Introducing The Lancet Global Health Commission on financing primary health care: putting people at the centre
Authors: Kara Hanson
Journal: The Lancet Global Health (2021)

Primary health care (PHC) is an essential component of high-performing health systems, delivering effective, affordable, and inclusive care to people when they need it, and providing the foundation for both universal health coverage and the Sustainable Development Goals. As the platform for providing basic health services and essential public health functions, and for responding to the ongoing challenges of infectious disease and to the rapidly expanding burden of chronic conditions, PHC has a commitment to equity and social justice. Policymakers worldwide are seeking to strengthen their primary care systems to secure the health of their populations across the lifecourse.1Organisation for Economic Cooperation and DevelopmentRealising the full potential of primary health care. OECD Publishing, Paris2020Google Scholar, 2WHOUNICEFA vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals.https://apps.who.int/iris/handle/10665/328065Date: 2018Date accessed: November 25, 2021Google Scholar Despite the calls to action in the Declarations of Alma Ata (1978) and Astana (2018), PHC is failing to meet the needs of the people—users, providers, and communities—who should be firmly at its centre.1Organisation for Economic Cooperation and DevelopmentRealising the full potential of primary health care. OECD Publishing, Paris2020Google Scholar, 3World BankWalking the talk: reimagining primary health care after COVID-19.https://openknowledge.worldbank.org/handle/10986/35842Date: 2021Date accessed: November 25, 2021Google Scholar Resources that are destined for PHC often do not reach frontline providers.4Barroy H Kabaniha G Boudreaux C Cammack T Bain N Leveraging public financial management for better health in Africa: key bottlenecks and opportunities for reform. Health financing working paper no. 14.https://apps.who.int/iris/handle/10665/339297Date: 2019Date accessed: November 25, 2021Google Scholar Services are often inaccessible and of poor quality.5WHOPrimary health care on the road to universal health coverage: 2019 monitoring report.https://www.who.int/publications/i/item/9789240029040Date: 2019Date accessed: November 25, 2021Google Scholar Users are frequently required to pay substantial amounts to use these services, which, over time, can accumulate to create a financial burden that can drive households into, or further into, poverty.6WHOGlobal spending on health 2020: weathering the storm.https://www.who.int/publications/i/item/9789240017788Date: 2020Date accessed: November 25, 2021Google Scholar Health financing arrangements provide the fuel for health systems: they establish the amount of resourcing available and the way in which risks are shared among those who are ill and those who are well, the ways that funds flow through the system to frontline providers, and the payment systems that create incentives for providers. Together, these arrangements shape the equity, effectiveness, and efficiency of PHC. The way in which health systems are financed can also drive changes in how services are delivered—for example by encouraging new models of provision and service delivery that are more people-centred than existing models. The design of health financing arrangements is not merely a matter of technical decisions: it is also deeply influenced by the political, social, and economic contexts. Spending more on PHC means spending less (in relative or absolute terms) on hospitals and specialists, which might then be favoured by the growing urban middle class. Prioritising PHC therefore requires a societal consensus, as realised through a political process. The need to ensure sufficient resources for PHC has become even more acute in the COVID-19 era. The pandemic has shown the crucial importance of PHC in maintaining access to essential services, while simultaneously undermining it by driving resources towards hospitals and acute care. As we move towards a world in which COVID-19 is managed as an endemic, rather than an epidemic, disease,7Medley GF Vassall A When an emerging disease becomes endemic.Science. 2017; 357: 156-158Google Scholar well financed PHC will be essential for delivering COVID-19 vaccinations, managing mild-to-moderate illness, and providing surveillance and support. Beyond COVID-19, health systems must be able to flex to provide surge response while continuing to deliver essential health interventions. Financing arrangements will be a crucial element of this resilience. We should consider how financing arrangements can enable PHC to reach its potential as the locus of people-centred care. This is the question addressed by the Lancet Global Health Commission on financing PHC in low-income and middle-income countries. Bringing together 22 experts from 15 countries—including academic researchers, technical advisers, and national-level policymakers and health systems experts—the Commission held its first meetings online in April, 2020, just as COVID-19 was beginning to spread around the world. The Commission aims to present new analysis of the amounts and patterns of global expenditure on PHC; analyse key technical and political economy challenges faced in financing PHC; identify areas of proven or promising practice that effectively support PHC across the core health-financing functions; and identify actionable policies to support low-income and middle-income countries in raising, allocating, and channelling resources in support of the delivery of effective, efficient, and equitable PHC. Commissioners began their initial deliberations around four themes: how to mobilise and allocate resources to PHC; using financial and non-financial incentives to influence provider and patient behaviour; unpacking the links between financing arrangements and service-delivery models; and understanding the influence of the political, social, and economic context on decisions to prioritise PHC in national health systems. The Commissioners have taken stock of existing evidence, commissioned new country case studies, and done a new survey of the arrangements for providing and paying providers for PHC. The Commission will report in the first quarter of 2022. The analysis will help low-income and middle-income countries to trace their pathway towards financing arrangements for PHC that place people at the centre. We acknowledge funding support from the Bill & Melinda Gates Foundation. The content is the sole responsibility of the authors and does not represent the official views of the Foundation. We declare no competing interests.