What are the core challenges?

Governance and coordination occur throughout PHC systems, from national-level policy setting to community-level delivery of care. Yet in many LMICs, the roles and functions of the distinct ministries, departments, and agencies are not always clear.

Fragmented health system governance undermines performance management and accountability and is another significant root cause of poor PHC performance. This fragmentation is, in part, due to investments in strengthening existing need-specific “vertical” programs (e.g., vaccinations, family planning, malaria, tuberculosis) from development partners.

Highly fragmented governance structures (sometimes fractured by design) are further complicated by differences between the formal roles of entities and their informal roles in practice. The focus on “vertical” need-specific programs from development partners has led to parallel governance structures and policies between vertical and horizontal structures. Additionally, given limited amounts of funding, the leadership and decision makers within a system must constantly be balancing factors such as priority setting versus emergency response and ensuring wide population accessibility versus quality improvements in targeted geographies or disease areas.

In a fragmented, disconnected PHC system, patients rarely experience continuity of care – which in turn undermines the quality of care they receive. By contrast, in a connected PHC system, patients and caregivers can see the big picture, sharing information and building relationships from visit to visit and place to place. Especially as PHC systems become more decentralized, providers need access to patient health and treatment histories so that care from multiple providers in various places can be coordinated, complementary, and responsive to a patient’s changing needs. This is especially important in rural settings, where response and referral time is critical and secondary care can be difficult to reach.

Simply having clinicians in place in a community is not enough. If physicians, nurses, and community health workers are not properly trained and motivated, the care and services they provide will be inadequate. For example, among doctors in Togo and India and nurses in Uganda, absenteeism rates approach 50 percent for health care providers.⁶

In general, a study of health care workers in 18 different countries found that the average clinician performs around 40 percent of the recommended actions for family planning, sick-child care, antenatal care, and delivery care.⁷ A World Bank study of doctors in rural China found that its subjects completed less than 20 percent of the items on a recommended-care checklist; misdiagnosed about 75 percent of their patients; and prescribed nearly three times more harmful medications than salutary ones. ^8,9 Similar studies in Kenya showed that across a range of conditions – asthma, child diarrhea, tuberculosis, and angina – providers completed patient histories less than half of the time and correctly managed just over half of cases.¹⁰

In fact, many existing facilities across LMICs still struggle with overcrowding, poor infection prevention and control, lack of essential health infrastructure, and resource constraints – even as the health systems themselves seek to expand. For example, in the Democratic Republic of Congo (DRC), close to 80 percent of births now occur in a health facility.¹¹ But because many of these facilities (especially those in rural areas) lack trained personnel, essential medicines, and even electricity and running water, researchers consider the DRC to be one of the world’s worst places to give birth, and high maternal and neonatal mortality ratio rates have persisted for decades. During one 3-month observation period, only one of 12 general hospitals in one region of the country offered all nine comprehensive emergency obstetric and neonatal care (CEmONC) functions; antibiotics, anticonvulsants, and oxytocin were available in just 69 percent of all facilities; only half had electricity and one-quarter had drinking water.¹²

Patients’ decisions about where to seek care reflect a desire for high-quality, reliable services. In rural parts of Haiti, for example, health care facilities with better infrastructure and service delivery are busier than others. The same is true in Mexico, Nigeria, and China, where facilities are underused, and people cite poor quality as a reason they avoid care. In many places, patients looking for higher-quality care often bypass lower-level public facilities and turn to the private sector.

Likewise, research shows that patients who feel heard, respected, and valued (via shorter wait times and clearer communication with caregivers, among other things) are more likely to seek care and adhere to the treatments their caregivers prescribe.¹³

Many countries have made progress in improving health outcomes, but equity remains a huge challenge. For example, between in 2005 and 2015 only 17 percent of mothers and infants in households in the poorest wealth quintile in LMICs received at least six of the seven basic services for maternal and child health, compared with 74 percent in the richest quintile.¹⁴ One primary cause is that many PHC systems fail to address the underlying social and structural determinants of health and health equity, which can exacerbate inequities across factors including income, race and ethnicity, geography, sex, and age.

Demand for health services is increasing, and patterns of utilization are changing. For instance, the burden of noncommunicable diseases (such as heart disease), road injuries, pollution-related illness (such as COPD), and mental health issues (including those surrounding domestic and sexual violence) is expected to increase. At the same time, especially in urban areas, the burden of communicable diseases such as diarrheal diseases has been falling. Demand for health services has changed accordingly – but in many places, health care systems have been slow to catch up. Effectively addressing changing population needs, increasing demand, and the constant threat of new challenges like a pandemic is difficult, as the COVID-19 pandemic has highlighted.