The Effectiveness of General Primary Care
Whereas it can be argued that highly cost-effective interventions deserve to be implemented, no matter the level for which they are designed, unique reasons exist for giving priority to those based at the primary level. As implied earlier, these reasons relate to the extent of the burden of disease that is potentially avertable through primary-level care (the health effect), the welfare benefits that accrue to households spared the experience of disease (the nonhealth effect), and the potential to provide widely accessible services (an equity effect based on degree of need).
Unfortunately, although many small-scale projects and assessments of single interventions have been able to measure such effects (see part 2 of this volume), the empirical evidence with regard to large-scale and routine primary care programs—whether in industrial or low- and middle-income settings—is scant (Doherty and Govender 2004; Starfield 1998). The key problem is to demonstrate the causal link between provision of general primary care services and positive health outcomes—and especially to disentangle the influences of socioeconomic conditions. This difficulty is compounded by other factors, ranging from the complexity of the study design required to convincingly evaluate routine programs (as opposed to field trials) to the difficulties faced by health ministries in ensuring that monies targeted at primary care are translated into the delivery of quality health services.
Thus, we are able to comment only in broad terms on the positive contributions of general primary care services, recognizing that, although these contributions are potentially enormous, the gains made by such services over the past two decades have been mixed. Importantly, Almeida and others (2001) caution against ascribing the failures of primary care to inherent weaknesses in the concept. In commenting on analyses of the effectiveness of primary care, they point to "the cataclysmic effect on public health systems in less-developed countries of the global economic recession of the 1980s and the application of policies stressing privatisation and decreased public spending in that decade and the next; [this] resulted in rising poverty and under-funding of health services in many less-developed countries, to the point of near-collapse in the poorest countries" (Almeida and others 2001,).
Health Effects
Investing in Health reported that in countries with moderate to high mortality only a few conditions accounted for the majority of the burden of ill health (World Bank 1993). Thus, in 1990, 55 percent of the global burden of disease was concentrated in children under 15, and 75 percent of this burden was caused by 10 disease conditions or clusters (Bobadilla and others 1994). Except for congenital malformations, all these causes could be aligned with highly cost-effective interventions, many of which are classic components of general primary care (labeled the "clinical services" component of the package). Indeed, almost all of the activities included in the "public health" component of the package also involve some element of individual service delivery in the primary care setting. Together, it was estimated, these interventions could eliminate 21 to 28 percent of the burden of ill health in children.
With respect to adults, the World Bank (1993) found the burden of disease to be less concentrated: here the 10 main causes of disease and injury accounted for some 50 percent of the burden.1 Most interventions against these problems were found to be quite cost-effective, but their overall estimated effect was moderate because they prevent or treat only part of the problems. Such interventions could thus eliminate 10 to 18 percent of the adult disease burden.
These figures give some sense of the potential effect of interventions at the primary level when they are targeted at common, high-burden conditions in the population. Subsequent work by the World Bank estimated that the primary care level could potentially deal with up to 90 percent of health care demands (World Bank 1994) and that only 10 percent of care needs require the services and skills typically associated with hospitals.
Shifting from estimates to empirical evidence, we find that some studies have been able to demonstrate large-scale success in the sphere of child health. For example, using data from a national survey in Niger, Magnani and others (1996) showed that children living in villages near health dispensaries were 32 percent less likely to die than children without access to modern primary care services (differential access resulted from the phased implementation of services, which produced a natural quasi-experiment). Drawing on earlier work, Ewbank (1993,) concluded that the results of surveys in Zaire and Liberia "suggest that child survival programmes in Africa can reduce mortality substantially in populations living in different environments at very different initial levels of child mortality.In both countries, it appears that the programme reduced mortality under age 5 by about 20% or more." More generally, many examples of successful health programs clearly depend on the existence of a strong primary health care system (see chapter 8).
Given the paucity of evidence from developing countries, turning to the experience of high-income countries is useful, although the configuration of primary care services in such settings may be quite different. Following a detailed comparative study of 11 industrial nations (which involved the methodologically complex—and at times controversial—assigning of primary care and health system scores by country and then associating these scores with a range of health status indicators and total health care costs per capita), Starfield (1994,) concluded that "countries with a stronger orientation to primary care indeed are more likely to have better health levels and lower costs." Shi (1994,) found that, in the United States, availability of primary care was "by far the most significant variable related to better health status, correlating to lower overall mortality, lower death rates due to diseases of the heart and cancer, longer life expectancy, lower neonatal death rate, and less frequent low birth weight." Although working largely at the level of health output rather than outcome, Blumenthal, Mort, and Edwards (1995), in reviewing a number of studies in the United States, found considerable evidence of the positive effect of primary care services (see box 64.1). They argue that the literature does not adequately address the issue of whether primary care reduces the cost of providing care for underserved populations, but they conclude that "a commitment to primary care should be made for its potential to improve the satisfaction and health status of the American public, not for its potential to save money" (Blumenthal, Mort, and Edwards 1995,).
[Box 64.1]
Nonhealth Effects
Although most of the recent literature on primary care packages places value on primary care services because of their ability to reduce the burden of disease considerably and at low cost, such services potentially bring other benefits to society. Among the most striking may be the welfare benefits that accrue to households as a result of the prevention of illness. Severe disease can limit the ability of patients and caregivers to work, leading to the consumption of household assets in the purchasing of care. Russell (2003) found that such costs amounted to just over 10 percent of household income in three developing countries, a proportion that can have a catastrophic impact on the sustainability of poor households. Through prevention and early treatment, geographically accessible and financially affordable primary care services can reduce the negative economic consequences of ill health for households, reduce absenteeism, and enhance children's performance at school.
Serving of Equity Goals
Primary care services have the advantage over hospital care of tending to be more physically, financially, and culturally accessible to local communities. Because of their staffing and organization, they are less costly and more easily able to provide comprehensive, integrated, personalized, and continuous care (World Bank 1993). Because that part of the burden of disease that is addressed by primary care services disproportionately affects the poor, primary care services are theoretically well placed to improve equity in health and health care. Again, few data exist to demonstrate the equity effects of primary care delivered on a large scale in middle- and low-income countries. This gap is compounded by the fact that cost-effectiveness analyses seldom take into account the costs incurred by patients in seeking care (Doherty and Govender 2004).
However, in studies by Shi and Starfield (2000, 2001) examining income inequality and primary care in the United States, a significant association between higher primary physician supply and good health status was established, even in a context of high income inequality: "The finding of a significant association between primary care and self-rated health contributes to the mounting evidence that specific aspects of health services have an independent [of income levels] effect in improving population health—in particular, the beneficial effects of primary care" (Shi and Starfield 2000,). The authors suggest that, at least within the particular settings studied, strengthening the primary care aspects of health services could mitigate some of the adverse impacts that income inequality has on individuals' health status.
Primary-level services are also potentially responsive to patients' nonhealth needs. These include a need for the range and quality of health services to meet community expectations and a need for services to treat patients in a helpful and dignified manner. In addition, primary-level facilities can act as community resources (providing communal meeting places, for example), and primary care services can contribute support to neighborhood sports and community development activities. All in all, well-functioning primary-level services represent the face of the health system and have the potential to inspire trust in the system as a whole.
Another source of suspicion regarding the cost-effectiveness approach is the fear that efficiency concerns will override these positive features of primary care. Paalman and others (1998,) note that "the fact that the most efficient interventionstend to specifically benefit the poor is more a result of coincidence than of principle." Indeed, the cost-effectiveness approach does not intrinsically protect equity and could, for example, count against the extension of services to populations living in remote areas. Governments will, at times, need to make explicit choices between serving equity goals and responding to efficiency concerns when determining service priorities. This tradeoff is easier to manage in wealthier countries, where resources are less constrained.
