in four papers.

Only 4% (5/119) of papers emphasized the values and principles of primary health care, including human rights and social justice, for guiding the development of health systems. These were highlighted in examples of large international organizations as well as the US-based community health center (CHC) models.

Characteristics of Articles Retrieved

Table 1 describes the characteristics of the articles retrieved. Only 29% target low income countries where disasters are more common and 16% included research.

Table 1

Characteristics of articles retrieved (LIC = low income country)

Topics and Lessons Learned

There is strong support in the literature for the importance of primary health care (as widely described) in preparedness, response and recovery.Reference Perrin^4–Reference Fernald and Clawson⁹ These comments originate from a variety of countries, high income to low income including the United States, Armenia, and Pakistan.Reference Millin, Jenkins and Kirsch^5–Reference Fernald and Clawson⁹ Primary health care often has been described as a very important component of the health sector with respect to health needs during disaster, and therefore should be incorporated in the planning for response to these events.

The majority of the literature related to PHC and disasters stems from disaster response, with less specific literature focusing on DRR, preparedness and recovery. Table 3 summarizes the most common themes encountered from the primary health care literature.

Preparedness—In terms of preparedness, there are some examples in the US¹⁰ and the United KingdomReference Hodgkin and Perrett^11,Reference Tregoning¹² that using current PHC infrastructure can help build capacity for community disaster risk reduction and for disaster response (The community health center example in the US and primary care trusts in the UK). Also, building infrastructure for surge capacity in the primary health care system including employing strategies that are not normally used has been described.Reference Mazowita^13,Reference Summerhill, Mathew, Stipho, Artenstein, Jagminas and Russo-Magno¹⁴ Examples include surge capacity of the known health care providers, but also consideration of roles of lay people in the health response, as well as alternate models of care like the Canadian example of home based hospital care.Reference Hogg, Lemelin, Huston and Dahrouge¹⁵

Response—Strong messages for disaster response include the need for mental healthReference Birketvedt, Rafey, Stein, Ho, Karson and Smith^16–Reference Weisaeth, Dyb and Heir³⁹ and chronic disease interventionsReference Millin, Jenkins and Kirsch^5,10,Reference Birketvedt, Rafey, Stein, Ho, Karson and Smith^16,Reference Redwood-Campbell and Riddez³³ soon after the disaster and during conflicts, primary care team roles needing to be modified during disasters,Reference Calderon-Abbo¹⁸ and the importance of identifying vulnerable groupsReference Clark, Besch, Murphy, Vick, Gurd and Broyles^41–48 in disaster-affected communities. Models of care described include the use of mobile clinics,Reference Krol, Redlener, Shapiro and Wajnberg^49,Reference Lane⁵⁰ the advantage of using distant sites to provide clinical care, and the importance of Disaster Medical Assistance Teams (DMAT)Reference Henderson, Lillibridge, Salinas, Graves, Roth and Noji⁴² and army hospitalsReference Fernald and Clawson⁹ focusing on mostly primary health care services and only dedicating a smaller part of the work to other services like surgery.

Recovery—Utilization patterns of primary health care facilities after a disaster have been demonstrated to be elevated for periods of longer than a year.Reference Mazowita^13,Reference de Bocanegra, Moskalenko and Kramer^20,Reference Polusny, Ries, Schultz, Calhoun, Clemensen and Johnsen^31,Reference Soeteman, Yzermans, Spreeuwenberg, Lagro-Janssen, Bosch and van der Zee⁵¹ This increased utilization pattern is not just related to servicing the needs of the injured, but also reflects the psychosocial needs of those who were affected by the disaster. Other rebuilding concepts include how to best rebuild health facilities, to integrate risk reduction into recovery and reconstruction, and to rebuild the health system using a PHC-centered approach.

Health care reform in Mexico before and after the 1985 earthquake is an example of how cuts in health care programs are not inevitable in response to emergencies or disasters. Soberon et al describe the importance of a universal and equitable health system when the majority of a population is in need.Reference Soberón, Frenk and Sepúlveda⁵³ This resonates with the emphasis on a PHC approach.

Bremer, using the 2001 Gujarat earthquake experience, considers how assigned indicators (the eight elements of the PHC system based on the 1978 Alma Ata) for measuring the level of heath care, together with the assessments of vulnerability may improve disaster preparedness and management.Reference Bremer⁵⁴ In addition to mapping disaster prone areas and identifying vulnerabilities, documenting strengths of the health care system were crucial to the strategic development of preparedness and relief. In the US primary health care facilities have access to the ‘primary care facility and program assessment guide’ to determine needs for disasters.⁵⁵

Literature

The literature, although arguably not often methodologically strong, (Table 2) does however highlight the importance of primary health care in HEM. A limitation of this review is that it targeted mostly the published and available literature. This may represent publication bias. Since much of this literature and lessons learned in disasters are often not published formally, perhaps most important lessons are still waiting to be shared.

Table 2

Level of Evidence (n = 119)

*taken from Hadorn DC et al Reference Hadorn, Baker, Hodges and Hicks⁶³

Table 3

Themes: Primary health care and disasters (CHC = Community Health Center)

The term ‘disaster’ as defined by ISDR 2009 was used as a search term. The term ‘emergency’ was not used because it elicited a large number of unrelated topics. When ‘health emergency management’ was searched with ‘primary health care’, no reference sources were found.

The lack of clarity about the terminology, for both the term primary health care and health emergency management is a challenge. For example, the terms primary health care and primary care are often used interchangeably and the definitions and conceptual understanding about what PHC is still varies in the literature and in practice. This is despite the Alma Ata declaration and the 2008 World Health Report, where PHC is clearly defined as a health system based on clear managerial and organizational structure. Components of PHC differ considerably as demonstrated by Haggerty et al, where >25 operational definitions of attributes have been described.Reference Haggerty, Burge, Levesque, Gass, Pineault, Beaulieu and Santor⁵⁷ The term “primary care” has also been defined in various ways. When primary care is distinguished from PHC, the definition of primary care usually refers to care provided by certain clinicians including a set of activities that primary care ‘does’ and a level of care as an entry point into the system. Primary care is often more closely associated with the PHC principle of person-centered care which also provides comprehensive and integrated responses and continuity of care.² Recent literature in the field of primary health care has called for greater clarity when specifying PHC in terms that allow for more standardized measurement and rigorous evaluation.Reference Macinko, Starfield and Erinosho³ A method to improve this situation is to encourage publication of literature using the WHO definitions of primary health care as the standard by which PHC and primary care is described in the literature.

Similarly, the terms related to health emergency management are not always clear. The key words; emergency, disaster, crisis, risk, humanitarian action, risk reduction, mitigation, preparedness, response, recovery, rehabilitation, reconstruction, hazard and vulnerability are not clearly defined when used in the literature.

In terms of disasters, there is a large body of experience in primary health care which is not documented, or if it is reported, is largely inaccessible. Many health personnel from government and non governmental organizations (NGOs), for example, have experiences working in PHC or primary care disaster settings. Although this has improved with the advent of the internet, the NGO community, governments and others involved in the health sector in disaster risk reduction, preparedness, response and recovery must be encouraged to share these experiences.

Open and available publication is the only way to make lessons identified in evaluations and reports easily accessible to the global community. Another limitation is that the articles were sometimes limited to English in certain databases. Future reviews might find benefit in searching other languages in greater detail, with the example of Spanish language articles originating in Latin America as one further option.

Not unexpected was the observation that although low income countries are most affected by disasters, the majority of published literature still reflects experiences in high income countries. In addition, most of the studies and documents do not include adequate representation of authors from low income countries. This is not unique to the topic of disaster primary health care.⁵⁶ There may be multiple reasons for this imbalance such as inadequate research partnerships between high and low income counties, lack of funding and time for researchers in low income countries and possibly lack of experience, expertise, and mentorship in health research. In order to hear the message and experiences of colleagues in low income countries, the research community needs to be cognizant of the importance of working in partnerships with colleagues from the north and south in true collaboration.

The missing pieces

The literature describes primary health care and medical assistance in disasters as concepts that have not, as of yet, been brought together effectively. The challenge has been that they have been conceived as fundamentally different models of providing health care. The reality in disaster situations is that both are needed together.Reference Macinko, Starfield and Erinosho^3,Reference Fan⁵⁸ A description of the possible synergies between the four strategic areas of the PHC renewal process and humanitarian health action is described in the World Health Organization Health Action in Crisis annual report.⁵⁹ Humanitarian Health Action has also been considered as part of the PHC renewal strategy in this document.

The literature does not reflect an extensive conceptualization of PHC for emergencies and disasters. On the other hand, the disaster literature is reporting the importance of PHC as part of the disaster response and DRR and emergency preparedness agenda. This development, combined with the reality of more than 1.3 billion people being faced with emergencies and humanitarian crisis, makes a strong case for the re-examination of PHC in disasters and emergencies and creates an opportunity to ask how to best bridge PHC and Health Emergency Management, and especially emergency medical assistance.

Most of this literature did not overtly describe the link between primary health care initiatives and the values and principles of human rights, social justice or health equity as described in the World Health Report 2008.² When this link was identified, it was predominantly by some of the large international organizations.^2,Reference Perrin^4,1059 Community health centers in the United States, by nature of their mandate to serve low income and medically underserved communities, identify equity as a key for the provision of primary healthcare in preparing and responding to disasters.¹⁰ The healthcare reform in Mexico after the 1985 earthquakes emphasized the importance of a universal and equitable health system through an ambitious primary care program.Reference Soberón, Frenk and Sepúlveda⁵³ Interesting also is the fact that few publications described the humanitarian principles as the basis of either the work being done or the paper being written.

Given the nature of disasters and conflict and primary health care needs, the humanitarian principles and the WHO values of health equity, health of communities, reliable health authorities and participation, these should be the foundation of all primary health care initiatives related to disasters. How to actually integrate these concepts into decision making, programming and service delivery in health and social sectors at all levels is the next step.

There continues to be a lack of ‘multidisciplinary’ and ‘multi-sector’ co-authorship' in the literature. The majority of papers published are case reports from the provider experience, navigating the system during a disaster. If these articles, for example, included the combined perspectives of different types of health care providers, policy makers, health planners, government and educators, the lessons learned, links to policy, legislation and education would be much stronger. Instead, these experiences are fragmented without the holistic or larger perspective often demonstrated.

The applicability of lessons learned from high to low income countries is salient and requires consideration. It appears that some lessons learned from high income countries could sometimes be applied to low income countries, but would need to be evaluated for that specific context. It is still unclear as how to best support primary health care in a country or region with weak primary health care systems. Priorities could be tested with a Delphi consensus of colleagues in low income countries but key disaster indicators for PHC need to be identified and validated with how to best integrate HEM as a key element of the PHC approach.

Developing PHC Specific Disaster Indicators

In order to measure the impact of a disaster on the primary health care system, the Gujarat paper demonstrates how indicators can be developed based on the eight elements of the Primary Health Care system.Reference Bremer⁵⁴ These eight elements include; education, local disease control, expanded program for immunization, mother and child family planning, essential drugs, nutrition and food supplies, treatment of diseases and safe water/sanitation. This allows a broad evaluation and assessment of public health. The challenge to date is that the specific indicators representing each of the elements need to be tailored to a disaster setting and then subsequently to the specific context. For example, indicators that may be included for PHC for the disaster context may include: mental health indices, chronic disease rates, and number of primary health workers and lay health workers educated and trained for rapid response to disasters. Identifying ‘disaster related PHC indicators’ testing and validation in different settings would allow for the objective measurement of disaster impact on PHC system but it would also significantly contribute to implementation, monitoring, and evaluation of disaster risk reduction, preparedness response and recovery in meeting the health needs of disaster-affected communities.

The International Disaster Response; The PHC Need

There is a very clear message in the literature. If the emergency medical response is not available within the first days after a sudden-impact disaster, then the disaster response for health should focus predominantly on supporting community needs and PHC capacities.Reference Kazzi, Langdorf, Handly, White and Ellis^6,Reference Hlady, Quenemoen, Armenia-Cope, Hurt, Malilay and Noji^7,Reference Hodgkin and Perrett^11,Reference Redwood-Campbell and Riddez^33,Reference Henderson, Lillibridge, Salinas, Graves, Roth and Noji^42,Reference Krol, Redlener, Shapiro and Wajnberg^49,Reference Fan^58,Reference Edwards, Young and Lowe^60–-Reference Smith, Traum and Poole⁶² This has implications for foreign medical teams which are often delayed. Good local infrastructure is needed to support safe and reliable hospitals and other health facilities that will function after the disaster. Restoring access to PHC or primary care services is a priority in health emergencies and disasters and in periods of stability by some international organizations.Reference Perrin⁴

How the international community supports primary health care needs will vary and will depend on the context of the affected country. For example, the disaster health response should aim to support and strengthen the current PHC system by capacity building and working with local health care providers in existing community health structures rather than ‘importing’ international ‘care.’ An international community that supports locally defined PHC through principles of risk reduction, preparedness and response contributes to a more resilient community.