The knowledge, ability, and skills of primary health care providers in SEANERN countries: a multi-national cross-sectional study

The year of 2018 marked the 40th anniversary of the Alma-Ata Declaration on Primary Health Care (PHC) [1]. The Declaration on PHC was endorsed by all the countries and was considered a watershed in terms of the concepts and practices of public health as a scientific discipline. World Health Organization (WHO) advocated PHC as the key to attain the goal of “Health for All (HFA) in 2000” [1]. WHO defined PHC in Declaration of Alma-Ata as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” [1].

Over the past 40 years, PHC provision has moved from thoughts and words to action and reality. Though the ambitious goals of HFA were not achieved in 2000, PHC, as a core value of WHO Constitution and Alma-Ata Declaration, is still crucial in current global health context [2], especially for developing countries [3]. The United Nations (UN) announced eight Millennium Development Goals (MDGs) by 2015 [4]. However, the achievements were uneven, and thus, the UN announced 17 Sustainable Development Goals (SDGs) and expected them to be achieved in 2030 [5]. These 17 goals should be taken seriously and actively implemented by all countries. Health and wellbeing is one of the SDGs and PHC is one way to achieve that goal. More specifically, Gillam stated that Alma-Ata Declaration is still relevant for effective health care systems, since the core principles of PHC are keys to moving towards health equity or universal health coverage under such a changing and challenging context [6]. In the World Health Report of 2008, WHO Director General Margaret Chan addressed that PHC deserved the greatest attention for policy makers and national governments [2]. Health systems which are oriented towards PHC are more likely to have better health outcomes and greater public satisfaction at lower costs and true access [7, 8]. PHC has usually been regarded as the initial point of contact for individuals wishing to access health care [1], especially for the vulnerable groups [6]. For example, about 75% of child and adolescent mental health problems were first treated by PHC providers, who were usually the first medical professionals consulted by children and their families [9]. Furthermore, the PHC links multiple sectors and disciplines, integrates a variety of elements of disease management, emphasizes prevention and early detection, and the maintenance of health. In fact, as the most affordable and accessible health service for residents, especially for those in remote areas, PHC has been long viewed as the “first element” as well as part of a “continuing health care process” [10].

Specifically, Alma-Ata Declaration has outlined eight essential components of PHC [1], including: (1) Health education on prevailing health problems and the methods of preventing and controlling them; (2) Nutritional promotion including food supply; (3) Supply of adequate safe water and sanitation; (4) Maternal and child health care; (5) Immunization against major infectious diseases; (6) Prevention and control of locally endemic diseases; (7) Appropriate treatment of common diseases and injuries; and (8) Provision of essential drugs. All these basic requirements are incorporated in the SDGs for 2030 from Goal 2 to Goal 4 [5].

Undoubtedly, providers of PHC play a crucial role in promoting, preventing, curing and rehabilitating residents. The appropriate delivery of PHC relies on physicians, nurses, midwives, community and ancillary workers, as well as traditional practitioners, suitably trained to work as a team and to respond to the expressed health needs of the community [1, 11]. However, due to the growing strain on resources and the shortage of PHC physicians and nurses in many countries, especially in developing countries [12, 13], policy-makers must consider new and creative opportunities to expand and enhance the provision of PHC [13].

From the updated population statistics of WHO [14], the Southeast and East Asian Nursing Education and Research Network (SEANERN) countries constitute almost 30% of the world’s population and 57.17% of the South-East Asia and Western Pacific Region. The SEANERN countries include 10 Association of Southeast Asian Nations (ASEAN) member states (i.e., Thailand, Singapore, Indonesia, Cambodia, Myanmar, Laos, Vietnam, Philippines, Malaysia, and Brunei) and 3 East Asian countries (i.e., China, Japan and Korea). Many SEANERN countries’ economies are considered as developing or transitioning and there are shortages of PHC providers in most of these countries [15, 16]. Importantly and specifically, a study within four of the SEANERN countries (Cambodia, Indonesia, Singapore and Vietnam) and India indicated that there was urgent need for more knowledge in terms of healthy ageing, life course approach, policies to support the access and quality of PHC for older people, and premature death can be reduced from chronic non-communicable diseases by means of applying effective PHC services [17]. A recent survey in China [18] showed that both physicians and patients of PHC rated “coordination” as the lowest score among the six indicators, including quality of care, equity, accessibility, continuity, coordination, and comprehensiveness. Therefore, it is an indispensable task to facilitate the coordination of care for PHC system reform in China. Thus, the capability of PHC providers of SEANERN countries are of far-reaching significance to provide accessible, qualified health care service for residents, especially for those in developing countries.

To date, there is sparse literature to investigate the knowledge, skills and abilities of PHC providers in this region. The purpose of this study was to characterize the knowledge, skills and abilities of PHC providers across SEANERN countries.

With a multi-national survey, this study investigated the status of capacity of PHC providers in seven countries of SEANERN. This study implies that the capacity perceived by PHC providers themselves remains underdeveloped and there is much room for progress. In particular, the transforming capacity from knowledge into skill and from skill into ability is relatively poor, and their competencies in four areas, including safe water and sanitation supply, nutritional promotion, endemic diseases prevention, and essential drugs provision, are of great concern. To address the problem, SEANERN should be considered as a network that is well positioned to facilitate PHC training within the member countries, and feasible, practical training plans will be formulated for future international collaboration, especially for developing countries.