What it is
What others have done
What to ask
How to succeed

What is comprehensiveness and why is it important?

Comprehensiveness refers to the provision of holistic and appropriate care across a broad spectrum of health problems, age ranges, and treatment modalities. 3 4 5 Comprehensive care should address a wide range of preventive, promotive, chronic, behavioral, and rehabilitative services and include an assessment of a patient’s risks, needs, and preferences at the primary care level. 6 7 More comprehensive systems are associated with reduced spending, better patient experience of care, and reduced inpatient services utilization. 3 5  Comprehensive primary care systems are essential for the future of sustainable development and the delivery of high-quality primary health care for all. 8 9 Listed below are central questions and considerations stakeholders should consider when planning and implementing system reforms and interventions that prioritize comprehensiveness:

  • Comprehensiveness versus selective primary health care models: what's the difference and why does it matter?
  • In what ways can systems support comprehensiveness?
  • What policies, strategies, and infrastructure should be in place to support comprehensiveness? 

Comprehensiveness should be prioritized alongside first contact accessibility, continuity, coordination, and person-centeredness to improve high-quality primary health care delivery for all. 3 10

  • Many PHC services in LMICs are organized through vertical programs that selectively target a specific health condition as a result of the widespread implementation of the selective primary health care model by national governments and aid agencies. 9 11 With a disease-focused, selective model, selective primary health care emerged as an alternative approach or “interim strategy” to the comprehensive primary health care model (proposed at Alma Ata) that was considered by some to be too idealistic and expensive. 9 12

    There are several shortcomings to the selective approach, including a lack of emphasis on building sustainable and equitable health systems and infrastructure and the lack of integrated management of health conditions and health services that leads to redundancy and waste to overburden already fragile health systems. 9 13

    Consequently, selective primary care models fundamentally undermine the ability of health systems to achieve universal coverage to comprehensive high-quality primary health care services. 8 9 14 In order to effectively and equitably meet the health needs for all, countries must invest in the development of person-centered primary care systems that deliver comprehensive, coordinated, continuous services with primary care as the first point of contact. 15 System-wide action on the delivery of comprehensive, person-centered primary health care is essential for the future of sustainable development and achievement of universal health care. 8 9 16 17 More information on high-level policies, social accountability mechanisms, and quality management infrastructure to promote a system-wide commitment to high-quality primary health care are discussed in Governance and Leadership.

  • As put forth by the Astana Declaration, all individuals should enjoy the right to health - defined as a state of physical, mental, and social well being. In order to address the comprehensive needs of an individual - including the economic, social, and environmental determinants of health - services must be wide in scope and integrated across and beyond the health sector. 18 19 20 To promote universal access to high-quality comprehensive services, health systems should strive to facilitate coordination efforts that both enhance the capacity and infrastructure of primary care (such as through integrated health service delivery and multisectoral action discussed below) and empower individuals and communities to participate in health promotion. 18

    Integrated health services delivery

    Integrated health service delivery is an approach to strengthening people-centered health systems through the promotion of comprehensive, coordinated services across the continuum of care. 21 22 Integrated care models serve to adapt to the complex needs of individuals, their families and communities to promote the equitable delivery of services. 23 24 To meet the complex needs of people and strengthen integrated health service delivery, integrated care models deliver care through community-based coordinated multidisciplinary teams across sectors and levels of care. 8 21 25

    Integrated models that offer a more comprehensive set of skills and services at the frontline (including diagnostic, pharmaceutical, behavioral, rehabilitative services) can help to increase the efficiency and timeliness of primary health care 16 26 27 Integrated models help to promote continuity and coordination through the use of referral networks and strong health information technology systems that promote communication channels among levels of care. 28 29 30 More information on different models and approaches to integrated care can be found here and in the WHO Framework on Integrated, People-Centered Services.  

    In communities where it is difficult to access routine and reliable care, integrated care models that deliver comprehensive care during single point of care interactions may be particularly useful, especially for patients with complex conditions. Standardized and simplified guidelines and training materials that allow for task-shifting and referral networks between frontline workers and facilities help to equip multidisciplinary care teams with the competencies to provide higher quality comprehensive and coordinated care to low-resource communities that face limited opportunities for prevention, treatment, and management of diseases. 31 The WHO Integrated Management of Adolescent and Adult Illness modules and the WHO Package on Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Resource Settings offer important implementation plans for integrated care strategies (with emphasis on chronic diseases) with lessons on providing equitable, efficient, and cost-effective care through the provision of comprehensive services. Additionally, users can learn about integrated care in the case study about the Integrated Care Cascade in Malawi, included in the What Others Have Done section of comprehensiveness.

    Across all integrated care delivery models, it is imperative to engage strategies that are cost-effective and efficient in the use human, financial, and physical resources (especially for the discovery and management on complex conditions) and coordinated with the broader health system.

    Proactive comprehensive care: integrating public health and primary care

    One such model to promote comprehensive person-centered care integrates public health into primary care. 32 Leveraging the strengths of both primary care and public health holds the potential to increase efficiency gains and opportunities to combine available resources to a mutual benefit. 33 The WHO Technical Series on Primary Care outlines six models to achieve integration between public health and primary care. These models are adaptable to different health systems and can be implemented individually or in combination, listed below:

    • Public health professionals integrated into primary care
    • Public health services and primary care providers working together
    • Comprehensive and proactive benefit packages that include public health
    • Primary care services within public health settings
    • Building public health incentives into primary care
    • Multidisciplinary training of primary care staff in public health

    While not all of the five core functions of public health (surveillance, monitoring preparedness for response, health protection, health promotion, and disease prevention) can be fully integrated into primary care, there are considerable gains to be made for primary care to take on a more proactive role in contributing to public health interventions, especially in the realms of health promotion and disease prevention. 34

    Skilled Workforce

    As discussed in first-contact accessibility, there is a substantial global shortage of skilled health workers appropriately trained to deliver comprehensive care. 41 A workforce competent in comprehensive PHC (preventive, promotive, chronic, behavioral, and rehabilitative) must exist and be appropriately distributed both in quantity and cadre as a precondition for ensuring universal access to high quality and comprehensive services. Presence of poorly trained staff in some cases may be worse than no staff at all. When a patient of any type shows up to a PHC facility, there needs to be: a facility with minimum equipment, methods, and medications to diagnose and treat a wide range of problem (especially those most common the local community), staff who are skilled at diagnosing and managing a broad spectrum of problems (including patients with multiple problems i.e. multi-morbidities) and providing preventive services, and a referral system that can effectively transfer care or solicit expert support (i.e. specialists) in managing the small number of problems that fall out of scope of what primary care can manage. Strategies for strengthening the health workforce will be discussed in more detail in the Workforce module. The case study on Malawi’s Integrated Care Cascade in the what others have done section of comprehensiveness showcases one innovative approach to addressing the complex burden of disease in the primary care setting through integrated care models and diverse care teams. Stakeholders can find more information on looking to skill-mix (assembling a diverse team of providers) as a potential solution to overcoming workforce shortages and providing high-quality care in the Team-Based Care Organization module and the World Health Organization’s Global strategy on human resources for health: workforce 2030 report.

    Multisectoral engagement and social accountability

    As a part of building comprehensive primary care systems, it is essential for primary care services to meet the complex needs and demands of the entire population. Intersectoral action in health promotes comprehensiveness by engaging other services and sectors, directly and indirectly, involved in the health of people and communities across the continuum of sectors engaged in primary health care delivery. (9,35–37) Multisectoral and intersectoral collaboration help to contribute to more comprehensive policies by taking on a systematic approach to the promotion of health and well-being a priority across sectors. 37 Stakeholders can access more information on the design of multi and intersectoral policies for overall health and well-being and sustainable development in the WHO Health in All Policies Framework.  The accompanying Health in all Policies Training manual offers comprehensive training materials to facilitate the engagement and implementation of the HiAP approach across sectors.

    To foster productive partnerships and actionable policies, strong political-commitment and mechanisms for social accountability must be in place. 38 Encouraging broader social participation in the policy process (such as citizen groups and media platforms) helps to strengthen accountability across sectors and forge collaborative partnerships for comprehensive initiatives. 37 More information on multi and intersectoral engagement and social accountability can be found in the WHO report on multi-sectoral and intersectoral action for health and well-being for all and in the Social Accountability module.

  • Comprehensive community-based policy drivers

    Comprehensive primary health care is supported by policies and infrastructure that promote integrated service delivery, local priority setting, and the skills and capacity of a workforce to provide a comprehensive set of services. (9,15,17,39) The EBAIS teams in Costa Rica offer one example of leveraging community-based approaches to simultaneously meet comprehensive social and primary health needs. The Costa Rican community-oriented team-based model of primary care delivery combines preventive and curative care to provide comprehensive primary health to all. More information on the Costa Rican model can be found in the report: Building a Thriving Primary Health Care System: The Story of Costa Rica.

    Frameworks and strategies for the development of high-quality primary health care policies and infrastructure are discussed in greater depth in Governance and Leadership.

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.​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

What has been done elsewhere to improve comprehensiveness?

  • Like many LMICs, Malawi faces a dual burden of communicable and noncommunicable diseases. 40 The population in the Neno District, an extremely rural district in Southern Malawi heavily reliant on subsistence farming, 41 42 face significant geographic and financial barriers to accessing high-quality comprehensive health care. While there are care systems in place - a district hospital, community hospital, and 12 health centers - these systems are marked by a disproportionate allocation of funding and staff to HIV care despite the rising burden of NCDs. As an integrated strategy to address the complex burden of disease and promote more efficient use of financial and human resources, 43 44 Malawi worked with Partners in Health to leverage the success of the HIV program to improve NCD outcomes. The Integrated Care Cascade is an integrated care management model that integrates HIV and NCD screening and treatment through a coordinated care and referral network between households, communities, and facilities. 45

    As a strategy to increase case finding and provide decentralized access to high-quality care, individuals may undergo either community-based or facility-based screening for HIV, diabetes, hypertension, TB, malnutrition, and family planning needs depending on their mode of entry to the Integrated Care Cascade. At the community level, individuals in remote communities would be screened by a mobile team or a community health worker and at the facility level, outpatients would be screened at the facility before seeing a clinician. From this point, all patients who screen positive for conditions would receive treatment and additional health screening at an Integrated Chronic Care Clinic (IC3) by a centralized clinical team. In efforts to retain patients and promote continuity in rural and remote areas, every household is assigned a community health worker who provides ongoing psychosocial support and supports staff members in making home visits to follow-up on missed appointments and incomplete referrals. (43) While the Integrated Care Cascade is still undergoing rollout, the person-centered approach at the core this strategy is an important example of how to use integrated models to work toward universal coverage of high-quality comprehensive care.

  • In 2006, the release of the document The Future of Children is Always Today highlighted widespread conditions of poverty in Chile and its detrimental effects of childhood development. The Presidential Advisory Council for Child Policy Reform, a multidisciplinary political body established in 2006, drew at length from this foundational document to design and implement Chile Creece Contingo (ChCC), a multisectoral public policy addressing the comprehensive nature of childhood development. 46 Through vertical and horizontal coordination mechanisms at the national, local, and communal level, ChCC synergizes the existing structures of Chile’s health, education, and social development sectors to expand the reach of the system and scope of activities. What emerged has evolved into a comprehensive, intersectoral, and multicomponent system of social development to help individuals reach their full potential, regardless of socioeconomic status.

    ChCC coordinates existing interdependent services and resources across sectors to deliver services at the local level in each of Chile’s 345 communes. The implementation of ChCC is flexible based on the characteristics of the local context, exercising local priority setting strategies to best meet the complex needs of individuals and communities. To make use of the usual points of contact and minimize the creation of new institutions, ChCC established the local health system as the public’s gateway to services and support, where over 80% of children were already being treated and born. Support is provided by a network of intersectoral teams with clearly defined roles, who can leverage upon the expanded referral network of regional and national agencies for additional support and resources. Teams are supported by an information system that captures the developmental history of a child from birth to allow for intersectoral communication and collaboration regarding the use of relevant services and support across sectors. 46

    The successes of ChCC serve as an important demonstration of the value of leveraging intersectoral action and community-engagement to achieve the delivery of high-quality comprehensive person-centered services and the realization of the Sustainable Development Goals. Four major contributors to the ongoing success of ChCC hold important lessons for strengthening primary care systems: 1) person-centered design, demonstrated by the focus on the local delivery of services and the social determinants of health, 2) sustainability, exhibiting through the emphasis on leveraging the strengths of existing frameworks and institutions to reduce service overlap and consolidate resources, 3) high-level political commitment, demonstrated by the establishment of a governing body to coordinate and the implement performance assessment measures (including monitoring and evaluation systems), and 4) the creation of a state budget established by law, to reinforce the continuity of the policy through ongoing financial commitment.

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.​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

What questions should be considered to begin improvements?

The questions below may be a useful starting place for determining whether Comprehensiveness is an appropriate area of focus for a given context and how one might begin to plan and enact reforms:

When patients access care in facilities, are they able to receive services for a comprehensive set of needs during a single visit?

Comprehensive care should address a wide range of preventive, promotive, chronic, behavioral, and rehabilitative services and include an assessment of a patient’s risks, needs, and preferences at the primary care level. In communities where it is difficult to access routine and reliable care, integrated care models that offer comprehensive care during a single visit may be particularly useful, especially for patients with complex conditions. Integrated, comprehensive services will reduce the need for multiple visits and may promote continuity and coordination as well.

If multidisciplinary teams are in place, are they managed in such a way that providers can contribute their unique expertise to deliver comprehensive care?

Teams with a diverse set of skills and knowledge are thought to be beneficial for complex tasks, better decisions, more creative solutions, and cross-disciplinary information sharing to foster more comprehensive care. Standardized and simplified guidelines and training materials that allow for task-shifting and referral networks between frontline workers and facilities help to equip multidisciplinary care teams with the competencies to provide higher quality comprehensive and coordinated care to low-resource communities that face limited opportunities for prevention, treatment, and management of diseases.

Which (if any) of the five functions of public health (surveillance, monitoring preparedness for response, health protection, health promotion, and disease prevention) are integrated into primary health care?

Integrating the strengths of both primary care and public health holds the potential to increase efficiency gains and opportunities to combine available resources to a mutual benefit. While not all of the five core functions of public health can be fully integrated into primary care, there are considerable gains to be made for primary care to take a proactive role in contributing to public health interventions, especially in the realms of health promotion and disease prevention.

What processes are in place to ensure that the primary health care system benefits from multisectoral engagement and social accountability?

As a part of building comprehensive primary care systems, it is essential for primary care services to meet the complex needs and demands of the entire population. Intersectoral action in health promotes comprehensiveness by engaging other services and sectors directly and indirectly involved in the health of people and communities across the continuum of sectors engaged in primary health care delivery. Multisectoral and intersectoral collaboration help to contribute to more comprehensive policies by taking on a systematic approach to the promotion of health and well-being a priority across sectors. To foster productive partnerships and actionable policies, strong political commitment and mechanisms for social accountability must be in place. Encouraging broader social participation in the policy process (such as citizen groups and media platforms) helps to strengthen accountability across sectors and forge collaborative partnerships for comprehensive initiatives.

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.​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

What elements should be in place to support effective improvements?

In order for interventions aimed at improving Comprehensivemess to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously:

  • Comprehensive primary health care is supported by policies and infrastructure that facilitate integrated service delivery, local priority setting, and the skills and infrastructure necessary to strengthen the capacity of a workforce to provide a comprehensive set of services at the frontline. 9 15 17 39 Policies should cut across sectors and levels of care to facilitate a system-wide commitment to the delivery of comprehensive, person-centered primary health care.

    Learn more in the Primary Health Care Policies Improvement Strategies module.

  • Priority setting at the national level should engage actors from multiple levels of the health system to reinforce a system-wide commitment to comprehensive primary health care and the concomitant investment in physical, technical, and human resources to equip local actors with the tools to achieve health gains in their communities. Effective priority setting involves assessing existing and emerging health needs (see A3.a: Surveillance), funding programs, communicating decisions, and managing feedback from stakeholders at national, regional, and local levels within the context of a country’s needs and values. 47 Local priority setting should translate national priorities into strategic action plans that respond to the needs and preferences of the population at the local level by engaging community actors to deliver comprehensive person-centered services.

    Learn more in the Priority Setting and Local Priority Setting Improvement Strategies modules.

  • In order to effectively deliver a comprehensive set of services, a skilled, diverse, and motivated workforce must be consistently available at the frontline of service delivery. Multidisciplinary care teams that are well-managed and well-communicated to patients can help to support primary care practices to deliver comprehensive services that meet the complex needs of populations. To achieve this, multidisciplinary teams should be skilled to provide high quality comprehensive and coordinated care to low-resource communities that face limited opportunities for prevention, treatment, and management of diseases.

    Learn more in the Workforce, Provider Availability, Provider Competence, and Team-Based Care Organization Improvement Strategies modules.

  • In order to provide care that addresses a wide range of preventive, promotive, chronic, behavioral, and rehabilitative needs across a broad spectrum of health problems, age ranges, and treatment modalities, primary care facilities and the frontline workforce must be equipped with essential equipment and supplies, including essential medicines, vaccines, and diagnostic equipment.

    Learn more in the Drugs and Supplies Improvement Strategies module.

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.​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

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How to use this Model

Brief Overview
Each section includes core principles and relevant background on the topic to help stakeholders understand how this topic relates to other parts of the health system and how to begin improvements.

In-depth exploration
Each section links to various external resources including research papers, toolkits, and implementation guides for readers who would like to learn more.

Diagnostic 
Countries that have a Vital Signs Profile can use it to identify gaps in their performance and find improvement strategies that are specifically relevant to their context. 

Sharing experience and learning from others 
Throughout the model, there are case studies that provide examples of how other countries have implemented reforms and the factors that supported implementation. Additionally, if you think others can learn from improvements in your country, you can submit your experience using the "share your experience" tab. 

Learn more in the Improvement Strategies user guide.