1. Primary Care and the Health System
Barbara Starfield, MD
University of Sao Paulo
Sao Paulo, Brazil
March 22, 2006

2. 06 Sao Paulo Mar
4/20/2017
Global Health Chart
Source: Karolinska Institute. Global health chart, accessed September 29, 2004.
Starfield 09/04
IC 2941
Starfield 10/04
04-198
Source: Karolinska Institute:

3. Country* Clusters: Health Professional Supply and Child Survival
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Country* Clusters: Health Professional Supply and Child Survival
Density (workers per 1000)
Child mortality (under 5) per 1000 live births 3 5 9 50
100
250 25 15 10
5.0
2.5 1
Source: Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M et al. Human resources for health: overcoming the crisis. Lancet 2004; 364(9449):
*186 countries
Starfield 12/04
HS 3083
Source: Chen et al, Lancet 2004; 364:

4. Life Expectancy Compared with GDP per Capita for Selected Countries
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4/20/2017
Life Expectancy Compared with GDP per Capita for Selected Countries
Country codes:
AG=Argentina
AU=Australia
BZ=Brazil
CH=China
CN=Canada
FR=France
GE=Germany
HU=Hungary
IN=India
IS=Israel
IT=Italy
JA=Japan
MA=Malaysia
ME=Mexico
NE=Netherlands
PO=Poland
RU=Russia
SA=South Africa
SI=Singapore
SK=South Korea
SP=Spain
SW=Sweden
SZ=Switzerland
TK=Turkey
TW=Taiwan
UK=United Kingdom
US=United States
Source: Economist Intelligence Unit. Healthcare International. 4th quarter London, UK: Economist Intelligence Unit, 1999.
Source: Economist Intelligence Unit. Healthcare International. 4th quarter London, UK: Economist Intelligence Unit, 1999.
Starfield 07/05
IC 3228

5. 06 Sao Paulo Mar
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Primary health care is primary care applied on a population level. As a population strategy, it requires the commitment of governments to develop a population-oriented set of primary care services in the context of other levels and types of services.
Starfield 09/04
H 2944
Starfield 09/04
04-133

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Primary care is the provision of first contact, person-focused ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care.
Starfield 09/04
PC 2943
Starfield 09/04
04-132

7. Why Is Primary Care Important?
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Why Is Primary Care Important?
Better health outcomes
Lower costs
Greater equity in health
Starfield 09/04
04-134
Starfield 09/04
PC 2945

8. Evidence of the Benefits of a Primary Care-Oriented Health System
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Evidence of the Benefits of a Primary Care-Oriented Health System
Starfield 09/04
PC 2946
Starfield 09/04
04-136

9. Primary Care Scores, 1980s and 1990s
06 Sao Paulo Mar
4/20/2017
Primary Care Scores, 1980s and 1990s
1980s
1990s
Belgium
France*
Germany
United States
0.8 -
0.5
0.2
0.4
0.3
Australia
Canada
Japan*
Sweden
1.1
1.2
0.9
Denmark
Finland
Netherlands
Spain*
United Kingdom
1.5
1.7
1.4
1.9
*Scores available only for the 1990s
Starfield 10/02
02-185
Starfield 10/02
IC 2238

10. 06 Sao Paulo Mar
4/20/2017
System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s UK
NTH SP
FIN
CAN
AUS
SWE
JAP
GER FR
BEL US DK
Based on data in Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):
*Best level of health indicator is ranked 1; worst is ranked 13; thus, lower average ranks indicate better performance.
Starfield 03/05
IC 3100
Based on data in Starfield & Shi, Health Policy 2002; 60:

11. Primary Care Score vs. Health Care Expenditures, 1997
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4/20/2017
Primary Care Score vs. Health Care Expenditures, 1997 UK DK
NTH
FIN SP
CAN
AUS
SWE
JAP
GER US
BEL FR
Starfield 10/00
00-133
Starfield 10/00
IC 1731

12. Relationship between Strength of Primary Care and Combined Outcomes
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4/20/2017
Relationship between Strength of Primary Care and Combined Outcomes
USA
GER
BEL
AUS
SWE SP
CAN
FIN UK
NTH DK
*1=best
11=worst
Starfield 1999
IC 1433
Starfield 1999
99-006

13. Primary Care Oriented Countries Have
Fewer low birth weight infants
Lower infant mortality, especially postneonatal
Fewer years of life lost due to suicide
Fewer years of life lost due to “all except external” causes
Higher life expectancy at all ages except at age 80
Starfield 08/05
IC 3242

14. Primary Care Strength and Premature Mortality in 18 OECD Countries
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Primary Care Strength and Premature Mortality in 18 OECD Countries
Year
High PC Countries*
Low PC Countries*
10000
PYLL
1970
1980
1990
2000
5000
Source: Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, Health Serv Res 2003; 38(3):
*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.
Starfield 09/04
IC 2953
Starfield 10/04
04-247
Source: Macinko et al, Health Serv Res 2003; 38:

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4/20/2017
Average Rankings for World Health Organization Health Indicators for Countries Grouped by Primary Care Orientation
DALEs
Child Survival Equity
Overall Health
Worse primary care
(Belgium, France,
Germany, US)
16.3
22.5
36.3
Better primary care
(Australia, Canada,
Sweden, Japan, Denmark,
Finland, Netherlands,
Spain, UK)
11.0
15.8
29.1
Calculated from: World Health Organization. The World Health Report Health Systems: Improving Performance. Geneva: World Health Organization, 2000.
Source: Calculated from WHO,
World Health Report 2000.
DALE: Disability adjusted life expectancy (life lived in good health)
Child survival: survival to age 2, with a disparities component
Overall health: DALE minus DALE in absence of a health system
Maximum DALE for health expenditures
minus same in absence of a health system
Starfield 09/04
IC 2952
Starfield 09/04
04-158

16. Overall, primary care oriented countries
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Overall, primary care oriented countries
Have more equitable resource distributions
Have health insurance or services that are provided by the government
Have little or no private health insurance
Have no or low co-payments for health services
Are rated as better by their populations
Have primary care that includes a wider range of services and is family oriented
Have better health at lower costs
Sources:
Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):
van Doorslaer E, Koolman X, Jones AM. Explaining income-related inequalities in doctor utilisation in Europe. Health Econ 2004; 13(7):
Schoen C, Osborn R, Huynh PT, Doty M, Zapert K, Peugh J, Davis K. Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Aff 2005; W5: (also available at:
Sources: Starfield and Shi, Health Policy 2002; 60: van Doorslaer et al, Health Econ 2004; 13: Schoen et al, Health Aff 2005; W5:
Starfield 11/05
IC 3326

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Is Primary Care as Important within Countries as It Is among Countries?
Starfield 09/04
WC 2955
Starfield 09/04
04-138

18. State Level Analysis: Primary Care and Life Expectancy
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State Level Analysis: Primary Care and Life Expectancy LA SC . GA NV MS AL WV DE NC KY KS TN ID MI TX IA UT NY CA MD ND WI NM AZ NE MA CT HI MN AK IL VA PA FL MT OR NJ ME NH SD AR WA RI
R=.54
P<.05
Source: Shi L, Starfield B, Kennedy BP, Kawachi I. Income inequality, primary care, and health indicators. J Fam Pract 1999; 48(4):
Starfield 09/02
02-160
Starfield 09/02
WC 2186
Source: Shi et al, J Fam Pract 1999; 48:

19. Primary Care and Infant Mortality Rates, Indonesia, 1996-2000
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Primary Care and Infant Mortality Rates, Indonesia,
Primary care spending
per capita*
10.3
9.6
8.5
8.2
Hospital spending
4.1
4.4
4.6
5.3
Infant mortality
20% improvement
(all provinces)
( )
14% worsening
(22 of 26 provinces)
Source: Simms C, Rowson M. Reassessment of health effects of the Indonesian economic crisis: donors versus the data. Lancet 2003; 361(9366):
*constant Indonesian rupiah, in billions
Source: Simms & Rowson, Lancet 2003; 361:
Starfield 05/03
03-115
Starfield 05/03
WC 2499

20. Primary Care Score and Self-Rated Health, Petrópolis, Brazil, 2004*
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Primary Care Score and Self-Rated Health, Petrópolis, Brazil, 2004*
(n=455)
Odds Ratio
95% CI**
Primary care score (0-5)
1.452
1.073, 1.966
Age (years)
0.969
0.957, 0.981
Chronic disease (yes/no)
0.578
0.360, 0.927
Recent illness (yes/no)
0.176
0.098, 0.316
Household wealth (scale 1-8)
1.219
1.007, 1.476
Completed primary school
0.733
0.374, 1.437
Clinic type
(0=traditional; 1=PSF)
0.998
0.594, 1.679
Source: Macinko J, Almeida C, Sa P. Evaluating primary care services in Brazil: a rapid appraisal methodology. Submitted 2005.
*1= excellent/ good health; 0=bad/fair/poor health
** standard errors adjusted for clustering by clinic
Starfield 06/04
WC 2896
Starfield 06/04
04-126
Source: Macinko et al, submitted 2005.

21. Association between High Satisfaction with Practitioner at the Most Recent Visit, Porto Alegre, 2002
Variables
Odds Ratio (IC 95%)*
Child hospitalized in past year
0.54 (0.31 – 0.96)
Mother works outside the home
1.50 (1.02 – 2.20)
Practitioner works in primary care setting
2.11 (1.30 – 3.41)
High primary score of practice
5.13 (3.08 – 8.56)
* Logistic regression
Starfield 08/05
WC 3246
Source: Harzheim E, 2004.

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From 1990 to 2002, infant mortality in Brazilian states (27) declined from 50 to 29 per 1000 live births, during a time when coverage of the primary-care oriented Family Health Program coverage increased from 0 to 36%. Family Health Program coverage was associated with a 4.5% decrease the in infant mortality rate, a two-thirds decrease in child deaths from diarrhea, and a halving of child deaths from acute respiratory illness, controlling for access to clean water, adequacy of sanitation, income per capita, women’s development indicators, and supply of physicians, nurses, and hospital beds.
Source: Macinko J, Guanais FC, de Fatima M, de Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, J Epidemiol Community Health 2006; 60(1):13-19.
Starfield 03/06
WC 3388
Source: Macinko et al, J Epidemiol Community Health 2006; 60:13-9.

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Many other studies done WITHIN countries, both industrial and developing, show that areas with better primary care have better health outcomes, including total mortality rates, heart disease, mortality rates, and infant mortality, and earlier detection of cancers such as colorectal cancer, breast cancer, uterine/cervical cancer, and melanoma. The opposite is the case for higher specialist supply, which is associated with worse outcomes.
Source: Starfield B. The primacy of primary care in health services systems. accessed September 29, 2004.
Starfield 09/04
WC 2957
Starfield 09/04
04-167
Source: Starfield B.

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In both England and the US, each additional primary care physician per 10,000 population (a 12-20% increase) is associated with a decrease in mortality of 3-10%, depending on the cause of death. This is true even after adjusting for sociodemographic and socioeconomic characteristics.
Source: Gulliford MC. Availability of primary care doctors and population health in England: is there an association? J Public Health Med 2002; 24(4):
Source: Gulliford, J Public Health Med 2002; 24:252-4, and personal communication 9/04.
Starfield 03/05
WC 3102

25. Source: Franks & Fiscella, J Fam Pract 1998; 47:105-9.
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Health Care Expenditures and Mortality 5 Year Followup: United States,
Adults (age 25 and older) with a primary care physician rather than a specialist as their personal physician
had 33% lower cost of care
were 19% less likely to die (after controlling for age, gender, income, insurance, smoking, perceived health (SF-36) and 11 major health conditions)
Source: Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. J Fam Pract 1998; 47(2):
Starfield 05/99
WC 1504
Starfield 1999
99-096
Source: Franks & Fiscella, J Fam Pract 1998; 47:105-9.

26. Major Determinants of Outcomes*: 50 US States
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Major Determinants of Outcomes*: 50 US States
Specialty physicians: More: all outcomes worse
Primary care physicians: Fewer: all outcomes worse
Hospital beds: More: higher total, heart disease, and neonatal mortality
Education: No relationship
Income: Lower: higher heart and cancer mortality
Unemployment: Higher: higher total mortality, lower life span, more low
birth weight
Urban: Lower mortality (all), longer life span
Pollution: Higher total mortality
Life style: Worse: higher total and cancer mortality, lower life span
Minority: Higher total mortality, neonatal mortality, low birth weight, lower life span
Note: All variables are ecologic, not individual.
*Overall mortality; mortality from heart disease, mortality from cancer, neonatal mortality, life span,
low birth weight.
Source: Shi L. Primary care, specialty care, and life chances. Int J Health Serv 1994; 24(3):
Starfield 1997
IH 1067
Starfield 1997
97-125
Source: Shi, Int J Health Serv 1994; 24:

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The Regional Primary Care and Specialty Physician Supply and Odds of Late-stage Diagnosis of Colorectal Cancer
Primary Care
Specialists
Percentiles 10 20 30 40 50 60 70 80 90
100
1.6
1.4
1.2 1
0.8
0.6
0.2
0.4
Odds Ratios
Source: Roetzheim RG, Pal N, Gonzalez EC, Ferrante JM, Van Durme DJ, Ayanian JZ et al. The effects of physician supply on the early detection of colorectal cancer. J Fam Pract 1999; 48(11):
Starfield 08/02
02-154
Starfield 08/02
WC 2179
Source: Roetzheim et al, J Fam Pract 1999; 48:850-8.

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Early detection of breast cancer is greater when the supply of primary care physicians is higher. Each tenth percentile increase in primary care physician supply is associated with a statistically significant 4% increase in the likelihood of EARLY (rather than late) stage diagnosis.
Source: Ferrante JM, Gonzalez EC, Pal N, Roetzheim RG. Effects of physician supply on early detection of breast cancer. J Am Board Fam Pract 2000; 13(6):
Starfield 09/04
WC 2960
Starfield 09/04
04-139
Source: Ferrante et al, J Am Board Fam Pract 2000; 13:

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For cervical cancer, rates of incidence of advanced stage presentation are lower in areas that are well-supplied with family physicians, but there is no advantage of having a greater supply of specialist physicians, either in total or for obstetrician/gynecologists.
Source: Campbell RJ, Ramirez AM, Perez K, Roetzheim RG. Cervical cancer rates and the supply of primary care physicians in Florida. Fam Med 2003; 35(1):60-64.
Starfield 09/04
WC 2961
Starfield 09/04
04-140
Source: Campbell et al, Fam Med 2003; 35:60-4.

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Melanoma is identified at an earlier stage in areas where the supply of family physicians is high, both in urban areas and non-urban areas. The same is the case for dermatologists, but the relationship is not statistically significant, and there is no relationship of early detection with the supply of other specialists.
Source: Roetzheim RG, Pal N, Van Durme DJ, Wathington D, Ferrante JM, Gonzalez EC et al. Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection. J Am Acad Dermatol 2000; 43(2 Pt 1):
Starfield 09/04
WC 2962
Starfield 10/04
04-249
Source: Roetzheim et al, J Am Acad Dermatol 2000; 43:211-8.

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Above a certain level of specialist supply, the more specialists per population, the worse the outcomes.
In 35 analyses dealing with differences between types of areas (7) and 5 rates of mortality (total, heart, cancer, stroke, infant), the greater the primary care physician supply, the lower the mortality for 28. The higher the specialist ratio, the higher the mortality in 25.
Source: Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The relationship between primary care, income inequality, and mortality in US States, J Am Board Fam Pract 2003; 16(5):
Controlled only for income inequality
Source: Shi et al, J Am Board Fam Pract 2003; 16:
Starfield 08/05
SP 3256

32. What We Already Know A primary care oriented system is important for
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What We Already Know
A primary care oriented system is important for
Improving health (improving effectiveness)
Keeping costs manageable (improving efficiency)
Starfield 09/05
PC 3316

33. Does primary care reduce inequity in health?
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Does primary care reduce inequity in health?
Starfield 09/04
EQ 2966
Starfield 09/04
04-142

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Equity in health is the absence of systematic and potentially remediable differences in one or more aspects of health across population groups defined geographically, demographically, or socially.
Starfield 04/04
EQ 2820
Starfield 04/04
04-050
Source:

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Low Birth Weight among US Rural, Urban, and Primary Care Health Center Infants
8.8
7.5
6.8
6.0
13.6
10.4
13.0
7.4
US urban infants
Urban health center infants infants
US rural infants
Rural health center infants
African American urban infants
African American urban health center infants
African American rural infants
African American rural health center infants
14.0
0.0
12.0
10.0
2.0
4.0
8.0
Geographic area
Source: Politzer RM, Yoon J, Shi L, Hughes RG, Regan J, Gaston MH. Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care. Med Care Res Rev 2001; 58(2):
Racial composition
Starfield 10/03
03-257
Starfield 10/03
WC 2637
Source: Politzer et al, Med Care Res Rev 2001; 58:

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In the United States, an increase of 1 primary care doctor is associated with 1.44 fewer deaths per 10,000 population. The association of primary care with decreased mortality is greater in the African-American population than in the white population.
Source: Shi L, Macinko J, Starfield B, Politzer R, Xu J. Primary care, race, and mortality in US states. Soc Sci Med 2005; 61(1):65-75.
Starfield 06/05
WC 3216
Source: Shi et al, Soc Sci Med 2005; 61(1):65-75.

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Primary Care Reform, to , Percent Decline in Mortality - Various Causes, Barcelona, Spain
Source: Villalbi JR, Guarga A, Pasarin MI, Gil M, Borrell C, Ferran M et al. An evaluation of the impact of primary care reform on health. Aten Primaria 1999; 24(8):
Starfield 11/00
WC 1800
Starfield 2000
00-131
Source: Villalbi et al, Aten Primaria 1999; 24:

38. Does Primary Care Reduce Inequity in Health in Developing Countries?
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Does Primary Care Reduce Inequity in Health in Developing Countries?
So far, the evidence for the benefits of primary care has come from industrialized countries. What about developing countries? Although there have been very few studies of this subject in developing countries, the conclusion is the same: better primary health care, more equity in health services and health outcomes.
Starfield 09/04
04-147
Starfield 09/04
EQ 2969

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In 7 African countries
The highest 1/5 of the population receives well over twice as much financial benefit from overall government health spending (30% vs 12%).
For primary care, the poor/rich benefit ratio is much lower (23% vs 15%).
Sources:
Gwatkin DR. The need for equity-oriented health sector reforms. Int J Epidemiol 2001; 30(4):
Castro-Leal F, Dayton J, Demery L, Mehra K. Public spending on health care in Africa: do the poor benefit? Bull World Health Organ 2000; 78(1):66-74.
“From an equity perspective, the move toward primary care represents a clear step in the right direction.”
Source: Gwatkin, Int J Epidemiol 2001; 30:720-3, based on Castro-Leal et al, Bull World Health Organ 2000; 78:66-74.
Starfield 03/04
04-023
Starfield 03/04
IC 2793

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Studies in other developing and middle income countries also show benefit from primary care reform.
In Bolivia, reform in deprived areas lowered under-5 mortality rates compared with comparison areas.
In Costa Rica, primary care reforms in the 1990s decreased infant mortality and increased life expectancy to rates comparable to those in industrialized countries.
In Mexico, improvements in primary care practices reduced child mortality in socially deprived areas.
Sources:
Perry H, Robison N, Chavez D, Taja O, Hilari C, Shanklin D et al. The census-based, impact-oriented approach: its effectiveness in promoting child health in Bolivia. Health Policy Plann 1998; 13(2):
Reyes H, Perez-Cuevas R, Salmeron J, Tome P, Guiscafre H, Gutierrez G. Infant mortality due to acute respiratory infections: the influence of primary care processes. Health Policy Plann 1997; 12(3):
Rosero-Bixby L. Evaluación del impacto de la reforma del sector de la salud en Costa Rica mediante un estudio cuasiexperimental. Rev Panam Salud Publica 2004; 15(2):
Rosero-Bixby L. Spatial access to health care in Costa Rica and its equity: a GIS-based study. Soc Sci Med 2004; 58(7):
Sources: Perry et al, Health Policy Plann 1998; 13:140-51; Reyes et al, Health Policy Plann 1997; 12:214-23; Rosero-Bixby, Rev Panam Salud Publica 2004; 15:94-103; Rosero-Bixby, Soc Sci Med 2004; 58:
Starfield 08/05
IC 3248

41. Additional children lost per 1000
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Share of Public Spending on Health among Countries with Similar GNP per Capita But Very Disparate Child Survival (to Age 5) Rates, 1995
Ratio*: percent of expenditures for health from the government to poorest 20% vs. richest 20% of population
High child survival
Low child survival
Additional children lost per 1000
Sri Lanka
1.1
Ivory Coast
0.3
150
Malaysia
2.6
Brazil
0.4 45
Costa Rica
2.1
South Africa
0.9 55
Jamaica
3.3
Ecuador
0.2 25
Nicaragua
1.0
India 50
Egypt
0.6
100
Sources:
Karolinska Institute. Global health chart, accessed September 29, 2004.
Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003; 362(9379):
Castro-Leal F, Dayton J, Demery L, Mehra K. Public spending on health care in Africa: do the poor benefit? Bull World Health Organ 2000; 78(1):66-74.
Carr D. Improving the Health of the World's Poorest People. Health Bulletin #1. Washington, DC: Population Health Bureau, 2004.
*Ratios of one or more signify a greater share of government expenditures to poorest segment of population.
Sources: Calculated from Karolinska Institute, Global health chart, Victora et al, Lancet 2003; 362: Castro-Leal et al, Bull World Health Organ 2000; 78: Carr. Improving the Health of the World's Poorest People. Population Health Bureau, 2004.
Starfield 04/04
04-084
Starfield 04/04
IC 2854

42. Primary Care and Health: Evidence-Based Summary
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Primary Care and Health: Evidence-Based Summary
Countries with strong primary care
have lower overall costs
generally have healthier populations
Within countries
areas with higher primary care physician availability (but NOT specialist availability) have healthier populations
more primary care physician availability reduces the adverse effects of social inequality
Starfield 09/02
PC 2214
Starfield 09/02
02-161

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Conclusion
Virchow said that medicine is a social science and politics is medicine on a grand scale.
Along with improved social and environmental conditions as a result of public health and social policies, primary care is an important aspect of policy to achieve effectiveness, efficacy, and equity in health services.
Starfield 03/05
PC 3112

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Conclusion
Although sociodemographic factors undoubtedly influence health, a primary care oriented health system is a highly relevant policy strategy because its effect is clear and relatively rapid, particularly concerning prevention of the progression of illness and effects of injury, especially at younger ages.
Starfield 11/05
HS 3329