Many countries of the world have market oriented health services systems. Evidence accumulated over the most recent 20 years indicates that these health systems have difficulty achieving high levels of overall health as well as equity in health. Such is the case, for example, in the United States, where both average health and equity in health across different population sub-groups is worse than in comparable countries, despite much higher costs. Although health services are widely considered a right available to everyone, health systems that focus on meeting consumer demand rather than on population needs generally result in suboptimal health, high costs, and great disparities in health across social groups in the population.

Responding to demands for care (rather than needs) creates a situation wherein health systems are dominated by private specialty services rather than primary care services. Even though existing public systems provide at least rudimentary primary care for those not able to afford care by private physicians, under-financing of these systems does not allow planning of services that adequately meet most health needs of the population.

International comparisons of health systems indicate that several characteristics of national health policy are required for the optimal effect of health systems to be realized. These characteristics are:

• Attempts to distribute health services resources equitably across the population. That is, the amount and type of workforce and facilities should be deployed according to the relative extent of health needs in different areas and among different population subgroups.
• Universal financial access. That is, ability to pay should not be a deterrent to receiving needed health services.
• Low or no copayments for primary care services. That is, more than minimal co-payments will be a deterrent to receiving needed care and should be avoided.
• Uniform benefits to comprehensive services. The broader the range of services provided in primary care, the more effective and equitable the health system. In most industrialized countries (but not the United States), receipt of primary care services is equitable in that these services are equally available across the social spectrum. A broad range of services provided in primary care reduces the need for specialty care which, in most countries, is inequitably accessible and which are always more costly than primary care. All healthcare needs in the population, except those that are too uncommon to maintain competence, should be provided in primary care, with appropriate specialty back-up to the primary care physician when necessary for complex diagnostic testing and advice and guidance on management.

All health systems face new challenges.

1. Co-morbidity
   Increasing survival and better management of existing conditions are creating increasing degrees of co-morbidity in the population. Guidelines for quality of care deriving from trials for particular conditions are becoming increasingly irrelevant in the presence of co-existing conditions.
2. Adverse effects of increasingly powerful interventions
   Individual variation in response to medical treatment is making it imperative to incorporate monitoring of the impact of interventions in individual patients as well as subpopulations of patients. Systems to monitor the occurrence of unexpected symptoms and signs is becoming even more important in clinical care; the International Classification of Primary Care (ICPC) will become an important tool in primary care.
3. Understanding the appropriate role in health systems of specialists
   Although the role and functions of primary care are now well-understood, the same is not the case for most specialist care - particularly medical specialist care. Concerted attempts to develop a better understanding of what is properly in the area of primary care versus what needs specialist care are an urgent priority in order to maximize effectiveness, cost-effectiveness, and equity of health services.
4. A greater focus on meeting people's health needs as they experience them should be added to the historical professional focus on diagnoses
   All quality assessment activities should incorporate generic measures of improvement to the armamentarium of outcome measures. Population health is not the sum of individual diseases. Rather, it is a reflection of people's responsiveness to the various threats to health and to the various interventions to modify it. How people function and how well and long they survive are the only appropriate criteria for health systems that are responsive to people needs and their health-related problems.

The challenges are even greater in developing and rapidly industrializing countries, particularly those without historical and cultural traditions towards solidarity across population subgroups. The health systems of these countries are vulnerable to repeating the mistakes of countries such as the United States as a result of global market forces and influences. There is now a strong conceptual basis to primary care and means of assessing and assuring its adequacy. In the interests of maximizing the health and the economic productivity that derives from it, these countries must base their health services reforms on a strong primary care foundation using both public and private resources to do it collaboratively.

Reading

Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Q 2005;83:457-502.