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Creating a new language for primary health care around the world

Olja Latinovic/World Bank
Photo Credit: Olja Latinovic/World Bank

The Ariadne Labs Primary Health Care team has been working with countries around the world on how to improve primary health care, a cornerstone of achieving universal health coverage. The team, including lead researcher Dr. Asaf Bitton, PHC Research Specialist Hannah Ratcliffe, PHC Research Assistant Emily Wendell, Program Manager Brooke Huskey and Ariadne Labs Affiliate Member Dr. Lisa Hirschhorn, are integrally involved in the global Primary Health Care Performance Initiative led by the Gates Foundation, World Bank and the World Health Organization. The Ariadne team, along with Project Manager Emily Benotti and intern Madeline Pesec, also helped author two chapters of the World Bank’s seminal report on health care reform in China, distilling their findings into 8 Tenets of Primary Health Care. Ariadne Labs Communications Manager Deborah O’Neil recently sat down with Dr. Bitton, who practices primary care for Brigham and Women’s Hospital, to discuss the team’s research.

Q: Let’s start big picture. What problem of primary health care are we trying to address at Ariadne Labs?

Dr. Asaf Bitton
Dr. Asaf Bitton

A: At Ariadne Labs, we are working on creating a clearer language around what primary health care is, linking it to set of measureable outcomes and focusing our attention on the interaction between people who would like to use the system and providers of that care. We ask the question, “How can we further the five key functions of primary health care: first-contact access, continuity, comprehensiveness, coordination and person-centeredness?” Each of those five buckets is a separate, massive endeavor. I would argue that the first part of this project is to create a consistent intuitive language that can demonstrate why health care systems need to focus on primary health care now. And then we move toward measuring performance and building effective interventions.

Q: Do we still need to prove the value of primary health care?

A: We need to highlight how much we already know about how valuable it is — and show that replicable models of primary health care exist that produce those five core functions — and provide the value that people want and need. You need to have a laser-sharp focus in this work on the point of interaction between a person, their family, the community and the system.

Q: What approach do we bring to country-level research in primary health care?

A: We recognize you can’t build one model for all countries; however, there also cannot be 192 models because there are 192 countries. For countries facing similar problems to those faced by China, the eight core tenets set forth in the China study are valid beyond that very specific context. On the other hand, we aren’t saying that this is so universal that Sierra Leone can pick them up tomorrow. We’re trying to build a ladder or stage-wise approach to primary health care improvement that’s appropriate to countries facing similar problems, so they can learn from each other.

Q: What is the connection between universal health coverage and primary health care?

A: Primary health care and universal health coverage are fully intertwined. Primary health care can and should be a principal investment for pursuing UHC; it should be a “top buy” of our collective effort to spread financial access to health care. We should be investing in primary health care since high-quality primary health care can effectively cover 80-90 percent of a population’s health care needs. We know that the effective delivery of these services can save lives and reduce inequity. And we know that investing in primary health care systems is an important investment in the future. Not only can it help improve and save lives today, but it can also make health systems more resilient by acting as an early-warning system for further health shocks like epidemics and by mitigating the effects of crises that will inevitably occur.

Q: Tell us about the goals of the Primary Health Care Performance Initiative.

A: We are working with the Gates Foundation. the World Bank, the World Health Organization and Results for Development to use effective data collection and measurement to drive improvement of  primary health care in low- and middle-income countries. We’ve just published our first paper in the Journal of General Internal Medicine on the PHCPI conceptual framework.

A big focus of PHCPI is bringing together country-level policy makers, health-system managers, advocates and clinicians to encourage learning. Our contributions center on testing novel metrics for under-measured domains of primary health care systems like management and patient experience. Additionally, we are leading an effort to synthesize best practices of service delivery from across the world into real-world pathways to better care.

Q: Let’s talk about the China study. What was the goal of the project?

A: China faces immense health challenges over the next 15 to 20 years: a rapidly aging population, incredible growth in health sector expenditures, enormous out-of-pocket costs, a system that’s not meeting the needs of the people who want to use it, and in some cases an over-reliance and over-investment in hospitals and specialist care. Those challenges are well-understood by the Chinese themselves. The goal of the study was to build a set of recommendations for a more people-centered model of health care that will be less expensive, more responsive to the people’s needs and will actually keep people healthier. This was a two-year partnership between the World Bank, WHO, Chinese Ministry of Finance, the National Health and Family Planning Commission and Ministry of Human Resources.

Q: What was our role in the China Study?

A: The Chinese decided that in order to have the best ideas available to fix their health care system, they needed to look within China, and also outside of China. So they commissioned 22 case studies on successfully integrated primary health care and service delivery. Twelve of the case studies were from countries across the world, and 10 from within China. We synthesized about 2,000 pages of case studies into a series of chapters for the report.

As we were synthesizing, we realized that there appeared to be a set of common tenets of high-performing, integrative primary health care systems with really different contexts. The tenets of these middle- and high-income countries could be distilled into learning and insights and an interconnected service delivery model.

We consulted initially with our World Bank colleagues, and then with our in-country colleagues in China as well as colleagues from OECD in Europe and the Gates Foundation. I went to Beijing in the summer of 2015 and presented the distillation of our findings —  integrated patient-centered care— to representatives from the Ministry of Finance, and the Health and Family Planning Commission. What’s exciting is that it has resonance and meaning with leaders and with clinicians and with finance officials within China. These tenets make sense to orient their investments in the next phase of health care systems development. It’s not just another report.

Q: Can you describe the Eight Tenets that you were able to synthesize for the China report?

A: To start, a successful reorientation of the Chinese system should, at a fundamental delivery level, start with making primary health care the key point of first contact with the system. That’s not a trivial statement. Right now, enormous bypass of primary health care occurs all across China, and really, all across the globe. People either don’t perceive that their needs can be met with existing primary health care, cannot access it, or when they do, they don’t have good experiences with that system. You really want to think about a concept called empanelment in which you assign part of a population to a set of providers and they feel a sense of mutual relationship and responsibility.

As you start to build out you move toward a second tenet that you need teams of well trained clinicians with a variety of skill sets that can include clinicians, nurses, community health workers, social workers, coaches, pharmacists and others to augment what primary health care can do.

The third tenet is the idea of vertical integration. Primary health care needs to reach out to the facilities, specialists and hospitals that it’s going to work with in a way that’s defined and produces bidirectional activity and goal targeting. At the same time you want to horizontally integrate a system between health care and public health, which is the fourth tenet. So much of primary health care is really the nexus point between the formal health care system and public health-care system: smoking, vaccinations, good nutrition, environmental health, promotive health, preventive health, rehabilitative care. When public health is integrated with primary care, you get very strong outcomes.

The fifth tenet has to do with building a communications or e-health backbone for the entire lattice underpinning primary health care to coordinate not just people, but information about people. The sixth tenet establishes a set of integrative clinical pathways. So, for a given condition like diabetes or TB, you build a set of standard work flows by which a health care system based on robust primary health care can take care of people. A seventh tenet lays out a measurement and evaluation foundation for understanding how the system is performing, and how to feedback key performance data to clinician teams on the front lines. And finally the eighth tenet is to promote accountability through accreditation and certification standards that provide a pathway for working on improvement goals.

Q: Will these tenets work everywhere?

A: You could take this patient-centered integrated care model to the U.S and to Europe. You could take this to Singapore and the difference would be how far they’ve come on each one of the tenets. Our challenge is to make these models work in lower-resource settings. If you’re having trouble getting a bar of soap and vaccines delivered to health workers in clinics, then it’s a little early to talk about integrated, clinical care pathways. If you’re a country that’s spending 80 to 90 percent of your money on fancy glass hospitals and those hospitals are always full, and people are unhappy about their care, then you need to consider these tenets.

Q: Now that you have the basic tenets, what’s next?

A: We’ve developed a piece of the puzzle for how successful primary health care systems can develop, grow and improve, but we’ve only done it for a set of problems that a country like China has. They aren’t unique to China, but there are other problems out there to fix. So we want to develop a ladder of primary health care improvement to make similar concepts resonate for countries that have even more protracted problems. We need to tie those to evidence-based intervention pathways for producing the five core functions of primary health care and then together with interested countries, test them in disparate settings. We really want to create robust learning channels between high- and low-income countries because both have a lot to learn from the bright spots in each other.

Q: The potential global impact of this work is enormous, isn’t it?

A: It is, if we get the interventions right, measure effectively and keep our eye on the target of building systems that work for the people who use them. I think Ariadne’s contribution will come from looking at this problem from a slightly different angle: a combined clinical and population focus. We use our clinical background to center us on the idea that this is about people and their interactions with health care systems on that one-to-one level. We use the tools of policy, finance, epidemiology, clinical medicine, anthropology and nursing and integrate them toward the North Star we’re trying to improve.

Q: Our approach is just like your model. It’s integrated.

A: It’s integrated and focused on the real people who are most important and most often forgotten in these discussions. This is actually about the care that people will or will not receive that will help them lead healthier, more productive lives. There’s nothing theoretical about that. That’s a bar that we should hold ourselves to.

Q: Has your research changed how you practice as a doctor?

A: I think earlier in my career being in public health and health policy gave me a broader focus so I could think about the larger picture. Lately, it’s made me refocus even more when I’m practicing medicine toward a more human, relational element. There was a wonderful primary-care doctor and leading thinker named Fred Brancati. He encapsulated the adage about what primary care is: “It’s all about the love.” If you don’t want to call it love, then call it caring or responsiveness to the human in front of you. If that is not the core of what you’re doing, then really what are you doing?