Appendix B – Primary Healthcare System in selected places

Over the decades after the Declaration of Alma-Ata in 1978, people are healthier, wealthier and living longer.  However, new challenges such as globalisation, ageing population and urbanisation have made health systems in the world difficult to meet the increasing healthcare demands and changing healthcare needs.  Besides, in many countries, healthcare is still disease-focused, treatment-focused, fragmented and inefficient in service delivery, and the opportunity to work across sectors and programmes, and involve the community in healthcare decision-making is often overlooked.  The concept of PHC has also been repeatedly reinterpreted and redefined, leading to confusion about the term and its practice.  In view of this, WHO proposed reforms for health systems to improve health equity, make health systems people-oriented, promote and protect the health of communities, and make health authorities more reliable in World Health Report 2008: Primary Health Care: Now More Than Ever in 2008.  In 2018, WHO reviewed the lessons learned over the decades and recapped the components of PHC in A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable.

In the 40^th anniversary of the 1978 Declaration, policy makers and health experts met in Astana and developed the Declaration of Astana on Primary Health Care in 2018.  The countries re-affirmed the commitments of health for all and the importance of strengthening PHC for it, and committed to engage multi-sectoral involvement in PHC; strengthen PHC system with policies, investment, knowledge, human resources, technology and financing; empower individuals and communities in health management; and align the supports and joint efforts of the stakeholders.

For effective implementation of PHC, WHO has also promoted district health system since 1980s. District health system is defined as a self-contained segment of the national health system which includes all the relevant healthcare activities and healthcare services in the area, whether governmental or non-governmental. It will be most effective if it is co-ordinated by an appropriately trained district health management team, provides as comprehensive as possible a range of promotive, preventive, curative and rehabilitative health services. Its components include district health office, district hospital or hospitals, health centres, community, neighbourhoods and households, private health sector, NGOs and mission health services.² In 1995, WHO reviewed the experiences of district health system and identified the critical areas for the success of PHC strategy at the district level, including: organisation, planning, and management; finance and resource allocation; information; community involvement in health; intersectoral action; capacity building; institutional strengthening of health centres and district hospital; urban district health systems; and quality assurance.³

COVID-19 pandemic has added to the challenges of chronic disease burdens and the risk factors from ageing population, healthcare accessibility and rising healthcare costs. It is shown that countries with strong PHC systems are more able to maintain access to essential healthcare services and minimise complications and death from COVID-19. Against this backdrop, the WHO Regional Office for the Western Pacific has developed a draft regional framework for PHC in April 2022. 

The proposed strategic directions of the framework included: 

1. creating effective service delivery models appropriate for the local context, including through use of integrated service networks and multi-disciplinary care, empanelment, expansion of service packages, linkages with social welfare services, and leveraging digital technology; 
2. creating a provider and healthcare worker base to align with the needs of communities through optimisation methods like task-shifting, workforce expansion and incentivisation, adapting recruitment, training and education, multi-disciplinary teams, and private sector engagement;  
3. realigning PHC financing with health needs through purchasing reform and benefits design to incentivise primary care and population health, prioritising public financing of PHC and public health, and addressing bottlenecks in public finance management; and  
4. building supportive enabling environments for PHC reform, through revising legal, policy and regulatory frameworks to support integrated and participatory services, strengthening health management and co-ordination, enhancing community participation, establishing monitoring mechanisms for learning and improvement, investing in PHC infrastructure, and facilitating the adoption of digital technology.⁴ 

For OECD countries, OECD examined PHC before and after the COVID-19 pandemic and has identified the key policy challenges and recommended changes in Realising the Potential of Primary Health Care published in 2020. The recommended changes included: new models of care in multiple professional team with the support of digital technology; more economic incentives to encourage teamwork, prevention-oriented and continuity of care; and giving boarder role to patients in management of their health with the support of digital tools. COVID‑19 pandemic stimulates many innovative development in PHC, such as allowing community pharmacists to extend prescriptions and community health workers to provide COVID‑19 information, developing telemedicine services, and providing add-on payments to enhance service delivery.   

A brief introduction on the policy direction, governance, strategic purchasing, service delivery and financing of the PHC in the five selected places, namely, Mainland China, the United Kingdom, Singapore, Australia and New Zealand, is set out at pursuing paragraphs. A table of comparison is also illustrated at Table B.1 below. 

The healthcare system of China is under rapid development in recent years, with emphasis on strengthening PHC system. In 2015, the State Council of China published National Healthcare System Planning Outlines 2015-2020 《全國醫療衛生服務體系規劃綱要 (2015—2020年)》 comprehensively set out the vision and goals of national healthcare system planning with a view to improving healthcare resources allocation, service accessibility, capacity and efficiency, and guiding the implementation of district healthcare development regarding the organisation, resources allocation, infrastructure building, the roles and responsibilities definition of local governments and providers, quality assurance, monitoring and evaluation.⁵ In 2016, the State Council published a healthcare policy paper Healthy China 2030” Planning Outlines 《健康中國2030規劃綱要》, launching the healthcare system development strategies in the later 15 years. The principles include to develop a prevention-oriented, prevention-treatment integrated and Chinese-western medicine integrated healthcare system.⁶ In 2018, the State Council established National Healthcare Commission (國家衛生健康委員會) to formulate national healthcare policies and measures, and oversee and co-ordinate the implementation of the “Healthy China” strategies.⁷ In 2019, a comprehensive action plan covering the actions towards public health education, healthy diet, physical exercise, tobacco control, mental health enhancement, environmental health, the health of women and children, the health of primary and secondary school students, occupational health protection, the health of elderly, cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, infectious diseases and endemic diseases, as well as the supporting systems of management, monitoring and evaluation, supervision and assessment, technical support and publicity for “Healthy China 2030” was prepared.⁸ In the same year, the Standing Committee of the National People's Congress passed the National Basic Healthcare and Health Promotion Law 《中華人民共和國基本醫療衛生與健康促進法》 to facilitate the healthcare and health system development, ensure basic healthcare service for citizens, improve citizens’ health status, and advance the construction of “Healthy China”.⁹ 

In regard to the prevention-oriented healthcare strategies, the “Healthcare-in-Levels (分級診療)” policy is proposed to emphasise community PHC service unit as the first level of contact, to triage preventive and curative care, chronic and acute care and co-ordinate the different levels of healthcare.¹⁰ To strengthen the PHC services, the “Family Doctor Service Agreement (家庭醫生簽約服務)” policy has been promoted since 2016. Each resident is encouraged to contract a service agreement with a family doctor service team with members including family doctor, community nurse and public health practitioners for a package of PHC services, so that each resident can enjoy comprehensive, continuing and co-ordinated healthcare.¹¹ To enhance the capacity of PHC system in the districts, “Healthcare Networks (醫療聯合體)” are established according to the districts’ characteristics under the government’s leadership. The hospitals with more resources, particularly the larger public hospitals, take lead to network with the local PHC units and remote areas. With appropriate referral and collaboration mechanisms, the leading hospital provides management supports, clinical supports and training to member service units, aiming at optimising healthcare resources and enhancing the capacity of PHC, enabling patients with stable and chronic conditions to receive care in PHC or lower level care settings, and providing co-ordinated and continuing healthcare services from prevention, diagnosis, treatment, rehabilitation to long term care. Among the hospitals and PHC units, the roles and responsibilities, benefits distribution mechanism, referral system, and data sharing system for medical appointment, referral, health management and telemedicine are specified and established accordingly.¹² 

Currently, PHC services play an essential role in the healthcare system of Mainland China. In 2021, 94.8 % of the healthcare service units were PHC service units, 50.2% of the total number of medical consultation was in PHC services. Healthcare financial protection has improved since the launch of the National Healthcare System Planning Outlines 2015-2020. As compared with 2015, individual’s out-of-pocket expenditure as a percentage of the national health expenditure decreased from 29.97% to 27.7%; social health expenditure (including social health insurance, enterprise financing/insurance schemes and social institutions financing schemes) increased from 39.15% to 44.9%; and government expenditure decreased from 30.88% to 27.4% in 2021.¹³ PHC teams are being strengthened with general practitioners as the focuses, PHC services improve gradually, and the equity and accessibility of basic healthcare services has been enhanced significantly.¹⁴ 

The National Health Service Act effective in 1948 stated that it should be the Government’s duty to provide free healthcare services to secure the improvement of people’s physical and mental health. The Act brought together a wide range of medical services under one organisation, National Health Service (NHS) has then been established. NHS is a huge organisation mainly funded by government from general taxation, with smaller proportion from National Insurance Contribution and private payment.¹⁵ 

NHS services are mostly free to ordinarily resident. Residents have to register a GP (i.e. family doctor) practice for NHS services. GP, the first point of contact of NHS services, works with a team of nurses, practice managers, healthcare assistants, receptionists and administrative staff in general practice. Pharmacists, occupational therapists, physiotherapists, midwives, district nurses, health visitors and other allied health professionals may be based in the same neighborhood of the GP. GP’s referral is required for NHS specialist and hospital services, except for accessing emergency treatment, sexual health, substance misuse or alcohol services. Patients can book NHS hospital appointments online via the NHS e-Referral Service which covers every hospital and every GP practice. The data collected through e-Referral are used both for treatment cost recovery and service planning, with NHS Digital ensuring the safe and better use of data.¹⁶  

In the community, GPs work together with community services, mental health services, social care, pharmacy, hospital and voluntary services to form a primary care network (PCN), with the lead of clinical director who may be a GP, general practice nurse, clinical pharmacist or other clinical profession working in general practice, enabling greater provision of proactive, personalised, co-ordinated and more integrated health and social care for people close to home. Each PCN usually serves a community of 30 000 to 50 000 people, a population size small enough to provide personal care, and large enough to have impact and economy of scale.¹⁷ Practices are not mandated to join a PCN. However, over 99% GPs have signed up to a PCN. If they do not, they will lose out significant extra funding and their neighboring PCN will be funded to provide services to the patients whose practices are not covered by a PCN.¹⁸

For governance and quality assurance, the Department of Health and Social Care supports the Secretary of State for Health and Social Care and ministers to oversee health and social care policies and NHS service delivery to help people live more independent, healthier lives for longer. The Care Quality Commission (CQC) regulates health and social care services in England including NHS services through monitoring and inspection. CQC awards services a quality rating (four ratings, from Outstanding to Inadequate), which is required to be displayed at service site. Poor performance is liable to fine penalty and cancellation of registration. CQC publishes their inspection reports and views for service improvements on their website.  

Currently, under ageing population, and increasing service demand and health spending, NHS is running huge deficit.¹⁹ The patients are experiencing longer waiting time for healthcare and lowering service quality. In 2014, the Government published a plan to improve primary care with personalised and proactive care for people most in need.²⁰ In 2019, NHS set out a Long Term Plan for healthcare improvement for the next five and ten years. The strategies include to give people more control over their own health and the care they receive, encourage more collaboration in PCNs, increase contribution to some of the most significant causes of ill health, increase the NHS workforce and enhance training, provide more convenient access to services and health information for patients, provide better access to digital tools and patient records for staff, improve on the analysis of patient and population data, reduce duplication in service delivery, and better use NHS’ combined purchasing power to reduce the costs.²¹ Embed the lesson learned from COVID-19 pandemic, Health and Care Act 2022 was enacted in April 2022 to support the effective delivery of the NHS Long Term Plan whilst strengthening democratic accountability through measures including the establishment of statutory Integrated Care Boards (ICBs) and Integrated Care Partnerships (ICPs) in every part of England to improve health and care systems integration and reduce bureaucracy in commissioning.²² 

With financial resources allocated from NHS England, ICBs are responsible for PHC commissioning (a process of service need assessment, planning, purchasing and monitoring), accountable for NHS spend and performance within the system, and have the flexibility to determine the governance structure (e.g. create committees) in their areas. ICP brings together ICBs, NHS providers with local authorities and other local partners to develop strategy for integrated care in the area.²³

The Government on one hand encourages the people to take responsibility for their own health, on the other hand prepares an “S+3M” (i.e. subsidy plus MediShield, MediSave and MediFund) multi-layered healthcare safety net to ensure affordable healthcare for all the people. Under low tax rates, public health expenditure is funded jointly by tax revenue, mandatory health insurance (i.e. MediShield Life, a basic health insurance plan contributed from employers and employees to pay for large hospital bills and selected costly out-patient treatments) and mandatory medical saving schemes (i.e. MediSave, a national savings scheme contributed from a proportion of people’s income for future medical expenses) administered by Central Provident Fund. For patients who face financial difficulties on medical payment after receiving government subsidies and drawing on MediShield Life and MediSave, they can apply for the government endowment fund MediFund.²⁴ 

PHC is the foundation of the healthcare system, patients’ first point of contact in the community. PHC service providers treat acute conditions such as upper respiratory tract infections, manage chronic diseases, provide preventive care such as health screening, co-ordinate patients' care with other providers and support patients to seek appropriate specialised care. PHC services are provided through a network of 23 out-patient polyclinics and private 1 800 GP clinics. Polyclinics provide subsidised primary medical treatment, preventive care and health education. Private GP clinics serve about 80% of the overall primary care attendances, more than half of the patients travel less than 1 kilometer to seek medical care. To support GPs and patients on chronic disease management, the Government has developed five Community Health Centres (CHCs), eight Family Medicine Clinics (FMCs) and ten Primary Care Networks (PCNs). CHCs provide ancillary health services such as DM foot screening, nurse counseling and PT services to support GPs and chronic disease patients. FMCs are multi-doctor practice supported by a team of nurses and allied health professionals. PCNs is a network to support GPs with a team of nurses and care co-ordinators. PCN GPs register patients in a Chronic Disease Registry so that patient’s progress and clinical outcomes are tracked and monitored. Patients would be referred to nurse counsellor and the relevant ancillary services such as Diabetic Foot Screening or Diabetic Retinal Photography if necessary. The electronic health record sharing system HealthHub acts as ‘digital front-door’ of government’s PHC intiatives, facilitates co-ordination among the care providers and enables patient’s access to their family doctor’s care plan, their own medical record and management of their transaction and medical appointment via mobile phone or computer. In view of the ageing population, the Government established Agency for Integrated Care (AIC) in 2009 to co-ordinate elderly care services, and enhance service development and capability building across health and social domains. AIC reach out to elderly and their carers, strengthen partners’ capability to deliver quality care, and bring partners together to meet elderly’s needs.²⁵

As the regional health manager for integrated care, the three healthcare clusters (namely, SingHealth, National University Health System and National Healthcare Group) work with Ministry of Health, operate a range of public hospitals and polyclinics, partner PCN to support private family doctors, bring together healthcare providers and community care partners to look after their region of each with about 1.5 million residents. SingHealth, for instance, is composed of acute hospitals, national specialty centres, community hospitals and polyclinics, collaborating with health and social care sectors in a regional health system. To strengthen community care, registered nurses from hospitals are deployed to Senior Activity Centres to deliver healthcare services in collaboration with medical social workers. Medical social workers work in public hospitals, national specialty centres, polyclinics, community hospitals, nursing homes and hospices in collaboration with healthcare professionals and community partners to provide psychosocial, environmental and financial support to patients and their families, and assist patients to transit to the community smoothly after hospital discharge. Patients support groups are also set up to support patients and caregivers. SingHealth charges on a fee for service basis. The fees on citizens and permanent residents are partly subsidised by government and partly paid by medical savings in Medisave. About half of the operation expenses is covered by government subvention.²⁶ 

The Government and healthcare services encourage patients to visit GP first before going to A&E. A&E attendance fees is round $121 to $160 in Singapore dollar, a rate much higher than in Hong Kong. For non-acute conditions, it would be cheaper and faster to visit a GP or clinic which opens 24-hour or on extended hours daily.²⁷ In 2014, Changi General Hospital piloted a GPFirst Programme to encourage patients with non-emergency conditions to seek treatment at GP rather than A&E. If patients see GPs first and then be referred to A&E, they will be given priority to be seen earlier at A&E, and be given a $50 subsidy in Singapore dollar on their A&E bill to help offset the cost of the GP visit. In view of a reduction of self-referred attendances at A&E, the Government has expanded GPFirst Programme to involve more GPs in more regions.²⁸ 

During COVID-19 pandemic, GPs has served as the first port of call for people in need of healthcare in the community. They deliver vaccination, out-patient consultations, health assessment, and manage home isolation patients together with polyclinics. The pandemic has strengthened the partnership between GPs and public healthcare programme. Leveraging on this foundation, the Government has launched “Healthier SG” strategy to focus on preventive care to address the challenges of ageing population and increasing chronic disease prevalence. With the White Paper on “Healthier SG” passed in October 2022, the national Healthier SG Enrolment Programme will be launched in the second half of 2023. The Programme will be open to residents aged 60 and above first, followed by those aged 40 to 59 in the next two years. Under the Programme, each enrollee will choose to enroll a family doctor/GP clinic, who will develop a care plan with the patient. Enrollee will receive regular scheduled check-ins at least once a year for health assessment, fully subsidised recommended screening and vaccination, partially subsidised chronic disease management, tracking of health results, and lifestyle adjustment advice if necessary. They may record the community activities and physical activities they participated for healthy lifestyle to earn Health Points through Healthy 365 App. The family doctor under the Programme will receive annual service fee on capitation basis and the overall performance of the Programme will be monitored with key performance indicators. To support this, training on community care and family medicine for medical students, doctors, nurses, pharmacists and allied health professionals will be enhanced, data system support and a one-off grant for family doctor’s necessary IT setup will be provided, and new legislation to mandate data governance and contribution of electronic health record to the National Electronic Health Record system will be developed.²⁹  

In Australia, Health Council is the overarching oversight body to shape Australia’s health system and regulate service delivery of all health professionals. Australia is under the challenges of ageing population and higher chronic diseases prevalence. The proportion of population aged 65 years and above was 16.1% in 2020 and more rapid increase is projected for the next decade.³⁰ 47% of the population were estimated to have one or more of the 10 selected chronic conditions in 2020-21.³¹ In view of this, Australia takes a national approach to co-ordinate care through Primary Health Networks (PHNs) and GP-led team in local areas. The Government developed the National Primary Health Care Strategic Framework in 2013 to strengthen the PHC system. Following a review on the traditional government funded services by Medicare Locals, which have confused roles of primary care providers, service co-ordinator and purchaser,³² the Government established 31 PHNs in 2015. The role of PHNs is to commission and co-ordinate services, rather than provide services. PHNs receive funding from the Government to commission services, which is a strategic and evidence-based approach of service planning and purchasing. They establish GP-led Clinical Councils and Community Advisory Committees to include clinicians and the community in their decisions about PHC services. They develop partnerships that bring together different health providers and state and territory-based health authorities to connect different elements of health system for integrated health services. They also work closely with GPs and other PHC providers in local areas to build their capacity, monitor their performance and implement change. Digital health and information sharing systems for providers and patients are developed to support the service integration. PHNs’ seven priority work areas include mental health, Aboriginal and Torres Strait Islander health, population health, digital health, health workforce, aged care, and alcohol and other drugs.³³ 

PHC in the community is the first point of contact of healthcare services in most cases. Services provided include health promotion, prevention and screening, early intervention, treatment and management. GPs play the central role in PHC, working together with nurses, allied health professionals, midwives, pharmacists, dentists, and Aboriginal health workers.³⁴ GP is the gate-keeper of public secondary and tertiary care, GP referral is necessary for specialist services covered by Medicare, Australia's universal health insurance scheme.³⁵ If patients need after-hours GP services, they could call a free government-funded GP helpline. Registered nurse will provide healthcare information and advice. If necessary, a GP will call back in an hour. If call-out services is needed, private after-hours doctor could reach out the community in major cities and centres. 

Australia has a high public expenditure on health³⁶ financed by high tax rates³⁷. Under the coverage of universal health insurance scheme Medicare, residents have access to a wide range of services at low or no cost, including medical services provided by doctors, specialists and other health professionals, hospital treatment and prescription medicines.³⁸ Medicare is financed from taxation revenue and levy. Most taxpayers pay a Medicare Levy of 2% of their taxable income. The Government imposes an extra 1% to 1.5% Medicare Levy Surcharge to the higher income groups if they do not have Private Hospital Cover for additional coverage in private healthcare services.³⁹ 

Australia has a comprehensive list of indicators in the Health Performance Framework to monitor and evaluate the performance of healthcare of different State or Territory across years. The Australia Government analyses the data and reports it publicly on Australia’s Health, providing reference for healthcare decision making.⁴⁰

The Ministry of Health is the Government’s chief strategic advisor and steward of the health and disability system. It appoints statutory advisory committees, regulatory authorities and Crown entities to provide advice on healthcare policies and funding allocation, and regulate the qualities of healthcare and healthcare professionals. The Ministry of Health collects data through established administrative systems and national population health surveys to monitor the health of New Zealanders, manage subsidies and services, and inform policy decisions, etc., and report the performance of the system and providers with health indicators publicly each year.  

With the Pae Ora (Healthy Futures) Act effective on 1 July 2022 after the Health and Disability System Review, four new entities, namely, Public Health Agency, Health New Zealand (Health NZ), Māori Health Authority and Ministry of Disabled People, are established to transform the health and disability system to support all New Zealanders to live longer and have the best possible quality of life. Public Health Agency is established within the Ministry of Health to provide system leadership for public health and advise the Director-General and the Minister of Health and Associates on public health matters. Health NZ weaves the functions of the 20 former District Health Boards (DHBs) into its regional divisions and district offices, and takes over the commissioning and operational roles, while the role of Ministry of Health focuses on stewardship, strategy and policy. Health NZ is responsible for day-to-day running of the whole health system, including primary and community care, and hospital and specialist services at local, district, regional and national levels. Māori Health Authority is established to support the Ministry of Health in shaping policy and strategy, and commission services for Māori communities in partnership with Health NZ.⁴¹ 

For disabled people, the Ministry of Disabled People is established to provide a wider lens on disability across the Government, and to drive transformation of disability support system and enable disabled people and their families to create good lives for themselves.⁴²  

About 80% of New Zealand’s total health expenditure is funded by government from general taxation, with smaller proportion from out-of-pocket and private health insurance. More than three-quarters the public funds is allocated to the districts, about 19% is for national health services and about 1% is for running the Ministry of Health.43 Disability support services and some health services are funded and purchased nationally by the Ministry of Health for the districts through Health NZ. Health NZ funds Primary Health Organisations (PHOs) to provide subsidised PHC services through general practices to people who have enrolled with a PHO. Most general practices are part of a PHO, which brings together GPs, nurses and other healthcare professionals in the community to ensure a seamless continuum of care between general practice services and other healthcare services, in particular to better manage chronic conditions.⁴⁴  

To address the challenges of ageing population with PHC reform, the experience of Canterbury is worthy of reference. Canterbury DHB is the largest by population of aged 75 and above and the second largest by population (over half a million people) among the 20 DHBs in New Zealand. In 2007, the DHB realised that the healthcare system would be unsustainable if nothing changed. With challenges included culminating deficit, amid rising admissions, growing waiting time and rapidly ageing population, they would need more hospital, doctors, nurses and care beds for the elderly, which would be unaffordable for Canterbury. Through public consultation, it was agreed that there had to be ‘one system, one budget’ for both health and social care. The patient should be at the centre of the health and social care service system. With the support of HealthPathways, PHC teams (with GPs, nurses, pharmacists and other healthcare professionals) were empowered with the skills and treatment information from hospital specialist doctors so that they could provide more specialised services which were normally provided in hospitals.⁴⁵ Electronic Shared Care Record View (a data portal which was built on the existing systems of individual GPs, hospitals and other services’ databases) provided a comprehensive care record accessible across GPs. Electronic Request Management System (a referral system among private and public healthcare services) enabled GPs, community nurses, pharmacists, specialists and hospitals to collaborate better in community care. With the PHC reforms, Canterbury has coped with the growing healthcare demand from ageing population without expanding hospital capacity, reduced acute and emergency admissions, shortened the length of hospital stay, and turned financial deficit to surplus. ⁴⁶