The universally-accessible primary care is a fundamental component of an effective health system as per the Declaration of Alma-Ata (1978). Global comparisons among different countries have repeatedly indicated that healthcare systems with a strong primary care sector evidently achieve better health outcomes and cost savings than underdeveloped primary care sectors. This finding led to international declarations and political movements with an aim to strengthen primary care and set up more primary care-centred health systems. An achievable initiative demanding a healthcare reform has been launched in 2009 and is still under development. Concerns about the difficulties of managing the global health issues with the quality of care in primary care settings are remarkably increasing. Due to the rapid ageing of the population and greater longevity, the number of individuals with chronic diseases (CDs) and multi-morbidity is on the move toward a higher peak. The environmental changes also drastically affect human health. There are multiple factors demanding for structural reforms of the healthcare system. The purpose of this article is to explain the rationale for quality primary care highlighting the appropriate health system infrastructure, and to indicate what attempts to be done in the future to maintain and strengthen its potential.

A quality primary healthcare approach can strengthen early detection and timely treatment, reduce the disease burden and improve the quality of life. In the current healthcare system, primary healthcare providers face difficulties in maintaining care continuity and applying guidelines due to lack of coordination. The quality of healthcare is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. Quality improvement involves understanding and modifying measures of care to ensure sustainable quality by reducing unintended and unwanted variation. Most importantly, public and patients demand primary healthcare in assessing and improving the quality.

Primary care is widely considered as a usual nexus for coordination of clinical care, public health, and communitybased services. Access to individuallevel or practice-level quality data on the social determinants of health (SDH) is crucial for health inequalities in primary care. In recent years, there has been increasing recognition of the SDH and the primary care professionals mentioned that social determinants could introduce a major challenge in providing effective primary care. The SDH is associated with higher rates of morbidity, mortality, and other adverse health outcomes. The existing health systems and quality of care strongly emphasise the careful consideration of social determinants through various investments, and recently penalties in the United States (US). In the US and Canada, recent health system reform has recognised the importance of focusing on the demands of critical and high-needs patients. The social complexity factors (housing, income, mental health, family structure, social status, etc.) are linked to poor physical and mental health outcomes. Thus, it is important for developing and implementing interventions to address future healthcare needs by defining the specific social complexities that affect the population health. In addressing the SDH is feasible by expanding the role of primary care professionals with the patient-centred healthcare model. Quality primary care is associated with the reduction of harmful health effects of income inequalities to create a most proper environment for assessing and intervening on SDH. The World Health Organisation (WHO) concluded that SDH should be kept foremost in the health policy of all countries.

Dramatic shifts in the pattern of diseases have been observed ranging from infectious diseases to the current leading causes of mortality led by CDs accounting for 71 per cent of death globally. Cardiovascular diseases account for the most chronic disease induced deaths of 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9 million), and diabetes (1.6 million). These four groups of diseases account for over 80 per cent of all premature CDs deaths. In addition, chronic kidney disease (CKD) is gradually becoming a major health problem (yearly 1.1 million deaths worldwide). Modifiable behaviours like tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets increase the risk of CDs and account for over 16.2 million deaths every year. Poverty is closely linked with CDs. Due to limited access to healthcare services, vulnerable and socially disadvantaged people quickly get affected by a disease and face accelerated death. CDs disproportionately affect people in low- and middle-income countries, and over 85 per cent premature deaths occur. CDs are the result of a combination of genetic, physiological, environmental and behaviours factors. Many studies reported that the increasing prevalence and complexity of CDs will account a significant increase in healthcare cost, and impose much wider burden in near future. This trend represents a challenge for a growing capacity problem in the healthcare system. Many countries with inadequate health insurance coverage are unlikely to provide universal access to essential chronic disease interventions. CDs threaten the progress towards the 2030 Agenda for Sustainable Development Goals. A strong primary healthcare system can recognise the role of primary care to ensure the appropriate utilisation of professional skills for CDs management.

Patients with CDs are the maximum and repeated users of healthcare services. It is essential to increase our understanding of primary healthcare needs for CDs prevention and management services and conceptual models of multidisciplinary approaches in primary care settings. This multidisciplinary team could be comprised of specialists, primary care physicians, general practitioners, nurse practitioners, practice nurses and other relevant allied health and government professionals. The opportunistic primary prevention is also possible by engaging community pharmacies as they have close links to local populations and widespread distribution with recognised trust and expertise. Connecting them into the identification of high-risk individuals and appropriate referral to primary care is a potential measure. Selfmanagement and disease management are the timely initiatives as the healthcare system is increasingly strained in providing health and medical services to the growing number of people with chronic illness. Implementation of selfmanagement programs can support patients’ awareness, skill development, coaching, and behavioural change. Many studies on specialised CDs interventions suggested that short-term intervention can improve patients’ selfefficacy, and in the long-term reduction of risk factors and psychological distress with an improvement in the quality of life. There are various ways to explain practice characteristics and their linkage to the quality of care in different settings resulting in heterogeneous findings. The Chronic Care Model suggests a multicomponent remodelling of services to improve patient outcomes. Quality improvement is associated with practice abilities related to the detection of patients at risk, management procedures and incorporated continuous providers' education into the healthcare system. Integrated disease management programs for patients with CDs promoting self-management result in improved disease specific quality of life, and a substantial reduction in hospital stay and admissions.

The ever growing and changing demand for healthcare is causing higher costs. There is also an impending shortage of professional healthcare workers. Both issues are jointly increasing the burden on healthcare, which is compromising quality, accessibility, and sustainability. Over the past few years, time constraints in primary care and the shortage of primary care physicians have been shown to limit the delivery of the services. The required time to meet preventive, chronic, and acute care treatments frequently exceeds the total available time of physicians for patient care. Compared with most developed nations, US citizens have less access to primary healthcare services while the waiting time is shortest for seeking specialist care. A promising solution is to develop the care management models requiring least time of primary care physicians. One proposed solution is to increase physician supply through programs and policies offering incentives for entry into primary care to overcome providers' shortage. An alternative approach can be maximum utilisation of non-physician providers, including physician assistants, nurse practitioners and other advanced practice nurses, midwives, and health educators who can provide the recommended health education, counselling, and follow-up guidance. A recent study suggested that the expanded use and full deployment of nurse practitioners is one promising strategy to alleviate the primary care shortage, and advanced practice nurses can perform as like as physicians in terms of clinical outcomes and patient satisfaction in primary care setting. The full extent of education and training can remove the barriers to allow nurses to practice to be a safe, logical and effective approach for addressing the primary care shortage.

Evidence from the developing countries are examples of diversification in primary care strategies. Brazil introduced a tax-based health services system in 1990 based on establishing strong primary care facilities. Throughout this period, there were remarkable improvements in maternal education, increased contraceptive use, vaccine coverage, antenatal care, skilled birth attendance, and large reductions in child mortality, stunting, and hospitalisations. Other studies comparing primary care intervention areas in Haiti, Bangladesh, India, Liberia, Zaire, and Bolivia also showed decreased inequalities in primary care. An integrated approach to primary care in low- and middle-income countries found improved health associated with primary care. It has been established that a strong primary healthcare system is associated with better health indicators and more sustainable costs. To prevent healthcare system gaps, integration of multi-sectoral services is a promising innovation in primary care delivery.

Primary care improves health system functioning through managing and triaging services, corresponding patients’ demands with healthcare resources, and strengthening systems’ ability to adapt to new circumstances. The benefits are a consequence of the joined effort of four unique attributes of primary care namely, first contact, person-focused care over time, comprehensiveness, and coordination. Improving the strategy for quality control in primary care could assess how well functions can be carried out based on these four key features and reduce the adverse events. Research on the quality of care consistently showed that primary care physicians provide a higher quality of care for personfocused measures of care. In the past, quality and improvement efforts in healthcare have focused on health professional perspectives. The 21st century healthcare quality indicates to patient-centredness together with safety, timeliness, effectiveness, efficiency, and equity as the essential components.

Technological evolutions in healthcare are the key requirements for earlier detection and appropriate treatment of diseases. In many cases, the necessary integration of required data into electronic medical records is still too limited to providing contextual information for clinical decision-making and recommended care. Primary care has been brought close-to-home incorporating technology developments and innovations. Nevertheless, deploying newer technologies and interventions has no alternative for better patient care management. Electronic health (eHealth) application helps in controlling diseases and patients' management, serving high-quality care with a reduction in healthcare costs and consumption, and therefore, uprising the satisfaction of patients and service providers. Depending on the expectation and level of education, eHealth is a useful tool to support chronically ill patients by increasing their understanding of diseases, sense of control, and willingness to involve in self-management. It is important to develop technological solutions to support decision-making and integration of care in general practice.

Healthcare programme assessment represents an important measure in the adaptation of evidence-based medicine to primary healthcare reality. Many countries and areas have adopted policies and standardised primary care measurements in their health reform efforts. To encourage practitioners and patients to pay due respect, the term ‘evidence-based medicine’ and ‘evidencebased-healthcare’ were developed to set the scope of implementation in healthcare practices. All stakeholders, including decision-makers and health professionals have to consider reliable evidence-based approaches to manage the allocation of resources as efficiently as possible and to improve the quality of care.

Healthcare systems include people, organisations, and technologies to achieve the better results. Improvements in process, outcomes and safety depend on the better understanding of interactions, which can help designing better healthcare system. Today, the 21st century’s healthcare system needs to use innovative strategies to evaluate the ongoing process and outcomes of interventions. Successful application of healthcare reform involves new concepts and directions that are strongly supported by outcome measures. Continuous program evaluations will promote the attainment of the primary goal of the healthcare improvement. The regulation of medical and healthcare professionals is an important component of quality improvement for ensuring a basic standard. Effective governance and regulatory reforms can encourage partnership and collaboration among a wider range of stakeholders to stimulate quality improvement.

The functions of primary care are wellknown and measurable. Accountability of health system for quality primary care orientation is possible. The future challenge is to make it a reality in moving towards developing similar approaches for speciality services as well. We conclude that the developments of the last two decades have led to a small increase in primary care quality. However, the future development needs to address the inequitable distribution of health resources, low priority of primary care in medical education and training, lack of formal guidelines for health professionals, and less attention in widespread implementation of electronic record keeping system. Quality improvement and safety are now essential knowledge for healthcare staffs in medicine, nursing, and allied health professionals.

--Issue 42--