By primary health care, we mean first-level care, that is to say the level of the care system which is the entry point into the care system, which offers general, comprehensive, continuous care, integrated, accessible to the entire population, and which coordinates and integrates the services required at other levels of care.
A more complete definition of the missions of primary health care is given below. It seems essential to us at this stage to agree on the words to have a common language but also to get out of inappropriate value judgments. One such difficulty is the confusion between primary care and primary health care.
If we observe a health system from the supply of services, we must be able to identify levels of healthcare supply: at its base, the primary level, not segmented, neither by age, by sex nor by type of problem neither by organ nor by financial capacity of users. This primary level is supposed to be able to respond to 90% of the health problems of an unselected population at all. Then the secondary level, reference level, and finally the tertiary level, that of high technology medicine (university hospitals). These last two levels are by definition specialized and therefore segmented.
The other angle of observation is that of the request, of the place where the patient makes contact with the system and submits his problem. This place will be the first line. Particularly in our country where access to the different levels is not staggered and therefore free, the first line can be located in many places, including at the secondary and even tertiary level: the emergency services are one of them. However, a Brussels menopause center too.
The role of primary health care should not be defined in isolation but in relation to the other components of the health system. Primary and secondary care, general and specialized, all have important roles. They are not mutually exclusive but necessary for the system. However, technological advances, improved education and training, changes in needs related to epidemiological transition, social and lifestyle changes are increasing the need for primary health care, and call for an organization such that this primary care is in the vast majority of cases the first line.
In his World Health Report 2003 – Shaping the Future, the World Health Organization strongly encourages a major shift towards the model of health systems based on primary health care. This report notes the fact that twenty-five years after the Alma-Ata declaration, many in the health community believe that the emphasis on primary health care is essential for equitable progress in health. The World Health Organization considers that primary health care covers key principles including: universal access to care, coverage according to needs, commitment to guarantee health equity within the framework of development oriented towards social justice, community participation in the definition and execution of health programs, the adoption of inter sectoral approaches to health.
For the OECD, the lack of staggering in Belgium leads to an inadequate use of medical care resources by patients. Current attempts to increase the incentives to go through the general practitioner are not strong enough. The increase in the responsibility of general practitioners by adding the role of gatekeeper, induced by staggering, must be compensated. The need for an integrated health care system is explained, with a pivotal role for the general practitioner. In addition to this role of gatekeeper, the role of coordinating long-term care processes and being the first source of contact for the patient and his family are also recognized. By the example of the granting of adequate guidelines, the OECD cites the need for the system to give general practitioners the means necessary to fulfill their growing role.
Regarding the financing of primary health care, we will again cite this report by the OECD (OECD 2005) which offers a good summary of what is happening in Belgium: “In Belgium, doctors are paid on a fee-for-service basis. This method of remuneration encourages practitioners to increase the volume of procedures by performing unnecessary services and prescriptions. A capitation system can encourage practitioners to subcontract their patients, to refer more quickly to the second line or to select people with a low risk of disease. In response to the impasses of the two payment methods, some countries are moving towards a more complex payment system which combines a fixed part (capitation or salary) with a fee-for-service payment for certain specific interventions.
Among the fifteen characteristics used to give a score to the countries studied, it emerges that three characteristics linked to the health system and two characteristics linked to primary care practices distinguish more particularly the countries that perform poorly in terms of primary health care. The characteristics linked to the system and insufficiently fulfilled in the less performing countries are: equitable distribution of resources, universal insurance coverage, and low direct personal financial participation; the characteristics linked to primary care practices are the offer of global and integrated services ( comprehensive primary care services), and family oriented. According to Star field and Shi, a reform of the health system that, in addition to giving greater importance to primary health care, would give priority to these characteristics, should contribute to better overall health, and to less cost.