The Importance of Primary Health Care in Health ... - What is GIS

The Importance of Primary
Health Care in Health
Systems
Barbara Starfield, MD, MPH
Qatar-EMRO Primary Health Care Conference
Doha, Qatar
November 2008

Life Expectancy Compared with GDP
per Capita for Selected Countries
Source: Economist Intelligence Unit. Healthcare International. 4th quarter 1999. London, UK:
Economist Intelligence Unit, 1999.
Country codes:
AG=Argentina
AU=Australia
BZ=Brazil
CH=China
CN=Canada
FR=France
GE=Germany
HU=Hungary
IN=India
IS=Israel
IT=Italy
JA=Japan
MA=Malaysia
ME=Mexico
NE=Netherlands
PO=Poland
RU=Russia
SA=South Africa
SI=Singapore
SK=South Korea
SP=Spain
SW=Sweden
SZ=Switzerland
TK=Turkey
TW=Taiwan
UK=United Kingdom
US=United States
Starfield 11/06
IC 3493 n

Country* Clusters: Health Professional
Density (workers per 1000)
*186 countries
25
15
10
5.0
2.5
1
Supply and Child Survival
3 5 9 50 100 250
Child mortality (under 5) per 1000 live births
Source: Chen et al, Lancet 2004; 364:1984-90.
Starfield 07/07
HS 3754 n

Primary health care is primary
care applied on a population
level. As a population strategy,
it requires the commitment of
governments to develop a
population-oriented set of
primary care services in the
context of other levels and
types of services.
Starfield 07/07
PC 3755 n

Primary care is the provision of
first contact, person-focused,
ongoing care over time that
meets the health-related needs
of people, referring only those
too uncommon to maintain
competence, and coordinates
care when people receive
services at other levels of care.
Starfield 07/07
PC 3756 n

Why Is Primary Care
Important?
Better health outcomes
Lower costs
Greater equity in health
Starfield 07/07
PC 3757 n

Evidence for the benefits of primary care-oriented
health systems is robust across a wide variety of
types of studies:
• International comparisons
• Population studies within countries
– across areas with different primary care
physician/population ratios
– studies of people going to different types of
practitioners
• Clinical studies
– of people going to facilities/practitioners differing
in adherence to primary care practices
Source: Starfield et al, Milbank Q 2005; 83:457-502.
Starfield 03/08
PC 3971 n

Primary Care Orientation
of Health Systems
Health system characteristics (9)
Practice characteristics (6)
Adapted from Starfield. Primary Care: Balancing Health Needs,
Services, and Technology. Oxford U. Press, 1998, Chapter 15.
Starfield 04/99 1999
PC 99-147 1475

Primary Care Orientation of
Health Systems: Rating Criteria
• Health System Characteristics
– Type of system
– Financing
– Type of primary care practitioner
– Percent active physicians who are specialists
– Professional earnings of primary care physicians
relative to specialists
– Cost sharing for primary care services
– Patient lists
– Requirements for 24-hour coverage
– Strength of academic departments of family medicine
Source: Starfield. Primary Care: Balancing Health Needs,
Services, and Technology. Oxford U. Press, 1998.
Starfield 11/02
PC 02-405 2366 sc n

Primary Care Orientation of
Health Systems: Rating Criteria
• Practice Characteristics
– First-contact
Source: Starfield. Primary Care: Balancing Health Needs,
Services, and Technology. Oxford U. Press, 1998.
– Longitudinality
– Comprehensiveness
– Coordination
– Family-centeredness
– Community orientation
Starfield 11/02
PC 02-406 2367 sc n

Primary Care Scores, 1980s and 1990s
Belgium
France*
Germany
United States
Australia
Canada
Japan*
Sweden
Denmark
Finland
Netherlands
Spain*
United Kingdom
1980s 1990s
*Scores available only for the 1990s Starfield 07/07
ICTC 3758 n
0.8
-
0.5
0.2
1.1
1.2
-
1.2
1.5
1.5
1.5
-
1.7
0.4
0.3
0.4
0.4
1.1
1.2
0.8
0.9
1.7
1.5
1.5
1.4
1.9

System Features Important to Primary Health Care
Belgium
France
Germany
US
Australia
Canada
Japan
Sweden
Denmark
Finland
Netherlands
Spain
UK
Resource
Allocation
(Score)
0
0
0
0
1
1
1
2
2
2
2
2
2
Progressive
Financing*
0
0
1
0**
Cost
Sharing
Sources: Starfield. Primary Care: Balancing Health Needs, Services, and
Technology. Oxford U. Press, 1998. van Doorslaer et al. Equity in the Finance
and Delivery of Health Care: An International Perspective. Oxford U. Press, 1993.
2
2
2
2
2
2
0
2
2
0
0
2
0
2
2
1
1
2
1
2
2
2
Comprehensiveness
0
0
0
0
2
2
1
1
2
2
2
1
2
*0=all regressive
1=mixed
2=all progressive
**except Medicaid
Starfield 11/06
EQ 3500 n

System (PHC) and Practice (PC) Characteristics
Facilitating Primary Care, Early-Mid 1990s
Practice Characteristics
(Rank*)
12
11
10
9
8
7
6
5
4
3
2
1
0
UK
DK
FIN
SP
CAN
NTH
SWE JAP
AUS
GER FR
BEL
0 1 2 3 4 5 6 7 8 9 10 11 12 13
*Best level of health indicator is ranked 1; worst is ranked 13;
thus, lower average ranks indicate better performance.
Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.
System Characteristics (Rank*)
US
Starfield 03/05
ICTC 3099 n

Primary Care Score vs. Health
Primary Care Score
Care Expenditures, 1997
2
1.5
1
0.5
0
SP
SWE
UK
DK
FIN
AUS
JAP
NTH
CAN
BEL FR
GER
1000 1500 2000 2500 3000 3500 4000
Per Capita Health Care Expenditures
US
Starfield 11/06
ICTC 3495 n

10000
PYLL
5000
0
Primary Care Strength and Premature
Mortality in 18 OECD Countries
Year
Low PC Countries*
High PC Countries*
1970 1980 1990 2000
*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled
for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2 (within)=0.77.
Starfield 11/06
Source: Macinko et al, Health Serv Res 2003; 38:831-65.
IC 3496 n

Primary Care Oriented
Countries Have
• Fewer low birth weight infants
• Lower infant mortality, especially
postneonatal
• Fewer years of life lost due to suicide
• Fewer years of life lost due to “all except
external” causes
• Higher life expectancy at all ages except
at age 80
Sources: Starfield. Primary Care: Balancing Health Needs, Services, and
Technology. Oxford U. Press, 1998. Starfield & Shi, Health Policy 2002; 60:201-18.
Starfield 07/07
IC 3762 n

Is Primary Care as
important within
countries as it is among
countries?
Starfield 07/07
WC 3765 n

State Level Analysis:
Primary Care and Life Expectancy
Life Expectancy
78
77
76
75
74
73
72
71
4.00 4.50 5.00 5.50 6.00 6.50 7.00 7.50
Source: Shi et al, J Fam Pract 1999; 48:275-84.
.
.TN . . KS
. . . DE KY
WV . NC
AL . MS
.
. NV
GA . SC
.
LA
ID
. . ND
.NE SD
. ME . .OR
NH
. . . .AZ RI.
ID
IA UT
.NM . . . MT . NJ
FL
WI
. .
. NY
TX . AR . PA
MI
.VA . IL
. AK
. CT
.MN
.WA
.MA
. CA
. MD
Primary Care Physicians/10,000 Population
. HI
R=.54
P

Primary Care and Infant Mortality
Rates, Indonesia, 1996-2000
Primary care
spending
per capita*
Hospital
spending
per capita*
Infant
mortality
*constant Indonesian rupiah, in billions
1996-1997
1997-
1998
1998-
1999 1999-2000
10.3 9.6 8.5 8.2
4.1 4.4 4.6 5.3
20% improvement
(all provinces)
(1990-96)
Source: Simms & Rowson, Lancet 2003; 361:1382-5.
14% worsening
(22 of 26 provinces)
Starfield 07/07
WC 3796 n

Percentage Reduction in Under-5
Mortality: Thailand, 1990-2000
Poorest quintile (1) 44
(2) 41
(3) 22
(4) 23
Richest quintile (5) 13
Rate ratio (Q1/Q5) 55
Absolute difference
(Q1-Q5)
61
Source: Vapattanawong et al, Lancet 2007; 369:850-5.
Policy changes:
1989 At least one primary care health
center for each rural village
1993 Government medical welfare
scheme: all children less than 12,
elderly, disabled
2001 Entire adult population insured
Activities of Rural Doctors’ Society
Starfield 07/07
WC 3797 n

Impact of PSF Coverage on Infant Mortality in
Brazilian States, 1990-2002: Marginal Effects *
Illiteracy
(women)
PSF coverage
Clean water
Fertility rate
Hospital beds
-5 0 5 10 15
Marginal effect (% change in IMR with 10% increase in variable)
*Based on 2-way fixed effects model of Brazilian states, 1990-2002, n=351 R^2=0.90. Non-significant
(p>0.05) control variables, including physician and nurse supply and sewage not shown.
Source: Macinko et al, J Epidemiol Community Health 2006; 60:13-19.
Starfield 10/06
WC 3457 n

Many other studies done WITHIN countries,
both industrialized and developing, show that
areas with better primary care have better
health outcomes, including total mortality
rates, heart disease mortality rates, and
infant mortality, and earlier detection of
cancers such as colorectal cancer, breast
cancer, uterine/cervical cancer, and
melanoma. The opposite is the case for
higher specialist supply, which is associated
with worse outcomes.
Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htm
Starfield 09/04
04-167 WC 2957

What We Already Know
A primary care oriented system is
important for
• Improving health (improving
effectiveness)
• Keeping costs manageable (improving
efficiency)
Starfield 09/05
PC 3316

Does primary care
reduce inequity in
health?
Starfield 07/07
EQ 3769 n

In the United States, an increase of
1 primary care doctor is associated
with 1.44 fewer deaths per 10,000
population.
The association of primary care
with decreased mortality is greater
in the African-American population
than in the white population.
Source: Shi et al, Soc Sci Med 2005; 61(1):65-75.
Starfield 07/07
WCUS 3770 n

Primary health care oriented countries
• Have more equitable resource distributions
• Have health insurance or services that are
provided by the government
• Have little or no private health insurance
• Have no or low co-payments for health services
• Are rated as better by their populations
• Have primary care that includes a wider range
of services and is family oriented
• Have better health at lower costs
Sources: Starfield and Shi, Health Policy 2002; 60:201-18.
van Doorslaer et al, Health Econ 2004; 13:629-47.
Schoen et al, Health Aff 2005; W5: 509-25.
Starfield 11/05
IC 3326

Health Workforce
Starfield 10/07
WF 3901

In 35 US analyses dealing with differences
between types of areas (7) and 5 rates of
mortality (total, heart, cancer, stroke, infant),
the greater the primary care physician
supply, the lower the mortality for 28. The
higher the specialist ratio, the higher the
mortality in 25.
Above a certain level of specialist supply, the
more specialists per population, the worse
the outcomes.
Controlled only for income inequality
Source: Shi et al, J Am Board Fam Pract 2003; 16:412-22.
Starfield 11/06
SP 3499 n

Percentage of People Seeing at
Least One Specialist in a Year
US 40% of total population; 54% of
patients (users)
Canada
(Ontario)
31% of population (68% at ages
65 and over)
UK about 15% of patients (at ages
under 65)
Spain 30% of population; 40% of
patients (users)
Sources: Peterson S, AAFP (personal communication, January 30, 2007). Jaakkimainen et al.
Primary Care in Ontario. ICES Atlas. Toronto, CA: Institute for Clinical Evaluative Sciences,
2006. Sicras-Mainar et al, Eur J Public Health 2007; 17:657-63. Starfield et al, submitted 2008.
Starfield 01/07
SP 3529 n

Resource Use, Controlling for
Morbidity Burden*
• More DIFFERENT specialists seen: higher total
costs, medical costs, diagnostic tests and
interventions, and types of medication
• More DIFFERENT generalists seen: higher total
costs, medical costs, diagnostic tests and
interventions
• More generalists seen (LESS CONTINUITY):
more DIFFERENT specialists seen. The effect
is independent of the number of generalist
visits.
*Using the Johns Hopkins Adjusted Clinical Groups (ACGs)
Source: Starfield et al, Ambulatory specialist use by patients in
US health plans: correlates and consequences. Submitted 2008.
Starfield 09/07
CMOS 3854

There are large variations in
both costs of care and in
frequency of interventions.
Areas with high use of
resources and greater supply
of specialists have NEITHER
better quality of care NOR
better results from care.
Sources: Fisher et al, Ann Intern Med 2003; Part 1: 138:273-87; Part 2: 138:288-98. Baicker &
Chandra, Health Aff 2004; W4:184-97. Wennberg et al, Health Aff 2005; W5:526-43.
Starfield 12/05
SP 3343

What is the right number of
specialists?
What do specialists do?
What do specialists contribute
to population health?
Starfield 01/06
SP 3354

Primary Care and Health:
Evidence-Based Summary
• Countries with strong primary care
– have lower overall costs
– generally have healthier populations
• Within countries
– areas with higher primary care physician
availability (but NOT specialist availability) have
healthier populations
– more primary care physician availability reduces
the adverse effects of social inequality
Starfield 09/02
PC 02-437 2218 sc n

Strategy for Change in Health
Systems
• Achieving primary care
• Avoiding an excess supply of specialists
• Achieving equity in health
• Addressing co- and multi-morbidity
• Responding to patients’ problems
• Coordinating care
• Avoiding adverse effects
• Adapting payment mechanisms
• Developing information systems
Starfield 11/06
HS 3494 n

Conclusion
Although sociodemographic factors
undoubtedly influence health, a primary
care oriented health system is a highly
relevant policy strategy because its
effect is clear and relatively rapid,
particularly concerning prevention of
the progression of illness and effects of
injury, especially at younger ages.
Starfield 11/05
HS 3329