Strengthening primary health care is essential to advance health equity

The effects of the COVID-19 pandemic on livelihoods, food security, and access to basic services have highlighted severe inequities in health and social outcomes across the world.  In many countries, communities, governments, civil society, and the private sector are coming together to address the root causes of disparities with interventions that enable fair and just access within foundational systems of universal health care.  Globally, on Universal Health Coverage Day, we must remember that strengthening primary health care is a viable way to reach marginalized and hard-to-reach populations, helping to advance health equity.

The importance of resilient primary health care systems

Primary health care (PHC) is the package of essential health services and community level public health functions that addresses health needs across a person’s lifetime, preventing disease, managing illness, and promoting well-being. Resilient PHC systems are central to addressing 21^st century health threats, including highly contagious infections and noncommunicable diseases.  Investing in strong PHC systems is a fundamental, necessary step to advance health equity and achieve health for all.

Five steps to advance health equity through primary health care

To advance health equity through primary health care, we recommend that the global health community:

1. Intentionally address barriers to access posed by social and political determinants, such as race, ethnicity, gender, age, disability, income levels, and geographic location
2. Tailor service delivery to be responsive to the local and cultural context, prioritizing consumers’ choice and health literacy, especially among underserved and at-risk populations. 
3. Facilitate the community’s ownership through active participation on oversight bodies, advisory boards, and cooperative ventures. 
4. Establish shared values between the community, health authorities, and commercial entities to level power dynamics and promote consumers’ interests with respect and dignity. 
5. Mobilize and empower local actors, extend their access to information, and enhance their advocacy skills to amplify their voice.

Lessons learned from operational primary health care challenges

In the last five decades, countries have accumulated a range of lessons in operationalizing PHC strategies that we can learn from.   

Building trust between local authorities, health providers, and the community during crises is paramount, and highlights the importance of leadership and communication skills. The West Africa Ebola epidemics and the recent COVID-19 pandemic have taught us the importance of timely and accurate public information on the nature of the pathogens and necessary actions for containment. 

Protecting frontline workers with personal protective equipment and coverage for medical care and disability is essential.  Drawing from past occasions around the world where health emergencies have led to disruption of services, “stress tests” to gauge the resilience of the health sector at the peripheral level could inform and reinforce preparedness measures.

Financing primary health care involves balancing resource allocation for public health functions against commercially profitable medical care.  The COVID-19 pandemic experience has also shown how repurposing field-based, primary level diagnostic services, surveillance systems, and supply chain capabilities for tuberculosis, polio, and malaria control have helped contain these diseases.  Going forward, flexibility in earmarked resources can enable primary care systems to tackle emerging threats as well as underfunded conditions such as mental health. 

Over the years, there has been a better understanding and shared interests with the for-profit private sector to advance equity.  While much work remains, many private companies are now incorporating measures to promote equity into enterprise-wide production, marketing, sales, and distribution processes such as through the Shared Value Initiative.

Finally, a key area for learning concerns the multi-sectoral nature of primary health care delivery.  Mobilizing stakeholders across relevant sectors especially those engaged in animal health, climate equity, and energy production and use, is labor-intensive but necessary.  The need for leadership support to operationalize coherent policies and concerted actions at the local level between the health, environment, security and border control, and livestock sectors to contain zoonotic threats and other communicable diseases should not be underestimated.

Opportunities for investment in health equity

Strengthening primary health care to advance equity requires building capabilities for evidence-based policy making, program design, and monitoring with rigor.  The integrity of programmatic investments depends on metrics, measurement tools, and data systems to study the drivers of inequities and the impact of interventions.  Breakthroughs with artificial intelligence and machine learning are enabling the analysis of large data sets and predictive modeling to determine healthy behaviors and the uptake of quality primary care services.  Globally, indices on inequality, vulnerability, deprivation, and sector specific measurements for climate equity, food justice, etc., are being applied to track the reach and effectiveness of PHC strategies on health equity. 

Deeper analyses into perceptions, attitudes, and practices will require mixed methods approaches combining quantitative and qualitative research techniques.  Technical assistance fostering collaboration between international, national, and regional institutions can help construct research agendas that directly support policy and program plans to strengthen equity-oriented systems.

Investments in workforce capabilities especially at the frontlines will update competencies and strengthen community-level preventive, promotive, curative, and rehabilitative service delivery.  The need to develop executive leadership skills is critical, especially at the local level, to balance data-based analyses against politically driven decisions.  Across the international community, several partnership platforms have emerged, with many opportunities to forge coalitions, promote development cooperation, and learn from each country’s efforts.  Thoughtful selection and application of analytical tools and data systems will help build in-country capabilities and promote organizational learning.

There is a stock of lessons to draw upon and improve on to achieve health equity worldwide. Building human capital to advance equity require both technical as well as soft skills. Investments in these areas, as described above, will help institutionalize a culture of diversity and inclusion leading to improved health of people worldwide, especially those currently marginalized.

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