The Tertiary Hospital vs Primary Health Care Debate
By Hao Yi Tan
Integrated Delivery Systems (IDSs) represent a significant potential transformation in healthcare delivery. Different systems adopt varying focal points, with some emphasizing large tertiary hospitals like Massachusetts General-Brigham, while others prioritize primary care.
The Case for Tertiary Hospitals
Historically, the integration of IDSs has revolved around large tertiary hospitals, encompassing physician services, specialty clinics, and post-acute care. These systems excel in providing specialized services, facilitating streamlined access to comprehensive care, enhancing the efficiency of diagnosis and treatment, and ensuring a consistent, evidence-based approach across the network. The proximity to research centers within such hospitals also fosters innovation in patient care.
However, this style of IDS potentially sidelines primary care in favor of focus on specialty hospital. This could lead to a neglect of preventive and chronic disease management, resulting in escalated healthcare costs, especially in rural regions. Moreover, the focus on expensive technology and specialized care within tertiary hospitals can contribute to rising healthcare costs, posing financial challenges for both patients and healthcare systems alike (1).
The Value of Primary of Health Care Centers
On the other hand, Primary Health Care (PHC)-based IDSs are gaining global recognition for their emphasis on preventive and community-level care (2). These systems empower primary care providers, bolster community-based services, improve accessibility, and enhance convenience for patients, potentially leading to long-term cost reductions and addressing healthcare disparities (3).
Nevertheless, PHC-based systems may encounter challenges related to limited access to specialized services and the need for rigorous quality standardization across diverse primary care settings (4). This underscores the importance of implementing robust monitoring mechanisms and ensuring effective data integration to maintain high-quality care delivery standards within such systems.
Global Movement Toward Primary Care
The choice between tertiary hospital-centric and PHC-based IDSs presents a nuanced policy dilemma that demands careful consideration from policymakers. In recent years however, health authorities such as the World Health Organization (WHO) have advocated strongly for a move towards primary care centric systems as the best option (5). According to the WHO, PHC provides 90% of the health services needed across the lifespan of an individual (6).
The evidence supporting PHC based systems is multifaceted. Studies have highlighted correlations between robust primary care and improved health outcomes, including lower mortality rates, decreased hospital admissions, and enhanced chronic disease management (7). Furthermore, investing in early intervention and prevention through primary care has been shown to lead to long-term cost savings by mitigating the necessity for costly specialist interventions (8,9). Additionally, primary care-heavy systems tend to exhibit greater equity and accessibility, thereby enhancing healthcare access for marginalized populations due to their broader geographical coverage and reduced financial barriers.
References
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Columbia University Mailman School of Public Health. Costa Rica | Summary. 2024. https://www.publichealth.columbia.edu/research/others/comparative-health-policy-library/costa-rica-summary (accessed 14 February 2024).
World Health Organization (WHO). Investing in the radical reorientation of health systems towards Primary Health Care: The best and only choice to achieve universal health coverage. 2023. https://www.who.int/news/item/09-11-2023-investing-in-the-radical-reorientation-of-health-systems-towards-primary-health-care--the-best-and-only-choice-to-achieve-universal-health-coverage (accessed 14 February 2024).
USAID. Primary Health Care. 2024. https://www.usaid.gov/global-health/health-systems-innovation/health-systems-strengthening/primary-health-care#:~:text=Primary%20health%20care%20(PHC)%20provides,prevention%2C%20diagnosis%2C%20and%20treatment.
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Friedberg MW, Hussey PS, Schneider EC. Primary care: a critical review of the evidence on quality and costs of health care. Health Affairs 2010; 29(5): 766-72.