London School of Hygiene & Tropical Medicine

A new vision for placing people at the centre of arrangements for financing primary health care  (PHC) has been set out in a major new report.

The Lancet Global Health Commission on Financing Primary Health Care comprised of 22 expert members, a research team at the London School of Hygiene & Tropical Medicine (LSHTM), and was supported by the Bill & Melinda Gates Foundation.

When successfully delivered, PHC can improve health equity and, by fostering good health and reducing risk of disease, it can avert the need for expensive secondary and tertiary health care. This limits the financial burden of health care for households and saves costs for governments.

However, despite being prominent in many countries’ political commitments and policy statements, average government spending level on PHC is US$3 in low-income countries and US$16 in lower-middle income countries, public spending that falls far short of the minimum amount needed to provide a basic package of health services.  

The team analysed new evidence on levels and patterns of global expenditure on PHC. They also reviewed areas of proven or promising practice and identified actionable policies to support low- and middle-income countries (LMICs) in raising, allocating, and channeling resources in support of the delivery of effective, efficient, and equitable, people-centred PHC.

The Commission concludes that countries need to both invest more and invest better in PHC by designing their health financing arrangements in ways that place people at the centre and focus on addressing inequities first.

Mobilising sufficient public resources for health is essential to finance PHC adequately and to limit the need for harmful user fees. Increasing public funding through tax revenue is possible by increasing the tax base, expanding the types of taxes levied, and tax collection capacity.  Health coverage schemes should also not be limited to hospital care, but should first cover PHC.

Professor Kara Hanson, Dean of the Faculty of Public Health and Policy at LSHTM and Principal Investigator and Chair of the Commission, said: “Public funding for PHC is insufficient, access to PHC services remains inequitable, and patients often have to pay out of pocket to use them. And so, this financing vision serves a greater ambition: health systems that provide equitable, comprehensive, integrated, and high-quality PHC delivered through platforms that are responsive to the needs of the populations they serve and fully aligned with the objectives of Universal Health Coverage. To reach this ambitious goal, PHC platforms must be supported by financing arrangements that have equity and social justice at their core.”

At all country income levels, households are exposed to high levels of out-of-pocket payments for primary health care. This is particularly concerning in low- and middle-income countries where most people die from preventable causes that could be managed by primary health care.

To protect people and promote equity, the Commission says PHC resources should be allocated based on the health needs of populations and adequate amounts must reach frontline PHC providers. A range of policy levers are available to channel and protect PHC resources.  These include budget formulation, budget execution, and service delivery arrangements. Ministries of Finance and Health need to work together to ensure that more resources are allocated to PHC and are visible in health budgets.  Alongside these efforts, governments must invest in and strengthen a range of health system capacities.

The ways that PHC providers are paid and the incentives that these create can ensure resources reach the frontline and are used efficiently. Countries should progress towards a blended payment model with a population-based, or capitation, provider payment mechanism at its core as this is most likely to create incentives for providers to deliver people-centred PHC.  

Commenting on the launch of the Commission’s report, Gro Harlem Brundtland, former Director-General of the World Health Organization and a founding member of The Elders, wrote: “This excellent report argues strongly that the COVID-19 crisis shows that we need to invest more in health, but that as well as spending more, we need to spend better. With all countries facing constraints in public financing, it is essential that pooled public funds are spent as efficiently and equitably as possible, to maximise health benefits for the most people. This means investing in the most cost-effective health interventions, that prevent people from becoming ill or enable them to be treated quickly in the community or a primary care setting, before they require costly hospital care.”

Each country should strategically plot its own vision for and clear pathway towards people-centred financing for PHC, and The Commission highlights how significant political, social and economic conditions are in influencing the design and implementation of the efficient and equitable financing of PHC. These conditions pose both constraints and opportunities and so PHC financing reform strategies need to both be politically informed and technically sound.

Dr Jeanette Vega Morales, Chile’s Minister of Social Development and Family and a Commission member, remarked: “Those pursuing PHC financing reform must be politically savvy. Having a clearly articulated long-term view is essential for making progress. You need to be consistent to stay on course in the pursuit of reform while retaining flexibility to take advantage of opportunities for collaboration and consensus building, which are at the heart of a ‘whole-of-government approach’ to achieving shared multisectoral goals that are about equity and social justice.”

Publication:

Hanson K, Brikci N, Erlangga D, et al. The Lancet Global Health Commission on financing primary health care: putting people at the centre. Lancet Glob Health 2022. https://doi.org/10.1016/S2214-109X(22)00005-5.