Primary care is more than a set of services, according to Asaf Bitton, MD, assistant professor of Medicine at Harvard Medical School and executive director of Ariadne Labs, a health system innovation center at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health. Instead, primary care is an all-encompassing mode of care: comprehensive, coordinated and centered on trust.
“It’s the coordination to care for a person throughout their lifespan and across the healthcare system,” said Bitton, who delivered an Institute for Global Health Seminar Series lecture on the importance of primary care in health systems around the world. “It builds trust and respect, and allows patients to have a long term healing relationship with providers.”
Bitton was introduced by Lisa Hirschhorn, MD, MPH, professor of Medical Social Sciences and of Psychiatry and Behavioral Sciences, who worked alongside Bitton at Brigham and Women’s Hospital at Harvard.
“Asaf is one of the biggest advocates for primary healthcare, and almost everything I know about primary healthcare, I’ve learned from him,” Hirschhorn said.
Bitton, who delivered the lecture via teleconference due to COVID-19 travel restrictions, made the case that primary care should be the bedrock of any health system and pointed to persistent underfunding as an issue around the world.
“If you’re going to pool resources as a society to prevent sick people from having catastrophic financial risk, what are you going to buy with those pooled resources?” Bitton said. “You could build glassy hospitals or implement vertical programs that are hard to integrate, or you could base your purchasing on primary healthcare systems that link with specialty care, emergency care and surgical care.”
Strong primary healthcare systems can support health equity, serve as an early warning mechanism and enable communities and individuals to become decision makers around their health, according to Bitton. In addition, effective primary care has the all-important effect of improving health outcomes, a key measure of success in any health system.
Building or bolstering primary healthcare is a complicated task, and it’s not the case that global health organizations can simply helicopter in to fix systems, Bitton said.
“I would argue there’s a little bit of magical thinking in global health, where we believe if we just put the inputs together, they’ll magically produce outputs and improve outcomes.” Bitton said. “Those working in implementation science and on the ground across the world understand those inputs are important, but service delivery, organization in frontline staff, confidence and motivation, and the ability to treat patients with respect are big factors, as well.”
To accurately measure these “soft” factors, Bitton and his collaborators at Ariadne Labs have led the Primary Health Care Performance Initiative (PHCPI), launched in 2015 by the United Nations, the Bill & Melinda Gates Foundation and the World Health Organization. This effort aims to measure primary care performance in a holistic way in low- and middle-income countries, to effectively tailor improvement and financing initiatives.
After conducting personnel and facility surveys, and combining that with financial and outcomes data, the PHCPI produces a set of nearly 40 measurements that provide snapshots of a countries’ primary healthcare system, shining a light on issues that may have been previously overlooked.
“This model is designed to capitalize on the wealth of information that already exists within the health system, and merge that with performance reports and platforms that no one ever puts together,” Bitton said.
These PHCPI dashboard measurements provide a holistic evaluation of primary care in a country, and Bitton hopes this system can help global health organizations and state healthcare administrators improve primary care.
“Primary healthcare has to be well-financed and prioritized, it has to have the right capacity, supplies, facilities, and this has to be translated into performance,” Bitton said. “We hope this can drive health system development.”