Policy bite: Primary (health) care: what’s in a name?

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Each month, WONCA President elect, Professor Amanda Howe writes a policy bite column for WONCA News. This month, she features a joint effort with Monica Burns and Luisa Pettigrew.

There is widespread international support for the establishment of universal health coverage, with frequent reference to the essential role of primary health care in order to achieve this. However what does primary health care actually mean? Is it the same as primary care? Where does family medicine fit? The answer is not straightforward, as evidence suggests that these terms can mean different things to different people, and that the terms are often used interchangeably.

The 1978 Declaration of Alma Ata originally identified five principles underpinning ‘primary health care’ including; (i) equity in access, (ii) community participation, (iii) the effective and appropriate use of technology, (iv) inter-sectorial collaboration and (v) the provision of affordable and sustainable health care. Yet varying interpretations of the declaration led to ‘selective primary health care’ programmes, today paralleled by ‘vertical’ programmes, that have resulted in limited investment in health system strengthening in favour of condition specific programmes - hardly the scope envisaged at Alma Ata!
 
The 2008 World Health Report, Primary Health Care: Now More than Ever, revisited the concept, identifying (i) universal coverage, (ii) leadership, (iii) public policy, and (iv) service delivery reforms as essential to delivering ‘primary health care’. The report identified the distinctive features of ‘primary care’ as the mechanism to deliver this more equitable, person-centred care with better health outcomes, and the role of the ‘primary care team’ as the hub of coordination, networking with the community and outside partners.

Based on this we could consider the term ‘primary care’ to refer to the health service delivery aspect of the wider political, social and economic concept of ‘primary health care’. Yet the two terms are often used interchangeably. Recently a European public consultation led by an expert panel on defining ‘a frame of reference in relation to primary care‘ used the terms interchangeably, and - whilst proposing a definition that is in line with much of the preceding international research defining the concept - it also outlines that primary care is not a static concept.

The point of this policy bite is to note that, globally, packages of care referred to as ‘primary care’ are often extremely variable and sometimes so limited that they would be unlikely to provide accessible, community based, comprehensive care in a coordinated and continuous fashion. This is often because, for a range for political, economic and social reasons, policy makers, funders and even healthcare professionals have tended to seek secondary care-oriented solutions rather than primary care-oriented solutions.

In order to work towards a common goal, the pressing challenge facing all stakeholders, including individual governments, multilateral and non-governmental development organisations as well as healthcare professionals, is to ensure that the labels used and the actual services associated with those labels are understood in the same way, have the same meaning between all of the parties, and actually utilise the five pillars of care that underpin effective health care for the people.

Amanda Howe
Monica Burns
Luisa Pettigrew