The Covid-19 pandemic has highlighted the importance of resilient health systems, rooted in the delivery of primary care at the community level, to outbreak detection and response. Some countries that had prioritized the delivery of primary health care (PHC)—by engaging the community in the design of health programs; ensuring high-quality training and professional development for health workers; and collecting data to analyze trends and improve services prior to the pandemic—have found it possible to focus on the maintenance of services for essential health programs during a prolonged period of crisis. At the same time, countries that had previously prioritized the delivery of PHC have also been able to pivot to provide additional services enabling populations to meet pandemic-related health needs, both in diagnosing and treating Covid-19 infections and in delivering Covid-19 vaccines.
Elements of strong PHC that have served populations well during the pandemic include routine immunization programs for children; a focus on gathering and analyzing data to improve service quality at the local level; a role for community health workers in educating about, monitoring, and reporting outbreaks; and an emphasis on equitable access to affordable and high-quality health services. The rapid scale-up of Covid-19 vaccination programs for adults, along with new efforts to collect, track, and integrate data about respiratory infections into existing health data platforms, now offers an opportunity to conduct outreach to older patients regarding PHC and improve monitoring of services to ensure quality of care.
Above all, experts increasingly recognize that high-quality PHC helps build the population’s confidence in the health sector and contributes to the resilience of the overall health system. Given the important role PHC has played in shaping countries’ responses to Covid-19, taking steps now to support countries in prioritizing PHC can help ensure continuity of health services and a more effective, community-centered outbreak response in future health crises and pandemics.
From Alma-Ata to Astana
According to the World Health Organization and UNICEF, primary health care is " a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being.”
PHC is related to primary care but differs from it in a few important ways. PHC services are rooted in a commitment to equity and include everything from health promotion and disease prevention to treatment, rehabilitation, and palliative care, whereas primary care typically refers to medical management of disease or health conditions. PHC and primary care are both distinguished from secondary care, which refers to specialized healthcare, and different from tertiary care, which refers to the provision of more advanced health services in a hospital setting.
The PHC concept gained traction in the 1970s at a global conference in the former Soviet Union, where national delegations adopted the Declaration of Alma-Ata. At that session, participants defined PHC as “the first level of contact of individuals, the family and the community with the national health system bringing health care as close as possible to where people live and work” and highlighted it as a means of reaching the goal of providing “health for all.”
Forty years later, the global community reconvened in Kazakhstan to assess progress in realizing the vision of accessible, equitable, and affordable healthcare. The 2018 Declaration of Astana both reaffirmed the importance of PHC in the quest to secure “health for all” and acknowledged the critical role PHC can play in promoting health security by strengthening communities’ capabilities to detect and respond to disease outbreaks.
PHC as a Platform for Reaching Universal Health Coverage
PHC is closely linked to the goal of universal health coverage (UHC), which the WHO defines as a situation in which “all people have access to the health services they need . . . without the risk of financial hardship when paying for them.” UHC is a key focus of the Sustainable Development Goals, in which target 3.8 emphasizes the importance of “financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” When global health advocates, national leaders, and health officials gathered for the UN High-Level Meeting on Universal Health Coverage in 2019, they issued a political declaration that pointed to PHC as the principal means of ensuring a population’s access to a set of basic services while reducing the risk of catastrophic health expenditures by the target date of 2030.
The UHC framework defines essential services as those related to child health, reproductive health, malaria, tuberculosis, HIV, and noncommunicable diseases, as well as mental health. It prioritizes preventive services, such as immunizations and regular checkups, and the provision of high-quality care by well-trained personnel. While a country’s approach to UHC depends on available resources, national priorities, and existing programs, there is invariably an element of public financing for health services through payroll or general taxes and an emphasis on insurance or pooled spending schemes to cover the costs of care. The WHO and World Bank track countries’ progress toward UHC through the Service Coverage Index, which uses household and other survey data to measure peoples’ ability to make use of a set of 16 essential services, which encompass PHC.
Country Experiences with Strengthening PHC
Recent analyses have demonstrated that the delivery of preventive care and treatment services through the PHC framework can be both cost effective and promote health. PHC includes health services such as nutrition; the provision of water, sanitation, and hygiene (WASH); public education regarding health; community engagement in the design and oversight of health services; maternal and child health; routine immunizations; infectious disease control; and the management of chronic, noncommunicable diseases.
How to measure countries’ financial and political commitments to PHC, as well as their success in reaching people with PHC services, is a question that has attracted global attention and generated considerable debate in recent years. Not all countries track public spending for PHC in the same way, and there are chronological gaps in country reporting on some of the most widely recognized indicators, making it difficult to compare countries’ progress over time. Organizations such as the Primary Health Care Performance Initiative, the Joint Learning Network for Universal Health Coverage, and Ariadne Labs, among others, work closely with countries to support their efforts to finance, govern, and evaluate progress in ensuring peoples’ access to PHC.
Countries have taken several different approaches to ensuring their populations can access the benefits the PHC framework has to offer:
Ghana: Improving PHC Through Community Engagement and Education
In the 1990s, recognizing that more than two-thirds of the national population lived a significant distance from a health provider, Ghana began implementing the Community Health Planning and Strategy (CHPS) program, situating health posts throughout the country. Staffed by a nurse and trained volunteers, each CHPS compound serves 4,500–5,000 people and provides the population in its catchment area access to family planning commodities, oral rehydration services, and immunizations, among other services. Thanks to a gradual rollout of the program and careful analysis of local-level data regarding attitudes toward health, the Ghana Health Service, which oversees the CHPS program, has prioritized the active engagement of people who use the health system to ensure alignment of health services with community needs and values. It places a high value on educating users about health and the health system as well as seeking community input regarding program design in order to improve health outcomes.
To help finance services provided through the CHPS compounds, Ghana created the National Health Insurance Scheme (NHIS) in 2003, which is funded by the proceeds of a 2.5 percent levy on luxury goods as well as payroll taxes and premiums paid by people working in the informal sector. Health services for young children, pregnant women, the elderly, and the indigent are provided at no cost, and these populations are exempt from paying such premiums. Roughly half of the more than 30 million people living in Ghana are enrolled in the insurance scheme. The NHIS benefits package covers most common health conditions seen at health facilities, and patients can seek services at a number of different sites, including CHPS posts.
However, regardless of where patients ultimately receive care, they are required to visit a primary provider first before being referred to higher-level clinic. Careful collection of data from clinics, community education, and user feedback has enabled Ghana to identify ongoing challenges, including low service coverage, despite the fact that nearly three-fourths of health funding is channeled toward PHC services.
During the early phases of the pandemic, Ghana prioritized protecting health workers and developing backup teams, in case health workers became ill or were exposed to Covid-19, in order to ensure continuity of services. By working to improve on the CHPS and NHIS models and protect those who deliver healthcare, Ghana has maintained high immunization rates for children and sustained maternal and child health services during Covid-19. Health workers are also contributing to the delivery of Covid-19 vaccines. By the end of March 2022, more than 9 million adults in Ghana have received at least one dose of vaccine. Compared to other lower-middle-income countries, Ghana has experienced a lower rate of Covid-19 cases and deaths per million since the pandemic began.
Vietnam: Investing in the Health Workforce to Improve PHC and Community Trust
Investing in the recruitment, training, and ongoing career development of a cadre of community-based health workers has been an important element in the transformation of Vietnam’s health profile over the past several decades. While all healthcare had been provided free of charge in the 1970s, by the mid-1980s, as Vietnam’s economy underwent a period of privatization and decentralization, rising user fees for many health services and the movement of care providers from the public sector to private clinics became obstacles to care for significant portions of the population.
By the early 2000s, Vietnam had only 2.6 health workers for every 1,000 people, with the majority of care providers focused on delivering services in the comparatively more prosperous urban areas, leaving the rural population underserved. In rural areas, care is provided through the commune health centers (CHCs), which are staffed with a doctor, a nurse, a midwife, pharmacists, and village health workers and serve a population of roughly 5,000 people each. But people’s lack of confidence in the quality of care provided in the CHCs led to overcrowding at higher-level facilities. In 2013, Vietnam initiated a series of reforms focused on improving the quality of services at the CHCs. One study identified few opportunities for career advancement as a reason the CHCs had trouble hiring and retaining well-trained providers.
A Working Group for Primary Healthcare Transformation was established to expand educational opportunities for practitioners working in rural areas. It brought together private, public, and non-profit organizations to scale up the use of digital technologies as a way of connecting with and engaging health workers, including those in remote settings. In 2015, the Ministry of Health, in cooperation with Hai Phong University of Medicine and Pharmacy and the India, Brazil and South Africa Trust, established an e-learning platform to provide ongoing professional education for health workers, such as those providing services in the CHCs. These approaches proved useful in the early months of Covid-19, as Vietnam was able to utilize this platform to provide training on Covid-19 for PHC providers, likely to be the first to observe and diagnose Covid-19 infections. This cadre of health workers has also been instrumental in delivering Covid-19 vaccines to Vietnam’s population of more than 97 million people, nearly 80 percent of whom have been fully vaccinated.
Costa Rica: An Emphasis on Data Collection and Analysis to Improve Outcomes
By prioritizing the collection of household-level data regarding health, Costa Rican health officials are able to analyze trends from the district to national level in order to improve service quality and accessibility.
In Costa Rica, which has a population of nearly 5 million, the right to health is enshrined in the national constitution. A goal of achieving universal health coverage through the provision of primary care at the community level has been in place since the 1970s.
More recently, the national government implemented a series of reforms in the 1990s to consolidate the delivery of health services by the Caja Costarricense de Seguro Social, which established a system of regionally based, comprehensive, and multidisciplinary teams, known as EBAIS (Equipo Básico de Atención Integral de Salud). Each team, which includes a doctor, nurse assistant, community health worker, and data specialist, serves a district of about 5,000 patients. In this system, everyone living in Costa Rica who is eligible for healthcare, which includes citizens as well as some migrants and temporary workers, is assigned to one of these health teams. A community health worker, known as an ATAP (Asistente Técnico en Atención Primaria), makes home visits to check on patients with chronic conditions, administer vaccines, or conduct well-baby examinations. The ATAP records patients’ health data in a digital format, which is then available to health practitioners at any level, and facilitates analysis of trends and conditions within the health district and across the nation.
Health services in Costa Rica are financed through a combination of payroll taxes and taxes on luxury goods and imports. While the country spends more per capita on healthcare than other countries with similar economic profiles, immunization rates are high, and life expectancy in Costa Rica is higher than in many wealthier countries that have greater rates of per capita health expenditure. At present, more than 79 percent of the population has been fully vaccinated against Covid-19.
PHC and Global Health Security
During the Covid-19 outbreak, several multilateral organizations have recognized the role of PHC in promoting health system resilience, that is, the ability of a health system to withstand shocks, such as the surge in demand for health services that might be provoked by a pandemic. In early 2020, the Global Fund to Fight AIDS, Malaria and Tuberculosis and Gavi, the Vaccine Alliance both allowed implementing countries to divert some funds designated for health systems strengthening to outbreak response. For example, the Global Fund established the Covid-19 Response Mechanism (C19RM) to support countries’ efforts to “mitigate the impact of COVID-19 on programs to fight HIV, TB and malaria” and initiate “urgent improvements in health and community systems.” And Gavi provided eligible countries with “immediate funding to health systems, enabling countries to protect health care workers, perform vital surveillance and training and purchase diagnostic tests.”
Even amid a public health emergency, countries can continue to deepen their commitment to PHC and, by extension, health security by investing more public funds into health programs. For example, the WHO encourages countries to devote at least 1 percent of GDP to healthcare. Some regions have determined that they need to spend even more, with the Pan American Health Organization (PAHO), the WHO’s regional office for the Americas, urging member countries to commit at least 6 percent of GDP to public expenditures on health. But the percentage of those funds that are channeled toward primary health care varies considerably, with estimates that only around 50 percent of low- and middle-income countries’ public spending on health is funneled toward PHC programs. And across the board, governments finance only one-third of total PHC expenditures, with many low-income countries dependent on foreign assistance to cover additional program costs.
But financing a greater proportion of health services is just part of the equation. Strong PHC programs that contribute to health security are also characterized by a high level of community participation in the organization and oversight of the health sector, equitable access to health services, and high quality of those services. Equally important factors include community engagement, investments in the health workforce, and a focus on data collection and integration to ensure ongoing analysis and quality improvement.
Given the important role PHC has played in strengthening health systems, building trust in health programs, and shaping countries’ responses to Covid-19, taking steps now to prioritize PHC can help ensure continuity of health services and a more effective outbreak response in future health crises and pandemics.
About the Author
Senior Fellow and Director, Immunizations and Health Systems Resilience, Global Health Policy Center
Katherine E. Bliss brings her expertise in the social sciences, Latin American studies, and international relations to her work analyzing U.S. government support for health programs in low- and middle-income countries. She is particularly interested in how political and cultural perspectives shape approaches to such global health challenges as HIV/AIDS; vaccine-preventable diseases; and access to safe drinking water and sanitation. Trained as a historian, Katherine spent the early part of her career teaching at the university level and publishing books and articles on gender relations and public health in twentieth-century Mexico. A Council on Foreign Relations International Affairs Fellowship enabled her to shift her focus to global health policy, placing her at the U.S. Department of State, where she worked on environmental health issues and the development of foreign policy approaches to pandemic preparedness.
At CSIS, Katherine has previously served as deputy director and senior fellow within both the Americas Program and Global Health Policy Center, where she oversaw a multi-program project on the influence of the BRICS countries on the global health agenda and directed the Project on Global Water Policy. Her recent work has examined the health situation in the context of the Venezuelan political crisis and the challenges facing immunization programs within fragile or disordered settings. Katherine received her A.B. in history and literature, magna cum laude, from Harvard College and her Ph.D. in history from the University of Chicago. She completed a David E. Bell Fellowship at the Harvard Center for Population and Development Studies.
This report was made possible through the generous support of the Bill & Melinda Gates Foundation.
The authors would also like to thank:
- Mackenzie Burke, Program Coordinator, CSIS Global Health Policy Center
- Michael Rendelman, Research Associate, CSIS Global Health Policy Center
- Maclane Speer, Research Assistant and Program Coordinator, CSIS Global Health Policy Center
- Michael Kohler, Associate Multimedia Producer, CSIS iDeas Lab
- William Taylor, Designer, CSIS iDeas Lab
- José Romero, Web Development Intern, iDeas Lab, CSIS
- Serven Maraghi, Senior Web Developer, iDeas Lab, CSIS
- Laurel Weibezahn, Multimedia Producer, CSIS iDeas Lab
- Jeeah Jehanne Lee, Senior Publications Manager, External Relations
A product of the Andreas C. Dracopoulos iDeas Lab, the in-house digital, multimedia, and design agency at the Center for Strategic and International Studies.