General Primary Care

Primary health care has always been a feature of health care systems and—from a modern perspective—involves four interrelated aspects: a set of activities, a level of care, a strategy for organizing health care, and a philosophy that permeates health care provision. At full stretch, then, the "primary health care approach" can affect the configuration and focus of the entire health system and extend to the development of communities (Vuori 1985).

It is not always easy to see how information on the cost-effectiveness of individual interventions—the focus of part 2 of this volume—contributes to the achievement of the wider features of primary health care. Indeed, Starfield (1998) points out that the importance of particular services or interventions is overrated, in part because of limited appreciation of the "essential and unique functions" of primary care. These functions are mutually reinforcing and include first-contact care; continuity in care (in Starfield's words, "person-focused over time"); comprehensiveness of available services; and coordination with specialized services and other levels of care. The functions point to the centrality of how primary care is organized and delivered, something with which the cost-effectiveness approach has hitherto not been greatly concerned. This chapter attempts to identify some of the common ground between the primary health care approach and the cost-effectiveness approach. We propose that resource constraints simultaneously require (a) the targeting of services toward burdens of disease that are amenable to highly cost-effective interventions and (b) the general strengthening of the health system, particularly at the primary care and district levels.