High-Quality Primary Health Care

The following principles should be prioritized simultaneously to improve the design of health systems that promote high-quality primary health care.

Person-centered care

While there are many supply-side considerations for first contact access at the system and organizational-level, services that are acceptable (trusted and of-value) from the patient perspective will make it more likely that patients will seek services. Person-centeredness is an important function for improving the capacity of PHC systems to deliver services that are trusted and valued by patients. Person-centered health-systems engage people as equal partners in promoting and maintaining their health in a way that integrates the existing cultural context such as attitudes, beliefs, and concerns. However, in order to be empowered users of the health system, patients must have the ability to make informed decisions and participate in their own care. While there are varying degrees of improvements to be made to achieve person-centered health systems to the fullest extent, a minimum level of acceptability (trust and value placed in the system) must be in place for primary health care to be utilized as the first point of contact.

Primary health care as the first point of contact

The capacity of PHC to effectively serve as the first point of contact hinges on the consistent delivery of high-quality comprehensive care that is trusted and valued by users. However, comprehensive care will not in itself translate to better health outcomes if it is not utilized as first contact care. In order for patients to receive high-quality primary health care, primary care facilities must be both accessible, (facilities are physically present and accessible to populations in terms of geographic proximity, cost, and convenient hours of operation and waiting times) and acceptable (trusted and valued by users). From the system level, this is influenced by the creation and enforcement of national standards and guidelines (across private and public sectors), the skill and motivation of the primary health care workforce, and the availability of inputs, infrastructure, and information systems. From the patient-perspective, utilization is influenced by contextual factors at the individual and local level, including social and cultural norms and beliefs and decision-making capacity. With these foundational elements in place, service delivery activities, such as empanelment and proactive population outreach, help to facilitate primary care as the first point of contact and enable coordination across the continuum of care.

Integrated care delivery systems

To best meet the complex needs and preferences of populations, primary health care services should be comprehensive. Integrated health service delivery is an approach to strengthening person-centered health systems through the delivery of comprehensive services, coordinated around the needs and preferences of a person throughout their life course and care settings.¹³¹⁴ Integrated models that offer a more comprehensive set of skills and services at the frontline (including diagnostic, pharmaceutical, behavioral, and rehabilitative services) can help to increase the efficiency and timeliness of primary health care, increasing the capacity of primary care to serve as the first point of contact.¹⁵¹⁶¹⁷ Integrated models are strengthened by the use of referral networks and interoperable information systems that promote bi-directional communication channels.¹⁸¹⁹²⁰

This subdomain focuses on the delivery of high-quality primary health care from the perspective of both the user and the system. High-quality primary health care is an outcome within Service Delivery - these functions of PHC are often a result of various elements within System, Inputs, and other components of Service Delivery. The framework below calls for a fundamental shift in the way health services are funded, managed, and delivered to promote universal access to high-quality person-centered care. The framework is adaptable to all countries and health systems.

WHO Framework on integrated people-centered health services

The WHO Framework on Integrated People-Centered Health Services proposes five interdependent strategies for the development of responsive people-centered health systems that deliver high-quality, safe, and acceptable services for all. The below strategies are synergistic, a lack of progress in one area may undermine progress in another.

• Empowering and engaging people and communities - This strategy aims to empower individuals (including underserved and marginalized groups) with the opportunities, skills, and resources to make decisions about their own health and be empowered and engaged users of quality health services. It aims to enable communities to be actively engaged in co-producing healthy environments for individuals and be capacitated to delivery informal care that improves the health of communities (training and networks for community health workers, social participation, community delivered care).
• Strengthening governance and accountability - This strategy aims to strengthen governance using a participatory approach to policy formulation, decision-making, and performance evaluation at all levels of the health system. To reinforce good governance, a robust system for mutual accountability across stakeholders and a people-centered incentives system should be in place.
• Reorienting the model of care - This strategy calls for a people-centered approach to primary health care for the design and delivery of efficient and effective services that are holistic, comprehensive, and sensitive to social and cultural needs and preferences.
• Coordinating services within and across sectors - This strategy leverages multisectoral and intersectoral partnerships and the integration of health providers within and across settings and levels of care to promote care coordination. Coordination focuses on improving the delivery of care to better respond to the needs and demands of people.
• Creating an enabling environment - This strategy involves creating an enabling environment to bring all stakeholders together to transform all of these strategies into an operational reality. In order to effect change, this task involves a diverse set of processes in the domains of leadership and management, information systems, quality improvement methods, workforce development, legislative and policy frameworks, and health financing and incentives.

The policies and interventions that stakeholders adopt to achieve the realization of these strategies are context-specific, and as such will need to be developed according to the local context, values, and preferences of the country at the national, regional, and local level. An integrated people-centered approach to service delivery is essential for the achievement of five elements fundamental to universal health coverage:

• Equity in access - Everyone has access to the quality services they need everywhere, every time.
• Quality - Care is safe, effective, timely, and responsive to a comprehensive set of needs at the highest possible standard.
• Responsiveness and participation - Care is coordinated around people’s needs and preferences and engages people as equal partners in their health affairs.
• Efficiency - Services are cost-effective and achieve an optimal balance of health promotion and in-and-out patient care to avoid duplication and waste of resources.
• Resilience - Health actors, institutions, and populations are capacitated to prepare for and effectively respond to public health crises.

More information on the Framework on integrated, people-centered approach, including the implementation approach and the role of stakeholders, can be accessed here.