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Copyright 2011, The Johns Hopkins University and Barbara Starfield. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed.
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Defining Primary Care
Barbara Starfield, MD, MPH
Primary Care Course (Based on Cape Town, South Africa, 2007;
and Barcelona, Spain, 2009)
This presentation explains why primary health care and primary care are a worldwide imperative and how they can be conceptualized and measured to provide accountability for achievement in different areas and countries.
Starfield 02/11 PCB 7458
Revolutions in Medicine, 1900s Ascendance of single disease and chronic illness focus
Diagnostic challenges/more technology
Single cause (? gene) – magic bullet
All fostered an INDIVIDUAL ORIENTATION in health services.
Starfield 07/07 LINK 5937
Revolutions in Medicine, 2000s Multiple interacting influences on illness/ health Disparities in health (inequity) Illness as morbidity burden, not as disease Risk factors as diseases Health as an impossibility (a healthy person is someone without enough tests)
All require a POPULATION ORIENTATION. Starfield 07/07 LINK 5938
Global Health Chart
Source: Karolinska Institute: www.whc.ki.se/index.php. All Rights Reserved. Starfield 09/04 IC 5644 n
Life Expectancy Compared with GDP per Capita for Selected Countries
Country codes: AG=Argentina AU=Australia BZ=Brazil CH=China CN=Canada FR=France GE=Germany HU=Hungary IN=India IS=Israel IT=Italy JA=Japan MA=Malaysia ME=Mexico
Starfield 11/06 IC 6440 n
Relationship between Health Professional Supply and Child Survival to Age 5
Starfield 12/04 HS 6332 n
0
1
2
3
4
5
6
7
8
9
0 5 10 15 20 25 30 Health Workforce Density
Und
er-5
Mor
talit
y
SP
UK
FI
NO
NE BE
US
CA
FR NZ
SW
DE
JP GE
AU
Derived from: Chen et al, Lancet 2004; 364:1984-90.
Societal Influences on Population Health and Equity
Dashed lines indicate the existence of pathways through individual-level characteristics that most proximally influence health.
Shading represents degree to which characteristics are measured at the ecological level (lighter color) or at the individual level aggregated to community.
SOCIAL POLICY
ECONOMIC POLICY
DEMOGRAPHIC STRUCTURE
EQUITY IN HEALTH*
HISTORICAL HEALTH
DISADVANTAGE
POLITICAL CONTEXT
OCCUPATIONAL & ENVIRONMENTAL
POLICY
HEALTH POLICY
RATES OF DISCOMFORT AND DISEASE
RATES OF DISABILITY AND DEATH
*“Health” has two aspects: occurrence (incidence) and intensity (severity).
Starfield 01/08 IH 6891 an
POLICY CONTEXT
COMMUNITY CONTEXT
WEALTH: LEVEL & DISTRIBUTION
POWER/STATUS RELATIONSHIPS
HEALTH SYSTEM CHARACTERISTICS
BEHAVIORAL & CULTURAL
CHARACTERISTICS
ENVIRONMENTAL CHARACTERISTICS
notes continued on IH 6891 bn
Societal Influences on Population Health and Equity (continued)
Dashed lines indicate the existence of pathways through individual-level characteristics that most proximally influence health.
Shading represents degree to which characteristics are measured at the ecological level (lighter color) or at the individual level aggregated to community.
SOCIAL POLICY
ECONOMIC POLICY
DEMOGRAPHIC STRUCTURE
EQUITY IN HEALTH*
HISTORICAL HEALTH
DISADVANTAGE
POLITICAL CONTEXT
OCCUPATIONAL & ENVIRONMENTAL
POLICY
HEALTH POLICY
RATES OF DISCOMFORT AND DISEASE
RATES OF DISABILITY AND DEATH
*“Health” has two aspects: occurrence (incidence) and intensity (severity).
Starfield 01/08 IH 6891 bn
POLICY CONTEXT
COMMUNITY CONTEXT
WEALTH: LEVEL & DISTRIBUTION
POWER/STATUS RELATIONSHIPS
HEALTH SYSTEM CHARACTERISTICS
BEHAVIORAL & CULTURAL
CHARACTERISTICS
ENVIRONMENTAL CHARACTERISTICS
notes continued from IH 6891 an
Commission on Social Determinants of Health Conceptual Framework
Starfield 05/09 IH 7139 n
Source: WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. World Health Organization, 2008.
The Commission on Social Determinants of Health
Chapter 9: Universal health care recommendations for national governments
Starfield 05/09 PC 7130
Source: WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. World Health Organization, 2008.
(Action area 1: build health-care systems based on principles of equity, disease, prevention, and health promotion)
Starfield 05/09 PC 7131
Source: WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. World Health Organization, 2008.
9.1 with civil society and donors, build health care services on the principle of universal coverage of quality services, focusing on Primary Health Care
(Action area 2: ensure that the health-care system financing is equitable)
Starfield 05/09 PC 7132
Source: WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. World Health Organization, 2008.
9.2 ensure public sector leadership in health-care system financing, focusing on tax-based financing, ensuring universal coverage regardless of ability to pay, and minimizing out-of-pocket payments
(Action area 3: build and strengthen the health workforce and add capacities to act on the social determinants of health)
Starfield 05/09 PC 7133
Source: WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. World Health Organization, 2008.
9.3 with donors, increase investment in medical and health personnel, balancing health worker density in rural and urban areas
9.4 with international agencies and donors, address the health human resources brain drain focusing on investment in increased health human resources and training, and bilateral agreements to regulate gains and losses
Commission on Social Determinants of Health, Health Systems Knowledge Network
1. The evidence base of the report 2. The health system as a social determinant of health and
health equity, and equity problems of health systems 3. Strengthen health systems to address health equity:
revitalize intersectoral action; promote social empowerment; strengthen the redistributive role of health care; revitalize Primary Health Care
4. Initiating and sustaining health system transformation: national processes to institutionalize change; international support for transformation
Starfield 05/09 PC 7134
Source: Gilson et al, Challenging Inequity through Health Systems. Final Report, Knowledge Network on Health Systems, June 2007. WHO Commission on the Social Determinants of Health.
Commission on Social Determinants of Health, Health Systems Knowledge
Network
1. Universal coverage 2. Public funding plays a central role 3. No or very low fees are charged 4. Comprehensive services 5. Private sector complements the public sector if
there is effective contracting
Starfield 05/09 PC 7135
“Overall, experience suggests that redistributive health care systems share five common features”.
Source: Gilson et al, Challenging Inequity through Health Systems. Final Report, Knowledge Network on Health Systems, June 2007. WHO Commission on the Social Determinants of Health.
The World Health Report 2008: Primary Health Care – Now More
than Ever 1. The challenges of a changing world 2. Advancing and sustaining universal
coverage 3. Primary Care: Putting people first 4. Public Policies for the public’s health 5. Leadership and effective government 6. The way forward
Source: World Health Organization. The World Health Report 2008: Primary Health Care – Now More than Ever.
Starfield 05/09 PC 7129
The Sixty-second World Health Assembly – WHA 62.12 – Agenda Item 12.4
22 May 2009
1. to ensure political commitment at all levels … 2. to accelerate action towards universal access to primary
health care by developing comprehensive health services and by developing national equitable, efficient and sustainable financing mechanisms …
3. to put people at the centre of health care …
… Strongly reaffirming the values and principles of primary health care, including equity, solidarity, social justice, universal access to services, multisectoral action, decentralization and community participation as the basis for strengthening health systems … URGES member states:
Starfield 05/09 PC 7136 n
The Sixty-second World Health Assembly – WHA 62.12 – Agenda Item 12.4
22 May 2009 (continued)
4. to promote active participation …empowering communities, especially women, in the processes of developing and implementing policy and improving health and health care, in order to support the renewal of primary health care
5. to train and retain adequate numbers of health workers, with appropriate skill mix, including primary health care nurses, midwives, allied health professionals, and family physicians … in order to respond effectively to people’s health needs
6. to encourage that vertical programs (be) … integrated and implemented in the context of integrated primary health care
Starfield 05/09 PC 7137
The Sixty-second World Health Assembly – WHA 62.12 – Agenda Item 12.4
22 May 2009 (continued)
7. to improve access to appropriate medicines, health products, and technologies, all of which are required to support primary health care
8. to develop and strengthen health information and surveillance systems, relating to primary health care … to facilitate evidence-based policies and program and their evaluation
9. to strengthen health ministries, enabling them to provide inclusive, transparent and accountable leadership of the health sector and to facilitate multisectoral action as part of primary health care …
Starfield 05/09 PC 7138
A framework based on structure, process, and outcome is helpful in describing and measuring the components of health services systems.
Starfield 10/07 HS 6849
Are there differences in structure, process, and outcomes that can explain variability in health even across areas with similar wealth and resources?
Starfield 10/07 IH 6847
The Health Services System
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 02/09 HS 5064 n
Longevity Comfort Perceived well-being Disease Achievement Risks Resilience
CAPACITY
PERFORMANCE
HEALTH STATUS (outcome)
Provision of care
Receipt of care
Personnel Facilities and equipment Range of services Organization Management and amenities Continuity/information systems Knowledge base Accessibility Financing Population eligible Governance
People/practitioner interface
Cultural and behavioral
characteristics
Social, political, economic, and
physical environments
Biologic endowment and prior health
Problem recognition Diagnosis Management Reassessment
Utilization Acceptance and satisfaction Understanding Participation
Community resources
Primary Health Care and Primary Care
Starfield 03/05 PC 6384
Primary health care is a system-wide approach to designing health services based on primary care.
Primary care is the representation, on the clinical level, of primary health care.
The framework of structure, process, and outcome is useful in defining primary care so that it can be measured and evaluated.
Starfield 10/07 EVAL 6856
Primary Care
Starfield 02/08 EVAL 5102 n
First Contact • Accessibility • Use by people for each new problem
Longitudinal • Relationship between a facility and its population
• Use by people over time regardless of the type of problem; person-focused character of provider/patient relationship
Comprehensive • Broad range of services • Recognition of situations where services are
needed Coordination • Mechanism for achieving continuity
• Recognition of problems that require follow-up
Primary Health Care Oriented Health Services Systems
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 02/09 HS 6848 n
CAPACITY
PERFORMANCE
HEALTH STATUS (outcome)
Provision of care
Receipt of care
Personnel Facilities and equipment Range of services Organization Management and amenities Continuity/information systems Knowledge base Accessibility Financing Population eligible Governance
Population-Services interface
Cultural and behavioral
characteristics
Social, political, economic, and
physical environments
Biologic endowment and prior health
Problem recognition Diagnosis Management Reassessment
Utilization Acceptance and satisfaction Understanding Participation
Longevity Comfort Perceived well-being Morbidity burden Achievement Risks Resilience
Community resources
Starfield, 4/97
Measurement of Primary Care
• Primary care shares attributes with other levels of care.
• Measurement of primary care should address its unique functions.
• Measurement requires knowledge of systems characteristics AND behaviors.
Starfield 04/97 PCM 5111
The Health Services System: First Contact Components
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
CAPACITY
PERFORMANCE
HEALTH STATUS (outcome)
Provision of
care
Receipt of care
Accessibility
Utilization
Starfield 1999 HS 5369 n
The Health Services System: Longitudinality
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
CAPACITY
PERFORMANCE
HEALTH STATUS (Outcome)
Provision of
care
Receipt of care
Eligible population
People/practitioner interface
Utilization
Starfield 1999 HS 5370 n
The Health Services System: Comprehensiveness
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
CAPACITY
PERFORMANCE
HEALTH STATUS (outcome)
Provision of
care
Receipt of care
Range of services
Problem recognition
Starfield 1999 HS 5371 n
The Health Services System: Coordination
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
CAPACITY
PERFORMANCE
HEALTH STATUS (outcome)
Provision of
care
Receipt of care
Information transfer (Continuity)
People/practitioner interface
Problem recognition
Starfield 1999 HS 5372 n
Structural and Process Elements of the Essential Features of Primary Care
Essential Features Performance
Utilization
Person-focused relationship
Capacity
Accessibility
Eligible population
Range of services
Continuity
First-contact
Longitudinality
Comprehensiveness
Coordination Problem recognition
Starfield 04/97 EVAL 5107 an
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