Primary and community health services play a pivotal role in the health system and is the part of the health system where most people receive most of their health care, most of the time. There is compelling international evidence from the research done by people such as Barbara Starfield, James Macinko, Leiyu Shi and others that primary care has an independent effect on improving health status and reducing health inequalities and that countries with well developed primary care systems have healthier populations and reduced health care costs.
In response to these findings, health systems around the world are reforming and developing their primary health care sector. In Australia this is happening at both national and state level. The focus of these reforms is strengthening general practice and supporting their collaboration with other parts of the health system, as well as strengthening community health services through clarifying their functions and contributions to meeting key policy priorities, developing new models of care and service delivery including integration with general practice, and building capacity though better information management systems. A key priority is also to build the evidence base through a national primary health care research agenda.
Defining Primary Health Care
There are a number of definitions of primary health care currently in use. The following definition endorsed by the Australian Health Ministers' Council in 1988 and widely used since then, takes as its starting point the WHO 1978 Alma-Ata declaration:
"Primary health care seeks to extend the first level of the health system from sick care to the development of health. It seeks to protect and promote the health of defined communities and to address individual problems and populates health at an early stage. Primary health care services involve continuity of care, health promotion and education, integration of prevention with sick care, a concern for population as well as individual health, community involvement and the use of appropriate technology."
Primary care is often used interchangeably with primary medical care as its focus is on clinical services provided predominantly by GPs, as well as by practice nurses, primary/community health care nurses, early childhood nurses and community pharmacists.
Primary health care incorporates primary care, but has a broader focus through providing a comprehensive range of generalist services by multidisciplinary teams that include not only GPs and nurses but also allied health professionals and other health workers, such as multicultural health workers and Indigenous health workers, health education, promotion and community development workers, as well as providing services for individuals and families, PHC services also operated at the level of communities.
Community health services may share a number of characteristics of primary care and primary health care services, as well as provide more specialised community based health services for defined target groups, for example post acute care, aged care, mental health, drug and alcohol, sexual assault.
Another approach to defining primary health care is to see it as a philosophy, an approach a level of service delivery. This is cogently summarised in the following extract from Primary Health Care and General Practice. A scoping report (2000) National Information Service, South Australia. Download PDF [211kb]
Primary Health Care: as a philosophical approach to health and health care
This approach is characterised by an holistic understanding of health as wellbeing, rather than the absence of disease. The presence of good health is dependent upon multiple determinants; health services are important but so too are housing, education, public works, industry, agriculture, communication and other services. The health status of communities is both a function of and a reflection of development in those communities. The locus of control is important in PHC; health services should reflect local needs and involve communities and individuals at all levels of planning and provision of services. Services and technology should be affordable and acceptable to communities. Through health promotion and preventive care, PHC aims to eliminate causes of ill health. Equity is a crucial part of PHC; health services must strive to address inequity and prioritise services to the most needy. Finally, PHC should be based upon social, biomedical and health services research in order to provide effective health care.
Primary health care philosophy
- holistic understanding of health
- recognition of multiple determinants of health
- community control over health services
- health promotion and disease prevention
- equity in health care
- research-based methods
- accessible, acceptable, affordable technology
Primary Health Care: a set of strategies
The second element of PHC is strategic in which PHC involves a set of strategies aimed at creating health care which is consistent with the underlying philosophy. These strategies include needs based planning of decentralised health services, offering management to local communities. Education is a key strategy in PHC; through education communities and individuals gain understanding of and control over health problems. Intersectoral cooperation and coordination is a significant part of PHC. This requires cooperation at all levels, from government planning through to local implementation, across traditional departmental boundaries. Primary health care services require balance between health promotion, preventive care and illness treatment. This is best achieved through the use of a team drawn from a variety of disciplines, not only including medical, and nursing health professionals but also including community workers, population health professionals, health promotion workers, and educators.
Primary health care strategies
- needs-based planning
- decentralised management
- intersectoral coordination and cooperation
- balance between health promotion, prevention and treatment
- multi-disciplinary health workers
Primary Health Care: a level of service provision
The third element of PHC describes the kind of services provided by PHC, both as a set of activities and as a level or model of service provision. Primary health care is the first level of health care, that which is directly accessible to individuals and communities. This means that effective PHC must be locally based, in proximity to the places where people live and work. Geographic barriers may be overcome by locally situated services; to be universally accessible, PHC services must also be free from financial barriers. As the first level of health care services, PHC services need to be well integrated with the secondary and tertiary health care sectors, in order to provide continuity of care for people throughout all levels of the health care system. This involves attention to cooperation and communication. Primary health care services require cooperative efforts from a team of health care providers drawn from a range of disciplines. Finally, PHC should offer a range of services in health promotion, preventive care, illness treatment and rehabilitation.
Primary health care services
- locally based
- affordable and accessible
- well integrated
- health care teams
- health promotion
- disease prevention
- illness treatment
- rehabilitation services
Comprehensive and selective primary health care
Primary health care, as defined in the Alma-Ata Declaration, sets a very demanding standard for health care. This has led to various changes and modifications of the original ideal, resulting in what is known as selective primary health care (Wass 1995; Baum 1998). Wass describes the debate between proponents of selective primary health care and the original (comprehensive primary health care), arguing that selective PHC does not espouse the philosophical principles of comprehensive PHC. The differences between the two approaches are summarised below
| ||Comprehensive PHC ||Selective PHC |
|View of health ||Positive Wellbeing ||Absence of disease |
|Locus of control over health ||Communities and individuals||Health professionals |
|Major Focus ||Health through equity and|
|Medical solutions for |
|Health Care Providers ||Multi-disciplinary teams ||Medical doctors|
|Strategies for health ||Multi-sectoral collaboration ||Medical interventions |
Differences between comprehensive and selective primary health care
The significance of this debate lies in the possible confusion between these two approaches; different people may mean vastly different kinds of health care and yet both are known as primary health care. In addition, the actual services provided by selective or comprehensive PHC may not differ greatly in practice; it is therefore important to identify the underlying values of any primary health care service as it is these which will determine the nature and overall aims of the service.