29.3 The Physician as Health Care Provider III: The Primary Health Care Concept (Alma-Ata, Astana, Philippine PHC) and Mental Health in Primary Care under RA 11036

Why this area matters

The TOS lists the primary health care concept and mental health in primary care as part of the physician's role as health care provider. PHC is the foundation of the Philippine health system and of the Universal Health Care Act. Mental disorders are common and often undiagnosed in primary care, and the 2018 Mental Health Act requires mental health services to be available at the community level.

Primary Health Care (PHC): Global Philosophies & Declarations

The 1978 Alma-Ata Declaration

Convened by the World Health Organization (WHO) and UNICEF in Alma-Ata (Kazakhstan), the 1978 conference defined Primary Health Care (PHC) 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. The declaration established the historic global target: "Health for All by the Year 2000."

The Core Pillars of PHC

1. Universal Accessibility and Coverage: Healthcare services distributed equitably according to clinical and social need, rather than ability to pay.
2. Community Participation: Active involvement of local communities in health assessment, planning, implementation, and resource management (e.g., engaging Barangay Health Workers and community health boards).
3. Intersectoral Collaboration: Recognition that health outcomes are fundamentally governed by non-medical social determinants, requiring coordinated action across agriculture, public education, housing, water sanitation, and public works.
4. Appropriate Technology: Health technologies, equipment, and pharmaceuticals must be scientifically validated, culturally acceptable, easily maintainable, and financially sustainable within local communities.
5. Support Mechanisms: Effective health systems require functional referral networks, reliable pharmaceutical supply chains, and continuous supervisory training.

The 2018 Astana Declaration

Forty years after Alma-Ata, the Declaration of Astana (2018) reaffirmed that primary healthcare is the most inclusive, effective, and cost-efficient foundation for achieving Universal Health Coverage (UHC) and the United Nations Sustainable Development Goals (specifically SDG 3: Ensure healthy lives and promote well-being for all at all ages). Astana emphasized digital health innovations, primary care gatekeeping, and resilience against emerging infectious and climate-related crises.

Primary health care in the Philippines

• Adoption: the Philippines adopted PHC as a national strategy in 1979 through Letter of Instruction No. 949. It emphasized community health workers, community participation and intersectoral linkages.
• Elements of PHC usually taught (from Alma-Ata):
  • health education;
  • nutrition and food supply;
  • safe water and sanitation;
  • maternal and child care including family planning;
  • immunization;
  • control of endemic diseases;
  • treatment of common diseases and injuries;
  • essential drugs.
  • Philippine programs added mental health, dental health and herbal medicines.
• Barangay health workers (BHWs):
  • community volunteers trained to give basic services: health education, weighing children, referral, TB treatment support, home visits and disease surveillance;
  • their benefits and incentives are set by RA 7883 (1995);
  • barangay nutrition scholars and traditional birth attendants, the latter now trained to refer women for facility delivery, are other community workers.
• Community health development follows community organizing: entry, social investigation, organizing a core group, community diagnosis, planning and action, and evaluation. The community then owns the program.
• Under the UHC Act, every Filipino is to register with a primary care provider, and health promotion is a whole-of-government responsibility.

Mental health in primary care: RA 11036

• The Philippine Mental Health Act (RA 11036, 2018):
  • establishes a national mental health policy;
  • integrates mental health into the general health system, from barangay to tertiary level, including community-based services and PhilHealth coverage;
  • protects the rights of service users: freedom from discrimination, informed consent, confidentiality, least restrictive care and access to treatment;
  • allows supported decision-making with a legal representative when capacity is impaired;
  • mental health promotion in schools and workplaces.
  • Involuntary admission is allowed only under specific conditions, such as imminent danger to self or others, with safeguards and review.
• The NCMH Crisis Hotline (1553) provides 24-hour crisis support.

The mhGAP approach

The WHO Mental Health Gap Action Programme (mhGAP) trains non-specialist health workers to assess and manage priority conditions:

Suicide and self-harm:

• Ask directly about suicidal thoughts. Asking does not increase risk.
• Higher risk comes with a plan, access to means, previous attempts, hopelessness, depression, substance use, recent loss and social isolation.
• For imminent risk: do not leave the person alone, remove means, involve the family and refer urgently.
• For all at risk: create a safety plan and follow up.

Psychological first aid after disasters and trauma:

• provide practical comfort and safety;
• listen without pressuring people to talk;
• link people to support and services;
• avoid psychological debriefing that forces retelling.

Common pitfalls to avoid:

• the stigma of mental illness;
• presentation with somatic complaints (headache, body pain, fatigue);
• the belief that problems should be solved within the family.

A non-judgmental, confidential approach that includes the family with the patient's consent improves engagement.