Croakey has been hosting a discussion about the difference between primary care and primary health care, and why this matters. Gordon Gregory of the National Rural Health Alliance kicked off the conversation here, and then a whole stack of experts chimed in here.
Now Denise Fry, who has longstanding experience in primary health care and health promotion, concludes the series by reminding us of some history, which appears to be in danger of being forgotten.
“What’s in a name? Romeo and Juliet may have been too pre-occupied with other matters to worry about language, but names generally matter a lot to people. Robust discussion over names and their meanings tends to indicate the argument is about values as well as ideas.
The ‘primary health care’ versus ‘primary care’ debate is a good example. It has been a contested debate, reflecting differing professions, perspectives and values. It is also a debate with a history at risk of being forgotten.
Primary health care –an Australian definition
Primary health care seeks to extend the first level of the health system beyond sick care to the development of health. It aims to focus on the health system’s first level of contact on protecting and promoting the health of defined communities, and on addressing their individual and collective health problems at an early stage.
In 1988 the above definition of primary health care was developed as part of the Health for All Australians Report by the Health Targets and Implementation Committee for the Commonwealth Government. In that decade the term ‘primary health care’ was used by many Australian researchers and practitioners, particularly in community health centres, who were part of a movement for health reform influenced by the work of the World Health Organisation.
Some meanings and interpretations of this definition of primary health care are discussed in more detail in F Baum, The New Public Health: an Australian Perspective (Oxford UP, 2008), and in F Baum, D Fry and I Lennie (eds), Community Health: Policy and Practice in Australia (Pluto Press, 1992).
The World Health Organisation and primary health care
‘Primary health care’ as a term was given currency by the World Health Organisation (WHO). The addition of ‘health’ to ‘primary care’ signaled an extension of the scope of the health task – from a focus on care for the already sick to the creation of the conditions for health.
In 1977 the Alma Ata Declaration on Primary Health Care was released by the WHO. In response to health inequalities within and between nations, the WHO made the development of primary health care systems central to its Health For All by the Year 2000 Strategy.
The Alma Ata Declaration defined primary health care in two, interdependent ways: as a focus on the first level of service delivery, and as a particular approach to health care, characterised by five key principles:
- Equitable distribution of resources
- Community involvement
- Emphasis on prevention
- Use of appropriate technology
- Working with other sectors (for instance, housing, water supply, education).
The WHO definition of and approach to primary health care implied significant changes were needed in the delivery of health care in many countries if health for all was to become a reality. Primary health care would need to be available to all, without barriers of cost and/or eligibility, and multi-disciplinary teams would need to work collaboratively to address physical, social and environmental aspects of health problems and social development.
What does ‘primary’ mean? – it all depends….
Not surprisingly, there were many responses to the WHO approach. ‘Primary’ can have multiple meanings. It can mean one and/or all of the following:
- First – as in the first place people go to seek help
- Early stage- as in the actions that are needed to avoid health problems, or in early detection and/or early intervention of health problems
- Basic –as in care that is accessible and affordable for people, and that deals with their main health problems
- Essential – as in the foundation for the rest of the health system
- Fundamental – as in affecting the major factors that determine health at individual and population levels.
What about ‘primary care’?
When the term ‘primary care’ is used, the kind of primary care is not described or specified. This implies a presumed understanding of the content and approach of this care, so no adjective is needed. When they use this term, most people are describing a quite specific type of care, usually primary medical care or general (medical) practice.
In Australia, most general practices are private practices, with access to and cost of services mediated by Medicare, the national health insurance system. General practices are focused on medical care for individuals, with some components of early detection/intervention and health information. By and large, the scope of their activity is shaped by their fee for service structure and their biomedical orientation. This is why I prefer the more explicit and descriptive term ’primary medical care’ rather than ‘primary care’ for these services.
I see primary medical care as an essential part of primary health care, but not the whole story. As primary medical care services have little capacity to prevent ill-health at a community or population level, or to create the conditions for health, different approaches are needed for these different tasks.
The use of ‘primary health care’ by some in Australia to describe primary medical care and/or the addition of some non-medical health professionals to a general practice structure is a fairly recent phenomenon. Perhaps those using ‘primary health care’ in this context are unaware of its history, its broader scope and how its concepts and values have been applied practically in Australia and internationally.
For me, the terms primary medical care and primary health care express related but differing concepts and values. We humans use names to describe and differentiate – there is meaning in this method.”
* Denise Fry has worked in primary health care and health promotion at local, state and national levels. From 1987-1997 she worked for the Australian Community Health Association, a national advocacy body for community health services.