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Primary care Concepts Health systems throughout the world are striving to manage their available resources to deliver the best value for the public’s health. For most nations, the general medical practitioner (GP), family physician (FP), or front line clinic or public health nurse is the keystone of their organizational approach to achieving the best mix of quality, public and individual satisfaction, and cost (Moore G, Managing to Do Better: General Practice in the 21st Century, Office of Health Economics, London). The Network: TUFH seeks to identify and promote the role of academic health institutions in identifying regional and national needs for primary care providers, preparing those providers with skills most needed to address community health needs, ensuring primary care graduates work in areas of greatest need, and experimenting with primary care health care models, systems and policies to determine the highest quality, most efficient and cost effective approaches for local needs. To achieve this goal optimally, Network: TUFH institution’s actions must reflect the voice of communities served, form bridges between health and education, social and behavioral sciences, individual and public health, and form links with other sectors of society that impact health. Definitions and developments WHO’s Declaration of Alma-Ata (l978) defined primary health care in broad terms, recognizing it’s role in development as well as care. “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford. It forms an integral part of both the country’s health system, of which it is the central function and main focus, and the overall social economic development of the community.” In l996, the U.S. Institute of Medicine revised its definition of primary care to broaden its scope and context. “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” In l991, Nepal instituted a new National Health Policy to upgrade the health standards of the majority of the rural population by extending basic primary care services to the village level. To address lack of quality assurance in health care delivery, the Nation’s ninth five-year plan (l997-2001) included an objective to train technically competent and socially responsible health personnel Cuba’s accomplishments in health status are, in part, dependent upon an emphasis on appropriate, affordable technology and such innovations as universal access to quality neighborhood-based family medicine as the cornerstone of primary care. Primary care is well integrated into regionalized systems of care. England’s latest reforms include the employment of general practitioners (GPs), individually and in groups, as the micro-managers of resources and of care. GPs are close to the individuals and populations that are the target of improved health and sit at the interface between community, social, and medical resource. New knowledge, skills, and, especially, attitudes will be needed if GPs are to carry out these expanded functions. Best evidence regarding health benefit of primary care (Starfield B. Is US Health Really the Best in the World? JAMA, July 26, 2000 v.284, No. 4, 483-485) Community health status is proportional to the ratio of primary care to specialist providers and the ratio of primary care to population. Countries with strong primary care systems generally have healthier populations and lower costs of care. Co-morbidities are so high, especially as populations age, that access to generalist providers who can provide comprehensive care for most illnesses and needs of patients becomes an increasingly cost-effective health service approach. More primary care provider availability reduces the adverse effects on health of social inequality. Why do so few AHCs embrace primary care? Faculty at AHCs are predominantly specialists. Rewards for faculty at AHCs are usually driven by biomedical research, research priorities of industrialized countries or pharmaceutical companies which often are not priority primary health care needs of communities. Faculty are often more desirous of specialty graduate trainees who can support their inpatient service needs. The unique training needs of a primary care work force of the future, including community health team leadership, community health skills, population health skills, and health promotion and disease prevention are not traditional competencies of academic faculty. The growth of primary care faculty is often perceived as a threat to the resources of established, specialty power bases in the AHC. The power base of primary care is to be found in communities, while in AHCs, primary care is often at the margins of power. What are the primary care goals of The Network: TUFH? Identify and disseminate strategies for - Encouraging a primary care base of research within each AHC - Building a research agenda in community health outcomes - Promoting within AHCs the role and image of primary care as a valued specialty Encourage equitable distribution of primary care resources in the community (by geography, by health need, addressing socioeconomic disparities). Advocate for universal health care. What necessary alliances should AHCs make to enhance primary care? Encourage links with other stakeholders that contribute to primary care goals such as professional associations, civil society and lawmakers. Encourage links between academic primary care and other disciplines at the university, such as economics, social sciences and education. Local and national public health delivery systems. Local, regional and national health policy development. What are the attributes of a primary care-oriented AHC? Curriculum for undergraduate students and number of training positions for postgraduates reflects balanced, primary care:specialist ratio of its graduates consistent with local, regional or national needs. A substantial portion of the training experience of learners takes place under the mentorship of primary care role models. Primary care research is supported as a vital component of the institution’s scholarly effort The learners are exposed to interdisciplinary models of primary health care service, training and research. What are different examples of Primary Care innovations at Network: TUFH Institutions? At the UNI Colima Programme in Mexico, an innovative learning and service program links multiprofessional work teams (nursing, medical, social work and psychology students) from the University with local health services through the Ministry of Health. Community input comes from local health committees, families and groups within the target communities receiving service. As a result, teachers, health services staff, and community leaders have learned new ways to work and co-operate. In Maastricht, The Netherlands, the “Hartslag” (Heartbeat) project is a joint initiative of the University, the regional Public Health Service, and family practitioners. This community education and risk-reduction project is targeted toward some of the poorer quarters of Maastricht City and surrounding villages. The aim is to reduce the incidence of cardiovascular disease, the countries leading cause of death and among its leading causes of morbidity. To improve the lives of rural children, in Gezira, Sudan, the University partnered with the Ministries of Health and of Education, and with WHO-Eastern Mediterranean Region to establish the Community Health Scout Programme. Boys and girls ages 13-15 were taught skills in promoting the health of younger children through six family-based interventions involving parents and community. Funding came though a 5% tax on long distance bus tickets through the region. The outcome was a significant improvement in childrens’ health on several parameters. The Cambridge Health Alliance in Boston, U.S.A. is a partnership between academia, primary care, and the public health care system. It includes small primary care practices in urban neighborhoods and in the secondary schools, several community hospitals, a nursing home, a municipal health department and a managed care program for uninsured patients. This integrated system offers patients a seamless system of care, overcoming the traditional fragmentation of community services. What actions can The Network: TUFH undertake to promote primary care orientation at AHCs? Increase the number and visibility of role models in primary care. Overcome the entrenched, urban-oriented, specialty-focused institutional leadership. Increase the support for primary care research and for an evidence-based documentation of the value of primary care to community health. Increase the base of support for innovations in pc education and service. Forge alliances with like-minded organizations that promote goals that overlap those of The Network: TUFH such as WHO’s “Towards Unity for Health,” WONCA, and the Council on Health Research for Development. Reduce fragmentation of primary care forces within the institution, separated by different departments (ex. internal medicine, family medicine, pediatrics), different colleges (ex. nursing, stomatology, medicine, pharmacy), fields (ex. medicine, public health), or government bureaucracy (ex. ministries of health, ministries of education). Corresponding author on behalf of the writing group: Arthur Kaufman Email: akaufman@salud.unm.edu