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Community Health Center edit

A healthcare center, health center, or community health center is one of a network of clinics staffed by a group of general practitioners and nurses providing healthcare services to people in a certain area. Typical services covered are family practice and dental care, but some clinics have expanded greatly and can include internal medicine, pediatric, women’s care, family planning, pharmacy, optometry, lab, and more. In countries with universal healthcare, most people use the healthcare centers. In countries without universal healthcare, the clients include the uninsured, underinsured, low-income or those living in areas where little access to primary health care is available.

History in the U.S. edit

South African roots [1940’s-1950’s]: edit

The establishment of community health centers in the U.S. largely emerged between the 1940’s and 1950’s with efforts in South Africa[1]. Black communities in South Africa faced many health barriers and disparities as a result of apartheid [2]. During this period, a group of physicians and other health professionals from the U.S. and South Africa established one of the first community health centers to aide in treating black communities facing health disparities under apartheid conditions[1].

Jack Geiger was among the many notable leaders during this effort who initiated the first community health center model to treat individuals facing health barriers as a result of apartheid[1]. In 1945 Geiger and other physicians took the opportunity of establishing these community health centers with the efforts of the Gluckman Commission which aided in pushing the public health agenda to enhance health care accessibility and outcomes for black communities[1][2]. Geiger among two other physicians, Sidney and Emily Clark, established the Phoela Health Center and Lamontville Health Centers as the first community based health centers in South Africa to provide aide for rural Zulu communities[1].

In 1948 the Nationalist Party established power and rejected the public health implementation of the Gluckman commission and apartheid continued to cause disparities within South Africa[2]. Although the Nationalist Party made it difficult to push the public health movements to improve health disparities, South Africa managed to successfully set up a total of 40 community based health centers[1].  However, in 1959 the apartheid agenda continued to cause issues for the centers and they were ultimately shut down by the government[1]. Geiger and other physicians who helped create South African community health centers took that experience back to U.S. where they aided in helping health disparities as a result of social injustices in minority communities.

Civil Rights Movement and Public Health [1960’s]: edit

The knowledge and experience with healthcare organization rooted in South Africa carried into community health centers efforts within the United States[1]. During the Civil Rights Movement, several social rights organizations contributed efforts into raising awareness and advocating for issues African-American communities faced during the segregation era. Among those issues, healthcare was one area that was included in these movements to improve the lives of African-Americans facing public health disparities as a result of racial prejudice in the U.S. [1][3].

 
"Protest signs during the Freedom Summer project"

The Summer of 1964 marked the creation of the Freedom Summer project[3]. The Freedom Summer project was initiated in Mississippi. It was an organized effort to raise awareness about voting disparities and the effects of government policy on African American communities. The Freedom Summer project involved a variety civil rights activist and leaders, which included 60,000 black Mississippi residents and 1,500 volunteers, whose goals were oriented towards helping African Americans during this period of a segregated political system[3].

Among the diverse group of volunteer groups who participated, The Medical Committee for Human Rights (MCHR) was established and contributed efforts in order to help create a community based health model to treating many public health issues rural African Americans in Mississippi faced[4]. The MCHR consisted of doctors, nurses, and other healthcare workers along with the knowledge of local communities in order to treat the local populations who were vulnerable to a variety of public health issues[1].

By establishing these community based health centers, the MCHR was able to identify the infant mortality rates that African American communities faced and develop solutions[1][3]. Between the period of 1965-1971 the MCHR successfully improved the infant mortality rates by 65%[1][4].  The MCHR continued to pursue efforts in civil rights activism throughout the 1960’s and up to the 1980’s when their organization dissipated as a result of a changing political environment[4]. Overall the MCHR made improvements in healthcare and improving lives of African Americans by contributing the Freedom Summer project.

The “War on Poverty” movement and effects on public health: edit

President Lyndon B. Johnsons War on Poverty movement had a tremendous impact on healthcare accessibility for low-income and other vulnerable populations[5][6]. With the combined efforts for providing healthcare accessibility for African Americans during the Civil Rights era and the creation of the War on Poverty efforts in 1965, this proved to be a crucial period for the expansion of community based health centers in the United States[1][5]. Medicare and Medicaid were created during this same period to address public health disparities, which pushed the agenda to expand health centers to low-income and rural areas in the U.S.[5] The War on Poverty also extended coverage to poor elderly and other elderly populations who were not able to get access to healthcare[5]. Overall the Johnson Administration’s concerns over the well-being of poor, minority and other vulnerable populations contributed in successfully expanding community based health centers that were oriented towards providing care for these populations[1]. This resulted in financially accessible healthcare and an increased supply of healthcare workers in low-income and rural areas[5].

Social Activism in the late 20th Century (HIV/AIDS awareness, Women’s health): edit

 
Protesters advocating for the security of Planned Parenthood services

Political and social activism continued to thrive during the late 20th century[3]. Campaigns revolving around feminism, gay rights and global issues relating to public health concerns continued to push the need for community based healthcare[1]. The HIV/AIDs epidemic in the 1980’s was one public health concern that pushed community based health services to cover stigmatized individuals[7]. During this time period, many false or biased views regarding HIV/AIDS created barriers for care for individuals living with HIV/AIDS[8]. Gay/bisexual men were adversely effected by the stigma surrounding living with HIV/AIDs and limited government urgency failed to advocate for treatment[8]. However, the HIV/AIDS awareness movement continued throughout the 1980’s and expanded community based health centers revolving around HIV/AIDS prevention and treatment[7][8]. In addition the efforts to treat HIV/AIDS populations continued outside the U.S. and helped to develop community based health centers in HIV/AIDS stricken countries like Haiti and Africa[1][7][8].

Women's health was another area in which social activism played a crucial role in developing community based health centers catered to the female population[9]. Organizations like Planned Parenthood have fueled the development, expansion and security of community health centers in the U.S. and has catered to providing accessibility for women and family planning treatments[9]. Overall social activism has played a crucial role in expanding the need for community based health centers globally.

Relevant Research and Impact edit

Scope and Service: edit

In 2015, community health centers received more than 85 million visits. Nearly 60% of the patients are women; almost all (93%) are children and working-age adults. A majority of health center patients are people of color. [10]   These centers provided access to care for low-income populations living in medically underserved communities throughout the country. In addition to medical visits, centers in 9,170 sites in 2015 provided 11 million dental visits, 6.6 million visits for behavioral health needs, and 5.1 million visits for case management and other services.[10]

Results: edit

Extensive data collected by the federal government through the Uniform Data System (UDS), provides data about community health centers. UDS and other data collected on community health centers covers patients served, services furnished, satisfaction levels, quality, performance, the health center workforce, and revenues received. [11]p5 Studies consistently show that community health centers provide care that improves health outcomes of their patients.[12] Community health centers have been widely recognized for the quality of their care, [11]p.26 and have had a documented impact on reducing infant mortality rates, tuberculosis case rates, death rates, and lack of access to prenatal care. [11]p.27  Other research has demonstrated that health centers perform comparably to, if not better than, private practice physicians and other primary care providers in these spheres of care. [10] 

Appropriate Community Care: edit

Community health center patients are more likely than Health Maintenance Organizations patients to report quality care. Patients report higher satisfaction with on-going care, coordination of services, comprehensiveness, community orientation, and overall performance. Patients report having better relationships with their health care providers. [12] p.3

Given their mission to provide care to vulnerable populations, community health care providers are trained to tailor services according to the special needs of vulnerable populations. [12]p.3 Because these neighborhood-based and patient-directed centers are so intertwined with their neighborhoods, they often identity the health needs earlier and design effective community-based solutions before others even understand the underlying dynamics.[12]P. 3

"Safety Net" for our Communities: edit

Community health centers are located in lower income medically underserved communities particularly in rural and inner-city neighborhoods. These are the same areas with the highest rates of unemployment and the highest percentages of uninsured.[12]p.3   The demographic profile of health center patients reflects these centers’ statutory mission. Over 70 % of all health center patients have incomes of less than 100 % FPL, which is $11,770 for an individual and $20,090 for a family of three in 2015 [10] compared to 17 % of the U.S. population generally.[13]  Health centers are an important source of health care for minority populations. Health centers also represent a critical source of health care for low income women and children. Reflecting the effects of poverty and more limited access to health care, health center patients are in poorer health than the general population.[11] p.16

Community Health Status and Populations Served: edit

Compared to the low-income population overall, community health center patients are more disadvantaged. Patients are twice as likely as low-income people overall to report being in only fair or poor health – 32% compared to 16%. [11]p16  Rates of chronic conditions are higher among the health center patient population. However, health center patients fare as well as or better than the low-income population in general. [10] The majority of community health centers are situated in neighborhoods and become part of the primary infrastructure for improving health, rather than as inside or alongside the healthcare systems that serve them.[13] Health centers adapt to the communities they serve, even while communities undergo demographic shifts. As patients change, so do the interventions needed to ensure that health care is both clinically and culturally appropriate. [11] p. 16 Veterans served by the nation’s community health centers increased by 43% in less than a decade.[14] Over 1,500 VA-approved community health centers improve access to care for veterans across the United States. In 2015, nearly 9 out of 10 health centers served veterans and therefore are important access points to care for this vulnerable population. [14]

Over the past decade, health centers have grown steadily and expanded the scope of their services to meet patient needs more fully. Building on their role they are a key source of primary health care for urban and rural medically underserved communities and populations. These centers play a major national role in providing health care. [15]

Costs Savings and Economic Impact: edit

Health centers ensure quality care at lower costs by providing a regular source of primary and preventive health care services. [13]p. 28   These centers save the U.S. health care system between $9.9 billion and $24 billion annually, in most part by eliminating unnecessary emergency room visits and other expensive hospital-based care. [12] p. 5

Studies demonstrate that increased funding to health centers creates additional economic stimulus both within the center and beyond.[12] p. 3   Community health centers utilize federal grants and funding allows for further improvement and expansion of patient access to medical, dental, and mental health services. Increases in federal funding enables these centers to enhance the provision of high quality, accessible care to the nation’s most vulnerable populations.[12] p. 7

Community Needs and Standards: edit

The Federal statutes that created these centers requires they meet four basic standards:[12]p3

  • They must be located in or serve a high-needs community.
  • They must provide health care to all, regardless of ability to pay
  • They must provide comprehensive health care services.
  • They must be governed by a community board.

Because health centers are governed by patient-majority boards, an orientation to the community is embedded in their operations and policies, [13] p17 which insures that they serve their neighborhoods efficiently and effectively. [12] p. 3 Still, health centers are challenged to respond to the needs of increasingly diverse communities during a time of economic uncertainty. [13] p.17 Estimates indicate that new health centers are needed in more than 900 poor counties (defined as over 35.3 % of their residents living below 200 % FPL). [13]p. 7 Over 20 million people live in these counties; 42 % are poor and more than 3 million are uninsured (representing 8 % of all uninsured persons nationally). [13]p. 7  Health centers face important new challenges in the area of quality improvement, [13]p. 16  A majority of community health centers require capital improvements covering a range of needs, from the additional sites required to the equipment, hardware and software systems essential to operating in the current information technology age. [13]p. 16-17

Current Oriented Primary Care: edit

Community Oriented Primary Care (COPC) is based on the concept of "ecology of medical care." [16] p. 257 COPC incorporates the elements of a good primary care delivery and adds a population-based approach to identifying and addressing community health problems. The main challenge has been how to bring together individual health needs in the larger context of community health needs.[16]p. 257

World Health Organization Factors of Successful Community Care edit

COPC incorporates the ideals of both World Health Organization (WHO) and the Institute of Medicine in the delivery of primary care. In 2010 the WHO offered some additional guidelines that encompass five key elements:[16]. p. 257

  1. reducing exclusion and social disparities in health through universal coverage reforms
  2. organizing health services around people's needs and expectations
  3. integrating health and all sectors
  4. pursuing collaborative models of policy dialogue
  5. increasing stakeholder participation

These principles have not yet materialized in the United States in a consistent practice. [16] p. 25

Effects of the Patient Protection and Affordable Care Act to Community Health Organization in the United States edit

The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 by President Barack Obama The new law was implemented to "expand access to health insurance, protect patients against arbitrary actions by insurance companies, and reduce costs."[17] Individuals can obtain health insurance and care through employment, business ownership, public programs. Additionally, the Affordable Care Act was implemented to provide individuals with access to preventable medical services, screenings, vaccinations,and counseling [18].

Under the Affordable Care Act there has been a very significant impact on community health organizations under Title One: Quality Healthcare for All Americans section 1323 and Title Two: Role of Public Programs, Subtitle E: New Options for States to Provide Long-Term Services and Supports; sections 2401, 2402, 2403, 10202, and 1205 [18].

The Affordable Care Act is resulting in a $11 billion-dollar investment within five years (2012-2017) towards community health organizations [19]. The funding is primarily to provide community health organizations with the financial support to comply with new health laws. The funding additionally allows more provisions such as: preventable services and screenings, various types of counseling, and vaccinations[15] including; abdominal aortic aneurysm one-time screening, alcohol misuse screening and counseling, aspirin use, blood pressure screening, cholesterol screening, colorectal cancer screening, depression screening, diabetes (Type 2) screening, diet counseling, hepatitis B screening, hepatitis C screening, HIV screening, Immunization vaccines, lung cancer screening, obesity screening and counseling, sexually transmitted infection (STI) prevention counseling, syphilis screening, tobacco use screening. [15]

For children, these preventative services and screening, counseling, and vaccinations include alcohol for adolescents, autism screening, Behavioral assessments, cervical dysplasia screening for sexually active females, developmental screening, dyslipidemia screening, fluoride chemoprevention supplements, gonorrhea preventive medication, hearing screening, Height, weight and body mass index (BMI) measurements, hematocrit or hemoglobin screenings, hemoglobinopathies or sickle cell screening, iron supplements, lead screening, tuberculin testing, and vision screening [18].

Lastly, women's preventative services, screening, counseling, and vaccinations include; anemia screening, breastfeeding comprehensive support and counseling, contraception, folic acid, gestational diabetes screening, gonorrhea screening, rh incompatibility screening, expanded intervention, and counseling [15].

Community Health Centers by Country edit

Canada: edit

Community Health Centers (CHCs) have existed in Ontario for more than 40 years. [20] Most CHC's consist of an interdisciplinary team of health care providers using electronic health records. [20] In Quebec, local community services centres known by their French acronym, CLSC, offer routine health and social services, including consultations with general practitioners with and without an appointment. [21]

China: edit

China, a country of transition, gradually introduced a primary care-oriented health-care system supported by community health centers. [22] In 2009, a health care reform plan was officially announced with the key component being the expansion of community health services facilities. [23] The number of community health centers increased dramatically from 17,128 in 2005 to 33,562 in 2012. [24]

Because of the socioeconomic diversity in different areas of the country, community health centers in China are shaped after three models: government owned and managed, government owned and hospital managed, and privately owned and managed.[23] Approximately 36.5% are government own and managed, 35.7% government owned and hospital managed, and 27.8% are privately owned and managed; out of the three models, evidence supports that government owned and managed centers can provide a high-quality and fair treatment because it succeeds in distributing health resources evenly,[25] resulting in a better patient experience.

Portugal: edit

The health center (Portuguese: centro de saúde) was the basic community primary healthcare unit of the National Health Service of Portugal, as well as acting as the local public health authority. Usually, each health center covered the area of one of the Portuguese municipalities, but municipalities with over than 15 000 habitants could be covered by more than one of the centers. Health centers were staffed with general practitioners, public health physicians, nurses, social workers and administrative personnel.

In 2008, the more than 300 health centers were aggregated into around 70 health center groups (agrupamentos de centros de saúde) or ACES. Each ACES includes several family and personalized healthcare units, these being now the basic primary health care providers of the Portuguese National Health Service. Besides family health care services, the ACES also include public health, community health and other specialized units, as well as basic medical emergency services.

Some of the ACES were grouped with hospital units into experimental local health units (unidades locais de saúde) or ULS. The ULS are intended to increase the coordination between the primary and the secondary healthcare, through both of these services being provided by the same health unit.

United Kingdom: edit

Lord Dawson of Penn was commissioned by Lord Addison to produce a report on "schemes requisite for the systematised provision of such forms of medical and allied services as should... be available for the inhabitants of a given area". The Interim Report on the Future Provision of Medical and Allied Services[25] was produced in 1920, though no further report ever appeared. The report laid down detailed plans for a network of Primary and Secondary Health Centres, together with detailed architectural drawings of different sorts of centers. By 1939 the term health centre was widely used to refer to new buildings housing local health authority services.[26] The Dawson report was very influential in debates about the National Health Service when it was set up in 1948, but few centers were built because "it was not practicable for local authorities to establish health centers without the full compliance of general practitioners," which was not forthcoming. Far more attention and resources were devoted to hospital services than to primary care. From 1948 to 1974 local authorities were responsible for the building of health centers.

A well known centre was opened at Woodberry Down in October 1952.[27] It had provision for 6 GPs, 2 dentists, a pharmacist and two nurses. It cost about £163,000, which included the cost of a day nursery and child guidance clinic. This was regarded as extravagant and used as an excuse by critics for not building more. Harlow, where 4 centres were built by the new town corporation, was the only community in Britain served exclusively by doctors working from health centers. [28]

The few centres that were built "functioned as isolated islands in a sea of General Practitioners generally indifferent to their success". There were later calls to establish a network of centres to include not only GPs but also dentists and diagnostic facilities.[29] In 1965 there were only 30 health centres in England and Wales, and 3 in Scotland. By 1974 there were 566 in England, 29 in Wales and 59 in Scotland.[30] After the NHS Re-organisation Act 1973, responsibility for promoting health centres was transferred to Area Health Authorities and there were renewed calls to establish more Health Centres.[31] It was suggested that these centres could arrange alternative medical care for patients "when their doctor is off duty, or for emergency calls when he is engaged elsewhere”.[32]

Lord Darzi set up a network of Polyclinics in England when he was a minister in 2008. These clinics had some features in common with earlier proposals for health centres, but shared with them considerable resistance from GPs

United States: edit

Community Health Centers (CHCs) in the U.S. are neighborhood health centers generally serving Medically Underserved Areas (MUAs) which includes persons who are uninsured, underinsured, low-income or those living in areas where little access to primary health care is available. Largely federally and locally funded, some health clinics are surprisingly modernized with new equipment and electronic medical records. In 2006, the National Association of Community Health Centers implemented a model for offering free, rapid HIV testing to all patients between the ages of 13 and 64 during routine primary medical and dental care visits.

Medically Underserved Areas/Populations are areas or populations designated by the Health Resources and Services Administration, or HRSA as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. Health Professional Shortage Areas (HPSAs) are designated by HRSA as having shortages of primary medical care, dental or mental health providers and may be geographic (a county or service area), demographic (low income population) or institutional (comprehensive health center, federally qualified health center or other public facility).

South Africa: edit

Dating back to the early 19th century, public health was highly segregated by race and gender.[33] Community health centers became a source of health services after apartheid in 1948 when resources were allocated to certain individual’s based on their race; the black community was ostracized and the United States took action to provide this part of the community healthcare services through community health centers.[33]The community health centers were not able to provide the necessary primary care to these populations and by the end of apartheid health services were focused on hospital care rather than primary care.[33]

In 1994 apartheid came to an end and the new democratically elected state had the task of creating an entirely new healthcare system; in order to do so, they published a health plan in 1994 that had a focus on community health centers.[33] In particular, the government would provide free primary care for all citizens and special cost-free community health centers for pregnant women and children under the age of six.[34] In 2002 additional legislation was passed to create a system of comprehensive primary care services though community participation; as a result, by 2013 there had been over 1,000 community health centers created.[34]

Since 2010 the United States Government’s South African Health Team has worked with the South African Government on a Global Health Initiative; within this initiative, community health centers are a key facilitator in providing education and health services. [35] These centers are focused primarily on HIV/AIDS, Tuberculosis, family planning, and proper nutrition. [35]

References edit

  1. ^ a b c d e f g h i j k l m n o p Grier, H. Jack. “The First Community Health Centers: A Model of Enduring Value”. Journal of Ambulatory Care Management. 2005; 28(5):313-320. ISSN: 0148-9917. 
  2. ^ a b c Coovadia, Hoosen, Jewkes, Rachel, Barron, Peter, Sanders, David, and McIntyre, Diane. “The Health and Health System of South Africa: historical roots of current public health challenges”. Lancet. 2009;374: 817-834. doi: 10.1016/S0140- 6736(09)60951-X 
  3. ^ a b c d e “What was the 1964 Freedom Summer Project?”. WisconsinHistoricalSociety.org.  http://www.wisconsinhistory.org/Content.aspx?dsNav=N4294963828-4294963805&dsRecordDetails=R:CS3707. Accessed on: 15 November 2016
  4. ^ a b c Rogers, Kara. “Medical Committee for Human Rights (MCHR)”.  britanica.com. Updated on: Nov 2015. https://www.britannica.com/topic/Medical-Committee-for-Human-Rights. Accessed on: 15 November 2016
  5. ^ a b c d e Swartz, Katherine. “The War on Poverty’s Effect on Health Care for the Elderly”. Russell Sage Foundation Policy Brief. Sep 2013. https://www.russellsage.org/sites/all/files/legacies_swartzbrief_08222013.pdf. Accessed on: 16 November 2016
  6. ^ Rosenbaum, Sara, Jones, Emily and Shin Peter. “Community Health Centers: Opportunities and Challenges of Health Care Reform”. The Kaiser Commission on Medicaid and the Uninsured. Aug 2010. http://www.nhchc.org/wp-content/uploads/2011/09/KaiserCHCsandhealthreformAug2010.pdf. Accessed on: 16 November 2016. 
  7. ^ a b c CDC. “Evolution of HIV/AIDS Prevention Programs—United States, 1981-2006”. MMWR. Jun 2006;55(21); 597-603. https://www.cdc.gov/MMWR/preview/mmwrhtml/mm5521a4.htm. Accessed on: 16 November 2016.
  8. ^ a b c d Landau, Elizabeth. “HIV in the 80’s: ‘People didn’t Want to kiss you on the cheek’”. CNN. Mar 2011. http://www.cnn.com/2011/HEALTH/05/25/edmund.white.hiv.aids/. Accessed on: 16 November 2016. 
  9. ^ a b Rosenbaum, Sara. “Planned Parenthood, Community Health Centers and Womens Health: Getting the Facts Right”. Health Affairs. Sep 2015. http://healthaffairs.org/blog/2015/09/02/planned-parenthood-community-health-centers-and-womens-health-getting-the-facts-right/. Accessed on: 16 November 2016.
  10. ^ a b c d e Peter Shin, Jessica Sharac, Zoe Barber, Sara Rosenbaum, and Julia Paradise. community health centers: A 2013 Profile and Prospects as ACA Implementation Proceeds. The Henry J. Kaiser Family Foundation. Mar 17, 2015. http://kff.org/medicaid/issue-brief/community-health-centers-a-2013-profile-and-prospects-as-aca-implementation-proceeds/. Accessed November 17, 2016. 
  11. ^ a b c d e f Rosenbaum Sara and Shin Peter, “Health Centers Reauthorization: An overview of Achievements and Challenges. Washington: Kaiser Commission on Medicaid and the Uninsured. The Henry J. Kaiser Family Foundation. https://publichealth.gwu.edu/departments/healthpolicy/DHP_Publications/pub_uploads/d hpPublication_5EE09986-5056-9D20-3DB4ABFCDFCEA1C6.pdf March 2006.Accessed November 17, 2016. 
  12. ^ a b c d e f g h i j Leiyu Shi, DRPH, MBA, Barbara Starfield, MD, MPH, Jiahong Xu, MPH, MS, Robert Politzer, and Jerrilyn Regan. Primary Care Quality: community health center and Health Maintenance Organization. Southern Medical Journal • Volume 96, Number 8, August 2003
  13. ^ a b c d e f g h i Singh, Prabhiot, Dying and Living In The Neighborhood: A Street-Level View of America's Healthcare Promise. Baltimore: Johns Hopkins University Press. September 2016. 
  14. ^ a b Veterans Served by Nation’s community health centers Increased by 43 Percent. Geiger Gibson/RCHN Community Health Foundation Research Collaborative, Washington. George Washington University’s Milken Institute School of Public Health. November 9, 2016. http://publichealth.gwu.edu/content/veterans-served-nation’s-community-health-centers-increased-43-percent-less-decade Accessed November 15, 2016
  15. ^ a b c d community health centers in an Era of Health Reform: An Overview and Key Challenges to Health Center Growth. Washington. Kaiser Commission on Medicaid and the Uninsured. The Henry J. Kaiser Family Foundation. March 2013. https://kaiserfamilyfoundation.files.wordpress.com/2013/03/8098-03.pdf Accessed November 14, 2016
  16. ^ a b c d Shi, Leiyu and Singh, Douglas. Delivering Healthcare in America a Systems Approach. Massachusetts. Jones and Bartlett Learning. February, 2015.
  17. ^ "Read the Law". United States Health and Human Services. Retrieved 27 November 2016.
  18. ^ a b c United States Health and Human Services .Read the Law. (2015). Retrieved November 20, 2016, from https://www.hhs.gov/healthcare/about-the-law/read-the-law/index.html U.S. Department of Health and Human Services. Read the Law. HHS.gov. https://www.hhs.gov/healthcare/about-the-law/read-the-law/index.html. Published 2015. Accessed November 18, 2016.
  19. ^ Results. Community Health Centers. (n.d.). Retrieved November 18, 2016, from http://www.results.org/issues/community_health_centers/
  20. ^ a b Association of Ontario Health Centres". Association of Ontario Health Centres. 2013-09-24. Retrieved 2013-09-24.
  21. ^ "Local Community Services Centres (CLSCs)". Santé Montréal Portal. Gouvernement du Québec. 2014. Retrieved 2014-08-10
  22. ^ Wang, H.H.X., S.Y.S. Wong, M.C.S. Wong, J.J. Wang, X.L. Wei, D.K.T. Li, J.L. Tang, S.M. Griffiths.“Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences.” Q J Med doi:10.1093/qjmed/hcu248 Advance Access Publication 18 December 2014 http://qjmed.oxfordjournals.org/content/early/2014/12/30/qjmed.hcu248. Accessed 16 November 2016.
  23. ^ a b Wang, Harry H. X., Samuel Y. S. Wong, Martin C. S. Wong, Xiao Lin Wei, Jia Ji Wang, Donald K. T. Li, Jin Ling Tang, Gemma Y. Gao, and Sian M. Griffiths. “Patients’ Experiences in Different Models of Community Health Centers in Southern China.” Annals of Family Medicine. 2013 Nov; 11(6): 517–526. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3823722/. Accessed 16 November 2016.
  24. ^ Shani, Michal, Harry HX Wang, Samuel YS Wong, Sian M Griffiths. International primary care snapshots: Israel and China. British Journal of General Practice: 10.3399/bjgp15X684913, Published 1 May 2015. http://bjgp.org/content/65/634/250. Accessed 16 November 2016.
  25. ^ a b Interim Report on the Future Provision of Medical and Allied Services 1920 (Lord Dawson of Penn)". Socialist Health Association. Retrieved 21 December 2013. 
  26. ^ Webster, Charles (1988). The Health Services Since the War. London: HMSO. p. 380. ISBN 0116309423.
  27. ^ ” Woodberry Down Health Centre". British Medical Journal. 1952 (2): 879. 18 October 1952. Webster, Charles (1988). The Health Services Since the War. London: HMSO. p. 386. ISBN 0116309423. 
  28. ^ "The Case for Health Centres". Socialist Health Association. 1964. Retrieved 18 October 2014.
  29. ^ Webster, Charles (1998). The National Health Service A Political History. Oxford: Oxford University Press. p. 131. ISBN 0192892967. 
  30. ^ Health Centres the Next Step". Socialist Health Centres. 1975. Retrieved 18 October 2014
  31. ^ Health Centres the Next Step 1975". March 10, 1975. Retrieved 1 November 2014. 
  32. ^ Community Health Centers Integrate Rapid HIV Screening Into Routine Primary Care, Leading to Significant Increases in Testing Rates". Agency for Healthcare Research and Quality. 2013-05-08. Retrieved 2013-05-10.
  33. ^ a b c d Coovadia, Hoosen, Jewkes, Rachel, Barron, Peter, Sanders, David, and McIntyre, Diane. “The Health and Health System of South Africa: historical roots of current public health challenges”. Lancet. 2009;374: 817-834. doi: 10.1016/S0140-6736(09)60951-X.
  34. ^ a b Maillacheruvu, Priya and Elaine McDuff, Ph.D. “South Africa’s Return to Primary Care: The Struggles and Strides of the Primary Health Care System.” The Journal of Global Health, 10 August 2014. http://www.ghjournal.org/south-africas-return-to-primary-care-the-struggles-and-strides-of-the-primary-health-care-system/. Accessed 16 November 2016.
  35. ^ a b Global Health Initiative Strategy, South Africa 2011-2016. July 2011 https://www.ghi.gov/whereWeWork/docs/SouthAfricaStrategy.pdf. Accessed 16 November 2016.
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