The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives

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Abstract

It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals. In this systematic review we described and assessed the contributions of major primary care initiatives implemented in low- and middle-income countries in the past 30 years to a broad range of health system goals. The scope of the programs reviewed was substantial, with several interventions implemented on a national scale. We found that the majority of primary care programs had multiple components from health service delivery to financing reform to building community demand for health care. Although given this integration and the variable quality of the available research it was difficult to attribute effects to the primary care component alone, we found that primary care-focused health initiatives in low- and middle-income countries have improved access to health care, including among the poor, at reasonably low cost. There is also evidence that primary care programs have reduced child mortality and, in some cases, wealth-based disparities in mortality. Lastly, primary care has proven to be an effective platform for health system strengthening in several countries. Future research should focus on understanding how to optimize the delivery of primary care to improve health and achieve other health system objectives (e.g., responsiveness, efficiency) and to what extent models of care can be exported to different settings.

Introduction

Since the Declaration of Alma Ata in 1978 and, in some instances before, primary health care has been the central, often contentious, strategy for expanding health services in many low- and middle-income countries. The recent 30th anniversary of the Declaration was marked by a global call to redouble support for primary health care.(Chan, 2008, WHO, 2008b).

The World Health Report 2008, draws a distinction between ‘primary health care’ and ‘primary care’. The former is defined broadly as “the mobilization of forces in society—health professionals and lay people, institutions and civil society—around an agenda of transformation of health systems that is driven by the social values of equity, solidarity and participation” while the latter refers more specifically to aspects of health service provision through the health system. Primary care, the focus of this paper, is a health service delivery approach characterized by first-contact care, ease of access, care for a broad range of health needs, continuity, and the involvement of family and community (see Fig. 1) (Declaration of Alma-Ata, 1978, Kekki, 2006Starfield, 1992). The effectiveness of primary care as a health service strategy has typically involved assessing its contribution to meeting health system goals: better health, broad and equitable access to services, responsiveness, and financial protection (WHO, 2000).

There has been substantial research comparing primary care to specialist-focused care in industrialized countries (Atun, 2004, Engstrom et al., 2001, Health Council of the Netherlands, 2004, Macinko et al., 2003, Starfield et al., 2005). For example, in a recent review, Starfield et al. noted that a variety of measures of primary care (e.g., primary care physicians numbers, having a primary care physician as a regular provider, and the availability of community health centers that focus on primary care) had beneficial effects on coverage of preventive and curative services and health outcomes (Franks and Fiscella, 1998, Starfield et al., 2005, Villalbi et al., 1999). Several studies have also found that a primary care approach reduces costs compared to specialist care for a range of chronic conditions in the United States (Baicker and Chandra, 2004, Franks and Fiscella, 1998, Welch et al., 1993).

However, the relative effectiveness of primary care versus other health service delivery approaches has not been systematically evaluated in low- and middle-income countries. Although primary care has been on the development agenda for at least the past three decades since Alma Ata, there are few systematic reviews of the impact of primary care on health in the developing world (Macinko et al., 2009, Rohde et al., 2008). In addition, while there is an increasing number of single-country evaluations, relatively few of these include non-health goals such as measures of health system responsiveness (Berman, 2000) or economic impacts of seeking (Briggs, Capdegelle, & Garner, 2001). This gap in the literature may reflect the value that policy makers and researchers assign to these outcomes as well as the difficulties inherent in measuring non-health outcomes.

Evidence on the effects of primary care is especially relevant today as primary care has been highlighted as a potential pathway to reaching the health Millennium Development Goals and as a core strategy for health system strengthening (Chan, 2007, Chan, 2008, Montegut, 2007). The recent World Health Report 2008 argued that health system research is necessary to clarify the specific contributions of primary care and to facilitate successful implementation of primary care strategies.(WHO, 2008b) Such research is also important to funders: while external funding for health to the developing world is rising, primary care is competing for the attention of funders and policy makers with a large number of vertical, disease-specific initiatives (Schieber, Gottret, Fleisher, & Leive, 2007).

Assessing the contribution of primary care in developing countries is challenging. One of the difficulties is the lack of a counterfactual or a control program with which to compare primary care. Whereas specialist-based health services are frequently used for comparison in industrialized countries, these services are not accessible to the majority of populations in low-income countries due to low levels of health spending. In 2004, the average health spending in high-income countries was USD 3810, whereas it was USD 91 in lower-middle-income countries, and USD 24 in low-income countries (Schieber et al., 2007). Even adjusting for purchasing power, the differential between high- and low-income countries is 30-fold (Schieber et al., 2007). Such spending implies that the vast majority of health services provided are in the realm of primary care. The well-documented shortages of physicians—particularly specialists—in the poorest countries also means that the most people obtain health care from generalist health workers (nurses, clinical officers, and sometimes GPs) and may never visit a specialist (Chen et al., 2004). Differences in the definitions of primary care also abound, complicating comparison across programs.

An alternative approach is to assess the effects of specific primary care experiments in the developing world on health and health systems. For over thirty years a number of low- and middle-income countries have implemented national and subnational reforms and programs in which a major component is strengthening of primary care provision. These range in design, scope, size, and implementation path but most are aimed at improving health outcomes and equitable access to health services—consistent with the major aims of Alma Ata. Some of these programs have been replicated (completely or in part) across a number of countries and as such may represent important new trends in primary care as well as permitting some limited inference about the generalizability of results.

The aim of this paper was to describe and assess the contribution of large primary care initiatives to a broad range of health system goals in low- and middle-income countries. These include improved health outcomes, service coverage, quality of care, responsiveness to patients and communities as well as equity and efficiency (See Fig. 2) (Kruk and Freedman, 2008, WHO, 2000). Given the shortcomings of the available evaluation research in this area a formal meta-analysis was not possible. We present here a critical review of a broad range of studies and suggest a research agenda for future work to help strengthen this field.

Section snippets

Methods

We conducted a critical review of the available literature related to major primary care initiatives in two phases: in the first phase we identified relevant primary care initiatives and in the second phase we searched for publications on the effectiveness of these initiatives. We identified major primary care initiatives implemented in low- and middle-income countries in the past 30 years by searching Pubmed, Eldis, the WHO and World Bank databases using the terms “primary health care” and

Findings

We identified a total of 16 national programs that addressed one or more pillars of primary care, met the inclusion criteria, and for which reliable data existed. We grouped these into broad categories to highlight similarities and potential trends in primary care experiments across countries (Table 1). We found 111 papers discussing the programs, including conceptual papers and qualitative descriptions. From these, we selected 76 papers that met the inclusion criteria for this review. The

Discussion and conclusions

The best evidence for the effectiveness of primary care in achieving health system goals comes from some of the recent Latin American experiments in expanding rural primary care services to broad segments of the population. However, although evidence directly attributing health and other benefits to primary care in other low-income regions is not as strong, from the experiences reviewed here, it appears that primary care initiatives are contributing to increased access to services as well as

References (70)

  • K. Nasseri et al.

    Primary health care and immunisation in Iran

    Public Health

    (1991)
  • K. Polluste et al.

    Satisfaction with the access to the health services of the people with chronic conditions in Estonia

    Health Policy

    (2007)
  • N. Ravishankar et al.

    Financing of global health: tracking development assistance for health from 1990 to 2007

    Lancet

    (2009)
  • J. Rohde et al.

    30 years after Alma-Ata: has primary health care worked in countries?

    Lancet

    (2008)
  • L. Rosero-Bixby

    Spatial access to health care in Costa Rica and its equity: a GIS-based study

    Social Science & Medicine

    (2004)
  • P. Vapattanawong et al.

    Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses

    The Lancet

    (2007)
  • N. Withanachchi et al.

    Healthcare rationing: a guide to policy directions in Sri Lanka

    Health Policy

    (2006)
  • A. Arredondo et al.

    Effects of health decentralization, financing and governance in Mexico

    Rev Saude Publica

    (2006)
  • R. Atun

    What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services?

    (2004)
  • K. Baicker et al.

    Medicare spending, the physician workforce, and beneficiaries' quality of care

    Health Affairs (Millwood)

    (2004)
  • P. Berman

    Organization of ambulatory care provision: a critical determinant of health system performance in developing countries

    Bulletin of the World Health Organisation

    (2000)
  • C.J. Briggs et al.

    Strategies for integrating primary health services in middle- and low-income countries: effects on performance, costs and patient outcomes

    Cochrane Database of Systematic Reviews

    (2001)
  • J. Bryce et al.

    Improving quality and efficiency of facility-based child health care through integrated management of childhood illness in Tanzania

    Health Policy Plan

    (2005)
  • M. Chan

    The contribution of primary health care to the millennium development goals

  • Declaration of Alma-Ata

  • D. Dovlo

    Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review

    Human Resource for Health

    (2004)
  • K. Dugbatey

    National health policies: sub-Saharan African case studies (1980–1990)

    Social Science & Medicine

    (1999)
  • S. Engstrom et al.

    Is general practice effective? A systematic literature review

    Scandinavian Journal of Primary Health Care

    (2001)
  • P. Franks et al.

    Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience

    Journal of Family Practice

    (1998)
  • Health Council of the Netherlands. (2004). European primary care. The...
  • A.G. Hill et al.

    Decline of mortality in children in rural Gambia: the influence of village-level primary health care

    Tropical Medicine and International Health

    (2000)
  • Johns Hopkins University, & Indian Institute of Health Management Research. (2006). 2006 Afghanistan Household...
  • R. Kalda et al.

    Patients' opinions on family doctor accessibility in Estonia

    Croatian Medical Journal

    (2004)
  • P. Kekki

    Primary health care and the millennium development goals: Issues for discussion

    (2006)
  • A.C. Laurell

    Health system reform in Mexico: a critical review

    International Journal of Health Services

    (2007)
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    We are grateful to the editor and three anonymous reviewers for their insightful comments on this paper.

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