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Implications for primary health care
demonstrates that it is paramount to move toward new ways of organizing care, so that patients get more health for their money rather than spend more money for health.
Substantial challenges face health systems in the 21st century. COVID-19 has exacerbated many of those challenges and exposed underlying weaknesses in health systems in countries at all levels of income. In the years ahead, as known threats intensify, others will emerge in domains not yet foreseen.
PHC systems offer proven tools to tackle existing challenges, as well as the flexibility and creativity to confront new threats. The evidence base on PHC’s contributions to population health has grown significantly since Alma-Ata. Asubstantial body of research from across the development spectrum shows the benefits of strong PHC systems for health outcomes (Macinko, Starfield, and Erinosho 2009), efficiency in service delivery (WHO 2019b), and quality of care (Friedberg, Hussey, and Schneider 2010). In many settings, comprehensive PHC approaches have been crucial to narrowing the health disparities (Macinko, Starfield, and Erinosho 2009). PHC offers the surest foundation for health system development to manage the trends that will shape health needs and opportunities in the decades ahead.
To fulfill this promise, however, PHC itself must evolve. In many cases, approaches that succeeded in the Alma-Ata period or even the MDG era cannot simply be transposed to today’s health system contexts. The powerful trends described are shaping a novel global health landscape with new risks and new rules—but also new opportunities with advanced technology. The COVID-19 pandemic and the response thereto embody these transformations. The pandemic has provided an opportunity to rethink established health system paradigms, including the role of PHC.
Demographic and epidemiological changes, evolving health needs, and rising public expectations raise the stakes for better-functioning health systems. Repositioning PHC to meet the demands of the new health care ecology will require rethinking governance and accountability in PHC systems. Governance and accountability structures shape the processes by which patients, providers, and payers interact, mediating these stakeholders’ divergent interests and power relationships.
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Accountable PHC systems will need to be more responsive to meet people’s expectations in their engagements with the health system, as embodied in professional ethics and human rights.
Achieving this will require PHC systems to enhance the structural aspects of care, including the quality of basic amenities, choice, prompt attention, and access to social support networks. It will also mean attention to interpersonal domains, including patient dignity and autonomy, better communication between providers and patients, and respect for patient confidentiality. PHC systems will need to invest in building relationships of trust with patients and communities to ensure that decisions are aligned with ethical standards and professional norms, as well as with societal and cultural values.
Building more accountable PHC systems will mean moving away from traditional ways of thinking about how to allocate scant resources. Although the evidence is still limited, global experience shows that, to improve PHC accountability, countries can employ a battery of strategic purchasing policies, including capitation, performance-based contracts, and global budgeting. Provider payment methods will need to reflect the care setting in which PHC services are provided, incorporating feedback from patients. It is paramount that payments to PHC providers signal a sense of fairness relative to the payments made to specialists.
Accountability hinges on the availability of accurate and relevant information to track performance over time and across providers. Transparency will need to be embedded as a core principle of accountable PHC systems. Greater transparency helps mitigate, if not eliminate, corruption and waste by facilitating closer monitoring of providers and payers and helping to realign provider incentives. Efforts to improve the transparency of PHC systems will entail instilling a culture of evidence-based, data-driven medical practice; tracking the most relevant data; and expanding venues for feedback from citizens. Facilitating input from system users may involve, for example, scaling up real-time feedback loops using culturally appropriate, patient-reported outcome measures and patient experience reports.
Reorganizing care delivery
Many people across the globe are living longer and healthier lives—and all aspire to do so. Rapid urbanization and increased digital connectivity will continue to fuel citizens’ expectations for high-quality health care. As these trends converge, traditional health care organization models are coming under increasing strain. Health systems in LMICs, where global population growth is concentrated, already struggle with poor infrastructure and digital connectivity, stark human resource gaps, and weak supply chains, fueling
shortfalls in service coverage, quality, efficiency, and equity. Many LMICs need new solutions to expand coverage of essential services while improving financial protection—the pillars of UHC. This new ecology of care magnifies the need to rethink traditional care models.
PHC systems have unique strengths to address the pressures caused by population growth, rising NCD burdens, population aging, and other trends that require more people to engage more often with the health system. However, some features of traditional PHC systems must be transformed to take full advantage of existing strengths and build new ones. This is particularly important for LMICs that bear a double burden of communicable and noncommunicable diseases. For instance, today, almost 8 in 10 patients receiving ART in LMICs reside in Sub-Saharan Africa. Thanks to recent efforts in HIV treatment (such as early ART initiation), many high-prevalence countries have achieved important gains in reducing HIV-related mortality. These gains, however, also generate new challenges for care delivery systems. The high prevalence of HIV/AIDS among working-age populations in Sub-Saharan African countries suggests that a greater proportion of the population will continue living with the disease, while concurrently confronting other chronic conditions. More generally, the double burden of disease coupled with the projected rise in working-age populations in LMICs will boost demand for sustained engagement with the health system, pushing up health spending.
These demographic and epidemiological trends underline the urgent need for additional investments in PHC systems. Population aging will require better integrated, long-term care that empowers health professionals to address both the expressed and unexpressed needs of populations (McConnell and Uwe 2019). Health expenditures are projected to escalate with a growing elderly population, because individuals tend to incur the highest medical costs closer to the end of their lives (Bloom et al. 2015). Compounding the effects of population growth and aging, health risks that are not addressed earlier in the life course will undermine health in older people and will increase the likelihood that a greater proportion of the aging population will be impacted by ill health, disability, and costly comorbidities.
New investments in curative care services alone are unlikely to curb these pressures on health systems. While some HICs are already scaling up longterm care programs, substantial work remains to be done to address the high degree of fragmentation, low-quality and low-value care, and waste. In many UMICs, efforts are needed to integrate primary care with other levels of care; address the chasm between service coverage and quality; and improve inefficiencies in service provision. Meanwhile, health systems in many LMICs
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are unprepared to address the needs of their aging populations. Long-term care arrangements in these settings remain weak and poorly integrated with social services, placing elderly people and their families at high risk for catastrophic out-of-pocket health care expenditures.
The potential benefits of improving health care models extend beyond the health sector. In many of today’s HICs, changes in the population age structure between the 1960s and 1990s enabled countries to reap a demographic dividend—faster economic growth due to drops in fertility and mortality, supported by economic and social policies to propel economic expansion. Today, many LMICs with young populations are poised to reap a similar demographic dividend—but its benefits will not be automatic. A strong body of evidence warns that changes in the population age structure, on their own, do not guarantee countries a demographic dividend. To secure it, LMICs need to deliver better education, health, and employment opportunities before their populations start aging. Building fit-for-purpose PHC systems is critical to ensure that people have access to high-quality care that meets their changing health needs over the life course. To achieve this, many LMICs urgently need to rethink their health care organization models. Their window of opportunity to do so is narrowing.
Harnessing the power of PHC in future public health emergencies
Among its many important lessons, the COVID-19 pandemic has highlighted the need for countries to reorganize existing health care delivery models so that they can better manage public health emergencies while meeting long-term health care needs. PHC provides the strongest platform to advance these changes, but few countries have yet made full use of this option. Global experience shows that PHC systems can curb the spread of outbreaks by disseminating reliable health information and prevention strategies, enabling rapid diagnosis of new cases, and contact tracing. During emergency response, effective PHC systems are also critical to ensure that people’s routine health needs are met without disruption; these needs include vaccinations and other preventive services and the treatment of the full range of chronic conditions, including mental health conditions.
Positioning PHC systems as an effective first line of response to public health emergencies will require that PHC professionals have access to up-to-date information and tools. This includes reliable access to medical supplies (such as testing kits), equipment (such as personal protective equipment), and medicines. It will also mean harnessing new technologies on the PHC front lines.
