What is primary health care?

The fundamental premise of primary health care is that all people, everywhere, have the right to receive the right care in their community.1 PHC attends to the majority of a person’s health needs throughout their lifetime, including physical, mental and social wellbeing. PHC is people-centred rather than disease-centred. It is a whole-of-society approach that includes health promotion, disease prevention, treatment, rehabilitation and palliative care.2

Primary health care was formally defined in 1978, in the landmark Declaration of Alma-Ata, but use of the terms “primary care” and “PHC” pre-date 1978, and approaches that we now call primary health care were being pioneered by progressive public health practitioners several decades earlier. The World Health Organization (WHO) Declaration endorsed an international definition of PHC in 1978 as follows:

The WHO declaration also established these key principles of primary health care:

• universal access to care
• health equity as part of social justice
• individual and community participation and empowerment
• multi-sectoral policy and action
• integrated health services that meet people’s health needs throughout their lives
• health attainment through a fuller and better use of resources.

The 2018 Global Conference on Primary Health Care, held in Kazakhstan, affirmed these principles in a new declaration emphasising the critical role of PHC in meeting contemporary population health and health system challenges. The Declaration of Astana reinforces the ethical, political, social and economic imperative of achieving health equity and reducing disparities in health outcomes globally and for vulnerable populations. The declaration sets out this vision:

“PHC” is a broader term than “primary care”, which is used – mainly in the United Kingdom and northern America – to describe primary medical care or family practice.

A comprehensive approach

Comprehensive PHC is the most important part of the health system. Comprehensive PHC is vital to improving health outcomes and reducing health inequities – unnecessary, unfair and avoidable differences in health between groups within a population.5 A comprehensive PHC approach, as described in the Alma-Ata and Astana declarations, provides care in and through the community. In addition to meeting health needs across a person’s life span, comprehensive PHC attends to the broader social determinants of health through the involvement of other sectors in policy and action, such as food supply, education, housing, public infrastructure and communications.

In contrast, a selective PHC approach focuses on a disease or issue in isolation (for example, family planning, eradicating smallpox, reducing tuberculosis). After the Alma-Ata declaration, selective PHC was advocated as an interim strategy for improving health in low-income countries. A selective approach has had success in reducing diseases but has failed to promote community self-determination, equitable care and multi-sector action to improve and sustain health.6

Comprehensive PHC aims to empower individuals, families and communities to take charge of their own health and health care, and to tackle broader public health issues and risks to health. It also aims to meet the needs of defined populations, such as Indigenous peoples and those who, for various reasons, are missing out on services.7

Comprehensive PHC has a rich heritage. We highlight two early examples from South Africa where, in the late 1930s, public health practitioners who understood the links between broad aspects of health and development laid the foundations for a comprehensive curative and preventive service characterised by intersectoral action. The group argued that clinical services must be brought within the sphere of a broader social health scheme, and that health policy and practice must be informed by evidence. With government support, Kark, Cassel and colleagues established a rural health centre and trained community health workers to conduct an annual household health census, using the results to argue for sanitation and food production planning, and to study epidemiology and the influence of various environmental factors on people. These steps were the basis for what later became known as “community-oriented primary care”.8 It influenced the work of other PHC pioneers, such as the epidemiologist Susser and colleagues, who in the 1940s highlighted the connections between social justice and health, and the family, community and societal influences on health and disease. Although related ideas originated in the environmental conditions and epidemic contexts created by mass urban immigration (for example, in 19th-century industrial Britain and Europe), the South African approach in the mid-20th century heralded the emergence of community-oriented PHC and was pivotal for establishing international principles of PHC: health as a human right, health equity between populations as an aim of public health and service delivery by multidisciplinary teams.9 The right to health was institutionalised in the 1948 United Nations Universal Declaration of Human Rights.10

Health systems that are focused on PHC deliver better and more equitable outcomes at lower cost than other aspects of the health services delivery system. Studies by Starfield and colleagues found that countries with stronger and more comprehensive PHC generally had a healthier population and lower all-cause mortality, while countries with low PHC scores as a group had poorer health outcomes across various indicators. There was a positive association between adequate features of PHC (accessible, comprehensive, coordinated, continuous and accountable care) and the provision of preventive services, and between PHC and (in contrast to specialty care) greater health equity within populations.11 High-quality PHC is also associated with strong PHC policy, lower hospitalisation rates for conditions managed by good clinical care, and lower healthcare costs.12

Population health

What is population health?

Population health can be described as the study of health and disease in defined populations. It is an organised response to protect and improve the health outcomes of a population: for example, children, First Nations peoples, refugees, people with low incomes.

In population health there is a focus on populations as entities (rather than the individuals who make up the population), an emphasis on health promotion and disease prevention strategies at a population level, and concern with the underlying social, economic, biological, genetic, environmental and cultural determinants of health of whole population groups. For example, using a population health approach one would ask “why does this particular population have a high incidence of diabetes or renal disease?”, whereas working at an individual level one might ask “why did this person develop diabetes or renal disease?”

Common principles

Population health shares many principles with comprehensive PHC, including a focus on holistic health and equity, community empowerment, intersectoral collaboration, health promotion, integrated services, multidisciplinary teams and evidence-based practice. These principles also align with the holistic definition of Aboriginal health (see below).

Population health responses often involve changes to policies, systems and structures to maintain and improve health and to prioritise health interventions for groups who are most in need. It is widely accepted that a comprehensive PHC approach can improve population health outcomes. It can link and strengthen health systems to meet population health needs.

A population health approach is fundamental in continuous quality improvement in primary health care. While CQI often uses data gathered from individual client records, these data are brought together to show trends in the population’s health or in service delivery, and to inform population health improvement strategies.

The social, cultural, structural and environmental determinants of health

“Social determinants” is the commonly used term to describe the non-medical and behavioural influences on health: the conditions in which people are born, grow, live, work and age, and the wider forces and systems that shape daily life (for example, food and housing security). According to the WHO, these social conditions are the single most important determinant of good health or poor health.13

The social determinants of health identified by the WHO are social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport.14 Education, gender and ethnicity also have a marked influence on how healthy a person is. Factors such as girls’ access to schooling and the number of years of education have been shown to affect maternal, infant and child health.15 Discrimination against ethnic and racial minorities shapes some people’s access to services, employment and resources, with significant effects on health and wellbeing.16 In these respects, the social determinants of health are shaped by political, social and economic structures – sometimes called “structural determinants of health” – that are largely beyond a person’s control.

The social and structural determinants of health highlight the inequalities in health between and within countries. For example, the average life expectancy in low-income countries is 62 years compared with 81 years in high-income countries.17 As a wealthy country with one of the highest life expectancies in the world and a universal health insurance system, Australia provides a telling example of how social and structural inequalities influence health and life expectancy within countries. There is an estimated 8-year gap in life expectancy between Aboriginal and Torres Strait Islander peoples and the Australian average, with two-thirds of the health gap attributed to preventable chronic conditions.18 The social determinants of health and wellbeing for Aboriginal and Torres Strait Islander Australians are complex, multi-dimensional and bound in the history and legacy of colonisation. At least 34 per cent of the health gap is linked to education, employment, income, incarceration and housing quality.19 Forty-four per cent of Indigenous peoples live in regional areas and 18 per cent in remote and very remote areas with poorer access to services and employment.20 Framed from an Aboriginal and Torres Strait Islander viewpoint, social determinants include the history of health, racism and marginalisation, poverty, control over health, powerlessness, family separation, land and reconciliation.21 Improving health involves genuine commitment to tackling these determinants and strengthening the cultural determinants of health and wellbeing, such as connection to Country and community, kinship, cultural expression, language and cultural leadership.

Environmental determinants, for example water and air quality and the impacts of extreme weather events, are also critical to health. The environmental effects of climate change pose an increasing risk to human health into the future.

A comprehensive approach to PHC takes intersectoral action on the various determinants of health to improve health and reduce health inequalities. It aims to improve the circumstances in which people live and work, and complements efforts to control major diseases, improve health systems and reduce poverty.22 This requires high-quality health systems that consistently deliver services to improve or maintain health, are valued and trusted, and respond to changing population needs.23

In Australia

In Australia, PHC encompasses a range of providers and services across the public, private and non-government sectors. PHC services include health promotion, prevention and screening, early intervention, treatment of acute conditions and management of chronic conditions. PHC services are delivered in settings such as general practices, community health centres, allied health practices and via communication technologies such as telehealth and video consultations. Use of these technologies increased during the Covid-19 pandemic. PHC professionals include, but are not limited to, general practitioners (GPs), nurses, nurse practitioners, allied health professionals, midwives, Aboriginal and Torres Strait Islander health practitioners and workers, pharmacists and dentists, and a broader network of community and social support workers. The Australian universal public health insurance scheme, Medicare, is funded to provide free or subsidised PHC, and approximately 35 per cent of total health funding is spent on PHC, similar to spending on hospital services.24

Despite Australia’s comparatively well-funded and well-functioning health systems, many Australians experience inequitable access to PHC services and a lack of integration between PHC and other parts of the health system. Policy and system reforms have been implemented to reduce the fragmentation of services and to improve the efficiency and integration of local systems to meet client and population needs. Examples include the 2020–2025 National Health Reform Agreement;25 the establishment of Primary Health Networks, which aim to streamline health services and improve care coordination; the trial of “Health Care Homes”;26 and MyMedicare,27 a voluntary patient registration model to formalise relationships between clients and general practices or between clients and PHC providers or both. Improvement is most needed in regional and remote areas, where around one-third of all Australians live, and where health outcomes are generally poorer relative to metropolitan areas. In fact, the prevalence of health risk factors, levels of illness and mortality generally worsen with increased distance from major cities, while access to PHC is reduced. So, while Australia matches or outperforms many comparable countries on selected measures of health, there is a need for a more equitable distribution of health resources and better access to core PHC services (listed below) across the population.28

A study conducted in 2012 found consensus among policymakers, academics, clinical practitioners and consumers on the essential PHC services that all Australians should expect to receive, regardless of where they live. These are the essential services:

• care of the sick and injured
• mental health and social and emotional wellbeing
• maternal and child health
• allied health
• sexual and reproductive health
• rehabilitation
• oral and dental health
• public health and illness prevention.

The essential PHC functions needed to support these services were identified as management (including governance and leadership), coordination, health infrastructure, quality systems, data systems, professional development and community participation.29

The Aboriginal and Torres Strait Islander approach

Aboriginal and Torres Strait Islander peoples are the first peoples of Australia, comprising hundreds of nations with distinct histories, languages and cultural traditions. Across diverse nations and communities, and shared with other Indigenous peoples, is a strong tradition of unity with the environment30 (often expressed in Australia as connection to Country) and a holistic view of health incorporating the spiritual, intellectual, physical and emotional dimensions of life. Health and survival are viewed as both a collective and individual intergenerational continuum.31 This concept underpins contemporary definitions of Aboriginal and Torres Strait Islander health and wellbeing. Seen through this lens, PHC is a holistic approach that is culturally embedded in a way that supports the social, emotional, physical and cultural wellbeing of Aboriginal and Torres Strait Islander peoples, families and communities.

Aboriginal and Torres Strait Islander Australians access PHC through Aboriginal community controlled and government-managed health services and through private general practices. Aboriginal community controlled health organisations emerged in the 1970s because mainstream services were not dealing adequately with the health needs of Aboriginal and Torres Strait Islander peoples who wanted to be able to provide care to their communities that was culturally appropriate, holistic and accessible. By the 1990s, these organisations were important providers of comprehensive PHC for Aboriginal and Torres Strait Islander peoples.32

Because most Aboriginal and Torres Strait Islander PHC services deliver care to the communities that operate and control them (through elected boards), they are also important for employment, professional education, community empowerment and social action. Aboriginal and Torres Strait Islander PHC services (which can be government-run or community controlled) have close relationships with the people they serve, local knowledge of community, and increased cultural awareness.33 The Aboriginal and Torres Strait Islander model of PHC delivery embodies comprehensive PHC as defined in the Declaration of Alma-Ata.

PHC complexity and systems approaches

PHC is complex in its scope and the way it is delivered. It requires the provision of holistic and client-centred care for people of all ages, for physical, psychological and social conditions, and for diseases affecting any body organ. It also needs to take account of complex health needs and personal and family circumstances. In terms of delivery, PHC providers are diverse, widely dispersed, relatively independent in their practice and work within a variety of funding and governance models with differing resources and infrastructure support. The PHC information systems available to providers are often relatively undeveloped and fragmented, yet PHC providers need to work closely with many other providers, funders, policymakers and their local communities to deliver effective care.34 Furthermore, the balance between acute and chronic health problems continues to shift globally, with increases in chronic conditions and comorbidities, and a corresponding need for health promotion, prevention, referral to specialised services (sometimes distant), integration of care and support for self-management. This complexity has implications for the PHC workforce, who need knowledge of public and population health perspectives and skills in client-centred care, partnering, using information and communication technology, and continuous quality improvement.35 The systems through which PHC is governed, managed and delivered need to respond effectively to these complexities.

Health systems and systems thinking

Advances in systems thinking have helped in understanding and attending to complexity in PHC. A system is a set of interacting parts, which form an integrated whole. All systems are made up of multiple elements, links between elements (the processes and interrelationships that hold the elements together) and a boundary that determines what is inside and outside the system. Systems thinking is a way of thinking about health systems as holistic, dynamic and interconnected.

The WHO defines a health system as “all organisations, people, and actions whose primary interest is to promote, restore, or maintain health”. This includes efforts to influence determinants of health as well as direct health-improving activities. The goals of a health system are “improving health and health equity in ways that are responsive, financially fair, and make the best, or most efficient, use of available resources”.36

Six building blocks for strengthening health systems

To advance health system goals, the WHO identified “six building blocks” for strengthening health systems:

• service delivery
• health workforce
• information
• medical products, vaccines and technologies
• financing
• leadership and governance.37

Each building block represents an essential health system function and is interdependent with other parts of the system, highlighting the need for integrated responses to build overall health system capacity.

The WHO model has been criticised for excluding a community health element, which may be added when interpreting the building blocks.38 Including “community” as a foundational building block recognises that health systems, through governments and policy leaders, need to respond to the effects of social and environmental determinants of health to design inclusive services tailored to community needs. It is also recognised that multi-sectoral approaches and community participation are needed to tackle underlying causes of poor health such as food insecurity, unsafe water and poor sanitation.39

Ten building blocks for high performance

Bodenheimer and colleagues studied exemplar PHC practices in the United States of America and used a similar building-blocks approach to describe key elements of high-performing, client-centred PHC. They propose engaged leadership, data-driven improvement, empanelment (patient registration) and team-based care as the foundation for implementing six other elements: client–team partnership; population management; continuity of care; prompt access to care; comprehensiveness and care coordination; and informing a template of the future (Figure 1.1).40

Innovative Care for Chronic Conditions Framework

The “Innovative Care for Chronic Conditions Framework” represents a systems approach to the prevention and management of chronic conditions in PHC settings. The Framework (Figure 1.2) presents the actions and interactions required at three levels of the healthcare system to achieve better outcomes for chronic conditions. Each part of the framework needs to function effectively, while interacting with and dynamically influencing actions and events at the other two levels.

1. A positive policy environment serves to strengthen partnerships, support legislative frameworks and integrate policies into care and provide leadership and advocacy. Consistent financing is promoted, and human resources are developed and allocated.
2. Healthcare organisations promote care continuity and coordination, encourage quality through leadership and incentives, organise and equip healthcare teams, use information systems, and support self-management and prevention.
3. Actions are taken at the community level to raise awareness and reduce stigma, encourage better outcomes through leadership and support, mobilise and coordinate resources, and provide complementary services. Informed community partners and motivated healthcare teams link patients and families.

In each of these concepts of health system frameworks, the individual elements (or building blocks) are important, and effective interactions between the building blocks are essential for effective system functioning. Both PHC frameworks highlight continuous, well-coordinated care and engaged clients and communities as important aspects of service performance.

Health services as complex adaptive systems

Health services are often described as complex adaptive systems. “Complexity” arises from a system’s interconnected parts, and “adaptivity” from its ability to change based on what occurs.41

Each individual PHC service is a complex adaptive system within larger complex adaptive systems (for example, government, organisation, community). Consistent with other systems, PHC systems have these characteristics:

• self-organising, whereby parts of the system tend to organise into an ordered state
• dynamic, interdependent and tightly linked – they are constantly adapting to change and evolving over time, with effects that may differ in the short and long term
• driven by interactions between systems components and governed by feedback, with responses having a flow-on effect that may be positive, negative or neutral
• nonlinear and often unpredictable, with changes in one part of the system producing unexpected changes in other parts, and effects that may be greater or less than what was intended
• sometimes counterintuitive in the way they behave – for example, a simple intervention that works well in one setting may not work in a similar setting
• often resistant to policy change, because of these features.42

Overall, a systems approach to PHC considers the many elements, dynamics and factors influencing health. By understanding how these elements operate independently, and how they depend on and influence one another, a systems approach can help with the design and integration of PHC staffing, processes, facilities, organisations and policies to promote better health and to improve client experiences and outcomes at lower cost.

Systems thinking is used to understand, analyse, learn from, manage and change how systems work. It is essential for improving the quality of PHC. We write about the skills and tools for systems thinking in Chapter 6.

Summary

This chapter has defined PHC and traced its development to understand how a comprehensive approach to PHC has evolved internationally and in Australia. We have explained important concepts in PHC, including population health, the social determinants of health, and systems approaches to care. These concepts also underpin quality improvement. In the next chapter, we define “quality” and CQI. We describe how CQI evolved in health care, before considering how conventional approaches to it need to be adapted for practical application in PHC in Chapter 3.

References