The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives☆
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
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We are grateful to the editor and three anonymous reviewers for their insightful comments on this paper.