The Covid-19 pandemic has reinforced the urgency of achieving universal health coverage (UHC) and the dangers and harms that societies face without health systems that protect everyone. Not only has the pandemic caused a health crisis, including stretching and diverting health and other social services, but also a financial crisis that could now compromise global progress towards UHC.
The UK Foreign, Commonwealth and Development Office’s long awaited Health System Strengthening position paper, published this week, recognises that strong primary health care systems are critical to delivering packages of services to promote good health and wellbeing, prevent illness, and provide treatment and care, but are often not well prioritised, resourced, organised, or integrated within countries’ health systems.
If primary health care is the so called ‘engine’ for realising universal health coverage by 2030, then how it is built, tuned, and fuelled is important.
Building trust
In many low- and middle-income countries, health systems comprise a plurality of public and private actors with diverse perspectives and interests. Improving access to and quality of PHC services requires trust, negotiation, collaboration, and experimentation between these actors to develop and maintain robust and appropriate governance, regulation, and accountability arrangements. Enhancing such arrangements is particularly urgent for managing the integration of rapidly emerging digital health technologies, which presents opportunities and risks for health systems as they respond and recover from the pandemic.
Covid-19 has increased the willingness of health systems actors, including governments, to experiment, innovate and learn from others. But interests and expectations must be better understood and aligned if new kinds of partnerships are to help address major public health challenges.
There is also a strong need for mechanisms, spaces, and intermediaries to help build trust and facilitate mutual learning on ‘what works well and how’ within and across national health systems. There is also a need for new forms of research, evaluation and data sharing that can enable improvements in health systems performance in challenging and changing contexts.
Fuelling the engine
Access to safe and quality health services that do not cause catastrophic financial burdens on individuals and families is a fundamental dimension of UHC. Good health financing policies are now explicitly identified by the World Health Organization (WHO) as essential for driving progress towards UHC, reducing financial hardship and inequity in service use.
Not only is this about the size and source of health budgets, including for PHC, but how funds are structured, how they flow into the health system, how they incentivise providers, and how they can help to change how services are provided, to influence the equity, effectiveness and people-centred nature of PHC. Therefore, the critical cycles of budget formulation and disbursement involving dialogue between ministries of finance and health must include considerations of the public financial management rules that govern health financing. There also needs to be better coordination with and by development partners in ways that respect and support country leadership and priorities.
Unless resources are allocated to service providers based on population health needs, ensuring that entire populations can obtain a set of priority health services, progress towards UHC will be hindered. Political leaders should understand that the effective financing of PHC as a critical pathway to UHC is a right, smart, and affordable investment that yields massive social and economic returns for countries and, given it is about political and policy choices, wins votes.
Tuning the engine
The PHC ‘engine’ must be tuned to commitments of equity and social justice. The new FCDO position paper recognises that no one should be left behind as a key principle in its approach to strengthening health systems. And yet many partners and observers have expressed concern about the way the UK Government has recently pulled back from its commitments to supporting many disadvantaged people around the world.
Launched in 2019, the then UK Department for International Development’s flagship £220 million investment into tackling some of the worst neglected tropical diseases (NTDs) across 25 countries in Africa and Asia was seen as a landmark moment in the fight against preventable and treatable conditions that kill, disable, disfigure, debilitate, and poverty-trap hundreds of millions of the most marginalised and vulnerable people. Three months into the programme’s work, implementing partners were informed that the programme was going to brought to a premature end as part of the UK’s deep cuts to overseas development aid.
Some have said that the success of the World Health Organization’s (WHO) ‘roadmap’ towards tackling several of the world’s most NTDs by 2030 is a ‘litmus test’ for attaining UHC. The roadmap’s integrated approach to NTDs programming, embeds treatment, care and rehabilitation within health systems and health system strengthening. However, if drug treatment programmes and other strategies are divorced from the realities and experiences of communities, then they may inadvertently exclude and stigmatise people and are likely to be less effective or even fail.
Overall, we must have PHC-driven inclusive health systems that are shaped by commitments of equity and social justice, including through the voices of poor and vulnerable people. This includes co-produced knowledge to inform and promote the shared ownership of PHC-driven health systems strengthening strategies and their integration and prioritisation in national health plans and budgets.
