Demand creation - trust and acceptability
In establishing primary care as the first point of contact with the health system, stakeholders should consider both the supply-side characteristics of the primary health care system and the demand-side drivers within the target population. 2 44 45 46 47 Scale up of primary care, the process of expanding and broadening the coverage of primary care service delivery to increase health impacts, is an important step toward establishing primary care as the first point of contact for all. 47 However, improving access to primary care through universal health coverage is not enough to achieve health impacts. 34 To gain public support for primary care as the first point of contact, the services provided by the system must effectively meet the needs and expectations of the public. 48 If services are not of high-quality (safe, effective, patient-centered and delivered in a timely fashion), patients often elect to seek care elsewhere. 47 48 49 50 This care seeking behavior reflects a lack of public trust in the primary care system to effectively meet their expectations and needs. 48 Three key mechanisms influence a user’s choice to seek care: trust, risk awareness, and acceptability. 51
- Trust: Trust exists at both the local and systems level. Patients must trust their local providers, facility, and the broader system to provide high-quality, equitable services. 48 49 50 51 In order to increase patient perception of the quality and value of primary care, services must be accessible (minimal direct opportunity costs, made aware to patients) and acceptable to meet the diverse needs of communities. (4,44,46,47,52–58)
- Risk-awareness: Patients must be aware of their general health and risks associated with their condition to seek appropriate care. Providers must competently deliver appropriate and acceptable care and increase patient awareness through proactive outreach. 51
- Acceptability: Acceptability involves the interaction between a service or provider and the socio-cultural processes (context, interactions, and expectations) of users and communities. These processes influence an individual’s ability and choice to judge a service as appropriate and seek care. 44 To ensure acceptability, stakeholders must strive to find a good fit between the characteristics of providers of health services and characteristics and expectations of clients. 44 59 To promote trust and increase value and acceptability, services should be person-centered and oriented toward community needs in a way that integrates the existing cultural context such as attitudes, beliefs, and concerns. 44 60 61
It is important to note the complex nature of choice in relation to care-seeking behavior and the effect of contextual factors in promoting or inhibiting a user’s ability to seek care. Structural, local, and individual contextual elements influence both a user's ability and choice to seek care including: 51
- At the individual level: Contexts triggering or inhibiting a user’s care seeking behavior relate to the availability of and control over financial resources (direct and indirect costs such as user fees or transportation), users’ perceptions of care quality and the value of services, and their social network within their communities and with service providers that may increase their access to resources as well as trust in providers, respectively.
- At the local level: Contexts triggering or inhibiting a user’s care seeking behavior at the local level involve the characteristics, including social and cultural norms and beliefs, of both the user and the provider/facility. Discrepancies between the social and cultural norms of users and their communities and those of health services (i.e traditional care practice preferences versus allopathic) may limit users’ choice. In addition, geographic local factors including the proximity of health facilities and availability of reliable and timely transportation influence care seeking behavior.
- At the structural level: Contexts triggering or inhibiting a user’s care-seeking behavior at the structural level involve the governance and organization of the health system and healthy policy values and principles (information and monitoring systems, financing and incentive mechanisms, human resource training interventions etc.) which in turn influence local and individual factors at the point of delivery to achieve the intended outcomes.
In order to be empowered users of the health system, users must be capable of making strategic life choices and health systems must be equipped to provide equitable, high-quality services. 48 62 More information on the interactive process between a health system and its target population and ways to expand coverage can be found in the Tanahashi Framework within the Tools & Frameworks subdomain of Access. Drivers for demand creation are discussed in The Rapid Routes to Scale report on Scaling up Primary Care to Improve Health in Low and Middle Income Countries.
Quality is central to the scale up of equitable health systems with primary care as the preferred first point of contact. Health systems that have improved quality and reduced access barriers (removing out-of-pocket payments, improving facility structure and equipment, better training health workers, and implementing clinical programs) have seen increased rates of utilization of primary health care facilities. 50 More information on the role of quality in health systems strengthening is discussed in the WHO Handbook for National Quality Policy and Strategy. It is important to link such efforts for first contact accessibility with greater coordination and integration efforts in the primary health care system to enable comprehensive, person-centered care. 54 63
Three pivotal reports describe the essential role of quality in the delivery of health care services for all. These include the documents:
- Delivering quality health services: a global imperative for universal health coverage, prepared jointly by the World Health Organization, The Organization for Economic Cooperation and Development, and the World Bank.
- High-quality health systems in the Sustainable Development Goals era: time for a revolution, prepared by the Lancet Global Health Commission on High-Quality Health Systems in the SDG Era, and the National Academy report.
- Crossing the global quality chasm: improving health care worldwide, prepared by the National Academies of Science, Engineering, and Medicine.
Achieving high-quality health systems requires a universal vision for quality within and beyond the health sector, system-wide commitment to service redesign to maximize quality, a transformation of the health workforce, and empowered societies to hold systems accountable to the delivery of high-quality care. 64
Community empowerment and participation are essential to ensure acceptability and motivate wider uptake of primary health care services. (4,47,52,54–58) Community engagement, such as through local health promotion and community mobilization campaigns, helps to build trust and awareness when used as a lever to tailor services to population needs and values. 47 54 Community engagement in the design, planning, governance, and delivery of health care services is essential to ensure that these services appropriately meet the needs of the people they are designed to serve. Central considerations for planning community engagement are addressed in greater depth in Population Health Management.
From the demand side, community engagement is a key strategy for providing people with the opportunity, skills, and resources to be empowered users of the health system 65 Patients must have the ability to perceive, seek, reach, pay, and engage with services to promote care-seeking from the demand side, involving factors such as health literacy, individual rights, personal mobility, available income, and decision-making capacity. 44 Here are some ways primary health care systems could better cater to these five abilities through community engagement:
- Ability to perceive: health literacy and education campaigns 14
- Ability to seek: education about options and individual rights
- Ability to reach:
- Ability to pay:
- Ability to engage:
As discussed in the above section, In what ways might primary care not be functioning as the first point of contact?, in order for primary care systems to effectively serve as the first point of contact, services must be accessible and sufficiently staffed by a qualified health workforce, taking into account the contextual realities of a population. This is influenced in part by decisions made in the allocation of resources, equity, and investments into infrastructure. More information on addressing the geographic-challenges to high-quality primary health care delivery is found in Geographic Access.
Additional Service Delivery Activities
Empanelment is an important population health management strategy for promoting primary care as the first point of contact in a health system. Empanelment is the active and ongoing assignment of an individual or family to a primary care provider (doctor, nurse, or other clinical provider) and/or care team for the provision of primary health care. It is the organizational foundation for population health management. 15 In addition to providing logistical structure and clarity to patients, empanelment can enable a patient-centered model of care where providers assume proactive responsibility for their panel, regardless of whether or not patients visit the facility. Empanelment establishes a point of care for individuals and simultaneously holds providers and care teams accountable for actively managing care for an enumerated panel of individuals. There are three methods for establishing panels: geographic, voluntary, and insurance-based. 15 Establishing panels based on pre-established geographic or municipal boundaries may help stakeholders understand where and why certain groups are experiencing geographic barriers to care and begin the process of developing infrastructure to remedy these gaps. Thus, while empanelment itself will not relieve geographic barriers, the structure may be a useful starting point for establishing community-based care and ensuring that all community members are under the purview of a provider to promote first contact accessibility. Find more information in the empanelment module here.
Gatekeeper systems help to facilitate primary care as the first point of contact and promote continuous, accessible, and coordinated care within a panel. In an “explicit” gatekeeper model, patients can only receive care from secondary or tertiary facilities if they first seek an approved referral from their primary care provider. In this way, primary care serves as the entry point to the health system and improves first contact accessibility. By contrast, “implicit” gatekeeping occurs if patients are encouraged but not required to visit their primary care provider before seeking secondary or tertiary care. 15 Gatekeeper systems can help reduce over-utilization of higher levels of care while ensuring that primary care providers are aware of all of the health needs of their panel, even when they must be addressed by specialists. This can improve coordination and continuity of care. However, gatekeeper models can limit access to needed specialty care if the system is not well-planned.
Gatekeeping is only effective if the following elements are in place: clear communication of patient panels; trust and respect between patients and providers; timely appointment availability at primary and specialty care facilities; effective referral systems, including communication between levels of care; and geographically and financially available primary and specialty care services. Reorienting a health system to actively manage the care of a panel of patients often requires a conceptual shift for all providers involved. In order to facilitate this change, facilities must have strong and engaged leadership and managers who can communicate the goals of empanelment and guide employees through new systems or processes. 16 Leadership qualities are discussed in greater detail in the facility organization and management Improvement Strategies module.
Proactive population outreach
Certain health activities can be effectively delivered directly in communities, decreasing geographic barriers to care. Some of these services include: diagnosis, referral, and treatment of certain illnesses; health education; identification of at-risk individuals or families; counseling and/or provision of family planning; and immunization. 17 While these services are not fully comprehensive, they cover basic health needs that may be neglected if individuals are unable to easily access a facility, and preventive and promotive care may effectively decrease the need for some curative care services. Additionally, many of these services can be provided by community health workers (CHW) who can be trained for targeted service provision, in a cost- and time-efficient manner. Community-based care is an effective strategy for increasing access to primary care services and improve first contact accessibility, particularly in areas with low population densities where it is not cost-effective to build and staff facilities. Proactive population outreach may also improve timeliness and provider workload in facilities; patients no longer have to visit facilities for certain health services, freeing appointment time for services that must be provided in facilities. Decreased wait times may improve patient preference for primary care services. 8 9 Find more information on strategies in the Proactive Population Outreach module here and through case study examples in the What Others Have Done section of First Contact Accessibility.
Electronic health or mobile health (collectively described as e-health here) can facilitate access to care in areas where clinics are inaccessible but sufficient technological infrastructure is in place. A review of e-health in LMIC by the Center for Health Market Innovations found that 42% of programs using information communication aim to extend geographic access to health. 18 Using computers and phones, patients and providers may access telemedicine video conferencing or receive consultations via helplines or text messaging. These services are not exclusive to primary care and can also be used to strengthen access to specialty care (see ECHO below). The following costs must be considered for budgeting at the outset of health programs as embedded costs in any program as well as continuing costs after implementation:
- Capital expenditures for hardware at both the facility level (i.e. computers, phones, wiring) and regional/national level (i.e. central services connectivity hardware)
- Ongoing maintenance costs for hardware
- Staffing for technical assistance and maintenance
An important consideration is the sustainability of these programs; 47% of the programs identified in the Center for Health Market Innovations review were donor-funded. 18 Additionally, often free platforms do not generate sufficient profits to sustain the programs, making them less reliable. As with any intervention dependent upon technology, implementers must consider learning curves and technological literacy, language barriers for any automated systems, and access to infrastructure for this technology. 19 Finally, when implementing electronic health interventions, it is important to consider if there are regulatory frameworks in place to govern how clinical care is provided. Find more information in the information systems use module.
Transportation can pose a barrier to first contact access if patients do not have access to vehicles or if available vehicles are too costly or not appropriate for the terrain. Additionally, transportation barriers may occur when primary care facility refer patients to higher level facilities. Most interventions intended to ease transportation barriers focus on antenatal care and delivery in an effort to increase facility-based births and promote practices that can prevent maternal and neonatal mortality. 20
As discussed in financial access, transportation vouchers may be a solution when cost is the primary barrier. In situations where there are no available transportation vendors regardless of cost, a multi-faceted intervention may be required. Facilities can work with community members to procure and stock vehicles (these may range from ambulances to motorcycles or carts). However, these transportation systems must be coupled with adequate means of communication so patients can access vehicles and drivers when needed.
It is important to reiterate that transportation to care is only one potential barrier to receiving the right care at the right place at the right time. Aligning with the WHO’s three components of emergency care, patients often face delays in seeking care, reaching care, and receiving care once at a facility. 21 Transportation interventions can only address the second delay and must be coupled with appropriate education on when and how patients can seek care as well as high-quality services at the point of care. (20) Some examples of transportation interventions are discussed in what others have done.