Primary health care perspective of clinical management: The legacy of Barbara Starfield

Xavier Bayona

Six years ago, the magnificent Barbara Starfield left us (December 18 1932 - June 10, 2011). She was a paediatrician and a major promoter of primary health care at the international level. Virtually her entire academic and professional life was tied to Johns Hopkins University. Since 1994 she directed the Department of Health Policy and Management of the Johns Hopkins Bloomberg School of Public Health in Baltimore (United States). From 1996, she was the co-director of The Johns Hopkins Primary Care Policy Centre (PCPC).

Those who had the opportunity to enjoy any of her conferences can say that she never left us feeling indifferent and she always allowed us to reflect on what we were doing and encouraged us to bring sanity to our workplaces as part of the health system. She was a great advocate for improving health systems by strengthening primary care and making sense of what is happening in the world by focusing health care on people and their needs. I still remember how in the conference room of the Catalan Oncology Institute (ICO), a few years ago, she told the audience that we were wasting time and resources with a lot of the screening we did and that we had to improve our orientation.

As a tribute to a great promoter of the universality and accessibility of quality health services, I wanted to remind you and share some of her principles:

1. Countries with a high percentage of specialists in relation to the population devote a greater part of the gross domestic product to health services than those with a smaller proportion. "Countries that have highly targeted health systems are not spending their money wisely." This is seen in most of the richer countries.
2. Primary care is oriented to the person, not to the disease. Diseases only exist in the context of people and populations, they are not isolated. Primary care is the first contact with the person. Some of the strengths of primary care-oriented health systems are: providing ongoing care over time and care focused on the person (avoiding a relationship based on illness), thoroughness of procedures and tests, better coordination based on better information systems and greater communication between primary and secondary care. Primary care "gives good results in health, with lower costs and greater reach over population."
3. In primary care oriented countries, we found a smaller proportion of underweight babies, lower infant mortality rate (especially neonatal) and fewer years of life lost due to suicide and longer life expectancy. These countries also have a more equitable distribution of resources, health services provided by the government (with little or no private presence), no copayments or very low copayments, are better evaluated by populations, have primary care that includes a wide range of services and is family oriented. In short: they have better health at lower costs.

Recommended bibliography:

• Barbara Starfield. Atención Primaria: equilibrio entre Necesidades de salud, servicios y tecnología. MASSON 2004.
• Starfield B, Gervas J. Family medicine should Encourage its clinicians tono specialize: negative position. In: Buetow SA, Kenealy TW. Ideological Debates in Family Medicine. New York: Nueva Science Publishers; 2007. p.107-19