Political economy dichotomy in primary health care: bridging the gap between reality and necessity
Authors: Dheepa Rajan, Melitta Jakab, Gerard Schmets, Natasha Azzopardi-Muscat, Juliane Winkelmann, David Peiris, Erica Di Ruggiero, Tracey Naledi, Adelson Guaraci Jantsch, Thiago Trindade, Nyawira Gitahi, Suszy Lessof, Faraz Khalid, Suraya Dalil, Josep Figueras
Journal: The Lancet Regional Health - Europe (2024)

Recent evidence synthesized in the WHO Global Report on Primary Health Care (PHC)1Rajan D. Rouleau K. Winkelmann J. Jakab M. Kringos D. Khalid F. Implementing the primary health care approach: a primer. Global Report on primary health care. World Health Organization, Geneva2024Google Scholar reiterates the case for prioritizing PHC in health and health systems with evidence clearly showing that long-term benefits of reorienting health towards PHC outweigh the costs (see Box 1).Box 1The evidence shows that the long-term benefits of reorienting health towards PHC outweigh the costs.PHC makes care more efficient and equitable, reducing the use of specialists and hospital services2Huntley A. Lasserson D. Wye L. et al.Which features of primary care affect unscheduled secondary care? A systematic review.BMJ Open. 2014; 4Google Scholar,3Organization for Economic Cooperation and DevelopmentRealizing the potential of primary health care. OECD, Paris2020Google Scholar by ensuring continuity, defined as ongoing relationships between physicians and patients, and fostering more appropriate use of care and lower health care costs.4Bazemore A. Merenstein Z. Handler L. Saultz J.W. The impact of interpersonal continuity of primary care on health care costs and use: a critical review.Ann Fam Med. 2023; 21: 274-279Google Scholar,5Sans-Corrales M. Pujol-Ribera E. Gene-Badia J. Pasari-Rua M.I. Iglesias-Perez B. Casajuana Brunet J. Family medicine attributes related to satisfaction, health, and costs.Fam Pract. 2006; 23: 308-316Google ScholarPHC improves access to quality services supporting continuity, comprehensiveness and coordination despite the heterogeneous impacts of PHC in different settings, provided that it is enabled by financing strategies, workforce development and community engagement.6Levine D.M. Landon B.E. Linder J.A. Quality and experience of outpatient care in the United States for adults with or without primary care.JAMA Intern Med. 2019; 179: 363-372Google ScholarPHC improves population health in the long-term, supporting better health outcomes including for mental and child health and noncommunicable diseases.7Starfield B. Shi L. Macinko J. Contribution of primary care to health systems and health.Milbank Q. 2005; 83: 457-502Google Scholar,8Gulliford M.C. Availability of primary care doctors and population health in England: is there an association?.J Public Health. 2002; 24: 252-254Google ScholarPHC contributes to higher user satisfaction and better self-reported health by providing care in a trusted setting where the patient, family and community contexts are understood.9Bitton A. Fifield J. Ratcliffe H. et al.Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017.BMJ Glob Health. 2019; 4Google ScholarPHC reinforces emergency preparedness and resilience through prevention, bridging individual and population-level perspectives, its multidisciplinary approach, and the ties it creates with and within communities.10Allin S. González Block M.A. Vargas E. Chapter 16: the impact of PHC on health system resilience including in the face of climate change.in: Implementing the primary health care approach: a primer. Global Report on PHC. World Health Organization, Geneva2024Google Scholar PHC makes care more efficient and equitable, reducing the use of specialists and hospital services2Huntley A. Lasserson D. Wye L. et al.Which features of primary care affect unscheduled secondary care? A systematic review.BMJ Open. 2014; 4Google Scholar,3Organization for Economic Cooperation and DevelopmentRealizing the potential of primary health care. OECD, Paris2020Google Scholar by ensuring continuity, defined as ongoing relationships between physicians and patients, and fostering more appropriate use of care and lower health care costs.4Bazemore A. Merenstein Z. Handler L. Saultz J.W. The impact of interpersonal continuity of primary care on health care costs and use: a critical review.Ann Fam Med. 2023; 21: 274-279Google Scholar,5Sans-Corrales M. Pujol-Ribera E. Gene-Badia J. Pasari-Rua M.I. Iglesias-Perez B. Casajuana Brunet J. Family medicine attributes related to satisfaction, health, and costs.Fam Pract. 2006; 23: 308-316Google Scholar PHC improves access to quality services supporting continuity, comprehensiveness and coordination despite the heterogeneous impacts of PHC in different settings, provided that it is enabled by financing strategies, workforce development and community engagement.6Levine D.M. Landon B.E. Linder J.A. Quality and experience of outpatient care in the United States for adults with or without primary care.JAMA Intern Med. 2019; 179: 363-372Google Scholar PHC improves population health in the long-term, supporting better health outcomes including for mental and child health and noncommunicable diseases.7Starfield B. Shi L. Macinko J. Contribution of primary care to health systems and health.Milbank Q. 2005; 83: 457-502Google Scholar,8Gulliford M.C. Availability of primary care doctors and population health in England: is there an association?.J Public Health. 2002; 24: 252-254Google Scholar PHC contributes to higher user satisfaction and better self-reported health by providing care in a trusted setting where the patient, family and community contexts are understood.9Bitton A. Fifield J. Ratcliffe H. et al.Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017.BMJ Glob Health. 2019; 4Google Scholar PHC reinforces emergency preparedness and resilience through prevention, bridging individual and population-level perspectives, its multidisciplinary approach, and the ties it creates with and within communities.10Allin S. González Block M.A. Vargas E. Chapter 16: the impact of PHC on health system resilience including in the face of climate change.in: Implementing the primary health care approach: a primer. Global Report on PHC. World Health Organization, Geneva2024Google Scholar Yet, political commitment for investing in PHC wavers. Why? One major overlooked reason is the persistent political economy dichotomy between where the investment is done and where it is actually needed. By shedding light on these dichotomies, we hope to equip policy-makers with the understanding needed to address them and thus firmly establish health systems on the foundations of PHC. The first dichotomy lies in the political and financial prioritization of specialist care and hospital services despite the overwhelming population need and policy emphasis on front-line community care, for which generalist skills are crucial. In many countries, insufficient investment in PHC has created a detrimental cycle. This cycle involves under-resourced front-line services provided by health workers who may not have received adequate training as generalists. As a result, public trust has been eroded, leading to underutilization of primary care and further reinforcing the undervaluing of PHC. Unfortunately, the medical community and the wider population often associate high-quality care with specialized, technology-intensive, hospital-based services. Consequently, the training of generalist physicians, nurse practitioners, community health workers, and other allied health professionals, who primarily work in primary care, continues to suffer from persistently low investment. While both generalist and specialist care are essential components of the PHC agenda, the current strong bias towards specialized care poses a significant problem. The second dichotomy relates to investments that take pro-poor approaches for primary health care, aiming to reduce poverty-related disparities. However, an emphasis on "the poor" has contributed to a distorted perception of PHC as inferior care for impoverished individuals or low-income areas. This is beginning to give way to proportionate universalism which aims to address the health needs of the entire population, while also tailoring the scale and intensity of support provided in proportion to the disadvantage people experience. PHC's association with poverty, but also with generalist care which is not 'high-tech' and not provided by those who have 'more' or 'better' specialist training, has cemented the perception of PHC somehow being 'not as good', making it difficult for governments to convince health stakeholders to move resources to PHC. Finally, the prioritization of vertical approaches to health service delivery, which focuses on specific conditions or subpopulations (e.g., diabetes control program or maternal and child health program), has hindered investment in PHC, particularly in lower-income countries. This preference for vertical approaches over more integrated, horizontal approaches, which aim to address the comprehensive needs of individuals across various services, has limited assertive investment in PHC. It is crucial to prioritize investments in horizontal approaches, such as strengthening comprehensive PHC centers that cover a full range of health services including child health, maternal health, mental health, chronic disease care, and more. Convincing development aid agencies (examples are GIZ, USAID, and AFD) to support a unified PHC-oriented health strategy remains challenging, especially in donor-dependent settings. Historically, private philanthropists, international donors, and national governments have favored verticalism due to its perceived ease of understanding, implementation, and tangible outcomes, particularly during times of crisis and austerity. Achieving a robust PHC-rooted health system requires a careful balance between vertical and horizontal approaches. Policy-makers require a deeper comprehension of these challenges and underlying dichotomy in order to bridge the gap during windows of political opportunity between the reality of where health investments go and where the health need is. It is during these opportune moments that one can more easily address the positions and interests of those who benefit from the status quo. In the meantime, we must invest heavily in known technical solutions such as publicly funding comprehensive PHC services, including medicines; investing in high-quality general practice including nursing; raising awareness of PHC's importance in the medical community and across the population; integrating primary care and public health; investing in data to drive performance; and bringing services closer to people through digital means, domiciliary care and self-care. These solutions aim to make PHC responsive and high-quality so that people trust it to become the true interface between their lives and the wider health system. DR conceptualized the manuscript, wrote the first draft, coordinated the input of all authors, and revised the first to the final draft. MJ, GS, NA-M, and JW provided overall substantive input to the manuscript. DP, EdR, TN, AGJ, TT, and NG provided substantive input to specific sections of the manuscript. SL, FK, SD, and JF reviewed all drafts, and provided substantive input to them. No declaration of competing interests.