Welcome to the
Malaysian Family Physician, a peer-reviewed open-access journal of family practice
and primary care research.
SPECIAL ARTICLES
THE RAJAKUMAR ORATION 2009
Delivered at the Convocation, Academy of Family Physicians Malaysia, on 4th April 2009, The Legend Hotel, Kuala Lumpur, Malaysia
Associate Professor Dr Jan Radford
Jan is Associate Professor of general practice at the University of Tasmania, Censor in Chief of the Royal Australian College of General Practitioners and a general practitioner with a specific interest in psychological aspects of care. Her research interests are in medical education, especially assessment.
PRIMARY CARE: THE EVIDENCE BEHIND DR RAJAKUMAR’S VISION
J Radford, FRACGP, MPM
Address for correspondence: Associate Professor Dr Jan Radford, Dept of General Practice, Launceston Clinical School, School of Medicine, University of Tasmania, Australia. Tel: 61 3 63488790, Email: J.Radford@utas.edu.au
Radford J. The Rajakumar Oration. Malaysian Family Physician. 2009;4(1):2-5
Members of the Academy of Family Physicians of Malaysia, ladies and gentleman, I am extremely honoured to deliver the inaugural Dr Rajakumar Oration to your 2009 convocation.
Dr Rajakumar was a revered leader in Malaysian and International Family Medicine.
The phrases I have encountered with regard to Dr Rajakumar include:
- a passion for life
- deeply devoted to family and friends
- selfless service to patients and society
- commitment to the poor
- leading left wing intellectual
- acted locally and thought globally
- concern for improving the general standard of health care
- a very intelligent man who was well read and a great orator – a leader
- always held onto his ideals
- a man of absolute integrity and honesty
- a caring doctor adored by his patients
- only interested in serving the poor and needy
- he was a family doctor first
- he promoted general practice as a modern discipline at a time when medical schools emphasised specialisation
- he advocated post-graduate training in family medicine
- he proposed university departments of family medicine
- he encouraged research and quality assurance in family medicine
- he championed rural health
- one of the icons of international family medicine... and from whose shoulders we have the privilege to stand and gain a better overview of the vast domain of primary health care
I can see that Dr Rajakumar must surely be missed as an exceptionally inspiring role model and leader in family practice.
I can understand that the grief you feel after his death in November 2008 must still be strong.
I very respectfully pass on the heartfelt condolences of the Royal Australian College of General Practitioners.
This morning I wish to speak to you about the world’s evolving understanding of just what primary care has to offer. Dr Rajakumar was indeed ahead of his time as he understood the power of primary care long before most others.
Primary care reduces social inequality in health
Dr Rajakumar noted “Equity is not a marginal philosophical issue but central to human civilisation”1 (p. 160).
The 14th of October 2008 was the 30th anniversary of the international signing of the Declaration of Alma-Ata, where the first international call for equity in health care was made under the auspices of the World Health Organisation (WHO). To mark this event the WHO has published a World Health Report, “Primary Health Care – Now More than Ever”.2 The report critically assessed the way health care is organised, financed, and delivered in rich and poor countries around the world.
The report found that when countries at the same level of economic development are compared, those in which health care is organised around the tenets of primary care produce better health outcomes for the same resource expenditure.
The evidence for this finding is very strong.3 Countries around the world are just starting to understand this – even the USA has just stated that primary care will be their designated approach to health care under President Obama’s administration. It will be interesting to watch them turn that ship around.
The definition of primary care I use is by Starfield et al, i.e. “the provision of integrated, accessible health care services by clinicians who are accountable for addressing the majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community”3 (p 458).
Overall the stronger the primary care approach in a country’s health system the better the health outcomes.3
Thirty years on from the Alma-Ata Declaration
On reading the WHO’s report, “Primary Health Care – Now more than ever”, lessons to learn from the world’s experience since the signing of the Declaration of Alma-Ata include2
- Primary health care should be the designated approach to health care. Primary care should not be seen as ‘the antithesis of the hospital’ but instead as the ‘coordinator of a comprehensive response at all levels’2 (p. XV).
- Action is needed, not just rhetoric.
- People with the most means – whose needs for care are often less – consume the most care with public spending benefiting the rich more than the poor.
- Health is limited if health systems are built around hospitals and consultant specialists.
- When health is skewed to consultant specialist care many preventative and protective health care activities are lost.
- Health care is often delivered according to a model that concentrates on diseases, high technology, and consultant specialist care rather than on primary care.
- Health systems built around vertically-orientated disease programs and other priority programs produce poorer outcomes than those built around primary care.
- Unregulated commercialism is toxic to good health outcomes. If health care is treated as a commodity and driven by profitability health care quality and equity is sacrificed.
- Primary care is not cheap but it provides better value for money than its alternative.
The benefits of primary care – the evidence
The evidence for the health benefits of primary care is strong. “Systems that explicitly distribute resources according to population health-needs (rather than demands), that eliminate co-payments, that assume responsibility for the financing of services, and that provide a wide range of services within the primary care sector are more cost effective”4 (p. 1365).
Let me present to you the evidence of the benefits of primary care. Barbara Starfield and colleagues3 have pooled data from numerous countries. They have measured the degree of primary care within international health systems and the primary care features influencing health outcomes. They note the four main features of primary care services as “First-contact access for each new need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere”3 (p.458).
Primary care is best when these four features are fulfilled along with a family and community orientation as relevant.
