No Better Health Without Functioning Primary Care

Decision makers in the health sector are preoccupied with hospital services though they play a role in less than 1% of all episodes of disease. This editorial tries to draw the attention to the most important health service level for all countries in this world: Primary care or first contact health services.  Without a functioning primary care health system, Universal Health Coverage (UHC) cannot be achieved.  Establishing a primary care health system demands a wide range of essential, applied research.  The slogan in the headline already provides the main research hypothesis:  A functioning Primary Health Care system results in better health of the targeted community. Many sub-hypotheses result from the aspects discussed below.     

The Kenyan Government has made Universal Health Coverage one of its 4 main development targets: When sick, every citizen should have access to the treatment needed without geographical, cultural or financial constraints.  This target can only be reached if every citizen can rely on a primary care provider (PCP), who is close enough to the community and trusted, who is well trained in family health, who is aware of the factors influencing health in the community, who can give at least 15 minutes to each visiting patient, and who has enough time to visit children and elderly at home when need arises.  Apart from giving health education, this PCP can handle 70 to 80% of all clinical cases and help to prevent complications. If needed, the PCP refers the patient to higher health service levels and receives feedback for follow-up care. 

Assuming that on average over all age groups, a person needs to see a health professional four times per year, one primary care provider can take care of an approximate catchment population of 2,000.  Thus a country, like Kenya needs 22,000 primary care health providers.  Everybody, who is serious about UHC must have these figures in mind. Many developing countries fall short of adequate health workers. Hence, it will be necessary to upgrade and/or re-orient other health provider cadres like registered nurses to assume a major role, if UHC should be achieved. So far, nobody seems to be planning for their upgrading in family medicine and primary care health services. 

A primary care health provider should not work in isolation.  He/she should work in a team, which could be a Primary Care Network. A Primary Care Network may comprise 10 to 30 colleagues depending with the local situation. The network has 5 main purposes: (i) Organizing continuous professional development, (ii) controlling integrity and quality, (iii) referring patients among each other according to specific competences (horizontal referral), (iv) cooperating with a defined set of referral facilities for  vertical referrals, and (v) serving as the “contracting unit” for the health care purchaser administrating the capitation-based, prepaid budget for the primary care providers. This could reduce administrative burden and costs considerably for the health insurance purchaser, e.g. in Kenya, the National Health Insurance Fund. The process to establish primary care networks will take time. However, favourable preconditions, such as participatory management as opposed to top-down administration, strong political will, and close cooperation with professional associations will be essential.