1.1 Defining primary health care

BOX 1.1 DEFINING PRIMARY HEALTH CARE

WHO Definition The current World Health Organization (WHO) definition of primary health care (PHC) provides the foundation and clearest expression of the concept of PHC used in this report. The WHO definition has three interrelated components that, taken together, cover all aspects of PHC. Under this definition, primary health care accomplishes the following: + Meet[s] people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services, and

+ Systematically address[es] the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviors) through evidence-informed public policies and actions across all sectors, and

+ Empower[s] individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services, and as self-carers and care-givers to others (WHO 2018b).

What PHC Is Not Related to WHO’s positive PHC definition are certain negative stipulations, that is, the things that PHC is not. Primary health care has often been presented as synonymous with other health-service models that actually differ in crucial ways from PHC as defined by WHO. This conflation of dissimilar concepts—sometimes unintentional, sometimes deliberate—has often had negative consequences both for the credibility of PHC and for the health and lives of people receiving health services labeled as primary health care. + PHC does not mean basic or rudimentary health care.

+ PHC does not equal gatekeeping. The latter is often understood solely from the supply perspective, with a view to efficiency. The objective of providing appropriate care at the right level is eclipsed. As a result, patients and communities may tend to perceive gatekeeping (and PHC itself) as a hurdle to clear to access specialized care.

+ PHC is not equivalent to “primary care” or “comprehensive primary care,” since these two terms in their most common usage do not cover the second and third components of the WHO definition cited. “Primary care” and “comprehensive primary care” as commonly understood do not fully encompass promotive, protective, rehabilitative, and palliative care throughout the life course. They largely focus on curative medical care, even if this is sometimes broadly defined (Peikes et al. 2018).

(Continued)

19

BOX 1.1 (continued)

+ Integrating primary care and public health to improve population health is not a supplementary enhancement of PHC. It is already part and parcel of PHC, properly understood (IOM 2012).

+ Integrating primary care and public health to improve population health is not a supplementary enhancement of PHC. It is already part and parcel of PHC, properly understood (IOM 2012).

+ Primary health care does not mean first-contact care, nor the first level of care in the health system. First-contact care could be emergency medical services. Historically, equating PHC with the first level of care has led to its being understood as low-quality health care, mainly for the poor. PHC should also not be seen as focusing only on first causes of community health problems, that is, the structural social and economic determinants. PHC recognizes the importance of health determinants and may support action to address them through multi-sectoral initiatives, but PHC’s concern with underlying health determinants does not downplay the importance of quality personal health care services for those who need them (Frenk 2009). + “Selective PHC,” a concept introduced shortly after the 1978 Alma-Ata Conference and widely applied subsequently, is not PHC. It distorts the concept of

PHC by focusing on selected diseases rather than the whole person and the full spectrum of services from promotive to palliative (Kluge et al. 2018).

Defining what PHC is and is not has implications for the connection between PHC and universal health care (UHC). This report understands PHC as the main vehicle for the realization of UHC. Some authors note that the universal inclusivity highlighted in the term “UHC” was anticipated in the PHC vision expressed at Alma-Ata. From its inception, PHC was understood to involve equitable access to health services (Sanders et al. 2019). This was reflected in the PHC goal of Health for All and the commitment to put people at the center of health systems (Ghebreyesus et al. 2018).

20

The main use of this definition is to highlight specific structural features and processes that are integral to countries’ success in the reform agendas described in the report, as well as to underscore the interdependence among some of these features. The term “platform” evokes a set of interlinked services and the delivery architecture required to provide them, including health-worker teams, the networks and resources that support them, and the infrastructure health workers use to deliver care to communities.