Background

The study lists three measures that relate to investments to strengthen primary health care (PHC) orientation in health systems, identifying both specific interventions and health systems requirements. The report discusses different measures of PHC costs, specifies the inputs required to strengthen PHC delivery across countries and estimates costs using country-specific data. PHC involves shifting health services from tertiary or inpatient care to primary level or outpatient care.

Methods

This modelling study analysed data from 67 low-income and middle-income countries (LMICs). To Recognise the variation in PHC services among countries, three measures for PHC with different scope for included interventions and system strengthening are conducted. Measure 1 is centred on public health interventions and outpatient care; measure 2 adds general inpatient care; and measure 3 further adds cross-sectoral activities. Cost components included in each measure were based on the 2018 Declaration of Astana, informed by work delineating PHC within health accounts, and finalised through an expert and country validation meeting. The subset of PHC costs are extracted for each measure from World Health Organization (WHO)’s Sustainable Development Goal (SDG) price tag for the 67 LMICs and projected the associated health impact. Estimates of financial resource need, health workforce, and outpatient visits are presented as PHC investment guide posts for LMICs.

Findings

An estimated additional US$200–328 billion per year is required for the various measures of PHC from 2020 to 2030. For measure 1, an additional $32 is needed per capita across the countries. Needs are greatest in low-income countries where PHC spending per capita needs to increase from $25 to $65. Overall health workforces would need to increase from 5.6 workers per 1000 population to 6.7 per 1000 population, delivering an average of 5.9 outpatient visits per capita per year. Increasing coverage of PHC interventions would avert an estimated 60.1 million deaths and increase average life expectancy by 3.7 years. By 2030, these incremental PHC costs would be about 3.3% of projected gross domestic product (GDP; median 1.7%, range 0.1–20.2). In a business-as-usual financing scenario, 25 of 67 countries will have funding gaps in 2030. If funding for PHC was increased by 1–2% of GDP across all countries, as few as 16 countries would see a funding gap by 2030.

Discussion

The resources required to strengthen PHC vary across countries, depending on demographic trends, disease burden, and health system capacity. The proposed PHC investment guide posts advance discussions around the budgetary implications of strengthening PHC, including relevant system investment needs and achievable health outcomes. Preliminary findings suggest that low-income and lower-middle-income countries would need to at least double current spending on PHC to strengthen their systems and universally provide essential PHC services. Investing in PHC will bring substantial health benefits and build human capital. At country level, PHC interventions need to be explicitly identified, and plans should be made for how to most appropriately reorient the health system towards PHC as a key lever towards achieving UHC and the health-related SDGs.

1. The added value of the guide is that it discusses the different measures of PHC costs: it specifies the inputs required to strengthen PHC delivery across countries and estimate costs using country-specific data. The guide presents and discusses the related investment guide posts, and adds to the evidence base on the potential impact to be brought by investments in PHC as well as the affordability of delivering high-quality PHC across different settings.
2. Impact modelling indicates that significant health gains can be achieved by investing in primary care and public health and confirms the catalytic role that PHC can play in the universal health care and Sustainable Development Goals agendas.
3. Notable health gains can be achieved by investing in PHC, with up to 6·7 years gained in life expectancy in just an 11-year timeframe. For an extra $32 per capita, these health improvements have substantial value in themselves, but will also result in improved economic productivity and overall human capital.
4. Expenditure estimates on PHC from health accounts only include recurrent expenditures since expenditure on capital goods is reported separately within health accounts and no proposed methods exist for separating out the PHC share of capital investments. Therefore, this investment guide posts for total PHC expenditure per capita are underestimated because current expenditure is limited to recurrent costs only.
5. Countries might find that one or more measures respond more closely to their policy context. During the validation process, although country participants expressed support for having multiple measures, most global experts supported measure 1 for universal assessment, with the main reason being that measure 1 is consistent with the current PHC expenditure methods.
6. Countries with the smallest GDP require the largest incremental investments. Even with a 1% GDP increased allocation towards PHC, almost 25 countries would not reach the modelled benchmarks, which is unfortunate because PHC can be a remarkably efficient and highly equitable investment.
7. Importantly, even the narrower measure 1 includes comprehensive services across disease burden and life course needs as relevant to the SDGs; this differentiates the current service-oriented approach from previous models of selective PHC, which made some significant health gains, but fell short of the vision of PHC in the declaration of Alma-Ata.
8. The boundaries within the model suggest that this guide posts are conservative estimates. Also, the assumption of baselines changed little between 2015 and 2019 might underestimate the baseline and thus overestimate incremental resource needs.
9. Country policy makers can apply existing models to a locally defined PHC package and estimate resource needs. Civil society organisations can push for transparent budget allocation and benefit packages for PHC. The global community should strengthen existing evidence on recurrent and capital expenditures on PHC, advocate for targeted donor support to countries most in need, and support countries to prioritise within limited budgets.