Financing primary health care

Today, millions of people in low- and middle-income countries do not have access to basic, good quality health services. The Alma Ata Declaration in 1978 defined primary health care as basic health care built on technically sound and socially adequate approaches, universally accessible and affordable to all individuals. This issue of id21 insights explores the challenges facing donors and national governments in providing and financing primary health care for all.

Selective primary health care and cost recovery

Soon after the Alma Ata Declaration, the concept of‘selective primary health care’ was proposed in the article by Walsh and Warrenin 1979, justified on the basis of scarce resources and a need for rationing.It argued that comprehensive primary health care (PHC) was too idealistic anddifficult to achieve. Instead, the idea emerged to concentrate efforts oncontrolling a few selected infectious diseases through cost-effectiveinterventions, based on disease mortality and morbidity rates.

Similarly, in the 1990s international agencies, led by theWorld Bank, proposed new mechanisms to organise financial contributions from userstowards the cost of care through, for example, user fees and community-basedhealth insurance. These proposals emerged in the context of broader healthsector reforms and suggestions to use the private sector in health service provision.

The rationale behind these cost recovery mechanisms was theneed to increase healthcare revenues and improve quality and efficiency throughgreater community involvement in PHC management. Although some studies have shown that this was partially achieved, the main criticismis that cost-recovery also increased inequity in access. As Barbara McPake pointsout, methods of achieving good quality PHC for those living in poverty have notbeen identified in most low income countries.

Driven by continuing resource scarcity, internationalagencies and low- to middle-income country governments continued to look forways to cut costs in the late 1990s and early 2000s, including basic oressential packages based on a list of cost-effective interventions.

Health systems strengthening

The international community, notably the World HealthOrganisation, recognised the limits of providing disease specific interventionswithout a functioning delivery system, and called for greater attention towardsstrengthening the health system as a whole. This led to the creation in 2002 ofthe Commission on Macroeconomics and Health, which advocated the use of a ‘close-to-client’system, including outreach services, health centres and local hospitals mostaccessible to poor people. It highlighted the various constraints affecting demandand supply which limit the ability of poor people to access such services.

Improving both demand and supply side barriers to health care

Historically greater emphasis has been placed on reducingsupply side barriers - which negatively affect quality, volume and price ofavailable services - with focus on key health service inputs, notably humanresources and drugs. As Eilish Mcauliffe suggests, staff motivation andultimately staff performance are associated with the availability of othernecessary resources, such as drug supplies, for service delivery.

However, the assumption that free public-sector healthservices result in universal access to PHC has become less plausible. Growingpreferences for non-free over free services, and the resulting growth inproviders of differing public and private characteristics, requires strategies thatextend beyond public sector provision. Contracts with the private sector emergedas another supply side strategy that may improve access to PHC. Maureen Lewis indicatesthat contracting out may increase efficiency (through greater competition),quality (staff morale, for example), and coverage (providing services to highrisk groups or people in remote areas). Yet, strong government capacity, oftenlacking in low- and middle-income countries, is required in order to design andoversee all stages of the contractual arrangement.

Strategies to remove or at least reduce demand side barriers,which disproportionately affect the poorest and most vulnerable in society, alsoneed to be prioritised. Demand side barriers can include physical, financial,cultural and social barriers, such as opportunity costs, lack of knowledgeabout appropriate care, or distance to the health centre. The balance betweensupply and demand is reinforced by research from Indonesia: Tim Ensor providesevidence that improving the availability of trained midwives and emergencyobstetric care is not enough to reduce maternal mortality if mothers cannotafford services. And lowering prices for essential health commodities, such aseffective anti-malarial drugs, as discussed by Lindsay Mangham and Kara Hanson,needs to be accompanied by community strategies to improve the knowledge ofthose purchasing the drugs.

Aid harmonisation

Given the high dependency of low income countries on aid, methodsof aid delivery are central to the debate on how best to finance PHC. SectorWide Approaches (SWAps) and General Budget Support (GBS)emerged in the late 1980s to 1990s, in response to frustrations with thedelivery of aid through ‘vertical’ projects. Such programmes were problematicbecause they were defined by donors, giving recipient countries little realownership, poor donor coordination lead to fragmentation and duplication ofefforts, and governments were unable to respond effectively to differing donor requirements.In 2005, further efforts by the international community to improve aideffectiveness resulted in the Paris Declaration. It highlighted the need for increaseddonor harmonisation and alignment with recipient governments.

In contrast to the way vertical projects operate, the principlesbehind GBS and SWAps include:

• pooling of government and donorfunds to contribute towards nationally agreed policies and expenditureframeworks
• emphasis on country ownershipand leadership
• donors gradual increase in the use of government procedures to eventually disburseand account for all funds.

SWAp funds areallocated to a specific sector such as education or health, whilst GBS fundsare channelled to the recipient government budget without allocation to aspecific sector, programme or activity. PHC funding can benefit from such shiftsin resource allocation, when government funds increase due to a change in thedonors’ method of budget delivery. This happened in Uganda in 2000, as discussed byFreddie Ssengooba, when a sector-wide approach was introduced along with other healthsystems reforms that prioritised PHC services.

Global health initiatives

Yet the advantages of vertically delivered donor projects – suchas the ability to respond swiftly to urgent health problems and increased flexibilityin avoiding recipient countries’ capacity problems - continue to make them apopular method of delivery for aid. In the past decade, project-based Global HealthInitiatives such as the Presidential Emergency Plan for AIDS Relief and the GlobalFund for AIDS, TB and Malaria have posed additional coordination challenges at thenational level. This is mainly due to the high volumes of funds they manage andthe resulting potential to disrupt existing health system development, and the policyand planning processes of recipient countries.

Conclusion

In the 30 years since the Alma Ata Declaration, there hasbeen continuous tension regarding whether to centre efforts on a few selectedinterventions or strengthen the health system as a whole. Focusing on a limiteddisease intervention package or a particular element of the health system, suchas human resources, risks the neglect of aspects such as management systems, andcompromising the effective and efficient functioning of health services.

Improving affordable PHC servicesin low income countries is complex. Differing political contexts, incentivestructures, management cultures and constraints on community participation allplay a role. Crucially, policymakers in donor agencies and recipient countriesneed to ensure adequate funding is allocated to the entire health sector.Secondly they need to channel new funding sources through pooled mechanisms,such as SWAps, and use established governmentprocesses.