After the Astana declaration: is comprehensive primary health care set for success this time?

Strategies for improving the financing of family medicine program: Evidence from Iran

Background and Aims

The impact of health financing on the performance of the entire health system, including access, quality, and efficiency of healthcare, has been emphasized in the Astana Declaration, and the need to strengthen primary healthcare (PHC) and policy integration has been emphasized. After about two decades, the family medicine (FM) program in Iran is still facing great challenges. The aim of this study is to explore strategies for strengthening financing of the FM program in Iran, a vital component of PHC.

Methods

A qualitative study was conducted in 2021. Purposeful sampling was used to select 34 policymakers, managers, and experts from various levels of the Ministry of Health, Iran universities of medical sciences, plan and budget organization of Iran, and health insurance organization in Iran. Thirty-four semistructured interviews were conducted to collect data, which were analyzed by content analysis.

Results

Through the analysis of interviews, our study has identified five strategies (identification and management of sustainable resources, pooling of sustainable resources, modeling of service provision, payment system model and its implementation process, and FM management structure), and 13 actions for strengthening financing of the FM program in Iran.

Conclusion

Our study has identified five strategies and 13 actions for strengthening the financing of the FM program in Iran. These strategies and actions should be considered by policymakers during the review of the FM program in Iran. Without implementation of the suggested strategies and action, allocated resources may be wasted.

Prevalence of unmet health care need in older adults in 83 countries: measuring progressing towards universal health coverage in the context of global population ageing

Current measures for monitoring progress towards universal health coverage (UHC) do not adequately account for populations that do not have the same level of access to quality care services and/or financial protection to cover health expenses for when care is accessed. This gap in accounting for unmet health care needs may contribute to underutilization of needed services or widening inequalities. Asking people whether or not their needs for health care have been met, as part of a household survey, is a pragmatic way of capturing this information. This analysis examined responses to self-reported questions about unmet need asked as part of 17 health, social and economic surveys conducted between 2001 and 2019, representing 83 low-, middle- and high-income countries. Noting the large variation in questions and response categories, the results point to low levels (less than 2%) of unmet need reported in adults aged 60+ years in countries like Andorra, Qatar, Republic of Korea, Slovenia, Thailand and Viet Nam to rates of over 50% in Georgia, Haiti, Morocco, Rwanda, and Zimbabwe. While unique, these estimates are likely underestimates, and do not begin to address issues of poor quality of care as a barrier or contributing to unmet need in those who were able to access care. Monitoring progress towards UHC will need to incorporate estimates of unmet need if we are to reach universality and reduce health inequalities in older populations.

Beyond Astana: Configuring the World Health Organization Collaborating Centres for primary health care

The understanding of primary health care (PHC) has evolved significantly, evident in key World Health Organization (WHO) reports, promoting PHC as a means for health for all, identifying key health systems reforms and focusing on health care experience. This study explores the WHO's current framing of PHC, and its configuration of WHO Collaborating Centres (WHOCCs) on PHC using the data available on the WHOCCs Portal. We analysed the following variables: title, institutions, location, economy, date of mandate, objectives, subject, and activity. There were 13 WHOCCs on PHC, nine based in North America and Europe, and none in Africa. Only three were in Low- and Middle-Income Countries (LMICs). The WHOCCs on PHC focused on three broad subjects: five focused on human resources for health (HRH); four on health systems research (HSR) and development, with an emphasis on family medicine; four on PHC systems. Activities were related to training and education, provision of technical advice, and research. Support to WHO on implementation of PHC was an activity for two LMIC based WHOCCs. The current configuration of WHOCCs on PHC is consistent with the evolution of PHC and its intersection with Universal Health Coverage and the Sustainable Development Goals. The increasing attention to people-centred health systems aligns with WHO's commitment to PHC in all health systems, though this needs special interpretation for LMICs with their limited HRH. There has been a shift in subjects from HRH towards primary care and family medicine, and HSR highlighting primary care and PHC systems. The concern is an absence of WHOCCs in the Africa and Latin and South Americas, and under-representation in LMICs. Designating more institutions from the South with expertise in PHC is necessary to address the challenges post-Astana.

Making districts functional for universal health coverage attainment: lessons from Ghana

Ensuring the sub national level in the health system can function effectively is central to attainment of health results in countries. However, the current health agenda has not prioritized how districts can deploy their existing resources effectively, to maximize the efficiency equity and effectiveness in their use. Ghana initiated a self-assessment process to understand the functionality of districts to deliver on health results. The assessment was conducted by health managers in 33 districts during August-October 2022 using tools pre-developed by the World Health Organization. Functionality was explored around service provision, oversight, and management capacities, each with defined dimensions and attributes. The objective of the study was to highlight specific functionality improvements needed by districts in terms of investments and access to service delivery in achieving Universal Health Care. The results showed a lack of correlation between functionality and performance as is currently defined in Ghana; a higher functionality of oversight capacity compared to service provision or management capacities; and specifically low functionality for dimensions relating to capacity to make available quality services, responsiveness to beneficiaries and the systems and three structures for health management. The findings highlight the need to shift from quantitative outcome indicator-based performance approaches to measures of total health and wellbeing of beneficiaries. Specific functionality improvements are needed to improve the engagement and answerability to the beneficiaries, investments in access to services, and in building management architecture.

Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia

National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a "cheap" solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the "community health worker" itself, creating unclear and unrealistic expectations for CHWs.

Global Health Strategies in the Face of the COVID-19 Pandemic and Other Unprecedented Threats

Global health is evolving as a discipline aiming at exploring needs and offering equitable health services for all people. Over the past four decades, several global initiatives have been introduced to improve the accessibility of primary health care (PHC) and solve most health issues at this level. Historically, the 1978 Alma-Ata and 2018 Astana Declarations were perhaps the most important documents for a comprehensive approach to PHC services across the world. With the introduction of the United Nations Sustainable Development Goals in 2015, developments in all spheres of human life and multi-sectoral cooperation became the essential action targets that could contribute to improved health, well-being, and safety of all people. Other global initiatives such as the Riyadh Declaration on Digital Health and São Paulo Declaration on Planetary Health called to urgent action to employ advanced digital technologies, improve health data processing, and invest more in research management. All these initiatives are put to the test in the face of the coronavirus disease 2019 (COVID-19) pandemic and other unprecedented threats to humanity.

Healthcare Provider Advocacy for Primary Health Care Strengthening: A Call for Action

Primary Health Care (PHC) is the backbone of health systems and a cornerstone of Universal Health Coverage. In 2018, political commitment to PHC, including a comprehensive approach based on essential care throughout the lifespan, integrated public health functions, and community empowerment was reaffirmed by international stakeholders in Astana. As recent events exposed weaknesses of health care systems worldwide, growing attention has been paid to strengthening PHC. While the role of care providers as health advocates has been recognized, they may lack skills, opportunities, and resources to actively engage in advocacy. Particularly for PHC providers, guidance and tools on how to advocate to strengthen PHC are scarce. In this article, we review priority policy areas for PHC strengthening with relevance for several settings and health care systems and propose approaches to empower PHC providers-physician, non-physician, or informal PHC providers-to advocate for strengthening PHC in their countries by individual or collective action. We provide initial ideas for a stepwise advocacy strategy and recommendations for practical advocacy activities. Our aim is to initiate further discussion on how to strengthen health care provider driven advocacy for PHC and to encourage advocates in the field to reflect on their opportunities for local, national, and global action.

Patient perspectives on integrated healthcare for HIV, hypertension and type 2 diabetes: a scoping review

INTRODUCTION

Antiretroviral therapy has reduced mortality and led to longer life expectancy in people living with HIV. These patients are now at an increased risk of non-communicable diseases (NCDs). Integration of care for HIV and NCDs has become a focus of research and policy. In this article, we aim to review patient perspectives on integration of healthcare for HIV, type 2 diabetes and hypertension.

METHODS

The framework for scoping reviews developed by Arksey and O'Malley and updated by Peter et al was applied for this review. The databases PubMed, Web of Science and Cochrane library were searched. Broad search terms for HIV, NCDs (specifically type 2 diabetes and hypertension) and healthcare integration were used. As the review aimed to identify definitions of patient perspectives, they were not included as an independent term in the search strategy. References of included publications were searched for relevant articles. Titles and abstracts for these papers were screened by two independent reviewers. The full texts for all the publications appearing to meet the inclusion criteria were then read to make the final literature selection.

RESULTS

Of 5502 studies initially identified, 13 articles were included in this review, of which 11 had a geographical origin in sub-Saharan Africa. Nine articles were primarily focused on HIV/diabetes healthcare integration while four articles were focused on HIV/hypertension integration. Patient's experiences with integrated care were reduced HIV-related stigma, reduced travel and treatment costs and a more holistic person-centred care. Prominent concerns were long waiting times at clinics and a lack of continuity of care in some clinics due to a lack of healthcare workers. Non-integrated care was perceived as time-consuming and more expensive.

CONCLUSION

Patient perspectives and experiences on integrated care for HIV, diabetes and hypertension were mostly positive. Integrated services can save resources and allow for a more personalised approach to healthcare. There is a paucity of evidence and further longitudinal and interventional evidence from a more diverse range of healthcare systems are needed.

Fighting non-communicable diseases in East Africa: assessing progress and identifying the next steps

Sub-Saharan Africa has seen a rapid increase in non-communicable disease (NCD) burden over the last decades. The East African Community (EAC) comprises Burundi, Rwanda, Kenya, Tanzania, South Sudan and Uganda, with a population of 177 million. In those countries, 40% of deaths in 2015 were attributable to NCDs. We review the status of the NCD response in the countries of the EAC based on the available monitoring tools, the WHO NCD progress monitors in 2017 and 2020 and the East African NCD Alliance benchmark survey in 2017. In the EAC, modest progress in governance, prevention of risk factors, monitoring, surveillance and evaluation of health systems can be observed. Many policies exist on paper, implementation and healthcare are weak and there are large regional and subnational differences. Enhanced efforts by regional and national policy-makers, non-governmental organisations and other stakeholders are needed to ensure future NCD policies and implementation improvements.

Towards universal health coverage in the WHO African Region: assessing health system functionality, incorporating lessons from COVID-19

The move towards universal health coverage is premised on having well-functioning health systems, which can assure provision of the essential health and related services people need. Efforts to define ways to assess functionality of health systems have however varied, with many not translating into concrete policy action and influence on system development. We present an approach to provide countries with information on the functionality of their systems in a manner that will facilitate movement towards universal health coverage. We conceptualise functionality of a health system as being a construct of four capacities: access to, quality of, demand for essential services and its resilience to external shocks. We test and confirm the validity of these capacities as appropriate measures of system functionality. We thus provide results for functionality of the 47 countries of the WHO African Region based on this. The functionality of health systems ranges from 34.4 to 75.8 on a 0–100 scale. Access to essential services represents the lowest capacity in most countries of the region, specifically due to poor physical access to services. Funding levels from public and out-of-pocket sources represent the strongest predictors of system functionality, compared with other sources. By focusing on the assessment on the capacities that define system functionality, each country has concrete information on where it needs to focus, in order to improve the functionality of its health system to enable it respond to current needs including achieving universal health coverage, while responding to shocks from challenges such as the 2019 coronavirus disease. This systematic and replicable approach for assessing health system functionality can provide the guidance needed for investing in country health systems to attain universal health coverage goals.

Strength in Diversity: Integrating Community in Primary Health Care to Advance Universal Health Coverage

The supplement highlights a systems approach that recognizes the communities' roles and their interactions with other health system actors to accelerate outcomes and reflect the diversity of the community health ecosystem. Several cross-cutting priorities emerge from the articles, namely coverage, community health financing, policy change, institutionalization, resilience, accountability, community engagement, and whole-of-society efforts.

Primary health care contributions to universal health coverage, Ethiopia

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

The COVID-19 Pandemic and Non-communicable Diseases-A Wake-up Call for Primary Health Care System Strengthening in Sub-Saharan Africa

Strengthening Primary Health Care Systems is the most effective policy response in low-and middle-income countries to protect against health emergencies, achieve universal health coverage, and promote health and wellbeing. Despite the Astana declaration on primary health care, respective investment is still insufficient in Sub-Sahara Africa. The SARS-CoV-2019 pandemic is a reminder that non-communicable diseases (NCDs), which are increasingly prevalent in Sub-Sahara Africa, are closely interlinked to the burden of communicable diseases, exacerbating morbidity and mortality. Governments and donors should use the momentum created by the pandemic in a sustainable and effective way by pivoting health spending towards primary health care.