How could this work?
Primary healthcare teams not only address the needs of the individuals, but are also looking at the community, especially when addressing social determinants of health. Therefore, there is an increasing interest in integration of primary health care with public health approaches.4 Community-oriented primary care (COPC) consists of a systematic assessment of healthcare needs in the practice population, identification of community health problems, implementation of systematic interventions, involving the target population (for example, modification of practice procedures, change of lifestyle, and improvement of living conditions), and monitoring of the impact of the changes to ensure that health services are improved and congruent with community needs.5 COPC teams design specific interventions to address priority health problems. A team consisting of primary healthcare workers and community members assesses resources and develops strategic plans to deal with the problems that have been identified. COPC integrates individual and population-based care, blending the clinical skills of the practitioner with epidemiology, preventive medicine, and health promotion. By doing so, it tries to minimise the separation between public health and individual health care.
Our hypothesis is that primary health care can be a strategy for promoting health equity and intersectoral action. The first prerequisite is a high level of accessibility of the primary healthcare team. The second is that the team should deliver high-quality care. Moreover, the team should interact with different networks (such as, education, work, economy, and housing) that are related to important sectors. Apart from an approach to individuals and families, the primary healthcare team should also address the community, utilising the COPC strategy. COPC, the direct action of the primary healthcare team, and intersectoral networking will enhance the social cohesion in the community. The actions of the primary healthcare team, curative and preventive, and the increased social cohesion in the community will lead to empowerment of the people. This empowerment is situated at different levels: physical, psychological, social, and cultural. The empowerment of the population will decrease the vulnerability to factors that may contribute to health inequity. Moreover, as the COPC action will address the living conditions of the local population, the exposure of the people to factors that may be a threat to their health will diminish and the differential vulnerability will decrease. Finally, a better education, better working conditions and decreased unemployment, better housing conditions, and access to safe food and water, will improve the structural determinants that influence the social stratification.
How this fits in
Both the World Health Report 2008: Primary Health Care: Now More Than Ever and the report of the Commission on Social Determinants of Health of the WHO: Closing the Gap in a Generation have challenged the priorities in primary care, including the family physicians/GPs, to reflect on the social accountability of their professional contributions. In this lecture we address this challenge from three perspectives; addressing the social determinants, the important choices in health care (horizontal versus vertical approach) and the implementation in the African context. Well-trained family physicians/GPs, operating in a community-oriented primary healthcare team, can contribute — also in Africa — to the achievement of the fundamental right of every citizen to have access to person-oriented quality primary health care.
Is the hypothesis that primary health care, through its contribution to social cohesion and empowerment, addresses the social determinants of health, documented by research findings?
In an excellent article, Barbara Starfield et al gave an overview of the contributions of primary care to health systems and health.6 Some studies looked at the impact of primary care on reductions in disparities in health: studies of physician supply, studies of the association with a primary care physician, and studies of the receipt of services that fulfilled the criteria for primary care delivery.6 Higher ratios of primary care physicians to population are associated with relatively greater effects on various aspects of health in more socially-deprived areas (as measured by high levels of income inequalities). Areas in the US with abundant primary care resources and high income inequality have a 17% lower post-neonatal mortality rate (compared with the population means); whereas the post-neonatal mortality rate in areas of high income inequality and few primary care resources has been shown to be 7% higher than the population mean.7
The fact that primary care, particularly family medicine, was found to be associated with better health outcome suggests that improving the ratio of primary care (especially family medicine physicians) to population could improve health outcomes, even in states with serious health inequalities.8 Eleven years of state-level data found the supply of primary care physicians to be significantly related to lower all-cause-mortality rates in both African–American and white populations, after controlling for income inequality and socioeconomic characteristics (metropolitan area, percentage of unemployed, and educational levels). In these state-level analyses, the supply of primary care physicians had a greater positive impact on mortality among African–Americans than among whites. The association between a greater supply of primary care physicians and lower total mortality was found to be four times greater in the African–American population than in the white majority population, indicating a reduction in racial disparities in mortality in the US states.8
The equity-related effect of having a good primary care source was also found in a study that examined the degree of primary care-oriented services that people received. Good primary care experiences were associated with reductions in the adverse effects of income inequality on health, with fewer differences in self-rated health between higher and lower income-inequality areas where primary care experiences were stronger.9 Another study showed that among white and African–American populations in both urban and rural areas in the US, the rates of low birth weight were lower, in absolute numbers and ratios of rates, where the source of care was a community health centre.10 A study comparing the situation of diabetes-related lower-extremity amputation in the UK and the US concluded that in the US the black population had rates that were two to three times higher than in the white population, whereas in the UK, the rates were lower in black men than in the white population. The findings persisted even after controlling for socioeconomic differences, thus confirming other findings that a health system oriented towards primary care services (such as in the UK) reduced the disparities in health care that are so prominent in the US.11
Primary care programmes, aimed at improving health in deprived populations in less developed countries, succeeded in narrowing the gaps in health between socially-deprived and more socially-advantaged populations. A matched case-control study in Mexico found that some aspects of primary care delivery had an important independent effect on reducing the odds of children dying in socially-deprived areas. These processes included adequate referral mechanisms, continuity of care (being seen by the same provider at each visit), and being attended in a public facility designed to provide primary care.12
A study in Bolivia found that a community-based approach to planning primary healthcare services in socially-deprived areas lowered the mortality of children under the age of 5 years, compared with adjacent similar areas of the country as a whole.13 In Kerala (India), 74% of the population lives in a village with a primary healthcare centre. Their infant mortality rate is 16 per 1000 live births. By contrast, in Uttar Pradesh State, only 4% of the population has access to primary health care, and the infant mortality rate is 87 per 1000 births.14
Studies in other developing countries showed the considerable potential of primary health care to reduce the large disparities associated with socioeconomic deprivation. In seven African countries, the wealthiest 20% of the population receives well over three times as much financial benefit from overall government spending as does the poorest 20% of the population (40% versus 12%). For primary care services, the ratio of rich to poor in the distribution of government expenditures was notably lower (23% to the top group versus 15% to the lowest group), leading one international expert to conclude that ‘from an equity perspective, the move towards primary care represents a clear step in the right direction’.15 An analysis of preventable deaths in children concluded that in the 42 countries accounting for 90% of child deaths worldwide, 63% of deaths could have been prevented by the full implementation of primary care. The primary care interventions included integrated care addressing the very common problems of diarrhoea, pneumonia, measles, malaria, HIV/AIDS, preterm delivery, neonatal tetanus, and neonatal sepsis.16
Starfield et al find a rationale for the benefits of primary care for health in:
greater access to needed services;
better quality of care;
a greater focus on prevention;
early management of health problems;
the cumulative effect of the main primary care delivery characteristics; and
the role of primary care in reducing unnecessary and potentially harmful specialist care.
The ‘evidence’ for this impact can be found in the original article by Starfield et al.17 Within the scope of this lecture, we limit ourselves to the first point: primary care increases access to health services for relatively deprived population groups. Primary care is the point of first contact with health services, and facilitates access to the rest of the health system. In the US, socially-deprived population subgroups are more likely to lack a regular source of care than more advantaged people.18,19
At present in many countries, health care is uncoordinated access to hospital, and specialist care is unrestricted for those who can afford it. Yet, direct specialist care often leads to a very costly cascade of diagnostic and therapeutic interventions, with even some potential for iatrogenic peril. The primary healthcare team is the point of access to medical care for the whole community and functions as ‘navigator’ through secondary and tertiary care and other sectors. The vast majority (over 90%) of presented problems — all the ‘common’ illnesses — are managed at the inexpensive primary care level.20 Difficult or uncommon problems are referred by the navigator primary healthcare team, which leads the patients through the complicated medical maze of specialists and procedures, thus making sure that the patients receive the most appropriate care, and avoiding unnecessary costs due to a mismatch of specialist and medical problems. This leads to better health outcomes, and at the same time makes health care much more cost-effective. The expensive, and often inadequate, use of specialist care will diminish, and the use of financial resources will be optimised. Money saved by avoiding unnecessary healthcare expenditures becomes available for further development and extension of and improved and increased access to primary health care, and for making secondary care affordable for those who need it. Maximal access to primary health care with sufficient referral opportunity will decrease health inequality and the differences in vulnerability.
Research has shown that in industrialised countries, health expenditure per capita is on average less in countries with a strong primary care orientation, including the navigator function.21 For developing countries, research data are lacking, but there would be no reason why results would be different.
To make this happen there is a need for a comprehensive medical clinical discipline that puts into practice the shift from ‘primary medical care’ to ‘primary health care’. Table 1 illustrates this shift.
Table 1 From primary medical care to primary health care, adapted from Vuori (1985).22
