Challenges

Exemplar countries improved their PHC systems in terms of coverage of key health services and health outcomes during the case study period. But several broad challenges pose ongoing barriers to the sustainability and equity of their PHC systems, including those listed below.

Inequitable access to PHC services

All Exemplar countries worked to increase access to key health services for people living in hard-to-reach places and socioeconomically vulnerable groups, such as pregnant women, children, and older people. But persistent geographic, income, and other inequalities continue to challenge efforts to deliver consistent and affordable care to those groups and others, including Indigenous populations.

In Peru, rural areas continue to suffer from a lack of nearby health facilities, health workers, and access to diagnostics and other key tools despite the country’s efforts to expand health insurance coverage and incentive programs to attract and retain workers.^1,2 These inequities are even more acute for the country’s Indigenous populations, for whom the lack of access to health services is exacerbated by a comparable lack of population-specific data to inform policymakers on how to fix the problem.

Bangladesh has the opposite problem: the government focused on establishing PHC services in rural areas and overlooked their urban counterparts. As a result, there is a dearth of facilities delivering PHC services in urban areas. This poses a substantial long-term challenge, as experts predict that more than half the population will be urban by 2050.³

Growing debt and funding uncertainty

Although all Exemplar countries stood out for the efficiency of their health spending, their relatively small health budgets were often insufficient and have continued to shrink in the face of macroeconomic shocks. Most notably, the COVID-19 pandemic strained health systems, shocked economies into sharp contraction, and increased debt obligations.

For example, Peru’s GDP declined 12% and the poverty rate soared to 26% in 2021.⁴ And Rwanda’s signature community-based health insurance program is in chronic debt, in large part because of reduced financial contributions from the Ministry of Health.⁵

In Ghana, health spending as a proportion of government spending has fallen steadily since 2019 as the country’s debt crisis ballooned.⁶ By the end of 2022, more than 70% of government revenue went to interest payments.⁷ To address the debt obligations, Ghana pulled back spending on poverty-reduction efforts, which pushed 30% of the population into poverty in 2023. That figure is expected to rise to 33% by 2025.⁸

Zambia has also been hit with a new wave of debt obligations in the fallout from the COVID-19 pandemic. As a result, the country spent four times more on external debt payments than it did on public health care in 2020.⁹ This has added further strain to expanding and sustaining health system reforms that had been reliant on donor funds, which had become increasingly unpredictable before the pandemic. For instance, the results-based financing program in Zambia was terminated after the World Bank stopped funding it in 2018.

Financial barriers to access

Financial barriers to access remain for individuals and families in all Exemplar countries, but have varied in magnitude and feasibility of improvement. In Bangladesh, as government and donor spending on health has steadily decreased since 2009,¹⁰ out-of-pocket expenditure has become the primary funding source of health care. It rose to 74% in 2020.¹¹ Research has shown that approximately 25% of people experienced catastrophic health expenditures and 14% of the population reported foregoing care, citing financial barriers as the most common reason.¹² One study estimates that the soaring out-of-pocket expenses pushed over 6 million people below the national poverty line in 2022.¹³

In Peru, out-of-pocket expenses fell thanks to Seguro Integral de Salud (SIS), free or low-cost health insurance for Peruvians living in poverty.¹⁴ But for many people, health care costs remain prohibitively high because SIS does not cover some key health services.^15,16

Similarly, although Ghana’s expanded National Health Insurance Scheme reduced financial barriers, problems with its implementation has limited coverage for people with low income and older people who need it the most.¹⁷ Enrolled people also report still having to pay out of pocket for services because of the government’s delay in reimbursing health providers.¹⁸

Health system fragmentation

Exemplar countries reoriented their health systems to promote equitable coverage and to coordinate services, strategic planning, and nimble decision-making. But even Exemplar countries still struggle with ongoing fragmentation.

Peru’s health care delivery is complicated by the system’s numerous funding sources, range of insurance schemes with different coverage levels, and multiple channels for health service financing. Access to health services remains fragmented because individual insurance schemes have varying resources and coverage levels.¹⁹ This feeds systemic inequities and hurts Peru’s ability to provide timely, high-quality care for all its citizens.^20,21

Health systems benefit from decentralization most when decision-making authority and participation in planning processes are carefully balanced across central and subnational levels. This balance increases health system responsiveness to local needs while maintaining a well-defined center. Some Exemplar countries, such as Ghana and Rwanda, have experienced an imbalance of key functions, which has caused bureaucratic friction and weakening managerial and financial autonomy at the district level.²²

For example, in Zambia, districts and local PHC facilities maintain managerial autonomy but have had financial autonomy only at certain points in history. The first instance of financial autonomy in Zambia was when user fees were still being charged. But even then, lower levels of the health system could not use the discretionary spending they had on administrative and operational costs such as maintenance, fuel, supplementary staff allowances, and additional drugs or supplies in cases of shortfall or delay.²³ Later, they regained financial autonomy when a trial of a results-based financing (RBF) system was implemented. This temporarily raised staff morale by enabling more flexibility to spend on unplanned events such as staff and drug shortages, but this effect might have ended when RBF was discontinued in 2018.

Health worker shortages

A shortage of health workers is still a chronic problem in nearly all Exemplar countries, particularly in rural areas. WHO recommends a minimum of 22.8 doctors, nurses, and midwives per 10,000 people.²⁴ Zambia had half that in 2017, while Bangladesh had even less as of 2018. Poor distribution of the workforce and skill mix has exacerbated the challenge—all of which impacted quality of care.

Research shows that as of 2018 Ghana had 47,758 unfilled vacancies at the Ghana Health Service, including 7,141 additional staff needed at the community health planning and services level, with wide variations across staff category, service delivery, and geographic location. Although addressing the shortage in full requires more funding, the same research shows that the staffing gap could be narrowed by 30% with better workforce and skill       distribution.²⁵

Political instability

Although the PHC services introduced during the study period endured multiple changes in government, political instability in some Exemplar countries eroded people’s trust in policymakers and public services, limiting their willingness to use government-backed initiatives like national health insurance programs and other reforms.

For example, Peru’s current president is its 10th since 2000; six have been accused of corruption and left office under a cloud. This instability has led to low rates of public trust in and satisfaction with the political system.²⁶ The impact of the continuous unrest was evident during the COVID-19 pandemic. Peru had three presidents in the span of one week in November 2020, and eight health ministers between April 2020 and April 2022, all of which affected the central government’s ability to respond quickly and coherently to the crisis.²⁷ Peru suffered one of the worst rates of deaths per capita in the world.

In Bangladesh, the operation of community clinics—the health facilities that deliver general health, family planning, and nutrition services closest to the community—were suspended between 2001 and 2008 when a different political party came to power.²⁷ More recently, in August, Prime Minister Sheikh Hasina fled the country after widespread demonstrations opposed her increasingly authoritarian rule.²⁸ The prime minister’s abrupt departure left a country in chaos: student demonstrators took charge; police officers abandoned their stations; operations at garment factories, the country’s economic driver, were interrupted.²⁹ And in early September, the health care system shut down when doctors went on a three-day nationwide strike after people assaulted the hospital staff where a student who had been injured during the demonstrations died.^30,31

Data limitations

Exemplar countries invested in digitized data systems to enable and support evidence-based decision-making. However, a key obstacle for the countries has been achieving interoperability across various systems and fragmented applications, which has hindered seamless integration and the efficient flow of information. For example, health information system efforts in Ghana are typically isolated and ad hoc, making any data collected harder to exchange and use to make decisions.³²

Furthermore, countries like Ghana and Bangladesh reported data quality and interoperability issues that limited the data’s utility. In Ghana, unstable IT infrastructure and internet connectivity hampered reliable data collection. In Bangladesh, poor data quality, characterized by inaccurate or incomplete data entry, led to its disuse, discouraging policymakers from going to the trouble of improving the quality.³³

Conclusion

These are some of the key barriers to the continued expansion and sustainability of PHC health systems in Exemplar countries. Nevertheless, the lessons from the Exemplar countries’ success can be shared across countries, to help them overcome the challenges of the future and continue the momentum of progress that has been achieved.