How to make primary health care work for everyone

The global goal to achieve universal health coverage (UHC) by 2030 is the most important opportunity to advance health equity in our lifetimes. Quality primary health care (PHC) is the expressway to meeting that goal.

As part of UHC2030, a multistakeholder platform that brings together diverse stakeholders around the common cause of health for all, PATH and partners advocate for a world where everyone, everywhere has access to high-quality essential health services, without experiencing financial hardship to access them.

Though lingering effects from the COVID-19 pandemic continue to challenge health systems, erode community trust, and threaten global progress, countries can ensure all people everywhere have access to the health products and services they need to thrive through sustainably financed, integrated, and people-centered PHC.

Kimberly Green, PhD, PATH’s Director of Primary Health Care, helps articulate what this means and what it will take to get there.

PHC has long been recognized as the means to achieving UHC, but investments have fallen short. Before the COVID-19 pandemic, there were strong global and national commitments to PHC (such as the 2018 Astana Declaration), but investment was far from adequate, with inconsistent coverage, access, and quality of care in many settings.

And now, PHC is still recovering from the pandemic. There have been significant losses of health care workers due to burnout—in Africa alone, there is shortfall of around 6 million health care workers. There are ongoing supply chains challenges, longer wait times to access essential health services, and too many people experiencing morbidity due to post COVID-19 sequelae or long COVID. The pandemic also exacerbated health inequities caused by poverty, racism, misogyny, ableism, homophobia, and transphobia.

PHC must grapple with these challenges while facing new threats brought on by climate change. This includes increasing antimicrobial resistance and infectious disease outbreaks. These and other factors are making epidemics and pandemics much more likely.

Furthermore, the burden of disease is changing worldwide. For example, the burden of noncommunicable diseases (NCDs) is growing. It is estimated that by 2040, 50 percent of all deaths will be attributable to NCDs. Meanwhile, NCDs receive only 2 percent of global health financing.

To achieve UHC, PHC must be inclusive, welcoming, and equipped to reflect the needs of all people. The late Paul Farmer said, “If access to health care is considered a human right, who is considered human enough to have that right?” His words ring true today—access for some is not sufficient. We must demand access for all.

Right now, PHC in most countries is underfunded—PHC receives about 40 percent of the health budget, while almost half the world’s population lacks access to essential health services. Higher levels of spending on PHC are associated with higher levels of service coverage and better health outcomes.

But how the money is spent also matters.

Global health financing is currently siloed, focusing on specific health areas. While those mechanisms have significantly reduced deaths and disease incidence and improved quality of life, there is little coordination across funding sources. This means that financing is not intentionally responding to countries’ health care priorities—in low- and middle-income countries, priorities tend to be things like better integration, digitalization, and a well-equipped and trained community health workforce.

Financing can better align with a country’s priorities when it is evidence-driven—governments need better data and information to identify specific needs, engage users (health care workers and patients), and target spending accordingly.

PHC financing must also be proactive—spending on supply chain infrastructure, laboratory and diagnostics capacity, and medical equipment that can support strong systems for keeping people healthy—rather than reactive, costly spending on treating the sick.

Siloed global health financing streams can, in some cases, result in verticalized services—distinct, issue-specific health care providers—which makes seeking care more challenging. A person living with HIV and hypertension should not need to travel to two different health facilities on different dates to refill their prescriptions or receive care.

To strengthen PHC, it is ideal to integrate health care into one service delivery unit with multidisciplinary teams that provide case management over time, such as through general practitioners.

For instance, in Senegal, Ukraine, and Vietnam, PATH works with governments and local partners to integrate HIV services with care for depression, anxiety, and substance abuse. Integrated care like this helps minimize health system fragmentation and delivers organized health services that make it easier for more people to access the care they need.

Integrating PHC is one way that PATH works to make PHC more people-centered.

Service integration alone does not necessarily mean services will be accessible or meet people’s needs. That’s why people-centered primary health care—which puts people and communities, instead of diseases, at the center of health systems—is so critical.

PATH does this by partnering with communities, using human-centered design, to really understand what they need and want. Together, we determine what kinds of solutions would work well for them.

We also partner with health leaders to deliver care to populations left out of mainstream services. When we talk about centering people in PHC, we mean all people. This includes internally displaced persons, communities in conflict-affected regions, transgender people, and any other groups facing challenges or discrimination that affects their ability to seek or access health care.

PHC is for everyone—with a people-centered approach, we can build resilient systems that everybody can access.

A key piece of this puzzle is addressing the major community trust issues with health care overall.

In communities around the world, trust is a challenge when it comes to health care. For many communities, trust was further eroded during the COVID-19 pandemic. These challenges must be considered when designing, implementing, and monitoring PHC.

During the pandemic, it was instructive to see which countries mobilized a successful whole-of-society COVID-19 response. The countries that were able to do this well already had stability and trust in local health services and leaders.

From Costa Rica to Ethiopia to Thailand, countries with previous investments in PHC had fostered trust among their communities. As a result, they had greater adoption of masking, testing, and vaccination. Even in countries where national governance was in flux, like in Brazil, the decades-long investment in their Sistema Único de Saúde (Unified Health System, in English) platform enabled a rapid, evidence-based, and consistent response.

Moving forward, systematic community engagement in PHC is essential for greater quality and accountability. The Global Fund and PEPFAR advance community-led monitoring, a forward-thinking approach in which community members conduct structured, repeated independent assessments of health care accountability, access, and quality. They document their feedback and share it with health leaders and providers.

The community-led monitoring approach has been very effective—it could and should be scaled up to more communities and countries.

Despite the challenges, I am very hopeful. There is a growing list of countries that have put renewed energy and investment into their PHC coverage and access plans.

In Egypt, Georgia, India, Kenya, and Togo, there is momentum to do things differently. They are developing new models for organizing services that better suit what communities need. These models include telehealth, mobile services, and private-sector engagement in national health insurance schemes.

I’m hopeful that more countries will prioritize PHC by investing in a community health workforce and meaningful social engagement in PHC.