Recommendations for countries

Management of the reform process

1. Create an inclusive leadership group to drive PHC reforms. This group will be responsible for delivering PHC reform on the path to UHC. It will work through dialogue and seek consensus, while recognizing the imperative for bold decisions and timely action. In most instances, the leadership group will include high-level representation from ministries of finance, health, and planning, among others; members of parliamentary health, finance, and budget committees; and representatives of professional associations, civil society organizations, and other stakeholder groups. Typically, the leadership group will be mandated to set up additional committees, commission reports, conduct public hearings, and initiate other activities to gather data and work toward consensus for decision-making.

Team-based care organization and delivery models

1. Assess health workforce strengths and gaps, and plan the transition to team-based delivery. Although all countries should aspire to build multidisciplinary care teams to deliver PHC, the specifics of team composition and empanelment strategies should be tailored to the local context.

Contextual factors to consider include national and local epidemiologic profiles and socioeconomic determinants of health (Borgès Da Silva et al. 2013). To start, each country—supported by technical partners and donors, as appropriate—can undertake a situation assessment encompassing the following: (1) the current structure and composition of the health workforce; (2) how well the workforce matches health and health care needs; (3)people’s care-seeking patterns across different provider types and levels of care; and (4) payment/financing mechanisms.

Building on the situation assessment, countries can develop a transition plan to organize existing health worker cohorts into teams; establish managerial relationships and reporting chains; and empanel populations to care teams. Empanelment approaches should be responsive to local contexts and engage the private sector, depending upon the level of their engagement in PHC that is often socially stratified in low- and middle-income countries (LMICs). These countries often have private and deregulated low-technology clinics and pharmacies for the poor and the rural areas, as well as higher-cost and often insurance-driven private care facilities complementing and competing with the public health sector on quality, amenities, and more personalized care (Private Sector Health Alliance of

Nigeria n.d.). Transition planning may consider short-, medium-, and longterm workforce and financing reforms to expand the comprehensiveness of care, extend the PHC teams’ outreach into the community, and support integrated service delivery within care teams and across levels of care.

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2. Equip care teams to engage communities. Reimagined PHC depends on care teams that are able to connect deeply with communities. Dedicated, skilled staff build community connections and trust through outreach and communication activities. These activities clarify local health needs and priorities; boost health literacy; and progressively empower local people to manage their own health. Such efforts may use surveys, community forums, and other tools to understand the socio-cultural and economic characteristics of the local population, as well as the health-related beliefs, attitudes, and behaviors. Teams will be able to use this knowledge to tailor messaging and action in public health, health promotion, and disease prevention.

3. Strengthen and integrate information technology on the PHC front lines.

Reimagined PHC involves broadening access to digital platforms and leveraging data analysis capabilities to improve outcomes. Interoperable and integrated digital platforms are needed to create a culture of transparency and accountability in PHC. Doing this will empower patients and providers alike. The COVID-19 crisis has confirmed the importance of harnessing technology to monitor population health on the front lines, detect threats early, and facilitate knowledge sharing and care coordination. These needs are experienced within local care teams and across levels of care in both public and private sectors. As empowered co-producers of their own health, patients should ultimately be able to access, review, and export their personal health data on demand; in the long run, they should be able to generate and contribute their own health data, including through mobile applications and self-monitoring of health indicators.

Countries can score efficiency gains by upskilling data analysis capabilities within local care teams. Teams that collect more data and know how to use them can boost the quality of care for the populations they serve. Better data-analytic capabilities will allow technology-enabled care teams to track and understand population health in real time, including identification of potential outbreaks; undertake risk stratification to inform patient-specific outreach and care strategies; and more actively manage the empaneled patient list.

Multidisciplinary health workforce development

1. Launch multidisciplinary medical education reforms. Following a workforce needs assessment, countries can develop and implement a multipronged, multidisciplinary set of medical education reforms to plug gaps and optimize training for community-focused, team-based care. As described in detail in chapter 4, countries should address lopsided allocations of human resources for health through educational reforms

designed to attract workers to locations where they are needed most. These include strategies to build medical education campuses within rural or underserved areas; recruit local students from those same communities; prioritize and elevate the prestige of community care; and promote generalist practice. A reformed medical curriculum should be designed to prepare health workers for service in the team-based PHC environment by emphasizing collaborative practice. Training programs should also support development of new health workforce competencies, including data analysis and interpretation; disease surveillance; risk stratification; team management and coordination; and soft skills for effective patient engagement, outreach, and partnership. Depending on the local context and results of the health workforce assessment, countries may also need to invest in building new medical education programs to expand the health workforce and meet evolving workforce needs. Indeed, reforming the existing medical education platform for the full health workforce may be needed; a fit-for-purpose health workforce for reimagined PHC requires a core team that also includes community health workers (CHWs), registered nurses (RNs), and administrators. The expanded PHC team in more resource-rich settings would also involve the same core team—albeit with enhanced skills—but also pharmacists, dentists, psychologists and other mental health workers, lab technicians, and other health care providers whose services may be enhanced by the use of information and communications technology (ICT).

2. Reform provider compensation models to promote rural practice and generalist care. In addition to medical education reforms, countries can address compensation imbalances that exacerbate inequitable allocation of the health workforce, especially in those with a predominant private sector. Governments should ensure that the compensation for health workers (such as salaries or reimbursement rates) in rural or underserved areas is at least equivalent to the compensation in more saturated urban regions. Depending on the local context, leaders may also consider additional compensation or in-kind benefits to offset quality-of-life concerns.

Reimbursement and salary reform is also needed to address the substantial differential between generalist and specialist physicians, thereby encouraging entry into generalist career paths and addressing the shortage of primary care physicians, as well as containing perverse and collusive dual practice in loose regulatory settings.

3. Expand tiered accreditation systems tied to reimbursement policy. In countries with mixed health systems, governments need to strategically engage with the private sector to leverage its workforce and infrastructure, while improving the quality of care and protecting citizens from out-of-pocket expenditures. Governments may leverage reimbursement

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and strategic purchasing for universal health care (UHC) to incentivize private sector participation in a tiered accreditation system. A minimum accreditation tier would qualify private providers to receive reimbursement with public funds; achieving progressively higher accreditation tiers could be tied to higher reimbursement rates or reimbursement coverage for a broader range of services. Public providers should also be required to participate in the accreditation system and be subjected to the same standards.

4. Reform regulations on telemedicine and labor mobility. To best leverage their entire workforce and promote technology-enabled care, countries can review the regulatory landscape and identify the barriers to telemedicine expansion and labor mobility. Once the barriers are recognized, countries can critically assess which regulations are necessary and remove or reform those that are not. Countries that have already relaxed such regulations due to COVID-19 can review that experience with the goal of incorporating productive reforms into permanent policy.

5. Support the frontline workforce. The COVID-19 pandemic has placed extraordinary stress on frontline workers, but work-related stress and burnout are common issues across the health workforce, even outside of crises. Governments need to ensure that those in the PHC workforce receive financial, practical, and psychosocial support to manage the unique pressures of their jobs, during normal times and particularly during emergencies. Governments, care teams, and institutions engaged in medical education should have regular touchpoints to assess the physical and psychosocial welfare of the health workforce and troubleshoot challenges.

Financing and resource mobilization

1. Develop a political strategy to deliver PHC financing goals. Health officials tend to analyze financing options in technical terms, but financing and resource allocation are inherently political. Securing funds for reimagined PHC requires building commitment and buy-in across government. Achieving this will not happen without a deliberate political strategy.

Leadership informed by such a strategy is key to translate countries’ formal commitment to UHC under the Sustainable Development Goals (SDGs) into practical policies and resource allocation. The evidence is strong that public health-enabled PHC is the health care organization model most apt to improve the efficiency, resilience, and sustainability of public spending on health, thereby promoting equity and shared prosperity. Such evidence is vital but insufficient. A political plan is needed to ensure its uptake by those with the power to deliver change.

2. Craft a tailored investment plan. Fit-for-purpose financing for public health-enabled PHC must be rooted in a comprehensive package of services that meets the priority health needs of communities and is free at the point of service. The benefits package needs to be designed through a participatory and fair process. A gap analysis based on the assessment of existing service delivery capacity (access, quality, and cost) with respect to the defined service package is essential. Such analysis should lead to a country-driven investment plan for strengthening PHC platforms that includes infrastructure, human resources, routine operations, overhead, removal of user fees, and other features.

3. Finance PHC without user fees through general government expenditure. As discussed in chapter 4, the source of financing for PHC has important implications for equity, financial risk protection, and resilience to financial shocks. To ensure equitable and comprehensive coverage—given existing socioeconomic inequities and widespread labor informality—PHC should be financed through general government revenue. Government efforts to achieve UHC should consider how to transition away from suboptimal sources of PHC financing. These include social health insurance contributions, private insurance premiums, and out-of-pocket health care expenditures—the most inefficient and inequitable form of health financing. In most countries, funding from these suboptimal sources can be progressively replaced with routine allocations from the government budget. PHC services should be free at the first point of contact with health services.

4. Implement pro-health taxes on tobacco, alcohol, and sugar. Even as countries move to finance PHC from general government revenue, they can often boost tax revenue by implementing or increasing pro-health taxes onharmful products—especially tobacco, alcohol, and sugar. These taxes can create additional fiscal space, including to support PHC, while reducing the burden of common noncommunicable illnesses like hypertension, cancer, and diabetes, along with related health system costs.

5. Ensure comprehensive and equitable coverage of PHC services through an affordable benefits package. Countries’ UHC benefits package needs to facilitate equitable provision of comprehensive PHC services. Countries need to reconcile the scope of the benefits package with the available resource pool, moving from implicit rationing to explicit and accountable priority setting for sustainability. A participatory benefits package design process offers a lever to rebalance overall health expenditure toward PHC in settings where PHC has been historically underprioritized.

6. Leverage payment reform to promote team-based care, coordination, and quality. Countries can expand the use of strategic/value-based

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