The price of primary care: from evidence to action
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2022)

In 2018, we published our first Commission entitled High-quality health systems for the Sustainable Development Goal era: time for a revolution. The Commission argued that, in the drive towards universal health coverage (UHC), there was a moral imperative to consider a basic level of quality, showing that more people globally die from poor quality care than from lack of access to it. One of the four main recommendations of the Commission was that countries should redesign service delivery to maximise health outcomes, not geographical access, and one of the key elements of service redesign was a greater focus on primary health care (PHC). PHC is ideally suited to managing the rise of non-communicable diseases and, as the 2018 Astana Declaration reaffirmed, “is the most inclusive, effective and efficient approach to enhance people's physical and mental health”. If we can agree that strengthened primary care is our ticket to UHC, how are we going to get there? And—more pertinently perhaps—how are we going to pay for it? This is the challenge tackled by our latest Commission, published in this issue. Here 24 Commissioners from 15 countries set out to explore the current landscape of financing for PHC, the best ways to generate funds, the best way to allocate those funds, and the best way to incentivise health-care providers. In all of these functions, the Commission uses a similar frame of reference to that of the high-quality health systems Commission—ie, people (both patients and providers) and equity. By adapting data reported by WHO and the OECD, the Commission found that, in 2018, annual government spending on PHC was a meagre US$3 per capita in low-income countries and $16 per capita in lower-middle-income countries, compared with the WHO estimated requirement of $65 and $59, respectively. The bulk of the funds for PHC in low-income and lower-middle-income countries is from poorly regulated private expenditure, most of which is out of pocket. Indeed out-of-pocket expenditure was found to be much higher at all income levels for PHC than for other health services, pointing to an urgent need for an equitable mechanism for protecting people from catastrophic expenditure on items such as essential medicines. The most appropriate mechanism, the Commission argues, is via government-generated pooled funds—ie, prepaid funds such as social security contributions, taxes, or health insurance premiums—that spread the financial risk across the population. Given the currently very low government expenditure on PHC, such a vision inevitably involves increased mobilisation of funds from taxation, borrowing, and donor funding, and the Commission provides advice on these areas based on the country context. From the provider side, the Commission found that user fees are a common source of payment for PHC in low-income and lower-middle-income countries. Where the source of payment was pooled funds, most low-income countries rely entirely on those funds being directed to specific items such as drugs and diagnostics. Such input-based payment mechanisms can reward inefficiency and encourage overtreatment. Other common payment mechanisms in low-income and middle-income countries were fee-for-service (whereby providers are reimbursed for each individual service provided), case-based payment (whereby providers are paid for each patient seen), and pay-for-performance (whereby providers are given bonus payments for achieving service coverage or quality targets). Only higher-income countries relied on population-based or capitation mechanisms, which is when providers are given a fixed per-capita payment, in advance, to deliver a defined set of services to each individual enrolled with that provider. Capitation provides a predictable and stable revenue stream and is the only payment mechanism that takes an egalitarian approach. However, it can risk the exclusion of patients with more complex needs and potentially lower the quality of care. For these reasons, the Commission recommends a payment mechanism that blends the best of each system, with capitation as the core. Throughout the Commission, the authors recognise that reorganising PHC financing is not merely a technical issue but a political one. It will necessitate a clear vision, long-term commitment, and a whole-of-government approach. Such a holistic view could also apply to the research landscape. Health economics is still a rather niche field in global health, with its own language and its own journals. We hope this comprehensive, yet comprehensible, Commission will encourage a blended approach to health systems research in the future. High-quality health systems in the Sustainable Development Goals era: time for a revolutionAlthough health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. Full-Text PDF Open Access