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June 24, 2002 

A Strong Primary Care System Is Good for a Nation's Health

A study by researchers at the Johns Hopkins Bloomberg School of Public Health has demonstrated that the stronger a country’s network of primary care providers, the lower the health care costs and the better a population’s health are generally. Primary care physicians are those who establish long-term personal relationships with patients and coordinate their overall care. The study appeared in the June 2002 issue of Health Policy.

Lead author Barbara Starfield, MD, MPH, University Distinguished Professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, said, “Weak primary care systems have higher health care costs and worse population health outcomes almost across the board.”

Using international data sets from the early and mid-1990s, the researchers characterized 13 industrialized nations, all with populations of at least five million, by the relative strength of their primary care infrastructures. Countries were also ranked as to smoking levels within each population (since smoking is a major behavioral determinant of health, and one that can be influenced by policy interventions) and as to the degree of national income inequality.

The study results indicated that the stronger a country’s orientation towards primary care, the lower the health care costs. Countries with weak primary care infrastructures (e.g., Belgium, France, Germany, and the United States) showed poorer performance on major aspects of health such as life expectancy and child survival. Those nations with the most robust systems of primary care (e.g., Denmark, Finland, Netherlands, Spain, and the United Kingdom) boasted the most favorable health indicators at young ages, and countries that approached them in primary care strength did well at older ages.

The authors also found that a strong primary care system is particularly crucial to the health of children. "Although countries that are intermediate in the strength of their primary care [e.g., Australia, Canada, Japan, and Sweden] generally had levels of health at least as good as those with high levels of primary care, this is not the case in early life, when the impact of strong primary care is greatest," said author Leiyu Shi, DrPH, an associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. Primary care scores, for instance, were highly and significantly related to the postneonatal mortality rate, and inversely related to low birthweight.

Interestingly, the researchers found no consistent relationship between income inequality, smoking, and health levels, as measured by various indicators in different age groups.

The authors stress that a certain level of health care spending may be required to achieve overall good health levels, even in the presence of strong primary care infrastructures. "Very low costs may interfere with achievement of good health, particularly at older ages, although very high levels of costs may signal excessive and potentially health-compromising care," said Starfield.

Five policy-relevant characteristics appear to be related to better population health levels, including efforts to distribute resources to where they are most needed, a government-sponsored national health insurance or system, and low or no cost-sharing for primary care, as well as practice characteristics such as comprehensiveness of primary care services and a family orientation.

"Within the past 15 years, almost all countries have undergone some type of health care reform, mostly directed at conserving costs," notes Starfield. "But except for the general finding that there is little association between costs of a health system and population health, more extensive analyses have not been done. This study indicates that a strong primary-care orientation within health service systems continues to exert a positive effect, particularly for indicators early in life."

This study was supported by the Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services, and the Johns Hopkins University Primary Care Policy Center.

"Policy-Relevant Determinants of Health: An International Perspective" was written by Barbara Starfield and Leiyu Shi.

Public Affairs Media Contact for the Johns Hopkins Bloomberg School of Public Health: Tim Parsons @ 410.955.6878 or