PHC encompasses a broad spectrum of activities to encourage health and wellbeing. These can include primary (initial) care and include follow-up activities for promoting the health of the community, protecting community members from harm, and/or preventing illness or injury. Importantly, the ultimate goal of PHC is to build community capacity to enable sustainable health and wellbeing. Community capacity building is based on the fundamental values of equity, community participation and self-determination, which embody human rights and shared social expectations (WHO 2008).

Two types of PHC have been described in the literature. ‘Selective primary health care’ is a term that emerged in the 1980s under neoliberal economic policies that emphasised medical and technical solutions to health problems (Baum 2007; deVos et al 2009). Health was seen as an investment, and selective PHC was aimed at ‘best investments in health’; ensuring that the health care system funded programs that would have a significant effect on certain groups in the population. The language of selective PHC was typical of the economic policies of the time. Certain population groups were seen as ‘targets’. Health care was ‘outcome focused’. Health planning was ‘target oriented’, and success was defined in terms of concrete health improvements linked to specific expenditures (deVos et al 2009:122). Selective PHC did not build sustainable communities, but led to fragmentation of services, draining expertise and resources (Baum 2007). However, today, selective PHC is seen as focusing on a specific group with high priority needs within the broader context of comprehensive PHC (Baum et al 2009).

‘Comprehensive primary health care’ adopts a community development approach, which is more closely aligned with the social justice agenda. Comprehensive PHC revolves around an empowerment framework, where community members work in partnership with health professionals to participate fully in health decision-making (Baum, 2007, Baum et al., 2009 and deVos P, et al 2009). This shifts the agenda from professional control over decisions about priorities and resources, to one where community empowerment is the main objective. Members of the community are not beneficiaries of health services, but rather have the power to control resources and how they are distributed, which is aimed at creating equitable conditions (Baum 2007; deVos et al 2009). Throughout this text PHC will refer to comprehensive PHC.

As mentioned previously, prevention is a major focus of PHC. Leavell and Clark’s (1965) three levels of prevention are widely accepted as encompassing the range of activities involved in preventing illness or injury. These levels, primary prevention, secondary prevention and tertiary prevention, distinguish between strategies aimed at maintaining health and wellbeing and preventing illness (primary), treating and limiting illness or injury (secondary), and rehabilitative or restorative actions (tertiary). The aim of primary prevention is to promote health by removing the precipitating causes and determinants of ill health or injury. This can include vaccinating children against communicable diseases, health education and promotion of healthy lifestyles in areas such as personal nutrition, rest, exercise and companionship, and protecting the physical, social and cultural environments. Secondary prevention usually refers to steps taken to recover from illness, to guard against any deterioration in health, screening for early detection and treatment of disease, and any measures to limit disability. Tertiary prevention is restorative. Programs revolve around rehabilitation, transitions to community care and education for industry support programs (Leavell & Clark 1965).

Conceptualising health professionals’ activities across these three levels indicates a holistic, PHC approach that can be applied across the life span. The metaphor of a waterfall illustrates. Primary prevention activities at the community level are ‘upstream’ actions, such as developing educational materials to portray the benefits of nutrition or regular exercise to help individuals stay healthy. Besides offering encouragement for healthy lifestyles, primary prevention includes lobbying the local council or government agencies to create the conditions that support community health and development. This type of activity might include helping secure cost-effective foods or safe spaces for children to play. Secondary, or ‘midstream’, prevention includes such preventative activities as screening for skin cancer, conducting mammography clinics, or establishing drop-in centres for adolescents or isolated older people. Tertiary prevention occurs ‘downstream’ and typically involves providing assistance or information to help people cope with a potentially disabling condition. This could involve the establishment of walking programs for those who have had a cardiac incident, support groups for family members coping with a loss, or any measure that helps ensure continuity of care and health literacy, such as access to timely health advice (see Figure 2.1).

When people require health care because of injury or illness, the first line of care is primary. So primary care is the initial decision as to what must be done and it usually guides the subsequent management of a person’s condition or needs. Primary care may involve only one intervention, or treatment over an extended period of time, but it is still primary, in that it is aimed at helping people with whatever problem required care in the first place. Physicians, nurses, paramedics, dentists, physiotherapists, complementary therapists and a range of other health professionals may provide the initial care.

An ambulance officer or paramedic may be first on the scene to deal with a road accident or injury; a physical education teacher, trainer or school nurse may be the first line of care in the recreational setting. Each would provide care and then would likely refer the person needing assistance to a physician who would assume the role of primary care provider. Paramedics, by nature of their role in responding to emergencies are quite often the primary care providers, usually in a life-saving capacity.

Similarly, nurses in a hospital emergency department or in a community clinic may provide initial treatment for an emergency, then either refer the patient to the local medical practitioner to manage the condition, or manage it themselves, depending on the situation. In the latter case, the nurse would be acting as a primary care provider. This role is often enacted by nurses and nurse practitioners in remote locations where there is no medical practitioner. There is also some discussion internationally regarding an expanded paramedic role. Given that paramedics often follow up primary care by providing care in a person’s home, there is growing acceptance of reframing the role of the ‘paramedic practitioner’ who provides a brief initial intervention and then appropriate referral (Stirling et al., 2007 and Woollard, 2006).

Another situation where someone other than a medical practitioner acts as primary care provider is in the workplace. Many manufacturing and mining companies, for example, employ nurses or other health professionals to manage occupational health and safety. For some workplace-based problems, the occupational health professional may be the most appropriate and available person to provide primary care. However, in addition to primary care, this role differs from the paramedic role in that it extends beyond ‘nursing in the community’ to ‘nursing the community’, as we mentioned in Chapter 1. Whereas the paramedic or other emergency personnel provide acute and sometimes ongoing care ‘in the community’, the occupational health nurse provides care of the occupational environment as well, which is ‘nursing the community’. This role will be elaborated on further in Chapter 4.

The model of primary care most people encounter is that of general practice. Most general practitioners (GPs) provide primary care and variable levels of follow-up of patients and families, depending on many factors. These factors include the time pressures of the practice, especially where there are staff shortages, demand and preferences of the practice clients, and the health care system in which the practice operates. In some countries such as Australia and Canada, general practice operates on a ‘fee-for-service’ basis, with reimbursement from Medicare for episodes of care.

This system has been described as creating a perverse incentive to provide more, rather than more comprehensive services, because the financial rewards flow from the number of care episodes rather than the quality of care (Australian Nursing Federation [ANF] 2009). In other countries, such as the United Kingdom, primary care is provided under a ‘capitation’ system, where the practice is paid on the basis of the number and type of people enrolled in a practice, or group of practices. In New Zealand, primary care is provided under a mixed system with ‘capitation’ covering most services but with many general practices still charging a fee-for-service to cover the shortfall in capitation funding. As in Australia, general practice in New Zealand is still largely run under a business model and fees for service vary widely. However, when funding is provided on a ‘per capita’ or population basis, as it is in New Zealand, there is a greater likelihood of comprehensive, multidisciplinary, integrated PHC. For this reason, the worldwide trend towards PHC is gradually creating an impetus for general practice to change to this system (Martin 2008; WHO 2008).

Nurses and midwives in Australia and New Zealand play an important role in the PHC movement. New Zealand was one of the first countries to make a national commitment to PHC (Ministry of Health New Zealand [MOHNZ] 2001), and New Zealand nurses worked hard to ensure their role was clearly identified as crucial to enactment of the new strategy. Evaluation of nursing developments since implementation demonstrate that, despite a range of barriers, there has been substantial growth in some nursing roles and capability in PHC (Finlayson et al 2009). As New Zealand nurses seek out opportunities for improving population health under the PHC strategy’s new funding streams, New Zealand is slowly seeing increasing numbers of nurse-led initiatives in PHC. These include a shift to name all nurses working in PHC ‘primary health care nurses’, increasing numbers of nurse practitioners working in PHC and increasing numbers of nurse-led clinics.

In Australia, recent government policy changes have recognised the important role of practice nurses in broadening primary care to PHC (Halcomb et al 2008). Similar examples of this trend are evident in countries such as Canada, with models of collaborative general practice between GPs and nurses effectively ‘infusing primary care principles in the delivery of PHC’ (Besner 2004:356). These initiatives are consonant with the recommendations of the WHO (2008) that care should be brought closer to people, relocating entry points from hospitals and specialist services to generalist, primary care centres aimed at improving coordination of care.

Population health is similar to public health in that it is:

The distinctions between public health, population health and PHC illustrate how the ideas of health planners and policy-makers have changed over time. Although the focus of public health has always been to ensure the highest level of health for the greatest number of the population, historically, public health has been about illness, not health. From the 19th century, public health authorities adopted a regulatory approach of surveillance and control to overcome infectious diseases. They tracked epidemics or potential epidemics, and ensured that government regulations were in place for monitoring illness in the population and responding quickly when it was required.

Public health was therefore defined according to a biomedical model where the emphasis was on understanding the causes of illness in order to apportion resources appropriately. In the biomedical model the public health focus is on midstream (interventions) and downstream (rehabilitation) activities to manage epidemics and protect people, rather than promote health. This resulted in concentrating resources in hospitals and acute-sector services (Bernier 2005). However, the current focus revolves around the SDOH and how these affect the population. This approach has become incorporated into social epidemiological models of health planning, which will be further explained in Chapter 3.

In the biomedical public health era, public health experts were guided by current medical knowledge, political factors and the availability of financial and personal resources. So, for example, in those parts of the world where health personnel and resources were plentiful, people were expected to have higher levels of health. Where vaccines were available and where the politics of the day encouraged medical research through generous funding schemes, diseases should be curtailed. Members of the public rarely questioned the medical experts on any of these public health matters. Yet, no relationship was found between good health and the provision of services. Clearly, there was a need to look for a broader set of criteria for good health.

In 1978 an important international meeting among members of 189 countries culminated in the Declaration of Alma Ata, named after the city in the former USSR where the meeting took place. The Declaration was the first global proclamation that a broader perspective of health was needed to galvanise the efforts of health planners around the world to meet current and future challenges. PHC was declared as the roadmap to achieving better health for all populations. The architects of the Declaration found no opposition to this approach among health professionals.

Four years earlier, the Lalonde Report in Canada had suggested a more socially contextualised definition of health, including strategies for achieving health that placed less onus on individuals and more emphasis on creating the right conditions in their environments (Lalonde 1974). PHC embodied this idea. It was not only a vision for health, it was seen as a philosophy permeating the entire health system, a strategy for organising care, a level of care (primary or ‘first line’ of care) and a set of activities (Chamberlain & Beckingham 1987).

The Declaration of Alma Ata represented a watershed in public health. Its focus was on empowering people to have control over decisions that affected health in their own families and communities. The PHC approach conceptualised health as a fundamental right, an individual and collective responsibility, an equal opportunity concept and an essential element of socio-economic development (Holzemer 1992). This represented a stark contrast to the historical ‘top-down’ approach to planning for public health in that people at the grassroots level of societies were now to have a greater say in planning from the ‘bottom-up’, or ‘inside out’ instead of ‘outside in’ (Courtney 1995). The PHC approach has been described as keeping health professionals on tap rather than on top; acting as a resource to the community (Baum 2007).