Politics, primary healthcare and health: was Virchow right?

This is the authors' abstract. We don't add key points for this paper.

In this issue of JECH, authors from both the People’s Health Movement 1 and WHO 2 agree that primary healthcare makes a considerable contribution to reducing the adverse impact of social inequalities on health. That is, primary healthcare is a ‘health equity-producing’ social policy. Both groups of authors agree that health systems do not exist in isolation from other social systems. Both provide examples of how the market orientation of neo-liberal globalisation has worked against improvements in general and equity in health specifically. The role of world trade agreements in compromising nutritional status of socially disadvantaged populations provides a powerful case for the importance of inter-sectoral approaches in health policy activities. Both papers speak of ‘primary health care’ rather than of ‘primary care’. The distinction between the two is at the heart of achieving greater equity in health through societal actions. Both clinical practices and system policies need consideration. 3 The literature on ‘primary care’ is largely clinical, having to do with the behaviour of health services professionals and their interactions with people and, increasingly, the subpopulations for whom they provide services. Within the last two decades there has been increasing clarity about which ‘behaviours’ are most important to adequacy of primary care: first contact accessibility and use, identification with a regular source of care that is person (rather than disease) focused care over time, comprehensiveness of services available and provided, and coordination (when care from other places is required). These characteristics, all amenable to assessment in reliable and valid ways, are now so well-known that tools for their assessment are rapidly being adopted in many different places around the world. 4 International comparisons demonstrate that good clinical primary care depends on good primary healthcaredthat is, on specific health system policies for population. Critical among these policies are attempts to distribute resources equitablydthat is, according to need; ‘progressive’ (as distinguished from ‘regressive’) financing under government control or regulation; low or no cost sharing for primary care services; and breadth of services available (comprehensiveness) within the primary care sector. 35 Each of these policy characteristics reflects more general system characteristics: focus on distribution of health characteristics in the populationdthat is, an equity focus rather than just on average levels; progressivity of financing of social services in general; and consideration of population needs rather than demands (which favour the more powerful rather than the disenfranchised). That is, societies that are more equitable tend to be more equitable in many regards, 6 because progressive governments generally promote more progressive policies across a range of social sectors. Primary healthcare-oriented health systems have been shown to be generally more effective in achieving better health (particularly at young ages) at lower costs than is the case for systems more oriented to disease management and specialty care. It is not often recognised that they have more equitable distributions of health as well. Even in the USA, one of the most inequitable societies in the industrialised world, better primary care resources preferentially improve health more in socially disadvantaged populations than in the majority population. 7 A comparison of age adjusted survival from breast cancer in Canada (which has a health system more oriented towards primary care than in the USA) showed a strong socioeconomic gradient in survival from breast cancer in the USA but not in Canada and demonstrated that the survival advantage in cancer is present in low-income areas only and that it is less in women over the age of