Holistic Approach in Strengthening of Primary Health Care Service

Sri Lanka is currently facing a demographic and epidemiological transition, which includes the rising burden of non-communicable diseases (NCD), immerging, and re-emerging of communicable diseases. Further, Population ageing in Sri Lanka is accelerating at a faster rate than in other South Asian countries. Primary Health Care, often abbreviated as ‘PHC’, has been defined by World Health Organization as “an approach that in whole society that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to

Reversing the service utilization pattern would likely yield substantial efficiency gains that maximize the benefit of existing resources as well as maximal utilization of higher-level institution for needy critical patients, while changing PHC as popular first contact points closure to their homes providing comprehensive care package.Further, Population ageing in Sri Lanka is accelerating at a faster rate than in other South Asian countries.The proportion of Sri Lankans above the age of 60 years will double by 2040, accounting for one-fourth of the total population of the country.This rapidly ageing population in the country and the growing burden of NCDs will DOI: https://doi.org/10.4038/sljma.v24i2.5438increase the demand for long-term care that requires more resources from the health system.
The COVID-19 pandemic, which created a profound impact not only on healthcare but also on the country's economy, has affected national healthcare priorities.The COVID-19 period shows the value of PHC to amplify preparedness in dealing even with future surges while maintaining the capacity to continue routine health care services within a constrained resource environment.Within such a context, having a robust primary health care system, which ensures universal health coverage would be an invaluable advantage for a country like Sri Lanka facing a 'dual pressure': to strengthen pandemic preparedness and also to meet the growing health care demand for NCDs in an ageing population.
In 2017, the government health expenditure was LKR 218 billion (USD 1.43 billion) or 1.62 per cent of the GDP.The level of public financing for health has remained virtually unchanged for many years and out-of-pocket (OOP) payments have dominated health financing.It has become critical for Sri Lanka to secure adequate resources for health care, which caters to the demand of managing routines as well as managing pandemic preparedness and the growing demand for emerging Communicable Diseases (CDs) and Non-Communicable Diseases (NCDs).A more promising approach should be implement within the current public health financing framework through more efficient use of available resources to overcome challenges facing.The aim of this work is to identify a sound comprehensive action framework with suitable strategies.

Primary Care and Primary Health Care
WHO defines, as "Primary care is a model of care that supports first-contact, accessible, continuous, comprehensive, and coordinated person-focused care.It aims to optimize population health and reduce disparities across the population by ensuring that subgroups have equal access to services.There are five core functions of primary care: • First contact accessibility creates a strategic entry point for and improves access to health services.• Continuity promotes the development of long-term personal relationships between a person and a health professional or a team of providers.• Comprehensiveness ensures that a diverse range of promotive, protective, preventive, curative, rehabilitative, and palliative services are provided.• Coordination organizes services and care across levels of the health system and over time.• People-centred care ensures that people have the education and support needed to make decisions and participate in their own care" [1] .
"Primary care is a key process in a health system that provides promotive, protective, preventive, curative, rehabilitative, and palliative services throughout the life course.Primary health care (PHC) is a broader whole-of-society approach with three components: (a) primary care and essential public health functions as a core of integrated health services; (b) Multisectoral policy and action; and (c) empowered people and communities" [1] .

Primary Health Care
Primary Health Care, often abbreviated as 'PHC', has been defined by World Health Organization as "an approach that in whole society that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people's needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people's everyday environment" [2] .Primary Health Care (PHC) ensures people receive quality comprehensive care that ranges from promotion and prevention to treatment, rehabilitation and palliative care, which is closely feasible to people's everyday environment [2] .PHC addresses the broader determinants of health and focuses on the comprehensive and interrelated aspects of physical, mental and social health and wellbeing.It provides whole-person care for health needs throughout the lifespan, not just for a set of specific diseases [2] .This means PHC is not only helping an individual after being diagnosed with a disease or disorder, but actively prevents such issues by understanding the individual as a whole including lifestyle and environment.
PHC provides "essential health care based on practical, scientifically sound and socially acceptable methods and technology, making universal health care accessible to all individuals and families in the community through their full participation and at an affordable cost to the community and the country to maintain at every stage of their development in the spirit of self-reliance and selfdetermination".In other words, "Primary Health care is an approach to health beyond the traditional health care system with basic level of health care that includes promotion of health, early diagnosis of disease or disability and prevention of them, attending for any emergency and sickness as the first contact as well as the follow up of basic ailments and palliative care ensuring the availability, coverage, affordability and equitable access to health services as well as ensuring the quality of available basic needs of citizens in the particular area".Behind these elements lies a series of basic principles identified in the Alma Ata Declaration that should be formulated in national policies in order to launch and sustain PHC as part of a comprehensive health system and in coordination with other sectors achieve empowering people and communities, multisectoral policy and action; and primary care and essential public health functions as the core of integrated health services:

Evolution of the Concept of PHC
• Equitable distribution of health care -Services for main health problems in a community must be provided equally to all individuals irrespective of their gender, age, caste, colour, urban/rural location and social class.The Sri Lankan health system is structured with Western, Traditional, Ayurvedic,   Director of Health Service (RDHS) in provincial health service with assistance of relevant other authorities.Preventive Healthcare network highly contributes for preventive aspects of many programmes with available limited resources, but curative care institution network is unsatisfactorily underutilized.

Availability, Accessibility and Coverage
Access to government health services from Households on average, 2.5 kilometres to a maternity clinic, 4 kilometres to a government dispensary, and 6.5 kilometres to a hospital and 93 per cent of the population has access to a hospital within 15 kilometres (3).It is estimated that out of the 21 million population 7 million receive inpatient care and over 57 million outpatient visits in the public sector (4).

Achievements
The crude birth rate is 15.2 per 1,000 population and the crude death rate in Sri Lanka is 6.2 per 1,000 population (5) and life expectancy at birth for female is 78.

Key challenges in strengthening PHC
According to a study done in qualitative methods with the participation of relevant stakeholder categories with objectives to identify gaps in the current system and obstacles / challenges in strengthening Primary Health Care especially revitalization of PHC curative care institution, following gaps/challenges in current service delivery at Primary Health Care level were identified and were suggested to be addressed with gradual

Primary Health Care as a Solution
Reversing the service utilization pattern would likely yield substantial efficiency gains that maximize the benefit of existing resources as well as maximal utilization of higher-level institution for needy critical patients, while changing PHC as popular first contact points closure to their homes providing comprehensive care package.The current trends in Sri Lanka is reduce Primary care utilization patterns that displayed in Figure 4.This has to be reversed as shown in the Figure 4, that is increase utilization of Primary Care services as a part of Primary Health Care improvement.This should be covered with broader areas such as community participating and involvement and involvement of other sector that defines more on Primary Health Care rather than focusing only Primary Care services.

Coverage of Administrative and Policy Guidelines
According to the circular number, HPC/09/2018 dated 2020/03/03 by the Ministry of Health facilities and services deliveries to be available at the Primary Care Institutions have been defined.
Facilities should be available at these institutions for the prevention and management of communicable diseases and non-communicable diseases as per the essential service package defined by the Ministry of Health [7] .
Sri Lanka has had a sound primary healthcare approach since the mid-1920s (even before the Declaration of Alma-Ata in 1978).The country has made notable progress in key healthcare indicators and has been recognized as a star performer in the region especially due to the achievements in preventive aspects of Primary Health Care Service.While continuing such preventive activities, it has needed to improve curative care service in PHC with a focus to give solutions for unnecessary workload in Secondary Care and Tertiary Care institutions and reduce health costs while providing patient-centred care through PHC with patient satisfaction.
Improving health promotion and prevention, especially through community awareness and empowerment and early detection of diseased preventing complications which need heavy expenses as well as identifying high-risk groups for thorough follow up will reduce the burden on higher-level institutions in the health sector.All of these could be done at the Primary Care Level since the operational basis of almost all the programmes is at the Primary Care Level.Considering the principles and the concept that Primary Health care is not a short-lived intervention, but an ongoing process of improving people's lives and alleviating the underlying socioeconomic conditions which contribute to poor health and hence to health and development, as well as primary care is the front door to health care, entry point into the health-care system which provides for basic everyday health needs, following changes and improvements of the system as a comprehensive care model with a holistic approach are proposed based on below three Key Result Areas and three Strategic Objectives.However, few strategies are already being tried to be implemented by the PHC strengthening projects in pilot areas, most of the innovative solutions proposed in this strategic framework or road map highlight how to reorganize the services at PHC and how to make it popularized.To strengthen and maintain PHC structure, system and processes addressing people's health needs in an efficient & effective way

Figure 1 :
Figure 1: Pillars of Primary Health Care

Figure 2 :
Figure 2: Primary Health Care within Sri Lankan Health System 6 years and 72 years for males on the year 2011 -2012 (Department of Census & Statistics Sri Lanka).Maternal Mortality Ratio (MMR) is 30.2 per 100,000 live births in 2020.Infant Mortality Rate (IMR) is 9.5 per 1,000 live births in 2021.

Figure 3 :
Figure 3: Organization of Provincial Health Sector

Figure 4 :
Figure 4: Reversing the service utilization Source: Author (2023) Availability of services according to Essential Service package also including oral health, Maternal and Child Health (MCH) services + Family Planning + Immunization Organizing as a cluster system (Shared Care Clusters) Arranging clusters around Apex hospitals sharing facilities Completing population empanelment process Registration of empanelled catering population in a Health database with unique PIN number suitably with details of census database Developing all the PMCIs with minimum requirement of facilities (address 6 building blocks of health system in activity plan) Upgrade all Divisional Hospitals into equal standard with infrastructure and equipment necessary to implement Sri Lanka Essential Service Package Establishing HLC in all PHC institutions for Screening + Health promotion + Counseling and awareness on acute and chronic NCDs + follow up of high risk groups + Screening for diseases relevant to other programmes even Develop a mechanism to make available all necessary drugs in all PHC institutions Upgrading of laboratories at apex hospital as the referral center for the satellite institutions and establishing satellite lab service covering all clusters Ensuring availability of optimum HHR requirement all the service delivery points Developing a forward and backward referral system Organizing a new mechanism to establish step down divisional hospitals Extended Specialist services through visiting clinics or e-consultation (through Tele Medicine consultation) Arranging visiting clinics / visiting surgeries Establishing Tele medicine / Tele consultation mechanism integrating PHC institutions and SC / TC institutions system of screening the target population considering all the possible risk factors ( Especially through screening of empanelled families to Family Medical Clinics) Screening & identifying diseased and high-risk groups Age /M/F/including other risk factors Screening as a package in all preventive care and curative care ( in both HLCs & WWC) Screening as a package for clinical conditions of all programs + Nutrition Screening all the eligible mothers for pre and post pregnancy for NCDs Establishing a proper referral system and centres at SC / TC institutions for newly identified patients set up for OPD patient care management with proper referral mechanism Establishing Family Medical Clinic set up in all PHC institutions Establish proper referral mechanism from primary care (DHs and PMCUs) to specialized care providing priority for referrals Refer back by high centres long term follow up patients to FM clinics at DHs and PMCUs Reorganizing OPDs to FM clinics at DHs & PMCUs Appointing Consultant FM physicians to all Apex referral hospitals Strengthen with more facilities such as investigative in apex of satellite cluster as the referral centre for the satellite family clinics Establish referral centers for PHC level at DH type A, for referrals from FM clinics, WWCs and HLCs etc. Implementing a Family Medical Record system in order to ensure the continuity of the care Make available all necessary needed drugs / investigation facilities / transport facilities Initiating CPD / training programs for the all MOO for family medicine at OPD Monitoring and supervision by FM physicians FM Physicians will visit and supervise all satellite FM clinics in the draining area Establish home visits to patients in Community based rehabilitation programme (CVA, Elderly etc.) Arranging consultant service Through attached FM consultants Through visiting clinics / tele medicine consultation from other specialties from higher centres situation and identify gaps Conduct a survey to identify the gaps in each level / institution with special focus to PHC level based on A&E policy and guidelines Strengthen ETUs (Level VI A&E units) in all PMCIs (DHs and PMCUs) and to develop as first contact points linking with main hospitals as its draining satellite centers Establish well equipped level 4 A&E unit (Emergency Room (ER) -in all PHC institutions with trained staff by EM Physicians in TC /SC level Necessary infrastructure improvements and provision of necessary equipment according to the identified gaps Ensure availability of all needed equipment for A&E management Establishment of a communication mechanism between Consultant Emergency Physicians in apex hospital and the primary care institutions for efficient & effective A&E care management Link through online Tele consultation mechanism Developing a well-recognized grading system of emergencies with relevant colleges Introducing alert mechanism for transfers (prior informed referral mechanism to high centre) Capacity building of teams engaged in A&E care Make arrangement with main hospitals (Director & consultants) to organize training programmes for PHC staff (MOs & NOs) on A&E and Critical Care -Local (in house and distant) & foreign Re organizing Ambulance services for efficient pre hospital care with competent staff members Strengthening pre hospital care service covering all areas with Suwasariya and linking all DHs with Suwasariya Strengthen efficient ambulance service through e-Establishing a coordinating cell for community based rehabilitative and palliative care at each PMCI to ensure the optimum patient care prescribed by the discharging physician including Managing the HHR according to the PHC requirement to achieve PHC objectives Capacity building of existing PHC staff in regular basis Developing CPD programme for staff in PHC Monitoring individual and group performances Establishing a proper performance appraisal system reporting system with information flow and monitoring mechanism Establish mechanism for new information flow & reporting mechanism flow based on identified indicators to assess the cost effective utilization of resources and assessment of performance Strengthening Supervision and Monitoring based on indicators and advanced plan Establish performance and facility evaluation database-Monitoring through the developed Health Net ( Facility & Performance Data Base) Monitored by District Intersectoral Coordination Committee Develop and integrate a comprehensive MIS for PHC Purchasing of IT devices and equipment as well as networking facilities Regular training of HHR for smooth and efficient utilization and managing of the informationTo strengthen measures to empower individuals, families and communities to take charge of their own health through community awareness Establish counselling services for identified target groups (pre marriage, post marriage and retirement) Establishing pre marriage and post marriage registration and counselling service Establishing pre-retirement preparation counselling Establish and arrange awareness materials Fixing Billboards for community awareness Educate & sensitize people on available health services such as disease screening, rehabilitative and palliative care as well as social / disability / elderly care services Community empowerment through awareness Strengthening Pre-Retirement Preparation Awareness Program for elders in the formal and informal sectors to direct them for having self-fulfilling retirement life Local area communication program to improve the awareness of elder care package of services Strengthening School health clubs First-Aid and Basic Life Support awareness programme for school and work settings.Motivation for organic farming, physical activity promotion Cluster operated centrally monitored Hotline for inquiry and Grievance handling coupled with web based flat form for FAQ and Service information identification Strengthening screening programmes in all setting to identify their health problems Screening & identifying diseased and high risk groups to be regularly followed up institutionally as well as out reach clinics with assistance of volunteer organization + GS + Samurdi officer Screening as a package for all programmes + Nutrition Organize awareness sessions in community, workplace & schools coupled with screening programmes ( through community clubs) in order to educate & sensitize people on their health as well as importance of promotion and prevention Improving broader determinants of health through Multisectoral coordination Advocacy and coordination with relevant sectors for policy and action ensuring the quality of available basic needs of citizens Water, Education, Agriculture, Local Governments, Housing, Road & Transport, nutrition, sanitation etc Advocacy to introduce provision of basic primary care needs of people and health promotion into other sectoral policies and plans Coordination & monitoring with other ministries for availability of quality basic needs of citizens Strengthening measures for food, water, housing , household hygiene / sanitation Strengthening measures for alerting & prevention of air pollution etc Strengthening measures for improving Nutrition

Table 1 : Distribution of healthcare institutions according to the system and category
Source Planning Unit, Ministry of Health, 2022 & Private Health Services Regulatory Council, 2022 Primary Health Care (PHC) -Primary Medical Care Unit, Divisional Hospital-Type A, B & C Secondary Care (SC) -Base Hospital-Type A & B Tertiary Care (TC) -District General Hospital, Provincial General Hospital, Teaching Hospital, National Hospital