Key messages
• Most primary health care services have focused on treating illnesses as and when they
arise rather than on the prevention of disease.
• Most health systems are based on an outdated “disease model”, which cannot meet the
individual and community health needs of the populations in today’s rapidly changing
world.
• With advances in interventional public health, personal and community services need to
be provided through an integrated service.
• Ageing, population growth, the rising burden of noncommunicable disease and
technological advances are driving the transformation of primary care.
• A comprehensive primary care that reaches everyone is the cornerstone of achieving
universal health coverage: “leave no one behind”.
• Securing the health of the whole population cannot be attained without universal
coverage achieved through effective comprehensive primary health care that focuses not
only on disease but also on health and how to improve it.
• Strengthening public health with universal coverage and access to all, irrespective of their
ability to pay for it, should be the aim of all modern health systems.
• The six models of integration described in this report provide an opportunity to focus
service around the population needs to improve health and longevity.
Introduction
The joint WHO-UNICEF vision for primary health care in
the 21st century in support of the Global Conference on
Primary Health Care on 25–26 October 2018 defines primary
health care as a “whole-of-society approach” to maximize the level
and distribution of health and well-being by acting simultaneously on
three components: 1) primary care and essential public health functions as
the core of integrated health services, 2) multisectoral policy and action, and 3)
empowerment of people and communities. Primary health care has been shown
to be the most equitable, effective, and cost-effective way to enhance the health of
populations.
To effectively implement the first component requires understanding how to effectively
integrate health services. Integrated health services respond to the needs of individuals and
populations and deliver comprehensive good-quality services throughout the life course
through multidisciplinary teams who work together across settings and use evidence and
feedback loops to continuously improve performance. Integrated health services, when based
on strong primary care and essential public health functions, strengthen people-centred
health systems and contribute to the best use of resources.
This working definition of integration is anchored in the principles set out in the health-for-
all agenda and vision for primary health care (1). It adopts a health system perspective that
acknowledges the importance of the alignment of all health system functions and effective
change management for integrated care to be achieved (2,3).
New challenges and demands in the 21st
century
In many countries, ageing populations and the growing burden of long-term chronic illness
and multiple morbidities cause current health care systems struggle to effectively meet the
rising demands for care. The cumulative effect of a number of sociodemographic, economic
and environmental changes as well as rising care expectations have placed new demands
on health services to deliver care that is proactive rather than reactive, comprehensive and
continuous rather than episodic and disease-specific, and that is built on sustainable patient-
provider relationships rather than incidental, provider-led care. Existing fragmentation is
the result of over-medicalization, excessive subspecialization, and separate vertical disease-
oriented curative models of care. Such fragmented approaches reduce the capacity of the
health system to provide continuity of care, which leads to difficulties in timely access to care,
the delivery of poor-quality services, duplication of efforts and inefficient use of resources.
These approaches also create low service-user satisfaction and gaps in care for patients with
multimorbidities (4–8).
An aligned response across the health system is needed to improve integration in order
to overcome these challenges (9). Such a response can generate significant benefits in all
countries.
1