Conjoint Associate Professor, School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
Received date: 8 January 2004; Accepted date: 16 February 2004
The World Health Report 2003 has brought to the fore the controversy concerning whether or not ‘primary care’ and ‘primary healthcare’ are coterminous. The term ‘primary healthcare’ is derived from the World Health Organization (WHO) Alma Ata declaration of 1988.
While stressing that the primary healthcare orientation is widely regarded as crucial for equitable progress in health, the report subsequently stated that:
Ambiguities were present in the Alma Ata document, in which the concept was discussed as both a level of care and an overall approach to health policy and service provision. In high-income and middle-income countries, primary healthcare is mainly understood to be the first level of care. In low-income countries where challenges to access in healthcare persist, it is seen more as a system-wide strategy.[1,2]
Point seven of the ten-point Alma Ata declaration states, in part:
Primary healthcare is essential healthcare based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and family in the community through their full participation and at a cost that the community and country can afford at every stage of development and in the spirit of self reliance and self determination. It forms an integral part of both the country’s health system, of which it is the central function and main focus, and of the overall economic and social development of the community. It is the first level of contact of individuals, the family and community with the national health system, bringing healthcare as close as possible to where people live and work, and constitutes the first element of a continuing healthcare process.
While some societies, health researchers, scholarly journals and health sectors consider primary care and primary healthcare as distinct disciplines, others regard them as coterminous. For instance, at the New South Wales Corrections Health Service, Australia (www.chs.health.nsw.gov.au), where the author is based, primary healthcare is structured as coterminous with population health. Activities undertaken under this banner include immunisation, screening, outbreak investigation, and other traditional public health functions. A distinct department, primary care, is concerned with ‘family doctor-type’ services such as diabetes management, treatment of minor injuries and acute clinical care services. In contrast, the ‘Aims and scope’ section of Quality in Primary Care, as well as the World Health Report 2003, apparently regard the two terms as coterminous.
As a descriptive term for both level of healthcare and overall approach to healthcare policy and service provision, ‘primary care’ appears more widely used in health literature compared with ‘primary healthcare’. A recent Medline and Cinahl search of articles with ‘primary care’ and ‘primary healthcare’ in their titles posted 11 531 and 4062 results respectively for ‘primary care’ in contrast to 3293 and 976 articles respectively for ‘primary healthcare’. This trend might be related to the fact that most health-related journals and journal articles originate from developed countries, where the term ‘primary healthcare’ is relatively unpopular. In the author’s experience as a clinician in Nigeria, ‘general medical practice’ is coterminous with ‘primary care’ in most West African Countries. A limited analysis of articles listed in Medline and Cinahl between 2000 and 2003 revealed that authors from developing countries are more likely to use ‘primary healthcare’ to describe issues framed as ‘primary care’ by authors from wealthier countries.[4,5]
The precepts of the Alma Ata declaration were viewed by leading health authorities as superfluous for developed countries, and over-ambitious for developing countries. Rather than support its wholesale implementation in developing countries, they championed the concept of ‘selective primary healthcare’.[6,7] These factors combined to undermine successful implementation of the Alma Ata declaration, thus swinging the pendulum towards what became known as ‘health sector reform’.[2,8]
One issue of concern regarding primary care is that it is traditionally aligned to the medical profession. Critics of this term regard it as a ‘rebirth’ of terms like ‘preventive medicine’ and ‘general medical practice’, frameworks of healthcare delivery in which the medical doctor’s role was pre-eminent. Furthermore, primary care is perceived by some critics as distinct from ‘public health’, and primarily concerned with the clinical care of individuals. In contrast, it is suggested that one of the defining characteristics of primary healthcare is that it entails both individual patient care and public health functions.
Given the clarion call of the World Health Organization for a return to primary healthcare principles, it is important that governments, academic journal boards, and health workers are clear about how this term is defined, and how (or if) such definition differs from that of ‘primary care’ in developing and developed countries. Indeed, as the World Health Report 2003 clearly indicated, ‘no uniform, universally acceptable definition of Primary Healthcare exists’. The same can be said for ‘primary care’.Resolving the controversy with regard to whether or not primary care and primary healthcare are synonymous is important for several reasons. First, it would facilitate efficient organisation of health systems, in part by minimising duplication of functions and/or suboptimal utilisation of scarce healthcare resources. Second, it would optimise the quality of searches for articles related to both terms. Third, it would enhance authors’ appraisal of the suitability of journals for article submission. Fourth, it should make for more accurate measurement of health-related outcomes of comparable health systems – currently, primary healthcare and primary care systems are not necessarily comparable.
In my view, the most important task in this regard is not to labour over the ‘true’ meanings of these terms, but rather to clarify, and subsequently be thoroughly consistent with regard to the way they are used by the World Health Organization, national and state health ministries, and academic journals.