Primary Health Care Models: A Review of the International Literature

A common element in many countries’ health system reform agenda is an emphasis on changes to the organization, financing and delivery of primary health care. Numerous objectives for primary health care reform have been cited in jurisdictions around the world with different approaches being taken toward achieving stated objectives. This paper reviews the literature which has described and evaluated experiences with different primary health care delivery models in Canadian and other jurisdictions. Models reviewed were categorized by dominant service provider (e.g., nurse-centred, physician-centred, collaborative). In addition to reviewing the literature on delivery models, literature was also reviewed which described or evaluated experiences with various characteristics of primary health care delivery models including: responsiveness to community needs, collaboration between health care providers, integration and coordination, provider payment, and management and accountability structures. Few delivery models exist in jurisdictions around the world. The physician-centred model is the predominant mode of primary health care delivery in the developed world. Health centres exist in many jurisdictions and are widely supported as a desirable model of health care delivery. Nurse-managed models are the least prevalent form of primary health care delivery in the developed world. There is an abundance of descriptive literature and a paucity of evaluation literature on primary health care delivery models. Most evaluation studies are moderate to weak in their methodological rigour and results are often limited in their generalizability to other settings. Although the research evidence does not point to an “ideal” model, there is evidence to suggest that certain directions for reform are more appropriate than others. These include multidisciplinary group practice, payment of providers on other than an exclusive fee-for-service basis, and increased accountability for the provision of care and services to defined population through practice registration. The paucity of rigorous evaluation research in such a broad policy area as primary health care delivery is striking. Whatever policies are contemplated for the reform of primary health care systems’ around the world, their implementation should be considered in the context of a strong policy-informing research agenda.