Many countries, particularly low- and middle-income countries (LMICs), struggle to scale up effective PHC systems. Consequently, around the world, people still lack access to quality PHC services. Under Sustainable Development Goal (SDG) 3.8, all countries have pledged to “achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.”1

PHC plays a key role in ensuring access to essential health services for all – but around the world, people still lack access to high-quality PHC services. For instance, more than 200 million women have inadequate coverage for family planning, almost 20 million infants fail to start or complete the primary series of DTP-containing vaccine, and many more infants miss other recommended vaccines.2 Meanwhile, expectations of health systems are rising, but satisfaction in them is not. For instance, a recent study showed that only about 42.4 percent of people in 28 sub-Saharan African countries were satisfied with the availability of high-quality health care in their areas of residence.3  

Getting PHC right is complex and challenging. A number of problems face decision makers who are working on PHC. These are a few core challenges associated with building and implementing a PHC system:

It is estimated that PHC spending per capita needs to increase over 250 percent (from the current US$25 to US$65) in low-income countries for required systems strengthening and the provision of essential PHC services universally.1 (This number does not account for COVID-related health system disruptions and setbacks on the path to the SDGs.) According to one 2020 paper, two key factors contributing to low levels of public spending for health across LMICs are low levels of government revenue generation and a failure to prioritize health in government budgets.4 To add to the complexity, many countries also face challenges with low budget execution (the amount of the budget that is actually spent) due to poor public financial management. One report estimates that billions of dollars are returned to the treasury every year.5

On average, LMIC governments fund a little more than 40 percent of outpatient and home-based consultations with health care providers. They pay for just 10 percent of medicine and supplies, which are critical for curative care, chronic disease management, and preventing more serious (and expensive) health problems. Likewise, governments fund less than half of the total amount that PHC systems spend on prevention services – and prevention is one of the core responsibilities of PHC.

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.

  1. 1
    Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkeley S. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study. Lancet. 2019; 7(11): E1500-E1510. https://doi.org/10.1016/S2214-109X(19)30416-4
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    World Health Organization (WHO), International Bank for Reconstruction and Development (IBRD), The World Bank. Tracking Universal Health Coverage: 2017 Global Monitoring Report. Geneva: WHO; 2017. Accessed November 27, 2021. https://apps.who.int/iris/bitstream/handle/10665/259817/9789241513555-eng.pdf;jsessionid=1CC7EDA354E6472876CE47BDA1B34030?sequence=1
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    Deaton AS, Tortora R. People in sub-Saharan Africa rate their health and health care among the lowest in the world. Health Aff (Millwood). 2015;34:519-527. https://doi.org/10.1377/hlthaff.2014.0798
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    Tandon A, Cain J, Kurowski C, Dozol A, Postolovska I. From slippery slopes to steep hills: Contrasting landscapes of economic growth and public spending for health. Soc Sci Med. 2020:259(113171). Accessed November 27, 2021. https://doi.org/10.1016/j.socscimed.2020.113171
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    Viola H. Supporting country progress towards better health budget execution: the LHSS-JLN Health Budget Execution Learning Exchange. USAID website. Published November 8, 2021. Accessed November 27, 2021. https://lhssproject.org/news/supporting-country-progress-towards-better-health-budget-execution
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    Giorgio L, Evans D, Lindelow M, Nguyen S, Svensson J, Wane W, Tarneberg A. An Analysis of Clinical Knowledge, Absenteeism, and Availability of Resources for Maternal and Child Health: A Cross-Sectional Quality of Care Study in 10 African Countries. Center for Global Development. 2020. https://www.cgdev.org/sites/default/files/analysis-clinical-knowledge-absenteeism-and-availability-resources-maternal-and-child.pdf
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    Soucat A, Scheffler R. The Labor Market for Health Workers in Africa : New Look at the Crisis; Chapter 5: Health Worker Performance. World Bank Repository. 2013. https://openknowledge.worldbank.org/handle/10986/13824 License: CC BY 3.0 IGO.
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    Sylvia S, Shi Y, Et. Al. Survey using incognito standardized patients shows poor quality care in China's rural clinics. Pub Med. https://pubmed.ncbi.nlm.nih.gov/24653216/
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    Sylvia S, Xue H, Et. Al. Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study. PLOS Medicine. 2017. https://doi.org/10.1371/journal.pmed.1002405
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    Daniels B, Dolinger A, Bedoya G, et al. Use of standardised patients to assess quality of healthcare in Nairobi, Kenya: a pilot, cross-sectional study with international comparisons. BMJ Global Health 2017; 2:e000333. https://gh.bmj.com/content/2/2/e000333
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    Ministère du Plan et Suivi de la Mise en oeuvre de la Révolution de la Modernité (MPSMRM), Ministère de la Santé Publique (MSP), ICF International. Democratic Republic of Congo Demographic and Health Survey 2013-14 Key Findings.. Rockville, Maryland, USA: MPSMRM, MSP, and ICF; 2014. Accessed May 21, 2019. http://www.dhsprogram.com
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    Carter R, Xiong X, Lusamba-Dikassa P-S, et al. Facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care in 72 rural health facilities in the Democratic Republic of the Congo: A cross-sectional study [version 2; peer review: 2 approved]. Gates Open Res. 2019, 3:13. https://doi.org/10.12688/gatesopenres.12905.2
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    Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence. 2012;6:39-48. https://doi.org/10.2147/PPA.S24752
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    World Health Organization (WHO), International Bank for Reconstruction and Development (IBRD), The World Bank. Tracking Universal Health Coverage: 2017 Global Monitoring Report. Geneva: WHO; 2017. Accessed November 27, 2021. https://apps.who.int/iris/bitstream/handle/10665/259817/9789241513555-eng.pdf
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    Causey K, Fullman N, Sorensen RJD, et al. Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: a modelling study. Lancet. 2021;398(10299):522-534. https://doi.org/10.1016/S0140-6736(21)01337-4
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    PATH. Essential health services during and after COVID-19: A sprint analysis of disruptions and responses across six countries. PATH website. Published December 2020. Accessed November 27, 2021. https://www.path.org/resources/essential-health-services-during-and-after-covid-19-sprint-analysis-disruptions-and-responses-across-six-countries/