Cross-Country Synthesis: Primary Health Care

AUTHORS:

Barasa E, Bozzani FM, Amboko, B, Madriz-Montero A, Muthuri RN, Arora N, Akhter Huda F, Akhter S, Affram A, Aryeetey G, Chewe M, Ferdous T, Hangoma P, Huayanay-Espinoza C, Huicho L, Humuza J, Kasumba E, Koduah A, Masiye F, Michelo T, Nyawira L, Uddin Mahmud M, Reinstein S, Umuhoza SM, Valladares R, Balabanova D, Vassall A.

Overview

This cross-country synthesis provides the highest-level insights from our primary health care research across all Exemplar countries. For policymakers, funders, and implementers seeking to understand what has worked to improve primary health care efficiency, this is a central repository of knowledge on our website.

Here, we have highlighted the most critical lessons and recommendations in primary health care based on insights across all the Exemplar countries. The hyperlinks on this page serve as a useful tool for locating corresponding background and illustrative examples that support our findings within each country narrative.

Primary health care (PHC) is essential health care that’s accessible and acceptable to individuals and families in the community, at a cost that the community and the country can afford.¹ An effective PHC system provides regular and comprehensive care near people’s homes and communities. It can promote wellbeing and prevent and detect illnesses early, which helps improve outcomes while reducing health care costs for countries. Researchers estimate that high-quality health care—largely PHC—could avert as many as 60 million deaths in low- and middle-income countries (LMICs) by 2030.²

Experts say PHC is essential to achieve universal health coverage worldwide, one of the UN Sustainable Development Goals, and can spur progress toward other WHO goals for promoting health, keeping the world safe, and helping the vulnerable.

(For further detail, see the accompanying Topic Page.)

The PHC Exemplar countries had higher levels of effective coverage relate to peers who spent the same amount on health—a proximate measure of system performance that indicates comparative efficiency as well as high quality (see Figure 1).

In the context of health systems, efficiency means getting the most care out of limited resources by ensuring those limited resources are directed to the right things.³ Figure 1 illustrates how the countries we studied increased health system efficiency over time, as measured by increasing universal health coverage (UHC) effective coverage related to total health expenditure per capita.

Figure 1: UHC effective coverage over time

Source: Institute for Health Metrics and Evaluation, GBD 2019; World Bank WDI (2020)

Note: GDP/capita and CHE/capita are in current US$. All values for 2020. Acronyms: GDP: Gross Domestic Product; CHE: Current Health Expenditure; HF: Health Facility; THE: Total Health Expenditure

Meanwhile, equity means minimizing differences in health access and outcomes among different population groups and ensuring everyone has access to the care they need.⁴^,⁵^,⁶ Figures 2 and 3 below show how countries included in our study were able to drive expansion in health coverage equitably, reaching the underserved (including people with low income) and across populations with different levels of education.

Figure 2: Improvements to equity in service coverage across wealth quintiles in PHC Exemplar countries over time (years vary)

Figure 3: Improvements to equity in health care coverage across education levels in PHC Exemplar countries over time (years vary)

As the world confronts growing health challenges with fewer financial resources in the post-COVID-19 pandemic era, it is important to draw lessons from these countries that have made impressive strides in achieving more health for each dollar spent.

In addition to driving equity in health coverage, the Exemplar countries each made progress in building PHC systems that generally outperformed their peers in expanding basic PHC coverage, as indicated in Figure 4.

Figure 4: PHC Exemplar coverage measures over time

Source: Institute for Health Metrics and Evalution; GBD 2019

As noted earlier, strong PHC systems are associated with improved health outcomes. Figure 5 shows how improvements in PHC coverage in Exemplar countries between 2000 and 2018 led to improvements in under-five mortality, maternal mortality, and overall disability-adjusted life years.

Figure 5: PHC Exemplar country health outcomes over time

Source: Institute for Health Metrics and Evalution; GBD 2019; UN IGME 2021; UN MMEIG 2023

Exemplar countries' focus on improvements in PHC coverage alongside vertical disease programs translated to improved outcomes, measured by DALYs, or the sum of premature mortality and years lived with disability; one DALY equals one lost year of healthy life. As Figure 6 shows, DALYS across all five countries declined significantly over the past two decades for HIV, tuberculosis, malaria, maternal neonatal disorders, nutritional deficiencies and neglected tropical diseases.

Figure 9: PHC Exemplars allocations to PHC

Source: Institute for Health Metrics and Evaluation; GHED (2018), Rwanda HRTT (2014-15)

Overall, our research identified the common reform strategies all the Exemplar countries used to varying degrees that enabled them to provide more efficient, equitable, and higher-quality health care for less.

The takeaways below explain how research was developed and synthesized.

Analysis was informed by the WHO Measurement Framework for PHC⁷, which identifies three core components that support a “whole-of-society” approach to building a strong PHC system:

Integrated, people-centered health services. Providing comprehensive integrated health services, composed of promotive, protective, preventive, curative, rehabilitative, and palliative care, through all stages of life.
Multisectoral policy and action. Systematically executing evidence-informed policies and actions that focus on broader factors that affect health. These include social, economic, and environmental circumstances, as well as a person’s character and behavior.
Empowered people and communities generating demand. Empowering individuals, families, and communities to advocate for policies that support their health and well-being.

Figure 7 shows the WHO framework that helped to identify the key reform strategies in each country that improved efficiency in these domains, and the subsystems driving positive change.

Figure 7: WHO Measurement Framework for PHC

To understand how we selected the countries we studied, see the Zambia, Peru or Ghana methodology pages. To understand how we arrived at cross-country findings, see the cross-country methodology page.

The five Exemplar countries implemented a range of reforms to meet their unique needs. However, they all followed three pathways that improved the efficiency, equity, and quality of their PHC systems.

Pathway 1: Spending enough, and spending well, on PHC. Leaders in Exemplar countries consistently allocated a substantial percentage of their total health expenditure to PHC, and ensured these funds reached the lower levels of the health system that typically deliver PHC services. They also had high budget execution rates, which suggest the Exemplar countries managed and used those resources effectively and efficiently.
Pathway 2: Implementing systems for performance management, accountability, and community engagement. All five Exemplar countries worked to meet local needs and priorities by making it easier for the community to participate in planning discussions and to share input. For example, the countries invested in information systems to enable more data sharing, which facilitated engagement with community governance structures and civil society organizations.
Pathway 3: Improving access to care and facility readiness, boosting utilization rates. To increase use of PHC services, Exemplar countries focused on reducing barriers to access in multiple ways. They addressed financial barriers by lowering out-of-pocket costs through poverty-reduction programs and by establishing national health insurance schemes. They built PHC clinics closer to where people live to reduce geographic barriers such as distance and added travel costs.

Over the two-decade Exemplar study period, all five countries continuously reviewed and tweaked the PHC system reforms they implemented. Often, later reforms were designed to complement and strengthen earlier interventions. Although individual country contexts influenced the timeline and extent to which the reforms were made, all five Exemplar countries made the following key changes in roughly the same order.

Figure 8: PHC system reform sequencing

Different country contexts and leadership strategies also influenced the success of many reforms. Findings from this research yielded five additional insights.

Policymakers responded to public demand to implement health system reforms. For instance, Ghana’s National Health Insurance Scheme was created in response to public demand. Before the National Health Insurance Scheme, Ghanaians paid for treatments at the time of delivery, a deeply unpopular and costly system that provided few protections from catastrophic health expenditures and discouraged people from seeking care.

Civil society groups were an influential force in forming and spurring reforms. In Peru, the work of local self-help organizations that delivered nutritional support to people with low income shaped the country’s early bottom-up approach to health system management and its subsequent decentralization efforts. In Bangladesh, advocacy by the civil society group BRAC led to new community-based service-delivery models. In Ghana, the community-based insurance schemes started by the Christian Health Association of Ghana in the 1980s became the blueprint for the country’s National Health Insurance Scheme that launched in 2003.

Exemplar countries overhauled their bureaucratic structures and processes to carry out the PHC reforms. For instance, three of the five Exemplar countries established semiautonomous agencies—the Ghana Health Service, the Rwanda Biomedical Center, and Zambia’s Central Board of Health—that focused explicitly on the work of implementation.

The Exemplar countries’ commitment to improve reforms to address shortfalls contributed to their longevity. For example, in Zambia, changing political circumstances led policymakers to abolish the Central Board of Health, but the capacity and strength to manage health service delivery were retained, while some of its responsibilities, such as establishing and managing routine monitoring and evaluation, were reassigned to other formal structures.

Underlying elements. Durable reforms were often supported by underlying elements, such as accountability measures, institutional capacity, feasibility for scale, population entitlements, or the law. Rwanda implemented performance-based contracts that hold local leaders and the president accountable to meeting a range of health objectives. Their performance is monitored and published publicly. In Peru, political reform in 1993 institutionalized decentralization of the health service. Social participation in health was a pillar of this reform.

Building a strong and comprehensive PHC system is an immense undertaking. It requires political will, state capacity, flexibility, and a commitment to efficiency and equity for all the system’s users. Crucially, countries can implement these PHC reforms even in the face of resource constraints, improving the performance of their PHC systems for all.

1
World Health Organization. WHO called to return to the Declaration of Alma-Ata: International conference on primary health care. Accessed November 27, 2021. https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata
2
World Health Organization. Primary health care fact sheet. Published April 1, 2021. Accessed November 27, 2021. https://www.who.int/news-room/fact-sheets/detail/primary-health-care
3
Culyer AJ. The bogus conflict between efficiency and vertical equity. Health Econ. 2006;15(11):1155-1158. https://doi.org/10.1002/hec.1158
4
Institute for Health Metrics and Evaluation. All-cause, total health spending, spending per person, 2000-2020 [data set]. http://ihmeuw.org/6chb
5
See also Whitehead M. The concepts and principles of equity and health. Int J Health Serv. 1992;22(3):429-445. https://doi.org/10.2190/986L-LHQ6-2VTE-YRRN
6
Asamani JA, Alugsi SA, Ismaila H, Nabyonga-Orem J. Balancing equity and efficiency in the allocation of health resources—where Is the middle ground? Healthcare (Basel). 2021;9(10):1257. https://doi.org/10.3390/healthcare9101257
7
World Health Organization. Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. Published February 28, 2022. https://www.who.int/publications/i/item/9789240044210