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Global Trends in Primary Care Development

Global Trends in Primary Care Development. Barbara Starfield, MD Presented at the Blekinge Conference Ronneby, Sweden September 19, 2007. 25. 15. 10. 5.0. Density (workers per 1000). 2.5. 1. 3. 5. 9. 50. 100. 250. Child mortality (under 5) per 1000 live births.

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Global Trends in Primary Care Development

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  1. Global Trends in Primary Care Development Barbara Starfield, MD Presented at the Blekinge Conference Ronneby, Sweden September 19, 2007

  2. 25 15 10 5.0 Density (workers per 1000) 2.5 1 3 5 9 50 100 250 Child mortality (under 5) per 1000 live births Country* Clusters: Health Professional Supply and Child Survival *186 countries Starfield 12/04 HS 3083 Source: Chen et al, Lancet 2004; 364:1984-90.

  3. Primary health care is primary care applied on a population level. As a population strategy, it requires the commitment of governments to develop a population-oriented set of primary care services in the context of other levels and types of services. Starfield 09/04 04-133 Starfield 09/04 H 2944

  4. Primary care is the provision of first contact, person-focused ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care. Starfield 09/04 04-132 Starfield 09/04 PC 2943

  5. Why Is Primary Care Important? Better health outcomes Lower costs Greater equity in health Starfield 09/04 04-134 Starfield 09/04 PC 2945

  6. Evidence of the Benefits of a Primary Care-Oriented Health System Starfield 09/04 04-136 Starfield 09/04 PC 2946

  7. Primary Care Scores, 1980s and 1990s *Scores available only for the 1990s Starfield 10/02 02-185 Starfield 10/02 IC 2238

  8. Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR Starfield 10/00 00-133 Starfield 10/00 IC 1731

  9. USA GER BEL AUS SWE CAN SP NTH DK FIN UK *1=best 11=worst Relationship between Strength of Primary Care and Combined Outcomes Starfield 1999 IC 1433 Starfield 1999 99-006

  10. GER FR BEL US SWE JAP CAN FIN AUS SP DK NTH UK System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s *Best level of health indicator is ranked 1; worst is ranked 13; thus, lower average ranks indicate better performance. Starfield 03/05 IC 3100 Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.

  11. Primary Care Oriented Countries Have • Fewer low birth weight infants • Lower infant mortality, especially postneonatal • Fewer years of life lost due to suicide • Fewer years of life lost due to “all except external” causes • Higher life expectancy at all ages except at age 80 Starfield 08/05 IC 3242

  12. 10000 PYLL Low PC Countries* 5000 High PC Countries* 0 1970 1980 1990 2000 Year Primary Care Strength and Premature Mortality in 18 OECD Countries *Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77. Starfield 10/04 04-247 Starfield 09/04 IC 2953 Source: Macinko et al, Health Serv Res 2003; 38:831-65.

  13. Average Rankings for World Health Organization Health Indicators for Countries Grouped by Primary Care Orientation Source: Calculated from WHO, World Health Report 2000. DALE: Disability adjusted life expectancy (life lived in good health) Child survival: survival to age 2, with a disparities component Overall health: DALE minus DALE in absence of a health system Maximum DALE for health expenditures minus same in absence of a health system Starfield 09/04 04-158 Starfield 09/04 IC 2952

  14. Is Primary Care as important within countries as it is among countries? Starfield 09/04 04-138 Starfield 09/04 WC 2955

  15. . . . HI . . MN . . CT WA . ND MA . . . . NE . SD ID . OR CA . . ME . NH . . . AZ RI . . ID . . NM . MT . IA UT . NJ . . TN . . FL . WI KS NY . . TX AR . PA . MI DE KY . WV . . NC VA AL MD . IL MS . . NV . AK R=.54 P<.05 GA SC LA State Level Analysis:Primary Care and Life Expectancy Starfield 09/02 02-160 Starfield 09/02 WC 2186 Source: Shi et al, J Fam Pract 1999; 48:275-84.

  16. Primary Care and Infant Mortality Rates, Indonesia, 1996-2000 *constant Indonesian rupiah, in billions Source: Simms & Rowson, Lancet 2003; 361:1382-5. Starfield 05/03 03-115 Starfield 05/03 WC 2499

  17. Primary Care Score and Self-Rated Health, Petrópolis, Brazil, 2004* *1= excellent/ good health; 0=bad/fair/poor health ** standard errors adjusted for clustering by clinic Starfield 06/04 04-126 Starfield 06/04 WC 2896 Source: Macinko, Almeida, de Sá, Health Policy Plan, forthcoming 2006.

  18. Impact of PSF Coverage on Infant Mortality in Brazilian States, 1990-2002: Marginal Effects* *Based on 2-way fixed effects model of Brazilian states, 1990-2002, n=351 R^2=0.90. Non-significant (p>0.05) control variables, including physician and nurse supply and sewage not shown. Starfield 10/06 WC 3457 Source: Macinko et al, J Epidemiol Community Health 2006; 60:13-19.

  19. Many other studies done WITHIN countries, both industrial and developing, show that areas with better primary care have better health outcomes, including total mortality rates, heart disease mortality rates, and infant mortality, and earlier detection of cancers such as colorectal cancer, breast cancer, uterine/cervical cancer, and melanoma. The opposite is the case for higher specialist supply, which is associated with worse outcomes. Starfield 09/04 04-167 Starfield 09/04 WC 2957 Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htm

  20. What We Already Know A primary care oriented system is important for • Improving health (improving effectiveness) • Keeping costs manageable (improving efficiency) Starfield 09/05 PC 3316

  21. Does primary care reduce inequity in health? Starfield 09/04 04-142 Starfield 09/04 EQ 2966

  22. Equity in health is the absence of systematic and potentially remediable differences in one or more aspects of health across population groups defined geographically, demographically, or socially. Starfield 04/04 04-050 Starfield 04/04 EQ 2820 Source: www.iseqh.org

  23. In the United States, an increase of 1 primary care doctor is associated with 1.44 fewer deaths per 10,000 population.The association of primary care with decreased mortality is greater in the African-American population than in the white population. Starfield 06/05 WC 3216 Source: Shi et al, Soc Sci Med 2005; 61(1):65-75.

  24. In 7 African countries • The highest 1/5 of the population receives well over twice as much financial benefit from overall government health spending (30% vs 12%). • For primary care, the poor/rich benefit ratio is much lower (23% vs 15%). “From an equity perspective, the move toward primary care represents a clear step in the right direction.” Source: Gwatkin, Int J Epidemiol 2001; 30:720-3, based on Castro-Leal et al, Bull World Health Organ 2000; 78:66-74. Starfield 03/04 04-023 Starfield 03/04 IC 2793

  25. Studies in other developing and middle income countries also show benefit from primary care reform. • In Bolivia, reform in deprived areas lowered under-5 mortality rates compared with comparison areas. • In Costa Rica, primary care reforms in the 1990s decreased infant mortality and increased life expectancy to rates comparable to those in industrialized countries. • In Mexico, improvements in primary care practices reduced child mortality in socially deprived areas. Sources: Perry et al, Health Policy Plann 1998; 13:140-51; Reyes et al, Health Policy Plann 1997; 12:214-23; Rosero-Bixby, Rev Panam Salud Publica 2004; 15:94-103; Rosero-Bixby, Soc Sci Med 2004; 58:1271-84. Starfield 08/05 IC 3248

  26. Life Expectancy Compared with GDP per Capita for Selected Countries Country codes: AG=Argentina AU=Australia BZ=Brazil CH=China CN=Canada FR=France GE=Germany HU=Hungary IN=India IS=Israel IT=Italy JA=Japan MA=Malaysia ME=Mexico NE=Netherlands PO=Poland RU=Russia SA=South Africa SI=Singapore SK=South Korea SP=Spain SW=Sweden SZ=Switzerland TK=Turkey TW=Taiwan UK=United Kingdom US=United States Source: Economist Intelligence Unit. Healthcare International. 4th quarter 1999. London, UK: Economist Intelligence Unit, 1999. Starfield 07/05 IC 3228

  27. Global Health Chart Starfield 10/04 04-198 Starfield 09/04 IC 2941 Source: Karolinska Institute: www.whc.ki.se/index.php.

  28. Share of Public Spending on Health among Countries with Similar GNP per Capita But Very Disparate Child Survival (to Age 5) Rates, 1995 *Ratios of one or more signify a greater share of government expenditures to poorest segment of population. Sources: Calculated from Karolinska Institute, Global health chart, www.whc.ki.se/index.php. Victora et al, Lancet 2003; 362:233-241. Castro-Leal et al, Bull World Health Organ 2000; 78:66-74. Carr. Improving the Health of the World's Poorest People. Population Health Bureau, 2004. Starfield 04/04 04-084 Starfield 04/04 IC 2854

  29. Primary Care and Health: Evidence-Based Summary • Countries with strong primary care • have lower overall costs • generally have healthier populations • Within countries • areas with higher primary care physician availability (but NOT specialist availability) have healthier populations • more primary care physician availability reduces the adverse effects of social inequality Starfield 09/02 PC 2214 Starfield 09/02 02-161

  30. Conclusion Virchow said that medicine is a social science and politics is medicine on a grand scale. Along with improved social and environmental conditions as a result of public health and social policies, primary care is an important aspect of policy to achieve effectiveness, efficacy, and equity in health services. Starfield 03/05 PC 3112

  31. Conclusion Although sociodemographic factors undoubtedly influence health, a primary care oriented health system is a highly relevant policy strategy because its effect is clear and relatively rapid, particularly concerning prevention of the progression of illness and effects of injury, especially at younger ages. Starfield 11/05 HS 3329

  32. Primary Care Orientation of Health Systems Health system characteristics (9) Practice characteristics (6) Adapted from Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998, Chapter 15. Starfield 04/99 PC 1475 Starfield 1999 99-147

  33. Primary Care Orientation of Health Systems: Rating Criteria • Health System Characteristics • Type of system • Financing • Type of primary care practitioner • Percent active physicians who are specialists • Professional earnings of primary care physicians relative to specialists • Cost sharing for primary care services • Patient lists • Requirements for 24-hour coverage • Strength of academic departments of family medicine Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 04/99 PC 1476 Starfield 1999 99-148

  34. Primary Care Orientationof Health Systems:Rating Criteria Each country was rated (scores of 0, 1, or 2) on the strength of 9 characteristics of health policy that are conducive to strong primary care. Starfield 09/02 02-285 Starfield 09/02 PC 2197

  35. Primary Care Orientation of Health Systems: Rating Criteria • Practice Characteristics • First-contact • Longitudinality • Comprehensiveness • Coordination • Family-centeredness • Community orientation Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 04/99 PC 1477 Starfield 1999 99-150

  36. Primary Care Orientationof Health Systems:Rating Criteria The countries were also scored (0, 1, or 2) with regard to the strength of 6 key characteristics of primary care practice. Starfield 09/02 02-286 Starfield 09/02 PC 2198

  37. Primary Care Features Consistently Associated with Good/Excellent Primary Care • System features • Regulated resource distribution • Government-provided health insurance • No/low cost-sharing for primary care • Practice features • Comprehensiveness • Family orientation Starfield 10/01 PC 1983 Starfield 10/01 01-174

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