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The phrase “healthcare system” is widely used in discourse on global health but enjoys no agreed-upon definition.1 “Healthcare system” actually combines 3 nebulous terms: health, care, and system. They should not be confused with one another but often are. The 3 subsections that follow attempt to unpack this phrase.


According to the World Health Organization (WHO), health is “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity.”2 Health has also been defined as an important capability “that enables individuals to pursue things they might value.”3 There are as many indicators of health as there are definitions. These include life expectancy at birth, infant mortality rates, the percentage of children underweight, the percentage of women with body mass index below 18.5, quality-adjusted life-years, disability-adjusted life-years, and disease prevalence (morbidity). These represent measures of health status, which constitutes one part of Don Berwick’s triple aim (see Chapter 5).

Getting a comprehensive picture of a country across lots of indicators is impossible and probably futile. The United States, for example, is commonly lambasted for ranking relatively poorly among developed countries on infant mortality; on other indicators, however, such as cancer survival, the United States ranks quite highly.


Care consists of efforts made to maintain or restore physical, mental, or emotional well-being, especially by trained and licensed professionals. This can include taking preventative measures (eg, alterations in a person’s lifestyle) or necessary medical interventions (eg, surgical procedure, prescription drugs) to improve a person’s well-being. These services are typically offered through organizations in which the licensed professionals work, including ambulatory care offices, retail clinics, ambulatory surgery centers, hospital outpatient departments, and inpatient hospital units. Researchers typically distinguish 3 levels of care:

Primary care is medical care provided by the clinician of first contact for the patient. Typically, the primary care physician is a general practitioner, family practitioner, primary care internist, or primary care pediatrician. Primary care may also be administered by health professionals other than physicians, notably, specially trained nurses (nurse practitioners) and physician assistants. Usually, a general practitioner, family practitioner, nurse practitioner, or physician assistant provides only primary care services, but a person with specialty qualifications may provide primary care, alone or in combination with referral services. Thus, it is the nature of the contact (first compared with referred) that determines the care designation rather than the qualifications of the practitioner.

Secondary care is medical care provided to a patient when referred by one health professional to another with more specialized qualifications or interests. Secondary care is usually provided by a broadly skilled specialist such as a general surgeon, general internist, or obstetrician.

Tertiary care is provided on referral of a patient to a subspecialist, such as an orthopedic surgeon, neurologist, or neonatologist. A ...

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