Primary healthcare fails to meet needs of people it was built for: Lancet study

People in low-, middle-income countries often have to pay out of their pocket and seek care elsewhere

By Taran Deol
Published: Thursday 07 April 2022
Public healthcare fails to meet needs of people it was built for: Lancet study Photo: iStock

Funding in primary healthcare systems in low- and middle-income countries is insufficient and access to it inequitable, a new study has reiterated.

Patients often have to pay for the services out of their pocket, the report published in the journal The Lancet Global Health April 4, 2022 noted, adding that these systems have failed to meet the needs of people it was built for.  

Primary healthcare is the backbone of health systems in India, like other low- and middle-income countries. The system in the country are strengthened by the National Health Mission and receive funding from state governments.

The central government put in place several mechanisms to encourage the states to invest in primary healthcare. These include assessing performance and accountability. The measures increased between 2008 and 2019, “state-level respondents did not feel that these policy levers necessarily increased effective use of funds,” the study found.

The 1978 Declaration of Alma-Ata — adopted at the International Conference — was the first to detail principles of primary healthcare. This was ratified four decades later at the Global Conference on Primary Health Care in Astana. 

The declaration underlined the three key components of public healthcare as meeting the needs of the people throughout their lives, using multi-sectoral policy and action to address health determinants and pushing for individuals and families to take charge of their own health. 

In most low- and middle-income countries, primary healthcare has failed to deliver on the above made promises and people are forced to seek care elsewhere, the Lancet study found. 

The needs of both users and providers have been overlooked, the report said.  “A vicious cycle has undermined PHC: Underfunded services are unreliable, of poor quality, and not accountable to users.” 

There are two ways in which primary healthcare is financed depending on the type of governance. In a centralised system, the finance ministry allocates funds to the health ministry, which then decides how much each programme will receive based on geography and level of care. 

In a decentralised system, such as India’s, local authorities fund primary healthcare. This has its pros and cons. “The system gives the opportunity for resource allocation decisions to be shaped by local needs, disease patterns and priorities,” the study noted.

However, it can also lead to a focus on financing services that are popular or visible, rather than those that bring the greatest population health benefits, it added.

Investing more and investing better is the key solution to “provide equitable, comprehensive, integrated and high-quality” care, according to the authors of the report. 

Stressing on the need for a people-centred approach, four funding features must be addressed through this prism. These are: Using public funds as the core for primary health systems, pooling arrangements — (accumulating prepaid funds such as social security contributions, taxes, or health insurance premiums) to cover out-of-pocket expenditure, equitable allocation of resources and making capitation the core of provider payment to bridge gaps in PHC expenditure.

To achieve this vision, the study recommends a five-pronged approach. These include an “adequately-financed health sector” with a special focus on inequalities in the system, using pooled funding to ensure free services, using available policy tools to enable a universally-accessible system, blended payment model built on capitation for providers and a “nuanced understanding of the political economy of each country throughout the development and implementation of all policy to accompany the technical approaches to ensuring people-centred financing for PHC.”

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