What Is a Quality Blue Primary Care Provider
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The following principles should be prioritized simultaneously to improve the design of health systems that promote high-quality primary health care.
Person-centered care
While there are many supply-side considerations for first contact access at the system and organizational-level, services that are acceptable (trusted and of-value) from the patient perspective will make it more likely that patients will seek services. Person-centeredness is an important function for improving the capacity of PHC systems to deliver services that are trusted and valued by patients. Person-centered health-systems engage people as equal partners in promoting and maintaining their health in a way that integrates the existing cultural context such as attitudes, beliefs, and concerns. However, in order to be empowered users of the health system, patients must have the ability to make informed decisions and participate in their own care. While there are varying degrees of improvements to be made to achieve person-centered health systems to the fullest extent, a minimum level of acceptability (trust and value placed in the system) must be in place for primary health care to be utilized as the first point of contact.
Primary health care as the first point of contact
The capacity of PHC to effectively serve as the first point of contact hinges on the consistent delivery of high-quality comprehensive care that is trusted and valued by users. However, comprehensive care will not in itself translate to better health outcomes if it is not utilized as first contact care. In order for patients to receive high-quality primary health care, primary care facilities must be both accessible, (facilities are physically present and accessible to populations in terms of geographic proximity, cost, and convenient hours of operation and waiting times) and acceptable (trusted and valued by users). From the system level, this is influenced by the creation and enforcement of national standards and guidelines (across private and public sectors), the skill and motivation of the primary health care workforce, and the availability of inputs, infrastructure, and information systems. From the patient-perspective, utilization is influenced by contextual factors at the individual and local level, including social and cultural norms and beliefs and decision-making capacity. With these foundational elements in place, service delivery activities, such as empanelment and proactive population outreach, help to facilitate primary care as the first point of contact and enable coordination across the continuum of care.
Integrated care delivery systems
To best meet the complex needs and preferences of populations, primary health care services should be comprehensive. Integrated health service delivery is an approach to strengthening person-centered health systems through the delivery of comprehensive services, coordinated around the needs and preferences of a person throughout their life course and care settings.13 14 Integrated models that offer a more comprehensive set of skills and services at the frontline (including diagnostic, pharmaceutical, behavioral, and rehabilitative services) can help to increase the efficiency and timeliness of primary health care, increasing the capacity of primary care to serve as the first point of contact.15 16 17 Integrated models are strengthened by the use of referral networks and interoperable information systems that promote bi-directional communication channels.18 19 20
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This subdomain focuses on the delivery of high-quality primary health care from the perspective of both the user and the system. High-quality primary health care is an outcome within Service Delivery - these functions of PHC are often a result of various elements within System, Inputs, and other components of Service Delivery. The framework below calls for a fundamental shift in the way health services are funded, managed, and delivered to promote universal access to high-quality person-centered care. The framework is adaptable to all countries and health systems.
WHO Framework on integrated people-centered health services
The WHO Framework on Integrated People-Centered Health Services proposes five interdependent strategies for the development of responsive people-centered health systems that deliver high-quality, safe, and acceptable services for all. The below strategies are synergistic, a lack of progress in one area may undermine progress in another.
- Empowering and engaging people and communities - This strategy aims to empower individuals (including underserved and marginalized groups) with the opportunities, skills, and resources to make decisions about their own health and be empowered and engaged users of quality health services. It aims to enable communities to be actively engaged in co-producing healthy environments for individuals and be capacitated to delivery informal care that improves the health of communities (training and networks for community health workers, social participation, community delivered care).
- Strengthening governance and accountability - This strategy aims to strengthen governance using a participatory approach to policy formulation, decision-making, and performance evaluation at all levels of the health system. To reinforce good governance, a robust system for mutual accountability across stakeholders and a people-centered incentives system should be in place.
- Reorienting the model of care - This strategy calls for a people-centered approach to primary health care for the design and delivery of efficient and effective services that are holistic, comprehensive, and sensitive to social and cultural needs and preferences.
- Coordinating services within and across sectors - This strategy leverages multisectoral and intersectoral partnerships and the integration of health providers within and across settings and levels of care to promote care coordination. Coordination focuses on improving the delivery of care to better respond to the needs and demands of people.
- Creating an enabling environment - This strategy involves creating an enabling environment to bring all stakeholders together to transform all of these strategies into an operational reality. In order to effect change, this task involves a diverse set of processes in the domains of leadership and management, information systems, quality improvement methods, workforce development, legislative and policy frameworks, and health financing and incentives.
The policies and interventions that stakeholders adopt to achieve the realization of these strategies are context-specific, and as such will need to be developed according to the local context, values, and preferences of the country at the national, regional, and local level. An integrated people-centered approach to service delivery is essential for the achievement of five elements fundamental to universal health coverage:
- Equity in access - Everyone has access to the quality services they need everywhere, every time.
- Quality - Care is safe, effective, timely, and responsive to a comprehensive set of needs at the highest possible standard.
- Responsiveness and participation - Care is coordinated around people's needs and preferences and engages people as equal partners in their health affairs.
- Efficiency - Services are cost-effective and achieve an optimal balance of health promotion and in-and-out patient care to avoid duplication and waste of resources.
- Resilience - Health actors, institutions, and populations are capacitated to prepare for and effectively respond to public health crises.
More information on the Framework on integrated, people-centered approach, including the implementation approach and the role of stakeholders, can be accessed here.
What others have done
This video shows the principles of high-quality primary health care in action in Costa Rica.
This video shows the principles of high-quality primary health care in action in Costa Rica.
Relevant resources
Many tools and resources focused on high-quality primary health care have been created over the last decade. Below is an interactive resource that provides the most useful documents within the context of our defined scope of first contact accessibility, continuity, coordination, comprehensiveness, and person-centered care.
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- Person-centered care
- Social determinants of health
- First contact accessibility
- Continuity
- Coordination
- Comprehensiveness
- Responsiveness to people
- Private and multisectoral engagement
- NCDs and mental health
- Infectious disease
- COVID-19
- Resilience of health systems
- Fragile and conflict affected settings
- Monitoring and evaluation
- UHC
This paper pursues a comprehensive discussion of conceptual frameworks for science and policy for health equity. "As an "action oriented" framework, it is designed to help policy-makers pinpoint where to intervene in these underlying processes to most effectively fight health inequities. The model includes three core components: 1) socioeconomic and political context; 2) structural determinants of health inequities; and 3) intermediary determinants of health."
This background report links the Declaration of Astana to the broader "case" for PHC, lessons learned over the past 4 decades, components of PHC, a vision of PHC in the 21st century and health system levers for action around PHC.
This website describes the importance of care coordination and provides examples of broad and specific care coordination approaches. It includes a multitude of resources on making actionable change within a medical practice.
This publication provides recommendations that "are designed to help standardize the ways in which primary care practitioners activate referrals to specialists, and then keep track of the information over time." It "describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner."
This practice brief supports the implementation of the WHO framework on integrated people-centred health services - addressing "the conditions and ongoing relationships needed to support seamless interactions among multiple providers within interdisciplinary teams and/or across care settings and/or sectors." The two concepts underlying this approach are continuity of care and care coordination.
This article underscores the importance of attention, measurement, and improvement efforts within to the three domains of continuity (relational, informational, and managerial). Naming continuity as a must-have priority in order to achieve UHC, the article elaborated on the feasibility of improved continuity "in low-income and middle-income country health systems by using comprehensive empanelment systems or community-based follow-up programmes to improve retention in care."
This implementation guide addresses "why care teams are important for improving patient care and ways to build an effective care team that meet patients' needs and expectations." It identifies "four principles that should guide any effort to provide continuous, team-based care, and presents detailed steps on how to implement continuous, team-based care."
This resource provides a proposed conceptual blueprint for patient-centered team based care and strategies for providing patient-centered team based care, of particular relevance in the midst of increasing emphasis on delivering high-quality primary care.
This practical manual contains "step-by-step guidance along with real-world examples and case studies to help facilitate public-private sector engagement around primary health care (PHC). The first two modules of the Manual provide practical guidance on Initial Communications and Partnership Around PHC and Provider Mapping."
This platform "is the first and only WHO instrument aimed at facilitating multistakeholder engagement and cross-sectoral collaboration to prevent and control NCDs. It convenes and connects diverse stakeholders comprising all WHO Member States, UN Organizations, and non-State actors, including relevant private sector entities, to address [the] five functions [of global coordination mechanisms]."
This article "argues that it is important to distinguish between three distinct but related concepts: longitudinal continuity from a minimum number of health professionals, caring relationships between patients and professionals, and well-coordinated care between professionals." It includes questions influencing evaluation indicators and ways to navigate decisionmaking within a variety of contexts.
This toolkit "outlines the integrated care system that Partners In Health (PIH) is using in Neno District, Malawi, to combine resources for the screening, treatment and follow-up care of HIV and NCD patients. The integrated system offers screening for diabetes, hypertension, TB, malnutrition and family planning, along with HIV screenings at patients' homes, community centers, and health facilities."
This framework for integrated people-centred health services can be adapted to all countries. The five recommended strategies are: engaging and empowering people and communities; strengthening governance and accountability; reorienting the model of care; coordinating services within and across sectors; and creating an enabling environment. The landing page for this resource outlines support countries can expect through partnering with WHO.
"The Knowledge Action Portal (KAP) is a flagship online community-driven platform launched by the WHO Global Coordination Mechanism on the Prevention and Control of Noncommunicable Diseases (WHO GCM/NCD). The KAP presents users with an innovative way to enhance global understanding, interaction, and engagement across sectors for the purpose of fulfilling existing - and initiating new - commitments to noncommunicable disease (NCD) prevention and control."
This document was produced as a part of the WHO's technical series on PHC. It offers actionable information on strengthening the role of PHC in health emergencies, supplemented by country examples of effective emergency response and opportunities for action. It concludes with evidence based lessons that countries can implement to help build PHC preparedness and response capacities to manage public health emergencies, structured around the core components of health systems.
"The Practical Approach to Care Kit (PACK) is a health systems improvement programme designed to support the work of primary care health workers in underserved communities strengthen the health services in which they work and thereby achieve the best possible patient outcomes." It comprsises 4 pillars: a clinical decision support tool, a training program, measures to strengthen health systems, and monitoring and evaluation tools.
This technical report focuses on possible models for the integration of public health functions into PHC. This integration is required to address population health needs at the individual and community levels, moving toward a more proactive approach to health rather than the dated disease-focused model.
"Amidst global consensus that high-quality PHC is the foundation of UHC, and that "significant disruptive innovation will be required to realize this goal," this publication offers "recommendations to the global community to catalye futher discourse and inform policy-making and program development on the path to Health for All by 2030."
This tool "was developed to assist health and program managers in obtaining and using information regarding the performance of referral systems. These systems play an increasingly important role in the health systems of developing countries as result of the recent impetus toward service integration."
This review covers 40 years of PHC implementation at country level (from the 1978 Alma-Ata Declaration on primary health care to 2018). It identifies "achievements, challenges, lessons and best practices associated with PHC generally until 2018, [and aims] to make recommendations on the way forward in order to accelerate national, regional and global health strategies and plans for UHC, PHC and the Sustainable Development Goals."
This study evaluates "the performance of several risk-adjustment/stratification instruments in predicting healthcare utilization." It found that Adjusted Clinical groups (ACGs) "generally performed better in predicting utilization, [but] use of any of the models [referenced in the study] will help practice implement care coordination more effectively."
"This tool is designed to help hospitals and health systems facilitate sensitive conversations with patients about their nonmedical needs that may be a barrier to good health. It includes strategic considerations for implementing a screening program, tips for tailoring screenings to hospitals' unique communities, case examples and a list of national organizations that can help connect patients with local resources."
This chapter defines people-centered integrated care (PCIC), "presenting its benefits, implementation challenges, core actions, and implementation strategies." Guidelines address (1) strengthening grassroots providers; (2) promoting grassroots level first contact; (3) establishing two-way referrals; (4) defining provider roles while fostering integration of providers; (5) emphasizing special care arrangements to treat and manage chronic diseases; (6) expanding the supply of general practice physicians to staff primary care facilities; (7) organizing provider networks; and (8) advancing information and communications technology use for electronic health systems.
This publication highlights the importance of high-quality PHC as the most effective way to deliver care that meets the majority of a population's health needs and to acheve UHC. It builds on Barbara Starfield's in '4Cs': first-contact accessibility, continuity, comprehensiveness and coordination, suggesting a schematic connecting the resources of strong PHC, processes that transform resources into high-quality PHC, and the functions of high-quality PHC.
This paper presents the Health Equity Measurement Framework (HEMF), "which was specifically designed to measure the direct and indirect effects of [social determinants of health] to support improved statistical modelling and measurement of health equity...The HEMF recognises the complexity surrounding the SDOH and provides a clear, overarching direction for empirical work on health equity."
This document "focuses on the first component of primary health care and provides an overview of the role of the private sector in health systems in terms of providing goods and health services, particularly in primary care. It describes ways to harness the efforts of all health services, both public and private, to achieve universal health coverage, including efforts focused on primary health care."
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
References:
- Doherty J. The Cost-Effectiveness of Primary Care Services in Developing Countries: A.
- Rao M, Pilot E. The missing link--the role of primary care in global health. Glob Health Action. 2014 Feb 13;7:23693.
- Agency for Healthcare Research and Quality. Care Coordination [Internet]. [cited 2018 Dec 4]. Available from: https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html
- Thomas-Hemak L. Closing the loop with referral management. Group Health Research Institute; 2013.
- Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.
- Phillips C. Care coordination for primary care practice. J Am Board Fam Med. 2016 Nov 12;29(6):649–51.
- Solberg LI. Care coordination: what is it, what are its effects and can it be sustained? Fam Pract. 2011 Oct;28(5):469–70.
- Framework WHO. Continuity and coordination of care.
- Friedberg MW, Hussey PS, Schneider EC. Primary care: a critical review of the evidence on quality and costs of health care. Health Aff (Millwood). 2010 May;29(5):766–72.
- Enthoven AC. Integrated delivery systems: the cure for fragmentation. Am J Manag Care. 2009 Dec;15(10 Suppl):S284-90.
- Montenegro H, Holder R, Ramagem C, Urrutia S, Fabrega R, Tasca R, et al. Combating health care fragmentation through integrated health service delivery networks in the Americas: lessons learned. Journal of Integrated Care. 2011 Oct 10;19(5):5–16.
- Ramagem C, Urrutia S, Griffith T, Cruz M, Fabrega R, Holder R, et al. Combating health care fragmentation through integrated health services delivery networks. Int J Integr Care. 2011;
- World Health Organization G. Integrated Health Services - What and Why? World Health Organization; 2008 May.
- World Health Organization. Framework on integrated, people-centred health services. World Health Organization; 2016.
- Vargas I, Mogollón-Pérez AS, De Paepe P, Ferreira da Silva MR, Unger J-P, Vázquez M-L. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016 Jul;31(6):736–48.
- Gittell JH. Organizing work to support relational co-ordination. The International Journal of Human Resource Management. 2000 Jan;11(3):517–39.
- McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft SA, et al. Closing the quality gap: A critical analysis of quality improvement strategies (vol. 7: care coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007.
- World Bank Group. FRONTLINE FIRST ... A FORWARD-LOOKING AGENDA FOR HEALTH SYSTEMS TRANSFORMATION. World Bank Group; 2018 Oct.
- Enabulele O, Enabulele JE. A look at the two–way referral system: experience and perception of its handling by medical consultants/specialists among private medical practitioners in Nigeria. International Journal of Family & Community Medicine. 2018;
- World Health Organization G. A practice brief to support implementation of the WHO Framework on integrated people-centred health service. World Health Organization; 2018.
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Source: https://improvingphc.org/improvement-strategies/high-quality-primary-health-care
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