What is ‘primary care’ (PC) and ‘primary health care’ (PHC)?
Primary health care and primary care have been used interchangeably for a long time by administrators and clinicians. The WHO world (International) website does have a definition for ”primary care”. However, the WHO Europe clearly defines the PHC, PC and also General Practice and Family Medicine [Reference link]. The WHO European site also has a book titled “Primary Care in Drivers Seat?” and an interesting article named “What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services?” [Reference link]
I have tried to give a historical view of the development of the concepts and will keep updating any relevant information about this important but not clearly defined area of health care.
1919 – Dawson report
In 1919 Sir Bertrand Dawson was commissioned by the new Ministry of Health to chair a council to advise on the systematized provision of health services. The report in 1920 proposed the linkage of hospitals into a single system.
The report suggested that the organisation of medicine had become insufficient and was failing to bring the advance of medical knowledge adequately within the reach of the people: ‘The insufficiency of organisation has become more apparent with the growth of knowledge, and with the increasing conviction that the best means of maintaining health and curing disease should be made available to all citizens.’ [Ref-1] [Ref-Original Report]
The report outlined the following service model:’
- Doctors surgery
- Primary health centers
- Secondary health centers
- Teaching hospitals
1978 – WHO Alma Ata declaration (Link to Full Report)
The ultimate goal of primary health care is better health for all. WHO has identified five key elements to achieving that goal:
- reducing exclusion and social disparities in health (universal coverage reforms)
- organizing health services around people’s needs and expectations (service delivery reforms)
- integrating health into all sectors (public policy reforms)
- pursuing collaborative models of policy dialogue (leadership reforms);
- increasing stakeholder participation
PHC is essential health care universally accessible to individuals and families in the community by means acceptable to them, at a cost that the community and country can afford, integral part both of the country’s health care system, of which it is the nucleus, and of the overall social and economic development of the community. It is the first contact of individuals, family and the community with the national health care system, bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process. PHC addresses the main health problems of the community, providing promotive, preventive, curative, supportive and rehabilitative services accordingly.
2008 – The World Health Report – Primary Health Care (Now More Than Ever)
“Why a renewal of primary health care (PHC), and why now, more than ever? Globalization is putting the social cohesion of many countries under stress, and health systems are clearly not performing as well as they could and should. People are increasingly impatient with the inability of health services to deliver. Few would disagree that health systems need to respond better – and faster – to the challenges of a changing world. PHC can do that.” This report was an attempt to reignite PHC, however, the PHC this report talks about and the PHC that was initially introduced in the 1978 Alma Ata report is not the same. With the passage of time may be the definitions also should change?
2018 Declaration of Astana – 30 years after Alma Ata [Ref]
On 25-26 October 2018, the world came together in Astana, Kazakhstan, at the Global Conference on Primary Health Care to renew a commitment to primary health care to achieve universal health coverage and the Sustainable Development Goals. The Conference was held at the Palace of Independence and was cohosted by the Government of Kazakhstan, WHO and UNICEF.
Primary Care: America’s Health in a New Era Page 33 [LINK]
“The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of the family and the community.” The concept of ‘primary care’ comes from the USA.
BOX 2-1 DEFINITION OF PRIMARY CARE
Primary care in the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
Integrated is intended in this report to encompass the provision of comprehensive, coordinated, and continuous services that provide a seamless process of care. Integration combines events and information about events occurring in disparate settings, levels of care and over time, preferable throughout the life span. Comprehensive. Comprehensive care addresses any health problem at any given stage of a patient’s life cycle. Coordinated. Coordinated ensures the provision of a combination of health services and information that meets a patient’s needs. It also refers to the connection between, or the rational ordering of, those services, including the resources of the community. Continuous. Continuity is a characteristic that refers to care over time by a single individual or team of health care professionals (“clinician continuity”) and to effective and timely communication of health information (events, risks, advice, and patient preferences) (“record continuity”).
Accessible refers to the ease with which a patient can initiate an interaction for any health problem with a clinician (e.g., by phone or at a treatment location) and includes efforts to eliminate barriers such as those posed by geography, administrative hurdles, financing, culture, and language.
Health care services refers to an array of services that are performed by health care professionals or under their direction, for the purpose of promoting, maintaining, or restoring health (Last, 1988). The term refers to all settings of care (such as hospitals, nursing homes, clinicians’ offices, intermediate care facilities, schools, and homes).
Clinician means an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients.
Accountable applies to primary care clinicians and the systems in which they operate. These clinicians and systems are responsible to their patients and communities for addressing a large majority of personal health needs through a sustained partnership with a patient in the context of a family and community and for (1) quality of care, (2) patient satisfaction, (3) efficient use of resources, and (4) ethical behavior.
Majority of personal health care needs refers to the essential characteristic of primary care clinicians: that they receive all problems that patients bring— unrestricted by problem or organ system—and have the appropriate training to diagnose and manage a large majority of those problems and to involve other health care practitioners for further evaluation or treatment when appropriate. Personal health care needs include physical, mental, emotional, and social concerns that involve the functioning of an individual.
Sustained partnership refers to the relationship established between the patient and clinician with the mutual expectation of continuation over time. It is predicated on the development of mutual trust, respect, and responsibility.
Patient means an individual who interacts with a clinician either because of illness or for health promotion and disease prevention.
Context of family and community refers to an understanding of the patient’s living conditions, family dynamics, and cultural background. Communities refers to the population served, whether they are patients or not. Community can refer to a geopolitical boundary (a city, county, or state), or to neighbors who share values, experiences, language, religion, culture, or ethnic heritage.
The paper “Contribution of Primary Care to Health Systems and Health” by BARBARA STARFIELD, LEIYU SHI, and JAMES MACINKO can be read at this link
This book published by Starfield, Primary Care: Balancing Health Needs, Services, and Technology (2nd Ed) is one of the classic books about ‘primary care’.
- ‘Is more than just the level of care or gate keeping; it is a key process in the health system. It is first-contact, accessible, continued, comprehensive and coordinated care.
- First-contact care is accessible at the time of need;
- Ongoing care focuses on the long-term health of a person rather than the short duration of the disease;
- Comprehensive care is a range of services appropriate to the common problems in the respective population and
- Coordination is the role by which primary care acts to coordinate other specialists that the patient may need.
- PC is a subset of PHC’.
Primary Care (PC) and Primary Health Care (PHC)
What is the Difference?
Primary Care and Primary Health Care are very similar terms which are often employed interchangeably, but which are also used to denote quite different concepts. Much time and energy is spent discussing which term is the appropriate one for a particular application. There is a growing recognition internationally that the two terms describe two quite distinct entities. Recent Canadian uses of the two terms are, for the most part, consistent with the international uses. Primary Care, the shorter term, describes a narrower concept of “family doctor-type” services delivered to individuals. Primary Health Care is a broader term which derives from core principles articulated by the World Health Organization and which describes an approach to health policy and service provision that includes both services delivered to individuals (Primary Care services) and population- level “public health-type” functions. [Ref]
Family Medicine – LINK
The WHO -WONCA MOU 2019 March
WONCA President, Donald Li, and Dr Tedros Adhanom Ghebreyesus, Director General of WHO sign a Memorandum of Understanding on behalf of both organisations, reflecting the crucial role played by family medicine in achieving the goal of Universal Health Coverage. The MOU offers all our members and Member Organisations an official entry point to build even closer collaboration with WHO colleagues globally. [Ref]