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12. How would you define primary, secondary and tertiary healthcare?

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PRIMARY CARE and primary health care refer both to a level of care and a strategy for organizing health systems. The 1978 Alma-Ata Declaration offers a description of primary health care. It

  • addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services; [and]

  • includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs; involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors—Section VII: 2-4.

A health worker immunizes a child with polio vaccine during immunization week in northeast India.
© 2006 Dr. Sanjeev Badiger, Courtesy of Photoshare

Primary care, according to Barbara Starfield, 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.” Thus, it includes prevention efforts aimed at both the population and individual level as well as curative care provided to individuals and their families.

SECONDARY CARE is generally described as medical care provided to individuals by physicians with specialized medical training that focuses on specific organs or diseases, e.g., cardiology, neurology, or oncology. It also includes special diagnostic and therapeutic services such as biopsy or dialysis. Often people come in contact with secondary care specialists through a recommendation from their primary care provider.

TERTIARY CARE is medical care given by providers in a specialized medical facility, e.g. a hospital, with more advanced diagnostic and treatment technology than is generally available elsewhere.

Of note are other critical elements of a HEALTH SYSTEM that support the delivery of personalized medical care. These include enabling services such as health insurance, which facilitates people’s ability to pay for needed care; and population-based services, such as health promotion and legislation designed to disseminate important health information and to ensure that environmental health risks are minimized. Infrastructure services ensure that basic systems are in place to provide clean water, build and maintain health facilities and equipment, and supply adequate training of healthcare providers over time.

Figure 1

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12b. Which type of health service has the greatest impact on population health?




All levels of care are essential for the health system to meet its objective of improving population health. However, there is a robust body of evidence showing that health systems with a strong basis in primary care have better outcomes that those that do not. (See B. Starfield, L. Shi & J. Macinko (2005). Primary care impact on health outcomes: A literature review. Milbank Quarterly 83(3): 457-502.

There are several reasons why primary care is thought to be so important for strong health systems, including: (1) primary care enhances access to needed services; (2) an emphasis on primary care promotes better quality of care and enhanced patient understanding of provider recommendations; (3) primary care may enhance focus on the prevention and early management of health problems over the life course; (4) the cumulative effect of primary care delivery characteristics, including the long-term development of a relationship with a healthcare provider, provision of whole-person comprehensive care, and care that is coordinated among different providers and healthcare services; (6) primary care can reduce unnecessary and potentially harmful specialist care. Obviously, for the health system to function well, each level of care needs to be accessible and/or of good quality.

A mother and grandmother bring their baby, sick with malaria, to Sherpur Sadar Hospital, Bangladesh.

© 2007 Mohammad Rakibul Hasan, Courtesy of Photoshare


The figure below illustrates rates of potential years of life lost (PYLL) among 18 OECD countries. PYLL is an indicator that tells us how well the health system is doing in eliminating causes of premature death – deaths for which there exist adequate preventive and curative measures. Therefore, lower rates are better than higher rates. The data are presented as “predicted probabilities,” that is, rates that have been adjusted for the determinants of health status in these countries: the log gross domestic product (GDP) per capita, the percent of the population that is elderly, the number of doctors per capita, the log average income (ppp-adjusted), the log of public expenditures on health, the number doctor visits per capita, and alcohol and tobacco use.

The upper (red) line shows these rates for countries whose primary care systems were assessed as being weak. The (lower) blue line represents countries with strong primary care systems. (For an explanation of the methods used to rate the primary care systems, see J. Macinko, B. Starfield, and L. Shi (2003). The contribution of primary care systems to health outcomes in OECD countries, 1970-1998. Health Services Research 38 (3): 819-854.) Both lines make clear that after taking other factors into consideration, countries with more effective primary care are better able to reduce unnecessary deaths over time.

Figure 2

The health system also needs to integrate person (medical) care with population-level interventions. Alma Ata’s definition of primary health care encompasses attention to the determinants of health outcomes, including access to clean water and sanitation systems; improved education; safe housing; and health, workplace and food safety systems, among others. The current director-general of WHO, Dr. Margaret Chan, has refocused attention on primary health care as a priority.

This renewed emphasis is important since what are often labeled as “personal behavior” choices are strongly influenced by the physical and social structure of our environment. So interventions must go beyond health education and encompasses policies and programs that alter the social and physical environment to reduce harm and enhance people’s ability to take control of their own health. A New York City response that follows this approach is their “Green Carts” initiative: a population-based intervention to address a structural barrier to health and healthy living.

A health care provider gives an infant the polio drop in Myanmar.
© 2008 Aung Kyaw Tun, Courtesy of Photoshare

(For more on the epidemiological shift from chronic to infectious diseases, see Question 2. For more on the social determinants of health, see Question 13.)



Eldis. Resource Guide: Building future health systems to deliver primary health care.

Issel, L. Michele (2004). Health Program Planning and Evaluation A Practical Systematic Approach for Community Health. Sudbury, MA: Jones and Bartlett Publishers.

Macinko, J., B. Starfield, and L. Shi (2003). The contribution of primary care systems to health outcomes in OECD countries, 1970-1998. Health Services Research 38(3): 819-854.

Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Karen Davis, Kinga Zapert, and Jordan Peugh. “Primary Care and Health System Performance: Adults' Experiences in Five Countries.” Health Affairs (28 October 2004): w4.487-w4.503.

Starfield, Barbara (1998). Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press.

Starfield, B., L. Shi & J. Macinko (2005). "Primary care impact on health outcomes: A literature review." Milbank Quarterly 83(3): 457-502.

World Health Organization World Health Report 2008, Primary health care: Now more than ever.

A Health Nurse cares for a child admitted to the special care unit at Vidisha district hospital. Vidisha is district in Madhya Pradesh, India.
© 2009 Anil Gulati, Courtesy of Photoshare

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