ANALYSIS SERVICES

Why strengthening primary is essential to achieving universal health coverage

Chris van Weel MD PhD, Michael R. Kidd AM n Cite as: CMAJ 2018 April 16;190:E463-6. doi: 10.1503/cmaj.170784

See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.180186

trengthening primary health care1 and the attainment of universal health coverage2,3 are both important current KEY POINTS policy initiatives. Primary health care is • Primary health care addresses the health needs of all patients at Sessential and affordable care that is accessible to everyone in the the community level, integrating care, prevention, promotion community, and includes , disease prevention, and education. health maintenance, education and rehabilitation.4 The concept • Primary health care improves the performance of health of universal health coverage, as noted in the United Nations’ 2015 systems by lowering overall health care expenditure while Sustainable Development Goals, is an aspiration to provide all improving population health and access. people with access to essential high-quality health services and to • The aims of primary health care overlap with those of universal safe, effective and affordable and , while health coverage, which aims to ensure access to essential health services and safe, effective and affordable essential ensuring financial risk protection by providing care regardless of a medicines and vaccines for all people. person’s ability to pay for it.2,5 It is clear from these two definitions • To achieve universal health coverage, reforms should focus on that there is overlap between the aims of primary health care and strengthening primary health care to ensure equity and cost universal health coverage; indeed, many have noted that primary containment. health care is essential to achieving universal coverage.6,7 • reforms should be monitored with indicators The two agendas have developed largely independently of that reflect the core characteristics of primary health care: each other, and yet the goal of both is to see healthier people liv- continuity of care, person- and population-centredness, ing in healthier communities. There seems to be a natural synergy coordination of care, prevention, health promotion and patient autonomy. between the two. Yet the World Bank, the Bill and Melinda Gates Foundation and the World Health Organization (WHO) have referred to primary health care as a “black box” for policy- makers8 — complex, mysterious and difficult to understand. Many popu­lation focus. The distinction between the two is not clear- health care policy-makers and funders have a poor understanding cut because both terms imply a strong emphasis on prevention, of primary health care, finding it difficult to quantify and assess health promotion, education and support delivered in a compre- its contributions to health systems. Here, we shine a light into the hensive manner. In countries with historically strong primary “black box.” We emphasize the importance of performance indi- care, such as the United Kingdom, Denmark and the Nether- cators to monitor health system reform to show how strong pri- lands,12 what is referred to as has broadened in mary health care contributes to the realization of universal health recent decades. Single-physician family practices have shifted to coverage. a model of multidisciplinary teams with shared responsibility for the care of target populations. Investment in primary health care What is the difference between primary care in these countries has resulted in more care provided at the com- and primary health care? munity level, and has improved integration of primary care with , specialist- and -based care. Thus, the dis- A core aspect of primary health care is that it operates in the tinction between primary care and primary health care has been local community and seeks to address all health problems of all blurred. Emphasizing primary health care’s focus on the individ- people.4,9,10 Strong primary health care relies on easy and conve- ual is important, because people with seemingly identical health nient access to a trusted provider or team of providers. The term problems may have distinctly different needs,13 which may “primary care” usually refers to a focus on the health problems of become increasingly complex if a patient has multiple chronic an individual.1,4,11 Primary health care encompasses a wider health problems.14

© 2018 Joule Inc. or its licensors CMAJ | APRIL 16, 2018 | VOLUME 190 | ISSUE 15 E463 ANALYSIS sions andgreatersocioeconomicequity. higher patient satisfaction, fewer unnecessary hospital admis their corehavelower health costs, betterpopulationhealth, firmed thathealthsystemswithstrongprimarycareat and other high-, low- and middle-income countries, has con- followed byresearchfromEurope,Canada,theUnitedStates with multimorbidity. tant diseasesandarebetterataddressingtheneedsofpatients systems havebetterratesofscreeningandfollow-upforimpor- systems. has promotedprimaryhealthcareasacorecomponentof E464 ism, comprehensivenessandcontinuityofcare(Box1) patients andcommunities,withapredominantfocusongeneral- toward healthsystemsthataddressthespecificneedsof shift from health care delivery focused on treating disease Strengthening primary health care represents a fundamental achieved? How canstrongprimaryhealthcarebe Since the1978DeclarationofAlma-Ata, primary healthcare? What istheimpactofrobustsystems take responsibilityforaspectsoftheirownhealth. supporting peopletodevelopandmaintainautonomy primary healthcareisreducedrelianceonprofessionalby primary healthcare.Starfield’slandmarkpublicationin1994, helped us to understand the benefits of effective and efficient ture andaspectsofhealthcareprocessesstructureshave formance inpopulationhealthrelationtotheirexpendi- cohesion and encourage greater resilience. people-centred supportofcommunitiestostrengthensocial port topatientsfacingthechallengesofeverydaylife,and supply-driven toneeds-drivencare,towardperson-centredsup- health system.Primarycarealsorepresentsashiftfrom social, culturalandeconomicfeaturesthatshapeacountry’s one sizefitsall.Theprocessmustaccountforthehistorical, by furtherresolutionsoftheWorldHealthAssembly, • • • • • • primary healthcare Box 1:Criteriathatmustbefulfilledtostrengthen in hospitalsorotherareasofspecialization, isrequired. health careproviderscomparedwith theircolleaguesworking Health policysupport,includingequitable paymentofprimary Training mustbebasedpredominantly inprimarycaresettings. population ofpatientsovertime. practice, allowingcaretobeprovidedanidentified Patients shouldberegisteredwithanindividualprovideror referral, whenneeded,tootherhealthcareprovidersandservices. Gate keepersandcoordinatorsareneededtoassistpatient Care mustbeaccessibleinthelocalcommunity. over time. problems inallpatientsatstagesoflife)andcontinuous Care providedmustbecomprehensive(i.e.,addressallhealth 1 International comparisons of individual countries’ per- 21 1,22 15 17–20, CMAJ whichwasreinforced 9,23 Inaddition,these Inherent in strong | APRIL16, 2018 16 theWHO . 1,4,22 No No 12 -

| VOLUME 190 expenditure over time, improving the performance of the health health the of expenditure over time,improvingtheperformance services withpublichealth,thus loweringoverallhealthcare improve populationhealththrough integrationofprimarycare strengthening primaryhealthcare. Strongprimaryhealthcarewill committed tooverthelongterm, withaparticularfocuson age, whichiswhyhealthcarereform needstobeunderstoodand making theinvestmentrequiredtoachieveuniversalhealthcover - Anticipating spendingincreasescoulddetergovernmentsfrom and MelindaGatesFoundationWHO, Health CarePerformanceInitiativeoftheWorldBank,Bill itoring ofprimary health carepolicy,asproposedbythePrimary Standardization ofdataandtheon-goinguseinmon- tem reforms,butwhereinvestmentinresearchmaybelacking. expense ofdatafromcountriesgoingthroughrecenthealthsys- mark andtheNetherlandscoulddominateresultsat data fromwell-researchedcountrieslikeCanada,theUK,Den- care structuresandperformance.Asaconsequence,reliable of availabledata,particularlyinformationaboutprimaryhealth different countriesisimportant. cated indicators to allow comparison between health systems in health care.Reviewingdevelopmentsovertimewithsophisti- ings andinvestmentsratherthantheperformanceofprimary tend that this finding is more a result of national policies of sav- periods oflimitedexpenditureinthe1980sand1990s.Wecon- invested moreintheirhealthsystemsrecentyears,afterlong health care,suchasthe UK andtheNetherlands,mayhave replicate thisfinding. health care,morerecentEuropeanstudieshavenotbeenableto people withhigh unmet healthneedswillbegintoaccesscare. health careexpenditureintheshorttomediumterm,giventhat socioeconomic groups,whichmightbeexpectedtoincrease to increasetheuseofhealthcarefacilitiesbymemberslower vented byfinancialbarriers.Universalhealthcoverageisexpected of goodquality;andaccessinghealthcareshouldnotbepre - health needs—musthaveaccesstocare;thecare be met: everyone—includingthepoorandpatientswithgreatest To achieveuniversalhealthcoverage,threeobjectivesmust be realizing universalhealthcoverage? How canstrongprimaryhealthcarehelpwith tury Although healthsystemsresearchdoneattheendoflastcen- primary healthcareto a nation’stotalhealthexpenditure. functions andtherebyaffecttheimplementationofpolicy. may affecttheoverallcohesionandintegrationofhealthservice including low-andmiddle-incomecountries. robust information for comparisons between all countries, ventions. avoidance of unnecessary hospital admissions and clinical inter- health care realized greater efficiency of health care through example, onlysomecountriesjudgedtohavestrongprimary system ofprimaryhealthcarerealizesallitsbenefits.For A limitationofinternationalcomparisonstudiesisthequality Much attentionhasbeenpaidtotherelationshipofstrong It is important to note that not every country with a strong 12,17,18 reportedlowercostsincountrieswithstrongerprimary 19 Politicalandculturalcontextinindividualcountries | ISSUE 15 19 However,countrieswithstrongprimary 8 shouldprovidemore 24,25

ANALYSIS ​

E465 will assist will assist 8 www.who.int/whr/2008/ 4,33 http://www.who.int/universal_ Available: No universal health coverage without that show the contributions of 2015. 2008. 4,33 et al. Available: To show the effect of investments 8 LM, 2017. www.un.org/sustainabledevelopment/sustainable - cover health universal of promise the on Delivering K. phcperformanceinitiative.org/about-us/measuring-phc Pettigrew accessed 2017 May 1). J, Abbasi Available: F, Available: ISSUE 15 ISSUE | Macinko 2015. FL, Godlee 2015. The contribution of family to improving health systems: health improving to medicine family of contribution M, editor. The people living in rural and remote locations people living groups vulnerable and marginalized referral to more specialized servicesacting as gatekeepers for and facilities and on-going care involvement in follow-up A, Geographic spread, availability and accessibility of primaryspread, availability and Geographic communities, with special for patients and health care facilities emphasis on • • their personal primary health careAbility of patients to identify providers the population they serve Ability of providers to define of primary health care services Multidisciplinary composition professionals in coordinating allRole of primary health care health problems, including • • into primary health care Integration of providers inCollaboration with other health and support service of all people the community to promote health and well-being healthEquitable income for professionals working in primary and other areascare compared with those working in of specialty care Training of providers in community settings accessed 2017 May 1). . 2nd ed. London a guidebook from the World Organization of family doctors. 2nd ed. London (UK), New York: Radcliffe Publishing; 2013. Jha -development​-goals/ ( Kidd Sustainable development goals: 17 goals to transform our world. Geneva: United Nations; health_coverage/en/ (accessed 2017 May 1). en/ (accessed 2017 May 1). Universal health coverage. Sustainable Developmental Goal 3: Health. Geneva: World Health Organization; age. BMJ 2016;353:i2216. Stigler The 2008 — primary health care (now more than ever). The World Health Report 2008 — primary health care (now more than ever). Geneva: World Health Organization; primary health care. Lancet 2016;387:1811. Consideration of the recommendations on strengthening community-based Health Organiza- — SEA/RC68/17. New Delhi (India): World health-care services tion Regional Office for South-East Asia; Measuring PHC: the measurement gap. Primary Health Care Performance Initia- tive; ( Box 2: Indicators of primary health care of primary health Box 2: Indicators • • • • • • • • • . . . 5. 4. 2. 6. 1. 7 8 3

in primary health care, the success of implementation of intercon- in primary health care, the success of implementation monitored. Indicatorsnected reforms in health systems must be need to be developed and applied - primary health care (Box 2) and capture characteristics such as con coordinationtinuity of care, person- and population-centredness, health promotion andof care between health sectors, prevention, for data collectionsupport for patient autonomy, and a mechanism must be established. Monitoring these contributions

References policy-makers to appreciate the contributions made by primary ­policy-makers to appreciate the contributions health coverage,health care toward the attainment of universal to strengthen andand support the ongoing investments needed reinforce strong primary health care. of future health care provision.

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- - 22 and a 27 26 APRIL 16, 2018 | International compari International CMAJ 32 and greater focus on the and greater focus on the that in turn increase the the that in turn increase 2,6,7 Canadian primary health care 30,31 for primary care, approaches for primary care, approaches 29 23,24 28 Implementation of primary healthImplementation of 1,3 develop more resilient and socioeco and resilient more develop 18,19 The improved efficiency and cost-effectiveness The improved 9 and outside the influence of government-led and outside the influence of government-led 22,26 Solutions must fit the local socioeconomic and political situa- Solutions must fit the local socioeconomic In seeking to attain universal health coverage, the development policies. For example, India has to cope not only with limited not only with limited policies. For example, India has to cope but with considerable health resources for its vast population, insurance. societal resistance to the principle of health tion. The UK introduced, and later abolished, fund holding tion. The UK introduced, and later abolished, has seen the recent introduction of innovations such as greater has seen the recent introduction of innovations such as greater support for interprofessional primary health care teams, greater qualityon focus strong a records, medical electronic of adoption improvement in family medicine management of complex health needs through the pan-Canadian SPOR (Strategy for Patient-Oriented Research) Network in Primary Innovations. Care Health Integrated and that Denmark and the Netherlands, with similar health care sys- that Denmark and the Netherlands, with role of the public sec- tems, have not implemented. Although the care in the Netherlands,tor is becoming more prominent in health while manag- the country has moved to private health insurance ing to contain health expenditure. quality and outcome framework

Implementation of primary health care and universal health cov- Implementation of primary health care and conditions; as a conse- erage has to take place under prevailing countries. Financial quence, approaches will differ between and specialist demands from previous investments in hospitals reallocation of funds services in many countries may hamper the care, which can be par- within health budgets to primary health countries. ticularly problematic for low- and middle-income What is the best way to achieve universal What is the best by strengthening primary health coverage health care? care system and ensuring the provision of improved equity and and equity improved of provision the ensuring and system care access for everyone. of care are found in enduring and substantial savings in other in other and substantial savings found in enduring of care are in all coun- result is expected care provision. This parts of health middle-income and low- in important particularly is but tries constraints. and economic with limited resources countries populations Healthier care should be supported by research to improve understanding of how, and to what extent, strengthening it can be done under the country, the of conditions cultural and socioeconomic prevailing and how these conditions will affect the likely costs and efficiency in many nations is often restricted to the publicly to the publicly Health policy in many nations is often restricted care may be pro- funded health sector, although much health vided privately nomically viable communities resources available to invest in future services, including health invest in future services, including health resources available to primary health care should be regarded care for all. This is why - in realizing the ambitions of universal cov as a core component development. erage as a sustainable sons of primary health care reforms aim to understand the gen- eral principles adopted, and the lessons that can be learned from country.prevailing conditions in each under place taking changes However, there is no single ideal set of interventions. of sustainable primary health care should continue to be the health priority of every nation. policy ANALYSIS 13. 12. 11. 10. 14. E466 18. 19. 17. 16. 15. 9. doch ChildrensResearchInstitute(Kidd),Melbourne,Australia;South- Community Medicine(Kidd),UniversityofToronto,Ont.;Mur- lian NationalUniversity,Acton,Australia;DepartmentofFamilyand Department of Health Services Research and Policy (van Weel), Austra- Radboud UniversityMedicalCenter,Nijmegen,TheNetherlands; Affiliations: DepartmentofPrimaryandCommunityCare(vanWeel), This articlewassolicitedandhasbeenpeerreviewed. Competing interests:Nonedeclared. olde Hartman Starfield B.Isprimarycareessential?Lancet1994;344:1129-33 National AcademyPress;1996. Institute ofMedicine. 2017 May1). %203rd%20ed%202011%20with%20revised%20wonca%20tree.pdf ( Available: WONCA EuropeSecreteriat,InstituteforDevelopmentofFamilyMedicine; The Europeandefinitionofgeneralpractice/familymedicine.Ljubljana(Slovenia): 2007;20:74. oriented primarycareineducationandpractice. Barnett Pract 2011;61:e839-41. encounter” shouldbeincorporatedintheanalysisofoutcomecare. Art Macinko and health.MilbankQ2005;83:457-502. May 1). Proefschrift-Dionne-Kringos-The-strength-of-primary-care.pdf ( lands): Nivel; Kringos ment (OECD)countries,1970–1998.HealthServRes2003;38:831-65. health outcomeswithinOrganizationforEconomicCooperationandDevelop- Starfield resources/A62_12_EN.pdf (accessed2017Oct.24). Geneva: WorldHealthOrganization. sixty-second WorldHealthAssembly.ResolutionWHA62.12; Primary healthcare,includingsystemstrengthening.Proceedingsofthe ( tion Health Care; Declaration ofAlma-Alta.ProceedingstheInternationalConferenceonPrimary sectional study.Lancet2012;380:37-43. implications forhealthcare,research,andmedicaleducation:across- accessed 2017May1). B, . De Roo Available

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| VOLUME 190 33. 32. 31. 30. 29. 28. 27. Correspondence to:ChrisvanWeel,[email protected] approved itsfinalversion. line, commentedandredraftedtheconceptversionofpaper of thepaper.MichaelKiddcommentedandredraftedconceptout- paper, wrotethefirstconceptofpaperanddraftedfinalversion Contributors: ChrisvanWeeldevelopedtheconceptoutlineof Adelaide, Australia gate InstituteforHealth,EquityandSociety(Kidd),FlindersUniversity, 26. 25. 24. 22. 21. 20. 23. Sustainable DevelopmentGoals.Lancet2015;386:2119-21. Pettigrew cihr-irsc.gc.ca/e/49554.html ( Ottawa: CanadianInstitutesofHealthResearch; Pan-Canadian SPORNetworkinPrimaryandIntegratedHealthCareInnovations. (Millwood) 2013;32:695-703. local carelandscape,butaplanisneededforongoingimprovement. Hutchison systems inmotion.MilbankQ2011;89:256-88. Hutchison review. Kroneman BMJ 2016;354:i4060. Roland policy making.BrJGenPract2002;52:141-4. Kay tion inSouthAsia.BMJGlobHealth2016;1:e000057. van Weel Watt G.Theinversecarelawtoday.Lancet2002;360:252-4 ua=1 ( social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf? Knowledge Network.Geneva:WorldHealthOrganization; achieving equitable care: a literature review commissioned by the Health systems De Maeseneer Med 2012;2:601-14. “people”: theneedforintegrated,peoplecenteredhealthcare. van Weel Stange KC,FerrerRL.Theparadoxofprimarycare.AnnFamMed2009;7:293-9 1, 2017). www.nivel.nl/sites/default/files/bestanden/w-schafer-pc34.pdf ( and theirpatients[thesis].Utrecht(TheNetherlands):Nivel; Schäfer De Maeseneer 2017;356:j634. A. accessed 2016May1). The abolitionoftheGPfundholdingscheme:alessoninevidence-based Health SystTransit M, WLA.

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