Treating patients before they develop illnesses: a call for primary health care

Primary health care (PHC) is essential health care that’s accessible to individuals and families in ways that are acceptable, affordable, and involve full participation of communities. The multi-sectoral approach to health is grounded in a fundamental principle: good health for all is not about treating patients only when they develop illnesses. Rather, it is about preventing illness; keeping people, families, and communities healthy; and improving the overall well-being of people and communities across all stages of life.

But despite PHC being able to meet up to 80 or 90 percent of a person’s health care needs over a lifetime, only half the world’s population has access to it. Estimates suggest that scaling up access to PHC in low- and middle-income countries could help prevent as many as 60 million deaths by 2030.

Exemplars in Global Health (EGH), meanwhile, is currently researching how PHC can be optimized to enhance physical, mental, and social health and well-being at different levels of expenditure. Ahead of the publication of this new research, we spoke with EGH research partners Dr. Edwine Barasa, Director of Kenya's KEMRI Wellcome Trust; Dr. Anna Vassall, Director of the Global Health Centre at the London School of Hygiene and Tropical Medicine (LSHTM); and Dr. Felix Masiye from the Department of Economics at the University of Zambia about the lessons from successful PHC programs, how COVID has impacted PHC, and how PHC can be the differentiator between life and death in many communities.

Exemplars News: Why is now the right moment to focus on PHC?

Dr. Edwine Barasa: First, while LMICs [low- and middle-income countries] have prioritized UHC [universal health care], they face the stark reality of constrained resources, [but] there is overwhelming evidence that PHC is the cost-effective and equitable pathway to UHC. It has been shown that health systems that prioritize PHC financing, coverage of basic services, and invest in health workforce development for PHC, and strengthen community health systems are likely to have more efficient health systems. Second, COVID-19 has focused the global attention on the need to strengthen health security and resilience of health systems to epidemic shocks. PHC and community health systems have been instrumental in providing surge capacity by providing home based care for COVID-19 patients, scaling access for testing and vaccination, providing continuity of care in settings where health care access is reduced because of physical distancing or avoidance of care seeking because of fear.

Dr. Anna Vassall: Strong PHC has always been critical to reaching the sustainable development goals. COVID has shown us what is possible when we can reach entire populations with diagnostics, vaccines, and improved treatments, even when faced with the gravest public health emergency. Yet, sadly, it has also shown us what happens when we do not. We need to take the opportunity to galvanize efforts to invest those services, health workers, and technologies that we know will substantially impact population health, and that is PHC.

Dr. Felix Masiye: Now, more than ever, is the time to focus on PHC for at least three reasons. First, Zambia’s recent health gains have been attributed to interventions delivered at the PHC level. As Zambia’s leading health burden remains communicable diseases, PHC remains the focus of health policy now and for the foreseeable future. The second reason relates to the challenge of sustaining success. Zambia is facing increasingly tighter health budgets resulting from subdued domestic fiscal space and flattening development assistance for health. Prioritizing investments into PHC, which is shown to be cost-effective compared with secondary and tertiary care, offers an important avenue of achieving efficiency gains. Third, the health threats from health emergencies require interventions that are mobilized at the PHC level since that is the primary point of contact of the health system and the people. In Zambia, this includes the expansion of health infrastructure, removal of user fees for PHC, and recruitment of health cadres. These investments also provide an opportunity to sustain coverage.

Exemplars News: What has your experience taught you about the determinants of success in a PHC system?

Dr. Barasa: The first determinant of success in a PHC system is the political and technocratic prioritization of PHC. Beyond the rhetoric, overcoming the hospital centric/secondary/tertiary care bias of most health systems is a critical first step. This explicit and intentional prioritization should be reflected in policy, in financial investment, and in strengthening all the building blocks (financing, human resource, information systems, infrastructure and commodities, and governance) at the PHC level. Beyond these investments, PHC success is determined by how these investments and service delivery are designed. It is important that there is a strong linkage between secondary care and the primary care level to facilitate continuity of care through referrals, operational support and coordination. It is also important to have strong linkages between facility-based PHC service delivery, public health programs, and community health systems. Providing financial and operational autonomy to PHC facilities and strengthening the governance arrangements at this level to include strong oversight and participation by communities is also critical.

Dr. Vassall: Many commentators on PHC have emphasized the importance of politics and societal factors in PHC systems. Those are pivotal. However, my experience in supporting the establishment of PHC services in post-conflict environments also highlights how important it is to get the basic systems design, operations, and technologies right too. As an economist, I also would emphasize the importance of correctly financing PHC services. However, strengthening financing systems, will only work alongside other actions such as strong information systems, and ensuring the right training and support for managers and front-line staff.

Dr. Masiye: Policy consistency and community empowerment are crucial for success. The policy focus identified human resource shortages, low levels of financing and poor infrastructure as major barriers to PHC success. Having communities take care of their own health is so important for sustaining success in PHC. Local initiatives have been the key factor in driving service delivery and mobilizing community resources to address resource shortages for health. For example, community health volunteers have been crucial in covering for some of the human resource shortages, with many of them involved in Malaria treatment and diagnosis, educating mothers on danger signs of pregnancies, treatment of childhood illnesses (IMCI), etc.  Such initiatives rely on community engagement and empowerment.

Exemplars News: Can you share one example that you’ve seen in your work of remarkable success in PHC delivery?

Dr. Barasa: Over the past decade, Kenya has reformed its PHC governance and financing by 1) removing user fees at the point of care in public PHC facilities 2) creating a fund to directly finance PHC facilities in ways that replaces revenues lost by the abolishing of user fees, and improve funds flow and access to funds by directly sending money to PHC facilities and giving these facilities financial and operational autonomy, and 2) establishing health facility committees that have strengthened the governance of PHC health facilities by providing oversight to the management of these facilities and facilitating citizen engagement. As a result, health-care utilization has shifted to lower-level facilities, and the incidence of catastrophic health-care costs in the population has reduced overall because of the impact of [the] removal of user fees at the PHC facility level.

Dr. Vassall: I am reluctant to highlight one example of remarkable successes, but I have been time and time [again] impressed by the ability and fortitude of community health workers. From identifying cases of tuberculosis in Bangladesh to delivering services to preventing violence against women and girls, their work is often critical but under-rewarded.

Dr. Masiye: Especially in the remotest parts of Zambia, we have seen the crucial role that community health volunteers and the community in general play in planning and delivering health services. There is a recognition that community volunteers can diagnose and treat simple malaria and childhood illnesses. These volunteers have nurtured a commitment to PHC that provide vital resources for PHC service delivery. I do not think that Zambia would achieve the current high levels of maternal and child health and HIV/AIDS treatment coverage without the resources that local health workers bring to the PHC delivery platform. With minimal training and almost no financial resources, they mobilize demand for almost all PHC services. But they also have given credibility to the local health service.

Exemplars News: The theme of UHC Day 2021 is “Leave no one’s health behind.” What does that mean to you, specifically?

Dr. Barasa: At this moment in time, what comes to mind at the mention of leave no one behind is the primacy of global equity in responding to global health challenges. It’s completely ironic that global health actors all push for equitable health systems at the country level but fail to practice this at the global level. Today, leave no one behind means to me that all countries of the world should have equality of opportunity to manufacture, procure, and make accessible essential health commodities to their populations during a health crisis – PPE, test kits, vaccines, medicines. Equitable global allocation mechanisms for these essential health commodities should be respected and supported by actions rather than just words and high-income countries should be willing to share technology and know-how to facilitate the self-reliance of LMICs. Further selective travel restrictions by high income countries on LMICs that amount to economic sabotage with health ramifications should be avoided.

Dr. Vassall: It means that the rickshaw driver with a cough, gets diagnosed with TB, and survives to keep his family out of poverty. It means the young woman pregnant with her first child is diagnosed with anemia and delivers safely, and the grandparent’s joy. It means that the child with fever does not die from malaria before having lived a full life. It means so many things to so many people, every day in every country around the world.

Dr. Masiye: To us in Zambia, this theme means that it is not enough to simply focus on average coverage of health interventions, but to also ensure that equity of coverage is high. There are still pockets of the population who have lower coverage of services in the country. UHC means extending health coverage to pockets of the most vulnerable populations with vital health interventions. It simply means reaching every child.