Primary health care: an international perspective

Five years have passed since the Alma Ata meeting, and with 17 years remaining in this century, one has to ponder whether the goal of health for all by the year 2000 through primary health care is achievable. This article explores the general situation of health and primary health care, especially in the developing world, where health problems are more acute. The slogan "health for all by the year 2000" has succeeded in creating an awareness of the problems throughout the world. The path toward this goal is not necessarily smooth or paved. Nevertheless, with goodwill and planned actions it can be achieved, though not necessarily by all nations or by the year 2000. This is the biggest challenge facing nations, professionals, international health organizations, and humanity. To achieve this goal they will need to improve and better use national resources, both physical and human. Developing physical resources entails comprehensive and integrated socioeconomic growth, improved health budgeting with multisectorial programming, the use of appropriate technology, and the adoption of scientific managerial processes; but what is even more important is the development of human resources at all levels.     

Primary care in Minnesota: an academic health center's perspective

Although Minnesota's overall supply of primary care physicians is as good as or better than that of many other states, Minnesotans in some rural and urban communities do not have ready access to primary care. Simply training more doctors using the current model is not a viable solution to this problem. In order to increase the supply of primary care physicians, the state, its educational institutions, and its health care provider organizations will need to develop new educational opportunities, explore new models of care, and create viable systems for health care delivery for all Minnesotans. This article describes the current status of primary care in the state and ideas for addressing anticipated workforce shortages and enhancin the vitality of primary care.     

Association between fee-for-service expenditures and morbidity burden in primary care

Background

In primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined.

Objectives

To examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures.

Methods

We applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics.

Results

Out of the individual expenditures, 31.6 % were explained by age, gender and RUB, and around 18 % were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0–RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44 %; 3.8–9.4 % of the variation in expenditures was related to the GP clinic in which the patient was treated.

Conclusions

Morbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.     

The health-illness process and health care from the perspective of child care providers

This article presents a case study of a public daycare center for low-income children in the city of S?o Paulo. Anthropological analysis focused on the organization and use of space, daily care, and rules of hygiene, reflecting values used by adults to organize social reality.     

Primary health care in a multi-level perspective: towards a research agenda

The authors propose to view primary health care (PHC) from a multi-level perspective. Studying how PHC is conceived and implemented at different levels of social organization (e.g. in international agencies, national governments, regional centres of health care and local communities) will reveal which interests may be competing in the planning and execution of what broadly and conveniently is called 'PHC'. Mapping out these conflicting views and interests will contribute towards a better understanding of how PHC works or why it does not work and provide suggestions for a more effective and equitable PHC. Five themes are proposed for a multi-level research approach: (1) vertical versus horizontal organization of PHC: (2) the role of medical personnel in PHC; (3) the distribution of pharmaceuticals; (4) the integration of traditional medicine in PHC; and (5) family planning.     

Indicators without a cause. Reflections on the development and use of indicators in health care from a public health perspective.

Indicators have a long history in public health. Since the end of the 18th century information on the health of communities has been gathered on a health system level and public health indicators have become more sophisticated over the vears. However, in many modern health care systems there is a separation between public health and health services. This paper discusses the need for integration and promotes a stronger public health orientation of health services. This has consequences for the nature of indicators on the health services level. The methodological problems of turning epidemiological data into management information for health services are discussed. The key message is that the health of the community should be the ultimate cause of all indicators.     

Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide

PURPOSE

Many patients consulting in primary care have multiple conditions (multimorbidity). Aims of this review were to identify measures of multimorbidity and morbidity burden suitable for use in research in primary care and community populations, and to investigate their validity in relation to anticipated associations with patient characteristics, process measures, and health outcomes.

METHODS

Studies were identified using searches in MEDLINE and EMBASE from inception to December 2009 and bibliographies.

RESULTS

Included were 194 articles describing 17 different measures. Commonly used measures included disease counts (n = 98), Chronic Disease Score (CDS)/RxRisk (n = 17), Adjusted Clinical Groups (ACG) System (n = 25), the Charlson index (n = 38), the Cumulative Index Illness Rating Scale (CIRS; n = 10) and the Duke Severity of Illness Checklist (DUSOI; n = 6). Studies that compared measures suggest their predictive validity for the same outcome differs only slightly. Evidence is strongest for the ACG System, Charlson index, or disease counts in relation to care utilization; for the ACG System in relation to costs; for Charlson index in relation to mortality; and for disease counts or Charlson index in relation to quality of life. Simple counts of diseases or medications perform almost as well as complex measures in predicting most outcomes. Combining measures can improve validity.

CONCLUSIONS

The measures most commonly used in primary care and community settings are disease counts, Charlson index, ACG System, CIRS, CDS, and DUSOI. Different measures are most appropriate according to the outcome of interest. Choice of measure will also depend on the type of data available. More research is needed to directly compare performance of different measures.     

The importance of the gender perspective in health interview surveys

The identification and measurement of the population health needs should be the first step in health planning. In order to guarantee equity criteria, to know the situation of the whole population, and therefore also that of women, is a key issue. Health interview surveys are a good tool for pinpointing the needs of the population, but mainly they are usually focused on health risk factors that explain men's health status such as health behaviours and paid job. These factors often fail to capture aspects that are relevant for women's health, such as household work. The main objective of this paper is to emphasise the importance of a gender perspective in the design and analysis of health interview surveys, and to propose variables that should be included in health surveys in order to better know gender health inequalities. Likewise, this article deals with the gender concept and its importance as a health inequality factor. Gender is an analytical construct based on the social organisation of the sexes that can be used to better understand the conditions and factors influencing women's and men's health beginning by the social roles that each culture and society assigns to people based on their sex. Health is a complex process determined by a wide range of factors: biological, social, environmental and health services related factors. Gender, because of its close relation to all of them, plays a key role. The gender approach is characterised by the analysis of the social relation between men and women, taking into account that sex is a determinant of social inequalities. This paper presents the variables that health interview surveys should include from a gender approach point of view: reproductive work, productive work, social class, social support, self-perceived health status, quality of life, mental health and chronic conditions. In addition, issues related to the wording of questions, data collection and analysis are discussed.