Shift 2: From fragmentation to people-centered integration

recognized as a driver of quality, comprehensive care. Effective primary care is now being delivered in many settings by multidisciplinary teams that provide a comprehensive package of services using more holistic models of care. Improving the quality of services requires equal attention to both clinical skills and nonclinical functions, such as effective community engagement, leadership, communication, and innovation (Bargawi and Rea 2015).

Leadership and governance underpin all efforts to improve quality across the health system. Strong commitment to and leadership for quality is required at all levels to ensure that all stakeholders work together to create the enabling environment needed to provide high-quality PHC (Bargawi and Rea 2015). Key characteristics of systems with strong leadership and governance include evidence-based policy making, efficient and effective service provision arrangements, regulatory frameworks and management systems, responsiveness to public health needs and the preferences of citizens, transparency, institutional checks and balances, and clear and enforceable accountability (Brinkerhoff and Bossert 2008). Leadership can be cultivated and exercised at all levels of the health system, from ministries of health to local governments and PHC facilities (Daire and Gilson 2014).

By its nature, health care delivery involves an asymmetry of information between those who provide services and those who receive them. Nevertheless, the “delivery” of effective care should not be seen as a one-way transfer from provider to patient;1 instead, the delivery requires providers to work as partners and collaborators in empowering the people they serve. This approach, in turn, often requires a mindset shift—from solving an acute health problem on the patient’s behalf to building long-term, trusting partnerships to strengthen health and wellbeing across the life course.

Three global trends in health care knowledge and delivery are sharpening this imperative. + First, as noted, patients and populations are increasingly informed about their own health and therapeutic options. Many enjoy rapid access to data and general information, an extensive understanding of their own medical conditions, and the ability to triangulate external information and knowledge with the information shared by their care providers.

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+ Second, transparency of provider performance and patient outcomes is fast becoming the norm, allowing people to make informed choices among providers.2

+ Finally, increasingly urbanized, educated, and informed populations across the world expect technical excellence to cure their illness, as well as respect for their dignity, wholeness as a person, preferences, and constraints.

These secular trends are particularly relevant for PHC—typically the first point of contact with health care outside of emergency settings. PHC practitioners are not only expected to be healers but also managers, coordinating the health care needs of the care seekers,3 their families, and the entire communities in which they reside. What is meant by people-centeredness in PHC?

The United States Institute of Medicine (which became the National Academy of Medicine in 2015) classically defined patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring thatpatientvalues guide all clinical decisions” (IOM 2001). As such, it comprises eight components: (1)respect for the patient’s values, preferences, and expressed needs; (2) coordination and integration of care; (3) information and education; (4) physical comfort; (5) emotional support and alleviation of fear and anxiety; (6) involvement of family and friends; (7) continuity and transition; and (8) access to care, mainly in relation to amenities (O’Neill 2015).

The basic tenet of people-centeredness is that the organizational model of health care, with PHC at the center, revolves around the health, health care, and broader psychosocial needs of the person, both as a care seeker and as a member of the community. Health and nutrition promotion and prevention are given as much importance as episodic, curative care, with the goal of enhancing lifelong health and quality of life (box 3.4). Achieving this also requires full integration with secondary and tertiary care; people-centeredness must go hand-in-hand with integrated care. The role of PHC is paramount as first point of care and coordinator across all health care levels. People-centeredness is an evolving concept. An expanded definition includes additional dimensions of structural and interpersonal responsiveness to ensure that health services are provided without discrimination on the basis of income, ethnicity, language, gender, or other factors (Murray and Evans 1990).