世界银行：在新冠疫情之后重新思考初级卫生保健（英文）

EXECUTIVE SUMMARY1WALKING THE TALKReimagining Primary Health Care After COVID-19Public Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure Authorized© 2021 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.orgThis work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent.The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.Nothing herein shall constitute or be construed or considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved.Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given.Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org.WALKING THE TALKReimagining Primary Health Care After COVID-19WALKING THE TALKContentsExecutive Summary12Chapter 1. Introduction: Primary Health Care: Time to DeliverAn unfinished journey21The shock of COVID-1922This report: practical options for stronger PHC23Chapter 2: Challenges for Health Systems: COVID-19 and BeyondHealth-system ecologies: trends for the coming decade31Trends in health care delivery and financing41Implications for primary health care43Chapter 3. Reimagined PHC: What Will It Look Like?2Four high-level shifts for stronger PHC50Chapter 4. Making It HappenPriority Reform 1: Fit-for-purpose multidisciplinaryteam-based organization761.1. From dysfunctional gate keeping to quality, comprehensivecare for all761.2. From fragmentation to person-centered integration821.3. From inequities to fairness and accountability871.4. From fragility to resilience90Priority Reform 2: The fit-for-purpose multi-professionalhealth workforce922.1. From dysfunctional gate keeping to quality, comprehensivecare for all922.2. From fragmentation to person-centered integration982.3. From inequities to fairness and accountability1032.4. From fragility to resilience107TABLE OF CONTENTSPriority Reform 3: Fit-for-purpose financing for public-health-enabled primary care1103.1. From dysfunctional gate keeping to quality, comprehensivecare for all1113.2. From fragmentation to person-centered integration1193.3. From inequities to fairness and accountability1223.4. From fragility to resilience127Enabling multisectoral engagement through PHC reform130Conclusions137Chapter 5: Policy RecommendationsPrerequisites for action139Recommendations for countries141 3Recommendations for donors and the international healthcommunity146What will the World Bank do?147Conclusion: Summary table of policy recommendations149Endnotes150WALKING THE TALK4FOREWORDThe Universal Health Coverage (UHC) agenda has reached a crucial crossroad.FOREWORDThe COVID-19 pandemic has laid bare the inherent weaknesses of health systems around the world. Confirmed global deaths almost reaching 4 million and continue to climb. The pandemic brought the world economy to a standstill—costing trillions of dollars, eroding progress toward poverty elimination, and widening domestic and international inequalities. Vaccination campaigns now offer hope for a postpandemic future, but uneven rollouts have once again revealed staggering inequities across and between countries. It is still too early to offer a definitive post-mortem on COVID-19, but early signs suggest failings at every level—from global governance all the way down to individual behavior. The pandemic has stolen the spotlight from the UHC agenda, even as it has reinforced the critical role of resilient national health systems as the very foundation of global stability and prosperity.So where do we go from here?In this report, we argue that a robust and reimagined Primary Health Care (PHC)agenda, as part of a broader reinvigoration of UHC, must be part of the post-COVID story—both to dig the world out of the COVID ditch and to prevent similarcatastrophes from future occurrence. To be clear, we do not claim that COVIDcrisis was entirely or mostly the result of weak or non-functional PHC services. YetPHC was often the weakest link in the national and community response, despiteits critical importance as a backstop to “flatten the curve” and prevent hospital5saturation. Core PHC functions like surveillance, testing, and contact tracing firstfell through the cracks, then were ultimately assumed by newly created teams orhospitals. And now we will again need PHC to close the COVID-19 chapter andmake up for lost time—by administering vaccines against COVID-19; recoupinglosses to reproductive health, preventive care, and mental health; and buildingback better to meet the evolving needs of the global population.This report builds on the vast literature on PHC, revisiting the concept, its underpinnings, country experiences and lessons learned. It also is fully aligned with the 2018 Declaration of Astana on PHC as the main pillar of Universal Health Coverage and the health-related Sustainable Development Goals and commits the World Bank to its global pursuit of Health-For-All. Yet its emphasis is on the “How”, namely what it takes to build a fit-for purpose Primary Health Care and spells out how countries could reimagine it to “walk the talk”, with assistance from their global partners including the World Bank Group.We hope that the organizing framework presented in this report would add value in our dialogue with our client countries for a better aligned and more effective pursuit towards Universal Health Coverage by 2030. Indeed, the challenge before us is how to build and retain the PHC workforce with the right skills mix, to organize their care environment, and to ensure that they are well-resourced so that the services they provide are of the highest quality, comprehensive, coordinated and integrated across all levels of care, yet affordable and sustainable at the same time. We extend an open invitation to all our partners in global health for collaboration and reaffirm our commitment to the Global Action Plan PHC Accelerator in providing technical and financial assistance to make the recommendations of this report a reality.WALKING THE TALKAcknowledgementsThis report was prepared under the Advisory Service and Analytics, “Reimagining Primary Health Care for UHC and HNP Strategy”. This activity was coordinated by Huihui Wang (Senior Economist) and Lydia Ndebele (Health Specialist) and supervised by Muhammad Ali Pate (Global Director, Health, Nutrition and Population Global Practice) and Feng Zhao (Practice Manager, Health, Nutrition and Population Global Practice, Global Engagement).Enis Barış (Senior Advisor, Global Health and Consultant) provided intellectual leadership in conceptualization and co-authored the report. Other authors of the report include Rachel Silverman (Consultant), Huihui Wang (Senior Economist), Ece Özçelik (Consultant), Manuela Villar Uribe (Health Specialist), Gianluca Cafagna (Health Specialist), Federica Secci (Senior Health Specialist), Denizhan Duran (Young Professional), Sarah Alkenbrack (Senior Economist, Health), Roxanne Oroxom (Consultant), Muntaqa Umar-Sadiq (Consultant) and Roger Strasser (Consultant).We acknowledge the helpful feedback received on the report drafts from HNPleadership team and HNP colleagues throughout the process, as well as written6comments provided for the decision meeting from Daniel Dulitzky (RegionalDirector), Gayle Martin (Country Manager), Susanna Hayrapetyan (ProgramLeader), Mark E. Cackler (Lead Agriculture Specialist), John Paul Clark (LeadHealth Specialist), Sherin Varkey (Senior Health Specialist). Chapters 3 and 4have incorporated content from the World Bank’s internal Frontlines First (FLF)series, developed in 2018 to commemorate the 40th anniversary of the AlmaAta Declaration. The team is also grateful to David Wilson (Program Director)and Mickey Chopra (Lead Health Specialist), Rachel Silverman (Consultant, leadauthor); Kojo Nimako (Consultant), and Danielle Fitzpatrick (Consultant) fortheir roles in compiling the FLF framework and briefs that have fed into thisFlagship Report.The team also thanks Alexander Irvin for his incredibly skilled editorial assistance, Latifat Agharese Okara for her support in finalizing the report, Ira Marina (Senior Executive Assistant), Marize de Fatima Santos (Program Assistant) and Kseniya Bieliaieva (Team Assistant) for their coordination and logistics support.ABBREVIATIONSAbbreviationsACOAccountable Care OrganizationADZUAteneo de Zamboanga UniversityARTAnti-Retroviral TherapyBHSBasic Health ServicesBMPHSBasic Minimum Package of Health ServicesBHCPFBasic Health Care Provision FundCBLCase-based LearningCCTsConditional Cash TransfersCEMECommunity Engaged Medical EducationCHACambridge Health AllianceCHPSCommunity-based Health Planning and ServiceCHWsCommunity Health WorkersCMSCenter for Medicaid and Medicare ServicesCNAMTSCaisse Nationale d’Assurance Maladie des Travailleurs SalariésCPC+Comprehensive Primary Care Plus7CVDCardiovascular DiseaseDAHDevelopment Assistance for HealthDCP3Disease Control Priorities (3rd edition)DRGDiagnosis-related GroupEAPHLNPThe East Africa Public Health Laboratory Networking ProjectEBAISEquipos Básicos de Atención Integral de SaludEHRElectronic Health RecordEPSSEvaluación de la Prestación de Servicios de Salude-RSE-referral System for Specialist ConsultationsFFSFee for ServiceFHTsFamily Health teamsFPsFamily PractitionersGAPGlobal Action Plan for SDG3GFFThe Global Finance Facility for Women, Children and AdolescentsGISGeographical Information SystemsGKGesundes Kinzigtal GmbHGPGeneral PractitionerGPsGeneral PractitionersGSPGlobal Skills PartnershipHANSAThe World Bank’s Health and Nutrition Services Access ProjectHCPHuman Capital ProjectWALKING THE TALKHFHealth financingHITAPThailand’s Health Intervention and Technology Assessment ProgramHMISHealth Management Information SystemsHNPHealth, Nutrition and PopulationHPVHuman PapillomavirusHRH Program Rwanda Human Resources for Health ProgramhearScreenTM Smartphone-based ApplicationHSRSHealth Sector Reform StrategyHTAHealth Technology AssessmentICTInformation and Communications TechnologyIHMEThe Institute for Health Metrics and EvaluationJLNThe Joint Learning Initiative for Universal Health CoverageLHINsLocal Health Integration NetworksLMICsLow- and Middle-income CountriesMAMedical AdministrationMBABusiness Administration8MCHMaternal and Child HealthMHAHealth AdministrationMEPIThe Medical Education Training Partnership InitiativeMoHMinistry of HealthMoFMinistry of FinanceMoEMinistry of EducationMoLMinistry of LaborMoIMinistry of the InteriorMoTMinistry of TechnologyMPAMultiphase Programmatic ApproachMPHPublic Health AdministrationM&EMonitoring and evaluationNASFFamily Health Support CentersNCDsNoncommunicable DiseasesNEPIThe Nursing Training Partnership InitiativeNHSCThe US National Health Service CorpsNICEThe National Institute for Health and Clinical ExcellenceNLCThe Nurse Licensure CompactNOSMThe Northern Ontario School of MedicineNPHWsNon-physician Healthcare WorkersPaRISThe Patient reported Indicator SurveysABBREVIATIONSPCMHThe US-based Patient-Centered Medical HomePFMPublic Financial ManagementPHCPrimary Health CarePHCPIPrimary Health Care Performance InitiativePNGPapua New GuineaPPEPersonal Protective EquipmentPPPPreferred Primary Care ProviderPREMPatient-reported Experience MeasuresPROMPatient-reported Outcome MeasuresRMNCHReproductive, Maternal, Newborn and Child Health ServicesRNsRegistered NursesRMNCAH-NImprove Reproductive, Maternal, Newborn, Child and Adolescent Health and NutritionR&DResearch and developmentSDGsSustainable Development GoalsSHISocial Health InsuranceUHCUniversal Health Coverage9WBOTWard-based Outreach TeamsWDCsWard Development CommitteesWALKING THE TALKFiguresFigure 1. Policy choices will be critical for health goals andeconomic recovery32Figure 2. Percentage of working age population (15-64 years of age) byincome group and geographic location, 1950-210034Figure 3. Percentage of population 65+ years of age by income groupand geographic location,34Figure 4. Living longer, living sicker: years lived in poor health, 1990and 201936Figure 5. Noncommunicable diseases will test already-fragile healthsystems37Figure 6. Urban populations continue to surge3910Figure 7. Service coverage and financial protection worldwide:slow progress even before COVID-1941TablesTable 1. Reimagining a PHC fit-for-purpose: outcomes andpriority reforms74Table 2. Team-based care models around the world79Table 3. Misalignments between traditional payment mechanismsand team-based care models119Table 4. Key recommendations for fit-for-purpose PHC149BOXESBoxesBox 1. PHC and health-system reform in the 21st century: a growingconvergence and strong alliances49Box 2. Four shifts to improve performance in PHC51Box 3: What has to change: dysfunctional gate keeping andquality gaps54Box 4. What has to change: discontinuous delivery56Box 5. What has to change: health financing gaps widen health careinequities59Box 6. The cost of not building fit-for-purpose PHC: collateralmortality in COVID-1962Box 7. What has to change: fragility to shocks6311Box 8. What has to change: sectoral silos inhibit collaboration69Box 9. Why team-based care?77Box 10. Harnessing technology to improve information sharing in PHC 86Box 11. Core competencies for interprofessional collaborative practice 101Box 12. Why finance PHC through general government revenue?113Box 13. Global Financing Facility and the World Bank –a partnership to support Primary Health Care126Box 14. A Whole-of-government approach to strengtheninghuman capital136WALKING THE TALK12EXECUTIVE SUMMARYEXECUTIVE SUMMARYThe world has waited long enough for high-performing primary health care (PHC). It’s time to deliver. Forty years ago, leaders embraced the promise of health for all through PHC. That vision has inspired generations. But for nearly half a century, countries have struggled to walk the talk on PHC. We have not built health systems anchored in strong PHC where they were needed most. Today, COVID-19 has brought the reckoning for that shared failure—but also the chance to do the job right at last.The pandemic has shown policy makers and ordinary citizens why health systemsmatter and what happens when they fail. By doing so, it has also created a once-in-a-generation chance for structural health-system change. Bold reforms nowcan prepare health systems for future crises and bring goals like universal healthcoverage (UHC) within reach. PHC holds the key to these transformations. But tofulfill that promise, the walk has to finally match the talk. This report charts anagenda toward reimagined, fit-for-purpose PHC. It asks three questions about13health-systems reform built around PHC: “Why?”, “What?”, and “How?”The “Why?” of PHC reform: confronting complex changeSince PHC has been around for decades, why write a thick report about it now? The answer is that the characteristics of high-performing PHC are exactly those that are most critical for managing the pressures coming to bear on health systems in the post-COVID world. The challenges include future infectious outbreaks and other emergent threats, but also long-term structural trends that are reshaping the environments in which systems operate in non-crisis times. This report highlights three sets of megatrends that will increasingly affect health systems in the decades ahead: demographic and epidemiological shifts; changes in technology; and citizens’ evolving expectations for health care.The trends most important for health systems include population growth in lowerincome countries; population ageing in advanced economies; and the worldwide explosion of noncommunicable diseases (NCDs). PHC has unique capabilities to help systems meet these challenges but features of traditional PHC systems must evolve to take full advantage of existing strengths and build new ones.WALKING THE TALKThe “What?” of PHC reform: four structural shiftsSo, PHC is great, but it has to get better. What about it needs to change? To meet the demand for quality, people-centered, integrated health care in the 21st century, all countries—despite their many differences—will need to achieve four fundamental shifts in how PHC is designed, financed, and delivered. Some countries have already made bold strides on these agendas, providing evidence for others. The four shifts can be described this way:From dysfunctional gate keeping to quality, comprehensive care for all: Its gate-keeping function makes PHC a cornerstone of efficiency in health systems. Often, however, patients—especially poor ones—perceive PHC gate keeping as an exclusionary barrier shutting them out from the care they want. Some countries have transformed this dynamic by creating PHC teams attuned to local realities and skilled to deliver the quality services communities actually wish for.From fragmentation to person-centered integration: In high- and lower-income countries alike, patients often experience health care as fragmentedand impersonal. Strong local PHC teams can fix this. Accountable teams buildcare around patients’ needs and preferences; treat all patients with respect;14collaborate and communicate internally; and coordinate patients’ movementthrough the health system, taking buck-stops-here responsibility for outcomes,no matter where their patients receive care.From inequities to fairness and accountability: COVID-19 has underscored inequities in health care access and outcomes between and within countries. But some countries are harnessing PHC’s distinctive capacities to tackle inequities. They prioritize PHC-driven essential service packages and reward accountability for health outcomes in frontline PHC.From fragility to resilience: In the wake of the pandemic, countries need to draw the lessons and undertake ambitious reforms. This will involve ensuring that PHC teams include public-health surveillance and outreach capacity, and that financial and human-resource surge capacity is built into health sector planning and resource allocation at the local level.The “How?” of PHC reform: directions for actionAfter identifying high-level shifts that describe the outcomes countries seek with PHC reform, this report presents evidence on the actions that countries can take—and are already taking—to bring these shifts about. Based on the available evidence, we emphasize three paths for action.EXECUTIVE SUMMARYPriority reform 1: multidisciplinary team-based careDelivering PHC services through multidisciplinary teams is key to fulfil the promise of PHC. In this model, a multidisciplinary team of health service providers—headquartered at a PHC hub facility but reaching out actively into the community—works collaboratively to serve a defined population that is assigned (“empaneled”) to the team. The specific composition of the care team and the size of the catchment population vary between and within countries, reflecting local health needs and resources. The core PHC team generally consists of at least three types of providers—community health workers (CHWs), nurses, and general practice/family medicine specialists.Though the evidence base on multidisciplinary collaborative care is nascent, emerging findings suggest substantial performance gains. Empanelment to dedicated care teams provides a strong foundation for care coordination and continuity, enabling long-term relationships between patients and providers. Patients with access to continuous, personalized care have been shown to receive better quality care, report higher satisfaction with health services, and incur lower health expenditures.Proactive PHC teams can tackle barriers to care that disproportionately affectvulnerable constituencies. Engaging directly with communities, local teams15can deliver health education and promotion; offer nutritional coaching andsupplementation; identify subclinical illness; and help sustain adherence totreatment for diseases from diabetes to TB. This may reduce health disparities.Multidisciplinary team based PHC platforms offer benefits for preparedness, response, and resilience in emergencies. These platforms can incorporate data collection, surveillance, and other public-health functions. Syndromic surveillance coordinated with national public-health authorities can help identify and contain outbreaks before they spread. Relationships of trust between the PHC team and community facilitate communication and behavior change during emergencies.Priority reform 2: building a multi-professional health workforceIn many countries, the PHC workforce remains insufficient—in numbers, competencies, distribution, and/or mandate—to deliver quality team-based PHC. Bringing high-quality PHC to all people, particularly underserved populations, will require changes in how health workers are trained, deployed, managed, evaluated, and paid.The transition to community team-based care requires a reorientation of medical education, particularly for physicians. Reforms can embed medical education within community clinical settings and orient medical graduates to generalist/ primary care specialization. Educational content must evolve beyond clinical knowledge and skills, nurturing additional competencies that are crucial for community-focused care. For example, provider teams need strategicWALKING THE TALKcommunication capacity to dialogue with communities about health needs and communicate the vision of PHC, along with interpersonal and political skills to build relationships with stakeholders that influence community health. These may include government agencies, businesses, religious authorities, community leaders, and others.Frontline strategies to get best results from the PHC workforce include taskshifting, where selected care tasks are delegated to non-physician health workers under physician supervision, optimizing the use of higher-skilled cadres. Evidence shows that CHWs and mid-level cadres can effectively deliver a range of health promotion and basic curative interventions, including management of common childhood illnesses, promotion of antenatal care and breastfeeding, and prevention and treatment for tuberculosis, malaria, and HIV. In countries including Nigeria and South Africa, CHWs have played a notable role in COVID-19 case detection and contact tracing.Key areas for PHC workforce policy also include health worker performanceevaluation and compensation. Primary care teams need quality measurementtools that promote accountable performance by rewarding team membersfor managing complexity, solving problems, and thinking creatively to addresspatients’ unique circumstances. Priorities for outcome and performance16management include patient-centered reporting and metrics.Priority reform 3: financing public-health-enabled PHCFinancing is critical for the transition to high-performing PHC. Significant investments, not just adjustments at the margins, are needed to put PHC at the center of health systems. Each country will identify its own locally relevant PHC policies; define a benefits package; and assess budget implications. Modelling from past studies suggests that most lower income countries will need to substantially raise their government health expenditures to achieve strong PHC. Those investments can be expected to pay substantial dividends—by improving population health and human capital, advancing economic inclusion, and improving countries’ competitiveness.General government revenue is increasingly recognized as the best financing source for PHC. Using it facilitates equitable access to health services and improves financial protection for the population. When it comes to deciding how public resources for health should be spent, best results come from prioritizing investment in the highest-impact health services, within countries’ budget constraints, and ensuring that services reach the whole population. A prioritized health benefits package for primary care, customized to the local burden of disease, community values, and citizen preferences, helps justify allocating resources to PHC and can also facilitate accountability.Traditional fee-for-service payments, line-item budgets, or capitation alone are increasingly seen as poorly aligned with team-based, integrated care models. Many countries have adopted financing innovations to foster team-based care, promote coordination and integration, and improve quality, outcomes, and efficiency. TheseEXECUTIVE SUMMARYemerging models, sometimes called “value-based” payments, shift clinical and financial accountability to providers by adjusting and conditioning reimbursement based on cost, quality, and patient-experience metrics.Given the severe health-financing constraints in many lower-income countries, especially post-COVID, the donor community will have a crucial role in supporting PHC reform in these settings. Rethinking development assistance for health (DAH) can drive the investments and capacity building needed to deliver on the promise of people centered PHC, while also addressing problems of DAH fragmentation. A new era of development assistance will require shifting from investing in specific priority programs towards investing in systems, including the capital investments and recurrent operational costs needed for stronger PHC. Many donors are signaling increased attention to investment in PHC systems and public financial management.Policy recommendationsEach country will have its own road map for PHC reform, reflecting nationalstarting conditions, health and development priorities, and political economy.However, some policy priorities will apply across settings. This report formulatesbroad policy recommendations for governments, then proposes actions for the17global health community, including the World Bank.TEAM-BASED CARE ORGANIZATION+Assess health workforce strengths and gaps, and plan the transition to teambased delivery. Countries can jump-start their PHC team composition and empanelment strategies through a situation assessment and team-based care transition plan.+Leverage information technology on the PHC front lines. Digital tools can foster transparency and accountability in PHC. Countries can score efficiency gains by upskilling data analysis capabilities within local care teams.MULTI-DISCIPLINARY HEALTH WORKFORCE DEVELOPMENT+Launch multidisciplinary medical education reforms. Medical education strategies will build the skills for community-focused, team-based care.+Reform provider compensation to promote rural practice and generalist care. Countries can use evidence-based options to tackle compensation imbalances and redistribute the health workforce.+Expand tiered accreditation systems, tied to reimbursement policy. Governments can engage with the private sector to leverage its workforce and infrastructure for PHC delivery, while improving care quality and affordability. Reimbursement and strategic purchasing policies can incentivize private sector participation in a tiered accreditation system.WALKING THE TALKFINANCING AND RESOURCE MOBILIZATION+Finance PHC through general government expenditure, without user fees. Countries get best results when they finance PHC through general government revenue. PHC services should be free at the point of care.+Implement pro-health taxes. Countries can often boost tax revenue by implementing or increasing pro-health taxes on harmful products, especially tobacco, alcohol, and sugar.+Leverage payment reform to promote team-based care, coordination, and quality. Countries can expand the use of strategic/value-based purchasing to facilitate team-based care models. Patients’ voices should be heard when designing provider payment mechanisms.+Create an accountability framework that links resources to results. Resource mobilization tends to be more successful when accompanied by a strong accountability framework. Transparent measurement of PHC financing, which has been a weak link in many countries, is critical.What the World Bank and its partners will do18The World Bank will use its lending, learning, and leadership to support countries indelivering the promise of reimagined PHC.+Lending: accelerate access to funding for PHC reforms. The World Bank will work with the Global Finance Facility (GFF) and other Global Action Plan (GAP) PHC Accelerator partners to facilitate countries’ access to funds for PHC-oriented system reforms. Advancing PHC assertively in COVID-19 health-system-strengthening operations and the GFF Essential Services Grants will be a “win-win” for countries and the World Bank’s programs.+Learning: mobilize practice-relevant PHC knowledge. Together with analytic and financial partners, the World Bank will strengthen global knowledge hubs for PHC, including the Primary Health Care Performance Initiative (PHCPI), and ensure that they are equipped to achieve even more in the years ahead. World Bank technical assistance to countries will support the integration and operationalization of PHC knowledge in policies and programs.+Leadership: develop country-specific policy options through dialogue. To support national leadership in PHC reform and facilitate a multisectoral whole-of-government approach, the World Bank Health, Nutrition and Population Global Practice, together with other global practices (e.g., Agriculture, Environment, and others) and the Human Capital Project, will establish a dedicated platform for policy dialogue, advice, and technical assistance to Ministries of Health and Ministries of Finance. Dialogue will identify entry points and strengthen relationships for subsequent countrylevel technical collaboration and financial support, building on and further leveraging the GFF country leadership program.EXECUTIVE SUMMARYConclusionsWith COVID-19, policy makers, health professionals, and ordinary citizens in most countries understand that business as usual in health care is no longer an option. Health systems need transformation on the scale of the crisis itself. COVID-19 has created a once-in-a-generation opportunity for sweeping systemic change backed by bold public investment and supported by broad social demand. The health care model that can drive this change is fit-for-purpose primary health care. This model is anchored in the values and lessons of the historical PHC movement. And it is reimagined for a world in which the pandemic has challenged much of what we thought we knew.Nearly half a century after the Alma Ata Conference, hasn’t the world talkedenough about PHC? Clearly not, because PHC’s proven benefits have still notreached hundreds of millions of people who urgently need them. And because,when COVID struck, PHC’s power to protect communities in health emergencieswas not used. We need to keep talking about PHC. But above all we need to walkthe talk—fast. The distinctive strengths of PHC are vital to “build back better” inhealth after the pandemic. Countries that choose the path of ambitious PHCreform will reap powerful rewards: through lower health care costs, more resilientsystems, stronger human capital, increased health literacy, higher economic19productivity, and above all longer, healthier, more satisfying lives for people.WALKING THE TALKChapter 1 Introduction: Primary Health Care:TIME TO 20DELIVERCHAPTER 1: INTRODUCTIONThe world has waited long enough for high-performing primary health care (PHC). It’s time to deliver. More than 40 years ago, health leaders embraced PHC, in an era that marked a turning point in global health. The PHC vision has inspired successive generations, and PHC systems have powered remarkable health gains in many settings.But countries where the needs for PHC are greatest have struggled to “walk the talk.” Even before the COVID-19 crisis, most lower income countries lagged far behind the pace of change needed to achieve their health targets under the Sustainable Development Goals (SDGs), including universal health coverage (UHC) backed by strong primary care. Today, the COVID-19 crisis has stripped away illusions and exposed the consequences of our collective negligence. By unmasking the latent failures of the status quo in health systems, the pandemic has created an opening for transformative change. The distinctive strengths of PHC are vital to “build back better” in health after COVID-19. But for PHC to play this change-leading role, the walk has got to finally match the talk.21An unfinished journeySince the launch of the global primary health care movement with the 1978 Declaration of Alma-Ata, some form of PHC has been implemented in virtually every country. For nearly half a century, well-designed PHC services have demonstrated their capacity to deliver population health gains and improve health equity at manageable cost across a wide range of country contexts. The PHC evidence base has grown steadily stronger.1 Practice-focused global networks have formed, including the Primary Health Care Performance Initiative (PHCPI) and others, to support countries in reaching PHC goals. In 2018, WHO Member States unanimously reaffirmed the foundational importance of PHC in a declaration marking the 40th anniversary of the Alma-Ata conference, and endorsed PHC as the cornerstone of universal health coverage (UHC) and sustainable health systems in the 21st century.2Yet, along with its recognized successes, there is a widely shared sense that PHC has not yet fulfilled its potential.3 While PHC principles are sound, efforts to implement those principles have recurrently fallen short of expectations, particularly but not only in low- and middle-income countries (LMICs). Since the early days of the global movement, countries at all levels of income have struggled to “walk the talk” on PHC.Well before the COVID-19 crisis, the consequences were visible in countries’ health results. Under the Sustainable Development Goals (SDGs), all countries have pledged to achieve UHC by 2030, providing their people with quality essentialWALKING THE TALKhealth services and financial protection from excessive health care expenditures. But, as of 2016, over 3.6 billion people, roughly half of the world’s population, still lacked access to basic health care.4 Financial protection has also lagged, so that people who do obtain health services risk being driven into poverty as a result. Between 2000 and 2010, every year approximately 100 million people were pushed into extreme poverty, and over 800 million people suffered financial catastrophe, from paying for health care out of pocket. These figures saw little improvement over time.5Countries have worked to narrow the gaps, but results are far too slow. At the rates of progress on service coverage and financial protection measured before COVID-19, the UHC goal was already practically beyond reach for the majority of LMICs. Meanwhile, health systems in many higher-income countries have achieved broad service coverage but face shortfalls in the quality of care, chronic health disparities among social groups, and soaring health care costs.Demographic, epidemiological, and socioeconomic trends show that even greaterchallenges lie ahead for health systems. Populations are rising fast in some of thepoorest countries and aging rapidly in higher-income settings. Many countriesface a protracted epidemiologic transition, where stunting coexists with obesity,and surging noncommunicable disease burdens come atop persistent infectious22threats. Rising citizen expectations for health care have followed urbanization andglobalization, even as climate change, economic crises, institutional fragility, andconflict threaten to overwhelm fragile health gains in many countries.The supply side of health care is also in flux, with new pressures and proliferating, often contradictory proposals across all health system domains, including financing, workforce dynamics, health technology, and the organization of care. On the eve of COVID-19, while shortfalls in service coverage and financial protection persisted in many settings, health leaders faced insistent demands to raise care quality and strengthen equity, while simultaneously bringing costs under control and making systems more efficient. Experts argued that PHC was critical for tackling all these challenges, yet many countries’ PHC investments stagnated.The shock of COVID-19COVID-19 has exposed health-system failures in countries around the world. By doing so, it has generated powerful momentum for change. The pandemic exploited multiple weaknesses across health-system platforms in rich and poor countries. Under-resourced surveillance networks failed to promptly detect the spread of the virus in communities, so waves of severe cases seemed to surge out of nowhere, overwhelming hospitals. Shortages of supplies and equipment quickly broke out, sparking bidding wars and leaving health workers without protective gear. System fragmentation hampered the efficient flow of patients, staff, and supplies.CHAPTER 1: INTRODUCTIONAmid these cascading failures, the crisis was exacerbated by specific weaknesses in countries’ PHC platforms—the predictable result of decades of benign neglect and chronic underinvestment in PHC. Few countries had connected PHC providers to tech-enabled event-based or syndromic surveillance systems. Many people in poor and rich countries alike lacked a regular PHC provider who could evaluate, counsel, and quickly refer them to testing or hospital care. Financial barriers in some countries kept many people from seeking early access to testing and care.Hitting PHC networks that were already stretched thin, the pandemic diverted resources and interrupted the delivery of routine essential services, including vaccinations, maternal and child health interventions, and care for infectious diseases other than COVID-19. Low- and middle-income countries bore the brunt of these impacts. Nigeria, for example, saw a 50 percent reduction in outpatient visits, antenatal care services, and immunization.6 Fit-for-purpose PHC networks could have facilitated control of the crisis and substantially reduced its human and economic costs.This report: practical options forstronger PHC23While flaws in health care organization may sometimes be apparent only to specialists, following COVID-19, few citizens of any affected country can be unaware of deep inadequacies in their health systems. This also means that, emerging from the pandemic, countries have an opportunity and a responsibility to undertake ambitious reforms. The time is right for reimagining PHC: not to redefine it abstractly, but to clarify practical steps countries can take to make PHC fit-for-purpose in the 21st century, starting now.The good news is that, even as COVID-19 exploited health-system weaknesses— including underdeveloped PHC—it simultaneously inspired health leaders to think and act beyond established paradigms. Policy makers and citizens recognized anew the life-or-death importance of strong, well-resourced health systems, the heroism of the frontline health workforce, and the value of equitable access to health services in protecting the health of the whole population.As the world emerges from the COVID-19 crisis, health systems will enter a period of critical risk and opportunity. Bold policy choices now can transform health systems for the decades to come, bringing goals like UHC within reach. In many countries, such decisions will enjoy unprecedented support from citizens. However, the deepening economic crisis is already putting pressure on health and social service budgets across the globe. Before austerity overwhelms ambition, there will be a brief window of opportunity to seize the momentum and launch the farreaching reforms that are needed to fix underlying systemic problems, not just treat superficial symptoms. Health leaders need to be prepared to act before that window closes.WALKING THE TALKThis report looks to the past months of worldwide upheaval—added to 40 years of global PHC experience—to chart an agenda toward fit-for-purpose primary health care. It reflects a renewed understanding of global and local vulnerabilities in the post-COVID-19 world. It affirms the unique promise of PHC, while analyzing deficiencies in PHC design, delivery, and financing that have reduced performance. And it seeks to harness the current global momentum with a practical reform agenda that takes existing constraints seriously and moves beyond business as usual.This report pursues four objectives: (1) contribute evidence to the growing consensus on PHC as the cornerstone of high-performing health systems, while also showing why PHC must evolve; (2) identify structural shifts most PHC systems need to undertake to further improve outcomes and efficiency; (3) propose proven reform steps and implementation strategies that countries can use to drive shifts in care organization, the health workforce, and health financing; and (4) show how countries can optimize domestic and external technical and financial resources to “walk the talk” on reimagined PHC.AudiencesThe report is addressed primarily to governments, in particular policy makers andtechnical advisers in ministries of finance and ministries of health. Since PHC is most24effective when supported by a whole-of-government approach to policy making,the report also aims to engage leaders in other government departments, clarifyinghow the recommended actions can advance some of those sectors’ priority agendas.The report’s recommendations prioritize options that are realistic for most low- andlower-middle-income countries. Adapted versions of these approaches are likely toyield solid results in many wealthier countries, as well.A second audience is the private sector, both for-profit and not-for-profit, who are on the front lines of providing essential health services in many countries. The aim is to persuade them that this approach to PHC has value for their work, too, and to engage discussion on how they can align their efforts with that of public-sector agencies that are responsible to implement the reforms.The report also addresses a wide range of development partners, especially Global Action Plan (GAP) collaborators, who are committed to accelerate progress towards the achievement of health-related SDG goal and targets, but also the wider community of bilateral and multilateral agencies, foundations, and civil society organizations engaged in global health and development. The approach to PHC described here is informed by the technical work and leadership of many of these agencies, and this report is an invitation to deeper collaboration.Finally, the report aims to advance collaboration on PHC within the World Bank Group itself. This includes promoting wider understanding of PHC as an effective platform to build and protect human capital within a multisectoral architecture, including One Health, as outlined in the Bank’s Health, Nutrition and Population Strategy Refresh (2020).7 The report lays out the case for raising the profile of PHC in World Bank lending. The lending, learning, and leadership that the World Bank Group brings can substantially benefit countries advancing on the change pathsCHAPTER 1: INTRODUCTIONdescribed here. The best results will come through broad collaborative alliances, as part of which the World Bank has long experience, including PHCPI, the Joint Learning Initiative for Universal Health Coverage (JLN), and others.Looking back at the history of PHC is humbling. Visionary health leaders, innovative practitioners, and exceptional scholars have built the PHC literature and legacy over the past half century. Recently, leading institutions and new generations of researchers have offered compelling proposals on how PHC can evolve to meet today’s health challenges. Against this background, the contributions of this report are necessarily modest. But, building on frontline country experience and previous research, it organizes actionable evidence so that policy makers and implementers may use it practically to plan, fund, and implement PHC reforms.Data sources and policy timeframeThis report draws on the peer-reviewed and gray literature, as well as data sources from the World Bank, OECD, WHO, other specialized UN agencies, and the Institute for Health Metrics and Evaluation (IHME).The report addresses a historical context in which policy makers and health-sector partners are grappling with the consequences of COVID-19. It offers25specific recommendations for leveraging the distinctive capabilities of high-performing PHC in this context of urgent action. The report’s technical and policyrecommendations also look beyond crisis response and early-stage recovery toconsider a longer timeframe appropriate for structural change in PHC systems.The report discusses actions and outcomes through 2030, the target year for theSustainable Development Goals, including countries’ pledge to achieve UHC.LimitationsIt is important to acknowledge this report’s limitations. One fundamental point concerns the availability of evidence and its applicability across different contexts. In general, relatively few studies compare different organizational and financing modalities of PHC systems in countries while controlling for other factors that may influence the outcomes of interest, such as political economy, features of the health workforce, and others. The report’s core arguments apply to countries at all levels of income, but its main concern is to suggest how low- and middle-income countries can improve their health systems through fit-for-purpose PHC. Historically, a large share of PHC research has taken place in high-income countries. Thus, the report cites considerable evidence on PHC challenges and solutions from higher-income settings, while recognizing the transposition challenges involved in applying these findings elsewhere. Wherever possible, the report draws on the growing body of PHC evidence directly derived from low- and middle-income settings. Over recent years, PHC research in LMICs has gained remarkable momentum. Networks including the JLN, PHCPI, and others support high-quality research and have created repositories of evidence for investigators and practitioners. Supporting these networks to further develop the PHC learning agenda in lower-income settings is an important commitment for the World Bank.WALKING THE TALKChapter 2 of the report discusses global megatrends that are coming to bear on health systems today, posing challenges for performance and sustainability. The range of forces in this category is large, and only a few can be analyzed here. We have focused on trends—including shifts in the age distribution of human populations, mobility, urbanization, and rising noncommunicable disease burdens—that will affect all countries, though in different ways, and where the link to practical choices facing health policy makers is relatively clear. We have chosen not to focus in detail on other important topics, notably climate change, that will also strongly impact health systems in the coming decades, but where implications for PHC policy and practice are currently less clear. Working cross-sectorally with countries and partners to better anticipate climate impacts on health and support climate-robust PHC is a key task for the future.The conceptual architecture of this report involves identifying four high-levelchange goals for stronger PHC and charting three priority reform axes thatcountries can use to reach those goals (Table 1, page 74). Both the changegoals and directions for reform have been defined based on literature reviews;analysis of existing PHC performance assessment tools and change frameworks;documented country experiences; and expert consultation. Readers will recognizebroad alignment between the conceptual architecture developed here andexisting, widely cited frameworks for understanding and improving PHC. However,26it is important to be explicit on two points. First, while this report’s agenda forfit-for-purpose PHC builds on and benefits from previous frameworks, research,and country experience, the fit-for-purpose PHC program is a new framingand therefore subject to caution. It is derived from ongoing original work, suchthat responsibility for its shortcomings rests entirely with the report team, notwith our sources. Second, the construction of the fit-for-purpose PHC agendais based on a primarily qualitative approach to prior frameworks and evidence.In foregrounding the promise of team-based PHC service delivery models, forexample, we have not attempted to generate original quantitative estimates of thebenefits that such models could produce in terms of population health indicatorsand health-system cost savings in specific settings. This is another importantfrontier for future learning.What does PHC mean in this report?Historically, defining PHC has been a difficult and often divisive problem. This report adopts the current definition of PHC formulated by WHO. In addition, the report formulates its own definition of fit-for-purpose primary health care (Panel 1). This definition reflects long-term aspirations in the spirit of the Declarations of Alma-Ata and Astana, but also identifies practical priorities for PHC reform today.CHAPTER 1: INTRODUCTIONPanel 1. Defining primary health careWHO definitionThe current WHO definition of primary health care provides the foundation and clearest expression of the concept of PHC used in this report. The WHO definition has three interrelated components which, taken together, cover all aspects of PHC. Under this definition, primary health care:+Meet[s] people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services;+Systematically address[es] the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviors) through evidence-informed public policies and actions across all sectors; and+Empower[s] individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as27co-developers of health and social services, and as self-carers and care-giversto others.8What PHC is notRelated to WHO’s positive PHC definition are certain negative stipulations, that is, things that PHC is not. Over the last half-century, and into the present, primary health care has often been presented as synonymous with other healthservice models that actually differ in crucial ways from PHC as defined by WHO. This conflation of dissimilar concepts—sometimes unintentional, sometimes deliberate—has often had negative consequences both for PHC’s credibility and for the health and lives of people receiving health services labeled as primary health care.+ +PHC does not mean basic or rudimentary health care.Primary health care does not equal gate keeping. The latter is often understood solely from the supply perspective, with a view to efficiency. The objective of providing appropriate care at the right level is eclipsed. As a result, patients and communities may tend to perceive gate keeping (and PHC itself) as a hurdle to clear in order to access specialized care.+PHC is not equivalent to “primary care” or “comprehensive primary care,” since these two terms in their most common usage do not cover the second and third components of the WHO definition cited above. “Primary care” and “comprehensive primary care” as commonly understood do not fullyWALKING THE TALKencompass promotive, protective, rehabilitative, and palliative care throughout the life course. They mostly focus on curative medical care, even if this is sometimes broadly defined.9+Integrating primary care and public health to improve population health is not a supplementary enhancement of PHC. It is already part and parcel of PHC, properly understood.10+Primary health care does not mean first-contact care, nor the first level of care in the health system. First-contact care could be emergency medical services. Historically, equating PHC with the first level of care has led to its being understood as low-quality health care, mainly for the poor. PHC should also not be seen as focusing only on “first causes” of community health problems (structural social and economic determinants). While PHC recognizes the importance of health determinants and may support action to address them through multisectoral initiatives, PHC’s concern with underlying health determinants does not downplay the importance of quality personal healthcare services for those who need them.11+ “Selective PHC,” a concept introduced shortly after the 1978 Alma-Ata Conference and widely applied subsequently, is not PHC. It distorts theconcept of PHC by focusing on selected diseases rather than the whole person28and the full spectrum of services from promotive to palliative.12Defining what PHC is and is not has implications for the connection between PHC and universal health coverage (UHC). This report understands PHC as the main vehicle for the realization of UHC. Some authors note that the universal inclusivity highlighted in the term UHC was anticipated in the PHC vision expressed at AlmaAta. From its inception, PHC was understood to involve equitable access to health services.13 This was reflected in the PHC goal of Health for All and the commitment to put people at the center of health systems.14Reimagining PHCIn addition to the WHO definition of primary health care, this report formulates a concept of “fit-for-purpose” in order to reimagine PHC. The term fit-for-purpose characterizes the PHC systems that countries establish progressively as they implement the reforms outlined in this report. Improving health outcomes and making health systems more efficient, equitable, and resilient can be understood as PHC’s “purpose.” PHC platforms are “fit” to the extent that they achieve this purpose.The definition of fit-for-purpose PHC is derived from the broader WHO definition and emphasizes a select set of attributes that appear particularly important for PHC in today’s health-system environments. We define fit-for-purpose PHC as:+A health- and social-service delivery platform uniquely designed to meet communities’ health and health care needs across a comprehensive spectrum of services – including health services from promotive to palliative – in a continuous, integrated, and people-centered manner. Services provided byCHAPTER 1: INTRODUCTIONthis platform are tailored to the socio-economic and cultural ecology to which communities belong, as well as to the financial and human resources of the health system within which the platform operates resiliently and sustainably. The platform ensures equitable access to quality health care and other services throughout people’s life course, advancing universal health coverage and contributing to sustainable development.The main use of this definition is to highlight specific structural features and processes that are integral to countries’ success in the reform agendas described in the report, and to underscore the interdependence among some of these features. The term platform evokes a set of interlinked services and the delivery architecture required to provide them, including health-worker teams, the networks and resources that support them, and the infrastructure health workers use to deliver care to communities.Structure of the reportThe remainder of this report proceeds as follows. The report asks “Why?”, “What?”and “How?” questions about PHC-driven health-system reform. Chapter 2shows why these reforms are urgent now. It analyzes trends in demographics,29epidemiology, technology, and citizens’ expectations for health care that posedaunting challenges for health systems today—challenges to which systemsbuilt around strong PHC will be best able to respond. Chapter 3 describes whatPHC reforms aim to achieve. It identifies four systemic shifts that characterizefit-for-purpose PHC: boosting service quality while expanding coverage;achieving greater integration of patient-centered care; enhancing fairness andaccountability in PHC; and preparing PHC networks to tackle emergencies withresilience. Chapter 4 summarizes evidence on how countries can deliver theseshifts. It describes three priority reform agendas: developing a multidisciplinary,team-based PHC platform; building a multi-professional health workforce; andcreating PHC financing solutions that can bring public-health crisis responsecapabilities to the front lines, while strengthening routine PHC services. Finally,Chapter 5 offers recommendations for countries and development partners todeliver PHC reforms and strengthen health-system performance in the post-COVID world. It also explains how the World Bank is changing its work to supportcountries as they walk the talk on PHC.WALKING THE TALKChapter 230 CHALLENGES FOR HEALTH SYSTEMSCOVID-19 and BeyondCHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSThe COVID-19 pandemic found health systems in most countries unprepared for a health threat that was widely predicted to be imminent: a newly emerging, deadly infectious disease capable of rapid global spread.15 This preparedness lapse alone would justify far-reaching healthsystem reforms. In the wake of a staggering public-health disaster about which the world was warned well in advance and whose worst effects could have been prevented, previous ways of organizing, delivering, and paying for health services need to change.But better preparedness for public-health emergencies is only part of what healthpolicy must now aim to achieve. The rationale, the “Why?” of health-systemreform, is more complex, because the challenges that health systems face extendfar beyond the threat of future infectious outbreaks. To better understand therationale for ambitious health-system reform now, we need a broader sense of thekey forces that will influence population health needs and health-system responseoptions in the coming years. To provide a portion of this background, this chapter31asks two questions: (1) What are the forces that are likely to shape the evolution ofcountries’ health ecosystems in the coming decade? (2) Are current health-servicedelivery and financing models ready to manage those forces? The chapter doesnot try to answer these broad questions comprehensively across all levels of carebut focuses on selected aspects that are especially relevant to the discussion ofhealth-system reform led by PHC.Health-system ecologies: trends for the coming decadeHealth systems reflect countries’ unique history and context. Today, however, health ecosystems worldwide are affected by a set of powerful trends that increasingly shape population health, the demands placed on health services, and the resources that policy makers have available to respond to health needs. This chapter focuses on three sets of trends: high-level demographic and epidemiological patterns, developments in technology, and citizens’ evolving expectations for health services.Before turning to those topics, it is important to acknowledge again the extent to which countries’ choices about PHC reform will continue to be influenced by the fallout of COVID-19 and how leaders frame and manage the crisis politically. The pandemic has hit most countries with a double shock: a public-health disaster rapidly overlaid by a brutal economic contraction that has spared few economiesWALKING THE TALKworldwide.16 More than a year into the pandemic, many hope that it will soon be brought under control, thanks in particular to the rapid development of vaccines. However, COVID-19’s epidemiological trajectory is uncertain, and its economic impact threatens to be long-lasting.17 Access to vaccines for most people in lowand lower-middle-income countries remains a distant hope.The pandemic’s implications for health financing are complex. Following the substantial government outlays required for the emergency response, countries face crucial decisions on health spending in the years ahead. Pressures to rapidly rein in public-sector health spending, along with other components of government expenditure, are already being felt. However, a compelling case can be made that countries that seize the crisis as an opportunity to invest in health—including but not limited to outbreak preparedness—will reap rewards, saving many lives and ultimately achieving a stronger economic recovery.18Figure 1. Policy choices will be critical for health goals and economic recoveryPerformance score of the UHC Effective Coverage Index2030 targetGlobal averageBetter scenario32Reference scenarioWorst scenario1002019 10090628070696063 6050403020100 19902000201020202030Source: Gates Foundation. 2020 Goalkeepers Report. https://ww2.gatesfoundation.org/goalkeepers/ downloads/2020-report/report_letter_en.pdfDemographic and epidemiological trendsToday, few would question that health systems in most countries need to prepare better for emergencies and unforeseen events. But in the decades ahead many of the greatest pressures on health systems will continue to come from causes that are not unexpected. On the contrary, they are well known, persistent, and evolving in largely predictable ways. These include secular trends in the size, composition, and distribution of human populations, together with long-observed shifts in the burden of disease, the recurrent emergence and recrudescence of diseasesCHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSof zoonotic origin, and the threats of “global public bads” such as antimicrobial resistance,19 environmental degradation,20 and climate change.21 These and related “public bads” will contribute appreciably to disease burdens, while complicating health service delivery in the large majority of countries.Population dynamics: rapid growth in poorer regions, rapid greying among the richThe global population will continue to increase in the decades ahead, raising the pressure on health systems that are already overstretched. Since the Declaration of Alma-Ata, the global population has almost doubled, from about 4.2 billion in 1978 to 7.6 billion in 2018.22 The world’s population is projected to increase further, to 8.5 billion by 2030 and 9.7 billion by 2050, adding an estimated 83 million people each year.23 Population growth rates differ sharply across regions, with the fastest rates in Sub-Saharan Africa, South Asia, Latin America and the Caribbean, and North Africa and the Middle East.24The bulk of the global population growth is projected to take place in LMICs,concentrating in the poorest countries across the globe. Populations of manySub-Saharan countries are expected to double by 2050. Eight of the nine countriesthat will account for more than half of global population growth in this period areLMICs (India, Nigeria, Pakistan, Democratic Republic of Congo, Ethiopia, Tanzania,33Indonesia, Egypt). Meanwhile, many high-income countries are projected toexperience modest growth or a decline in their populations.25Populations in many high-income countries (HICs) are growing older. Since the early 2000s, high-income countries have seen drops in the proportion of workingage population, with the fall expected to continue: from 66.2% in 2015 to 58.3% in 2050. This trend coincides with an increase in the proportion of the population at and above the age of 65 (Figures 2 and 3). The share of the elderly in the total population will expand from 16.7% to 26.9% over the same period.26 In contrast to high-income countries, most LMICs are expected to see an increase in the proportion of working-age population in the years ahead. For instance, the working-age population share in low-income countries is estimated to have risen from 54.1% in 2005 to 62.7% in 2015, while the share of the population 65 years of age or older likely grew modestly, from 3.2% to 5.4%. Recent work highlights that half the growth in working-age populations from 2020 to 2050 will occur in SubSaharan Africa.27 On the other hand, while the proportion of older adults in LMIC populations will continue to grow modestly, the absolute numbers of people in this age category will expand substantially, placing important additional demands on health systems that must meet the complex care needs of large numbers of seniors. This trend is already marked in some though not all lower-income countries.WALKING THE TALKFigure 2. Percentage of working age population (15-64 years of age) by income group and geographic location, 1950-21007070(% of working age population)606050 19502000LMICs UICs20505021001950200020502100UMICs LICsAfrica Europe North AmericaAsia Latin America Oceania34Notes: Data extracted from the World Population Prospects 2019 website curated by the United Nations, Department of Economic and Social Affairs, Population Division (2019). LMICs = Lower-middle incomecountries, UMICs = Upper-middle-income countries, HICs = High-income countries, and LICs = Low-incomecountries.Figure 3. Percentage of population 65+ years of age by income group and geographic location, 1950-21003030(% of population 65+ years of age)202010100 195020002050021001950200020502100LMICs UICsUMICs LICsAfrica Europe North AmericaAsia Latin America OceaniaNotes: Data extracted from the World Population Prospects 2019 website curated by the United Nations, Department of Economic and Social Affairs, Population Division (2019). LMICs = Lower-middle income countries, UMICs = Upper-middle-income countries, HICs = High-income countries, and LICs = Low-income countries.CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSThe upshot of these population trends is concerning for health leaders everywhere. High-income countries face exploding health care costs linked to the care needs of aging populations, even as these countries’ working-age population shrinks— exactly the demographic whose contributions would have been expected to finance the rising use of complex medical services among the aged. Under these conditions, health systems face powerful pressures to boost efficiency and rein in costs. The proven capacity of strong PHC to contain costs offers a crucial advantage. High-performing PHC has been regularly found to reduce unnecessary hospitalizations and costly emergency room visits, offering cheaper and better management of high-prevalence chronic conditions (for example, diabetes, asthma, hypertension, and congestive heart failure) in community settings at unit costs far below those that apply in higher-level health facilities.28 The health promotion and disease prevention facets of PHC offer a powerful means to lower longer-term treatment costs and ensure the future solvency of systems.Meanwhile, health systems in LMICs have an even more pressing need to make surethat limited health resources are used efficiently. The promotion and preventionlogic applies still more strongly in these contexts. So, increasingly, does theimperative to manage chronic conditions in community settings where costs aremuch lower. This argument gains strength as the absolute numbers of older citizensrise, together with the prevalence of multi-morbidities and “lifestyle” diseases(obesity, diabetes) once seen largely in rich countries. In LMICs with rapidly35growing younger populations, another key advantage of PHC is its capacity toefficiently deliver key maternal and child health services, along with promotive,preventative, and curative services that can boost the productivity of working-agepopulations (for example, nutritional supplementation, malaria prevention andtreatment, treatment of minor injuries, routine monitoring of vision and hearing).Such PHC services are critical to build and protect the human capital embodiedin LMICs’ young people and working adults—the cornerstone of these countries’economic future.Longer, healthier lives—but not for allGlobal average life expectancy at birth rose from 65.4 years in 1990 to 72.6 years in 2018. However, low-income countries lag more than a decade behind the global average, though the gap narrowed from 14.7 to 11.8 years during this period.29 This persistent gap in life expectancy is driven by factors including high rates of maternal and child mortality, the ongoing impact of the HIV pandemic, proliferating conflict and violence, and inadequate access to quality health care services.30Healthy life expectancy (HALE) is a summary measure that combines changes in mortality and non-fatal health outcomes.31 As such, HALE may provide a clearer snapshot of overall population health than life expectancy per se. Global average HALE at birth increased from 58.5 years in 2000 to 63.3 in 2016 (WHO 2020). While this is a welcome trend, in 2016, the difference between life expectancy and HALE at birth was some 9 years, a stark reminder that many people will spend aWALKING THE TALKsubstantial portion of their later lives afflicted by chronic illness, which in many cases could have been prevented (Figure 4). Wide disparities in HALE persist across countries at different income levels. In 2000, the average HALE in lowincome countries was about 12.6 years below the global average. While this gap narrowed to about 9 years by 2016, the contrast with wealthy countries remains striking. The average HALE in high-income countries exceeds the global average by almost 7 years. In this context, the proven capacity of high-performing PHC to narrow health equity gaps within and between countries takes on increased salience.32 Multiple systematic reviews confirm the evidence base that associates strong PHC with lower health inequalities.33Figure 4. Living longer, living sicker: years lived in poor health, 1990 and 201915.0 12.5GBD super-regionCentral Europe, eastern Europe, and central Asia High income Latin America and Caribbean North Africa and Middle East South Asia Southeast Asia, east Asia, and Oceania Sub-Saharan AfricaYears lived in poor health, 201910.0367.55.0NicaraguaPhilippines Tajikistan Uzbekistan Zimbabwe Lesotho005.07.510.0Years lived in poor health, 199012.515.0Notes: The scatter plot shows years lived in poor health, calculated by subtracting HALE from life expectancy at birth, for 1990 and 2019. Datapoints are coloured by GBD super-region. GBD=Global Burden of Diseases, Injuries, and Risk Factor Study. HALE=healthy life expectancy. Source: GBD 2019 Demographics Collaborators (2020). Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019”. Lancet (London, England), 396(10258), 1160–1203. https://doi.org/10.1016/S0140-6736(20)30977-6The changing burden of disease calls for reinforced PHC and action across sectorsThe wide lag between HALE and overall life expectancy in all countries points to inadequate prevention and management of chronic diseases all along the country income spectrum. The global burden of noncommunicable diseases (NCDs) is rising steadily. The trend is particularly marked in LMICs, but all countries are affected (Figure 5). This spells unprecedented challenges for health systems, many of which are already struggling to meet surging demand for NCD services while containing costs. The total number of deaths attributable to NCDs increased by 22.7% worldwide between 2007 and 2017. In 2017, NCDs accounted for 73.4% of all deaths, compared to 18.6% from communicable diseases and maternal,CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSneonatal, and nutritional causes, and 8% due to injuries.34 One recent study found that the absolute number of NCD deaths that could be averted with quality and timely provision of health care services increased by 49.3%, reaching 34.5 million in 2017.35 These averages mask substantial variation across countries and regions. About 40% of premature mortality due to avertable NCDs in 2017 was clustered in Southeast Asia, the Eastern Mediterranean, and Sub-Saharan Africa.36 Feasible, cost-effective means exist to tackle this soaring burden of preventable suffering and death. The solution backed by the strongest evidence is reinforcing PHC networks to cover the whole population with the services required for prevention, early detection, and low-cost, high-quality community management of chronic NCDs, as some countries at all income levels have already found.37Despite gains during the MDG period, preventable diseases remain a majordriver of mortality and morbidity in developing countries. Between 2000 and2017, the proportion of global population with at least basic drinking waterservices increased from 82% to 90%. This trend was coupled with a rise in accessto basic sanitation services from 56% to 74% of the population.38 Despite theseimprovements, globally, 12.6 million deaths – corresponding to 23% of all deaths-- are attributable to environmental risk factors modifiable by multisectoral policiessuch as investment in water and sanitation services. Children under 5 years ofage are particularly vulnerable, with mortality due to environmental risk factorsconstituting 28% of global deaths for this age group.37Figure 5. Noncommunicable diseases will test already-fragile health systemsProjected change from 2015 to 2040 in percentage of disease burden due to noncommunicable diseases (NCDs), by score on the health system capacity indexChange in share of disease burden due to NCDs35%30% 25% 20% 15%Rwanda BotswanaEthiopia TanzaniaTurkmenistanZambia IndiaBangladesh HaitiSouth AfricaIndonesia MaliNigeria10%Kazakhstan BrazilUnited Russia5% StatesChina ChileCentral Europe, eastern Europe, and central AsiaHigh income countriesLatin America and CaribbeanNorth Africa and Middle EastSouth AsiaSoutheast Asia, east Asia, and OceaniaSub-Saharan Africa19,410 15,000 10,000 5,000 138Size of noncommunicable disease health burden in 2040 measured in disability-adjusted life-years0%050100150200Score on health system capacity indexSource: Lower-Income Countries That Face The Most Rapid Shift In Noncommunicable Disease Burden Are Also The Least Prepared,” by Bollyky, T. J., Templin, T., Cohen, M., & Dieleman, J. L., 2017, Health affairs (Project Hope), 36(11), 1866–1875. https://doi.org/10.1377/hlthaff.2017.0708For children, environmental factors contribute to the burden of infectious and parasitic diseases, neonatal and nutritional disorders, and injuries, whereas for older adults, environmental risk factors primarily exacerbate the NCD burden.39 The importance of hygiene practices and access to clean water and sanitationWALKING THE TALKhas again been highlighted by the COVID-19 pandemic. Simple public-health measures, like hand hygiene, have become an integral part of efforts to curb the spread of COVID-19. However, in communities without reliable access to clean water, such measures cannot be consistently implemented.The persistently high burden of preventable diseases highlights other opportunitiesfor intersectoral action in areas critical for countries’ human capital and economicdevelopment. For instance, over the last three decades, many countries madeimportant strides in improving the food security for young children.40 Thepercentage of stunted children under 5 years of age stood at 21.3% in 2019,down from 39.3% in 1990. Yet important gaps in child nutrition persist. As of2019, globally, an estimated 149 million children under 5 were stunted, 49.5million suffered from wasting, and 40 million were overweight.41 Rigorousevidence is mounting on the close links between health outcomes and a range ofsocioeconomic and environmental determinants, including housing security,42,43access to water, sanitation, and hygiene,44 and vector control.45 Intersectoral actionon health determinants has historically proven to be among the most difficultcomponents of the classic PHC agenda for countries to implement and measure.However, a growing body of recent evidence suggests that the continuous,comprehensive care provided by well-trained, multi-disciplinary PHC teams canbe an effective way to tackle risk factors and other social determinants of health,38which in turn improves equity of health outcomes.46Urbanization brings new challenges for health service deliveryThe global population has urbanized rapidly since the launch of the global PHC movement in the late 1970s. The proportion of the global population residing in urban areas is estimated to have increased from 39.3% in 1980 to 56.2% in 2020.47 By 2050, some 70% of the global population will live in cities (Figure 6).48 The degree of urbanization varies between countries across the development spectrum and across geographic regions. As of 2020, about 8 out of 10 people in highincome countries live in urban centers, compared with almost 6 out of 10 in middleincome countries. This contrasts with low-income countries, where only about 3 out of 10 people reside in cities. In North America, the world’s most urbanized region, approximately 82.6% of the population live in urban centers, compared to 81.2% in Latin America and the Caribbean and 74.9% in Europe. On the other hand, many countries in Africa remain mostly rural, with only about 41.1% of the region’s population residing in urban areas.49CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSFigure 6. Urban populations continue to surgeUrban and rural population projected to 2050, WorldTotal urban and rural population, given as estimates to 2016, and UN projection to 2050. Projections are based on UN World Urbanization Prospects and its median fertility scenario.8 billion6 billionUrban4 billion2 billionRural0 15001600170018001900Source: OWID based on UN World Urbanization Prospects 2018 and historical sources2000 2050Rapid urbanization poses major challenges for traditional models of healthcare delivery, especially in slums. In 2014, almost 30% of urban populationslived in slums.50 People living in slum areas face multiple health threats relatedto socioeconomic and environmental factors including housing insecurity,39overcrowding, and absent or insufficient access to clean water, sanitation, andother essential services. Slum conditions pose new organizational and logisticchallenges for PHC systems. Meanwhile, slum populations face disproportionaterisks for some childhood diseases and greater prevalence of water-borne diseases(e.g., cholera and typhoid), among others health problems.51Migration and forced displacement increase people’s vulnerability and make them harder to reach with servicesMigration has become a crucial element of global population trends. The number of international migrants has increased substantially in the last decade, from about 221 million in 2010 to 272 million people in 2019.52 This trend suggests that the pace of international migration exceeded the growth in population globally during this period. The international migrant population is comprised predominantly of younger people, with children and adolescents under 20 years of age and working age individuals between ages 20 and 64 years representing 14% and 74% of all international migrants, respectively. Emerging evidence suggests that the major drivers of global migration trends are the rising demand for migrant workers on the one hand and violence, insecurity, and armed conflict on the other.53 In 2019, one-third of all international migrants were from 10 LMICs, including India, Mexico, China, Russia and Syria. Whereas just 20 countries, primarily high-income, hosted two-thirds of all international migrants.WALKING THE TALKIn the last decade, the world has seen an unprecedented surge in the number of people who have been forcibly displaced from their homes. Rising conflict and violence across the globe displaced 79.5 million people during this period. Of those who are forcibly displaced, 26 million are estimated to be refugees. In 2018, 9 of the top 10 countries together hosting approximately 57.5% of all refugees were LMICs.54 These included Turkey, which hosts more than 14% of all refugees in the world, Colombia, and Pakistan. It is estimated that 45.7 million people are internally displaced within their own countries, including in Syria, Colombia, Democratic Republic of Congo, and Yemen. Forcibly displaced populations tend to be younger, with children and adolescents under 18 years of age representing 40% of this population, and often live in hard-to-reach areas that pose additional organizational and logistical challenges for health care services.55 Forced population displacement due to climate change is expected to accelerate internal and international migration in the years ahead.56New technologies can connect people—but only if they are widely accessibleBy many measures, the world is becoming increasingly connected. Yet the digitaldivide between under-connected and highly digitalized countries threatens to40deepen existing inequities. In the world’s least-developed countries, only 20% ofpeople are online, compared to about 80% in developed countries. Exacerbatingcross-country variation in digital connectivity, disparities exist within countriesbased on gender, income, geographic location, and level of education. Forinstance, on average, only about 63% of rural households in the least developedcountries have access to a mobile phone, compared to 89% of urban households.Similar connectivity gaps exist between genders. Globally, the share of womenwith online access is 12% lower than for men, with this gap reaching 30% in theleast developed countries.57,58Disparities in digital connectivity has become all the more important during the COVID-19 pandemic where the traditional face-to-face rendition of PHC services became problematic. Cognizant of the fact that access to a smart phone alone would not be of much help, many countries have been able to rapidly deploy digital solutions in the form of telekiosk, telemedicine, telehealth or telecare to continue providing much needed PHC services to their citizens.Rising expectations for health care— and lagging performanceIn many countries, people now expect more from their health systems. Greater access to information has reinforced this pattern, along with some people’s new experiences in seeking care in urban settings. Even if over-burdened, urban health care networks tend to be more physically accessible, better staffed, and better equipped, compared to rural settings. Rapid urbanization has also meant expanded job opportunities for many citizens, raising incomes and, in turn, tax contributions. As these trends continue, there will be greater expectations for highquality public services, as well as demand for better governance, transparency, and control of corruption.CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSIn some settings, the COVID-19 pandemic may have accelerated these shifts, prompting citizens to look to their governments for reliable information, publichealth guidance, and crisis leadership. Moving forward, citizens’ expectations for high-quality health care will continue to rise. Yet confidence in health systems in many LMICs remains low. A recent study showed that only about 42.4% of people in 28 Sub-Saharan African countries were satisfied with the availability of highquality health care in their areas of residence.59 A survey spanning countries in Latin America found generally low confidence in PHC systems, though with substantial variation across countries. For instance, in Brazil, 32.1% of survey participants reported having confidence that they will receive effective treatment, including medications and diagnostic tests, compared to 54.9% in Colombia and 73.4% in Mexico.60Trends in health care delivery and financingAs the global megatrends just described impact health systems, core system components are necessarily changing. As the pressures on systems intensify, change will accelerate—for better or worse.Prior to COVID-19, many countries had registered progress in the two key domains41of universal health coverage: coverage with quality essential health servicesand financial protection from excessive health care costs. But even before thepandemic struck, gains had not been sufficient to keep most LMICs on track toachieve UHC and other SDG health targets by 2030 (Figure 7).61Figure 7. Service coverage and financial protection worldwide: slow progress even before COVID-19Service coverage index (SDG 3.8.1, 2015)90Quadrant I8070 Average60504030 200LowQuadrant IVAverage5101520Incidence of catastrophic spending [SDG 3.8.2 – 10% threshold, latest year]Lower middleUpper middleHighQuadrant IIQuadrant III2530Source: Primary Health Care on the Road to Universal Health Coverage: 2019 Global Monitoring Report Conference Edition,” by World Health Organization, 2019, retrieved from https://www.who.int/healthinfo/ universal _ health _ coverage/repor t/uhc _ repor t_ 2019.pdf ?ua=1WALKING THE TALKOn the service delivery front, traditional models of health care organization have helped reduce but not eliminate important gaps in access, utilization, and quality of health care services in countries across the development continuum. Substantial gains have been achieved in ensuring access to essential health care services since 2000.62 Yet this progress slowed after 2010. It is estimated that in 2017 only 33%-49% of the global population had access to the essential health care services that they needed. Health service coverage is especially low among vulnerable population groups, including poor women and women residing in rural areas. Current projections suggest that, if the pace of expanding service coverage does not pick up markedly, only between 39% and 63% of the global population will have access to essential health services by 2030, far below the UHC target. Moreover, these projections do not reflect the impact of COVID-19. Facing this stark shortfall, many countries urgently need to rethink the traditional organization of health care.63Before the pandemic, results in financial protection were also mixed.64 Out-of-pocket spending, the most inequitable and inefficient form of health financing,continues to dominate health financing in LMICs. Recent evidence shows thatfinancial protection against debilitating health care costs worsened between 2000and 2015. Globally, the number of people with out-of-pocket health expendituresexceeding 10% of their household income increased by 3.6% during this period,42reaching 927 million in 2015. Similarly, the number of people who spent more than25% of their household income on health was estimated at around 210 million.65 Acloser look at the data reveals that progress towards providing better financialprotection differed across the development continuum. For instance, between2000 and 2015, the sharpest increase in out-of-pocket expenditures occurredamong upper-middle-income countries. In contrast, low-income countriesstarted out in 2000 with the highest numbers of people spending 10% or 25%of their household budgets on health services, but subsequently saw declines inthis indicator. Importantly, these declines could stem from a variety of causes,including better coverage of basic health services, but also foregone health carebecause of people’s inability or unwillingness to pay.An important driver of rising out-of-pocket expenditures relates to the ways in which health care services are produced. Mounting evidence shows that, in many health systems, patients often do not receive the right type of health care service. Low-value care has been found across the care continuum, including over-testing, unnecessary surgical interventions (e.g., unnecessary caesarean sections), and imprudent use of antibiotics. Many health systems miss opportunities to reduce costs, for example by using lower-cost inputs (e.g., generic drugs) that would provide the same benefits to patients as expensive options.In many countries, hospital resources are being used for conditions that could be prevented by timely access to quality PHC services. For instance, recent studies estimate that the inappropriate use of emergency department resources costs the United States approximately US$38 billion annually. Combined, this evidence demonstrates that it is paramount to move towards new ways of organizing care, so that patients get more health for their money rather than spending more money for health.CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSImplications for primary health careVast challenges face health systems in the 21st century. COVID-19 has exacerbated many of those challenges and exposed underlying weaknesses in health systems in countries at all levels of income. In the years ahead, as known threats intensify, others will emerge in domains not yet foreseen.PHC systems offer proven tools to tackle existing challenges, and the flexibility and creativity to confront new threats. The evidence base on PHC’s contributions to population health has grown significantly since Alma-Ata. A substantial body of research from across the development spectrum shows the benefits of strong PHC systems for health outcomes,66 efficiency in service delivery,67 and quality of care.68 In many settings, comprehensive PHC approaches have been crucial to narrowing health disparities.69 PHC offers the surest foundation for health system development to manage the trends that will shape health needs and opportunities in the decades ahead.But to fulfill this promise, PHC itself must evolve. In many cases, approachesthat succeeded in the Alma-Ata period or even the MDG era cannot simply betransposed to today’s health-system contexts. The powerful trends just describedare shaping a novel global health landscape with new risks and new rules, but43also new opportunities with advanced technology. COVID-19 embodies thesetransformations. The pandemic has also provided an opportunity to rethinkestablished health-system paradigms, including the role of PHC.Strengthening governance and accountability in PHC systemsDemographic and epidemiological changes, evolving health needs, and rising public expectations raise the stakes for better-functioning health systems. Repositioning PHC to meet the demands of the new health care ecology will require rethinking governance and accountability in PHC systems. Governance and accountability structures shape the processes by which patients, providers, and payers interact, mediating these stakeholders’ divergent interests and power relationships.Accountable PHC systems will need to be more responsive to meet people’s expectations in their engagement with the health system, as embodied in professional ethics and human rights. This will require PHC to enhance structural aspects of care, including the quality of basic amenities, choice, prompt attention, and access to social support networks. It will also mean attention to interpersonal domains, including patient dignity and autonomy, better communication between providers and patients, and promoting patient confidentiality. PHC systems will need to invest in building relationships of trust with patients and communities to ensure that decisions are aligned with ethical standards and professional norms, but also with societal and cultural values.WALKING THE TALKBuilding more accountable PHC systems will mean moving away from traditional ways of thinking about how to allocate scant resources. Though evidence is still limited, global experience shows that, to improve PHC accountability, countries can employ a battery of strategic purchasing policies like capitation, performance-based contracts, and global budgeting. Provider payment methods will need to reflect the care setting in which PHC services are provided, incorporating feedback from patients. It is paramount that payments to PHC providers signal a sense of fairness relative to the payments made to specialists.Accountability hinges on the availability of accurate and relevant information to track performance over time and across providers. Transparency will need to be embedded as a core principle of accountable PHC systems. Greater transparency helps mitigate, if not eliminate, corruption and waste by facilitating closer monitoring of providers and payers and helping to realign provider incentives. Efforts to improve the transparency of PHC systems will entail instilling a culture of evidence-based, data-driven medical practice; tracking the most relevant data; and expanding venues for feedback from citizens. Facilitating input from system users may involve, for example, scaling up real-time feedback loops using culturally appropriate, patient-reported outcome measures and patient experience reports.44Reorganizing care deliveryMany people across the globe are living longer and healthier lives—and all aspireto do so. Rapid urbanization and increased digital connectivity will continue tofuel citizens’ expectations for high-quality health care. As these trends converge,traditional health care organization models are coming under increasing strain.Health systems in LMICs, where global population growth is concentrated, alreadystruggle with poor infrastructure and digital connectivity, stark human resourcegaps, and weak supply chains, fueling shortfalls in service coverage, quality,efficiency, and equity. Many LMICs need new solutions to expand coverage ofessential services while improving financial protection—the pillars of UHC. Thisnew ecology of care magnifies the need to rethink traditional care models.PHC systems have unique strengths to address the pressures caused by population growth, rising NCD burdens, population aging, and other trends that require more people to engage more often with the health system. However, some features of traditional PHC systems must be transformed to take full advantage of existing strengths and build new ones. This is particularly important for LMICs that bear a double burden of communicable and noncommunicable diseases. For instance, today, almost 8 in 10 patients receiving antiretroviral therapy (ART) in LMICs reside in Sub-Saharan Africa. Thanks to recent efforts in HIV treatment (e.g., early ART initiation), many high-prevalence countries have achieved important gains in reducing HIV-related mortality. But these gains also generate new challenges for care delivery systems. The high prevalence of HIV/AIDS among working-age populations in Sub-Saharan African countries suggests that a greater proportion of the population will continue living with HIV, while concurrently confronting other chronic conditions. More generally, the double burden of disease coupled with the projected rise in working-age populations in LMICs will boost demand for sustained engagement with the health system, pushing up health spending.CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSThese demographic and epidemiological trends underline the urgent need for additional investments in PHC systems. Population aging will require better integrated, long-term care that empowers health professionals to address both the expressed and unexpressed needs of populations.70 With a growing elderly population, health expenditures are projected to escalate, because individuals tend to incur the highest medical costs closer to the end of their lives.71 Compounding the effects of population growth and aging, health risks that are not addressed earlier in the life course will undermine health in older people, increasing the likelihood that a greater proportion of the aging population will be impacted by ill-health, disability, and costly co-morbidities.New investments in curative care services alone are unlikely to curb these pressureson health systems. While some high-income countries are already scaling uplong-term care programs, substantial work remains to be done to address thehigh degree of fragmentation, low-quality and low-value care, and waste. Inmany UMICs, efforts are needed to integrate primary care with other levels ofcare; address the chasm between service coverage and quality; and improveinefficiencies in service provision. Meanwhile, health systems in many LMICs areunprepared to address the needs of their aging populations. Long-term carearrangements in these settings remain weak and poorly integrated with socialservices, placing elderly people and their families at high risk for catastrophic out-of-pocket health care expenditures.45The potential benefits of improving health care models extend beyond the health sector. In many of today’s high-income countries, changes in the population age structure between the 1960s and 1990s enabled countries to reap a demographic dividend – faster economic growth due to drops in fertility and mortality, supported by economic and social policies to propel economic expansion. Today, many LMICs with young populations are poised to reap a similar demographic dividend—but its benefits will not be automatic. A strong body of evidence warns that changes in the population age structure, on their own, do not guarantee countries a demographic dividend. To secure it, LMICs need to deliver better education, health, and employment opportunities before their populations start aging. Building fit-for-purpose PHC systems is critical to ensure that people have access to high-quality care that meets their changing health needs over the life course. To achieve this, many LMICs urgently need to rethink their health care organization models. Their window of opportunity to do so is narrowing.Harnessing the power of PHC in future public-health emergenciesAmong its many important lessons, the COVID-19 pandemic has highlighted the need for countries to reorganize existing health care delivery models so that they can better manage public-health emergencies while meeting long-term health care needs. PHC provides the strongest platform to advance these changes, but few countries have yet made full use of this option. Global experience shows that PHC systems can curb the spread of outbreaks by disseminating reliable health information and prevention strategies, enabling rapid diagnosis of new cases, and contact tracing. During emergency response, effective PHC systems are alsoWALKING THE TALKcritical to ensure that people’s routine health needs are met without disruption, including vaccinations and other preventive services and the treatment of the full range of chronic conditions, including mental health conditions.Positioning PHC systems as an effective first line of response to public-health emergencies will require that PHC professionals have access to up-to-date information and tools. This includes reliable access to medical supplies (e.g., testing kits), equipment (e.g., personal protective equipment), and medicines. It will also mean harnessing new technologies on the PHC front lines.*****Exceptional pressures will come to bear on health systems in all countries inthe decade leading to 2030, the goal-line year for major global health anddevelopment targets, including universal health coverage under SustainableDevelopment Goal 3. But already, for health policy makers in countries facing theimpacts of COVID-19, “exceptional pressure” is not a threat hovering in the future.It is right here, right now. Leaders also know that COVID-19 is not the only nor evennecessarily the most devastating health problem many of their countries face.The pandemic is part of a broader and more complex ecology of health risks andopportunities in the advancing 21st century. It is that ecology as a whole that policy46makers have to manage.One of the most powerful tools for this task is primary health care. Yet PHC today remains a promise incompletely fulfilled. The early PHC movement mapped out a bold agenda of health action that included but went far beyond reorganizing the delivery of medical services. But in the decades following the 1978 Alma-Ata conference, implementation of PHC stumbled, especially but not only in some lowincome countries. Key reasons for these shortfalls often included weak governance and accountability mechanisms and inadequate financing. Poor results in some settings also reflected unresolved disputes about what is essential in PHC, how key implementation steps should be designed and sequenced; and what ultimately constitutes success in PHC.Lessons have and are still being drawn from these experiences. It is also the case that, for nearly half a century, well-designed PHC models have demonstrated their capacity to deliver population health gains and improve health equity at manageable cost. Now, in a post-COVID-19 world shaped by complex and interacting megatrends, strong PHC networks offer the best platform for countries to solve old and new health challenges.If PHC systems in most countries are not yet prepared to play this role, what will it take to get them ready? A series of recent publications have provided important evidence and analysis on this issue, while global networks such as PHCPI are reinforcing their efforts to help countries diagnose and tackle PHC gaps.72,73 In the next chapter, we build on that work to describe four high-level shifts to improve performance in PHC systems.CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMSGlobal experience shows that PHC systems can curb the spread of outbreaks by disseminating reliable health information and prevention strategies, enabling rapid diagnosis of new cases, and contact tracing. During emergency response, effective 47 PHC systems are also critical to ensure that people’s routine health needs are met without disruption, including vaccinations and other preventive services and the treatment of the full range of chronic conditions, including mental health conditions.WALKING THE TALKChapter 3Reimagining PHCWHAT WILL IT48LOOK LIKE?CHAPTER 3: REIMAGINED PHCThe previous chapter explored complex forces reshaping today’s health ecosystems. Joining a growing consensus among health policy makers, scholars, and practitioners, it argued that the best health-systems solutions to these new challenges will be anchored in primary health care (Box 1). That chapter also argued that, to drive ambitious reforms in health systems, PHC in many countries must undergo important changes.Over the decades, calls to transform PHC have emerged frequently. It has been relatively easy to describe plausible ways to make PHC work better. Successfully implementing these plans has been more challenging. This chapter aims to spell out in clear terms the high-level shifts that evidence suggests many PHC systems need to undertake today. Chapter 4 then marshals data on how countries can make these changes happen. It recognizes the serious difficulties that await these efforts, especially but not only in LMICs, and shows how some countries have been able to solve them.49BOX 1. PHC AND HEALTH-SYSTEM REFORM IN THE 21ST CENTURY: A GROWING CONVERGENCE AND STRONG ALLIANCESA series of recent landmark studies have presented visions and practical guidance for PHC reform. Some of these emerge from innovative global networks that are supporting countries to take PHC performance to the next level, including the Primary Health Care Performance initiative (PHCPI)74 and the Joint Learning Network (JLN) for Universal Health Coverage.75 This report builds on these important contributions and introduces additional data and analysis that can help countries implement PHC reforms successfully. In preparation for the 40th Anniversary of the Declaration of Alma-Ata, WHO and UNICEF developed A Vision for Primary Care in the 21st Century, stressing the three components of PHC to meet evolving health needs: (i) integrated health services with an emphasis on primary care and essential public health functions; (ii) empowered people and communities; and (iii) multisectoral policy and actions.76 An accompanying operational framework includes 14 levers for action, building on the 2008 World Health Report “Primary Health Care: Now More Than Ever” and the related Framework on Integrated, People-Centered Health Services geared toward engaging and empowering people and communities; reorienting care models; and coordinating services within and across sectors, supported by governance reforms.77,78 At an operational level, PHCPI’s Strategies for Improving Primary Health Care offer step-by-step, evidence-based guides to upgrade and reform specific PHC components or inputs.79 The OECD’s Realising the Potential of Primary Healthcare has recently emphasized team-based care models, smart economic incentives, and patient empowerment as “necessary changes” in PHC systems.80WALKING THE TALKFour high-level shifts for stronger PHCTo meet the evolving demand for quality, people-centered, integrated health care in the 21st century, all countries—despite their many differences—will need to achieve four fundamental shifts in how PHC is designed, financed, and delivered. This chapter describes those shifts. They involve progressively reconfiguring key aspects of care delivery, patient-provider relationships, workforce composition and preparation, and financing in PHC. One way to think about these shifts is as the outcomes of change processes in PHC systems—the results health leaders are aiming for when they introduce PHC reforms. The importance of most of these outcomes is intuitively clear and has often been affirmed in the history of PHC. Yet, while some countries have made remarkable progress toward reaching these outcomes over the years, many more have struggled, made limited gains, and at times gone backward. Following COVID-19, these specific high-level shifts are once again critical for PHC systems to respond, recover, and “build back better.”81 Box 2 presents short definitions of the shifts.50CHAPTER 3: REIMAGINED PHCBOX 2. FOUR SHIFTS TO IMPROVE PERFORMANCE IN PHCThe four high-level shifts described in this chapter can be summarized in this way:From dysfunctional gate keeping to quality, comprehensive care for all: High-performing PHC networks carefully assess each patient’s needs, ensuring that people receive the care they require at the most appropriate level of the health system. This “gate keeping” role makes PHC a cornerstone of efficiency in health systems. Often, however, patients experience PHC gate keeping in a very different way. Since at least the 1990s, surveys in many countries find that patients tend to perceive PHC as low-quality health care for poor people and local PHC personnel as unskilled and disrespectful. This form of dysfunctional gate keeping becomes an adversarial relationship that complicates patients’ access to “real” health care in advanced clinics and hospitals. The solution is an ambitious shift that strengthens the range and quality of services that people can obtain at their local PHC facilities. Some countries have scored impressive gains by creating multi-skilled local PHC teams and rewarding them for delivering high-quality services that meet the bulk of health needs in communities. These PHC teams practice “positive gate keeping,” better termed personalized care coordination.From fragmentation to person-centered integration: In high- and lower-income countriesalike, patients often experience the search for health care as a solitary, bewilderingjourney. Many patients must patch together their care from multiple institutions andproviders who are physically dispersed and systemically uncoordinated, practice51inconsistent pricing regimes, may give different answers to the same diagnosticand therapeutic questions, and provide services of variable quality. Health servicefragmentation and the absence of stable, trusting patient-provider relationships thatresults are cited in many surveys as key reasons for people’s dissatisfaction with healthcare. This situation demands a shift toward cohesive local PHC teams that build carearound patients’ needs and preferences; treat all patients with respect; collaborate andcommunicate internally; and coordinate patients’ movement through the health systemand back to the community.From inequities to fairness and accountability: COVID-19 has underscored the stark inequities in health care access and outcomes that exist globally, within countries, and often from one urban neighborhood to the next. Shared anger at such inequities was one of the main reasons that the original PHC movement was launched and gained global support. Today, PHC’s potential to tackle equity gaps remains unfulfilled in many settings. However, strong examples exist of countries that have harnessed PHC’s distinctive capacities to address inequities in health and health care. These countries have made policy and implementation choices that support the equitable, efficient delivery of a PHC-driven essential service package and that foster and reward accountability for health outcomes in frontline PHC.From fragility to resilience: COVID-19 revealed the vulnerability of under-resourced PHC systems to public-health threats and showed the consequences for people and economies of health systems insufficiently prepared for infectious outbreaks. In the wake of the pandemic, countries need to draw the lessons and undertake ambitious reforms. At the PHC level, this will involve, for example, ensuring that PHC teams include public-health surveillance and outreach capacity, and that financial and human-resource surge capacity is built into health sector planning and resource allocation at the local level.WALKING THE TALKShift 1: From dysfunctional gate keeping to quality comprehensive care for allThe concept of “gate keeping” as a core function for primary health care first gained prominence in some high-income countries in the 1980s and 90s. The concept has spurred recurrent controversy in policy debates. Proponents argue that gate keeping at the primary level streamlines healthcare so that the right services will be provided at the right level of the system. A clear aim of gate keeping in PHC is to reduce unnecessary referrals to more expensive higher-level specialists. This helps limit burdens on hospital outpatient and inpatient services and contain costs, especially in healthcare settings where geographic and financial access to care is less of a concern, and patients have greater freedom to choose their providers.The gate-keeping function, broadly understood, is a feature of any rationally organized health system, except where it exists as a result of shortage of trained practitioners.82 Coordinating care by using this function well improves service quality as well as efficiency and is likely to produce better patient outcomes. The term gate keeping as commonly used, however, refers above all to managed care in a pluralistic healthcare environment, with a multiplicity of providers and insurers, where cost-containment is a dominant concern, as in the United States.83,84 52 While changing words does not yet change reality, some have found it useful to refer consistently to care coordination, rather than gate keeping. There are at least two good reasons for this. First, in modern health system ecology, people seeking health care tend to be more demanding, better informed, and more empowered to participate in shared decision making with their providers than in the past. As populations age, and NCDs and multi-morbidity become more prevalent, requiring advanced medical skill sets and a multiplicity of complex interventions, care coordination and care integration best capture the sense of what care seekers need and demand. Second, the benefits packages now envisioned for UHC in many countries render the care coordination function increasingly vital. As described in DCP3, these packages typically involve several service delivery platforms for the provision of a large set of essential health interventions, whereby four of the five cited platforms85 and 198 of the 218 interventions are meant to be delivered at the PHC level.86 The vocabulary of care coordination keeps us reminded of how pivotal (and challenging) this function is in today’s healthcare landscapes.What is meant by high-quality comprehensive care?Health care quality can be succinctly defined as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”87 As such, care quality encompasses two key domains: effectiveness, that is, providing appropriate care based on scientific knowledge and safety, or avoidance of harm through inappropriate care. Beyond these core features, some authorsCHAPTER 3: REIMAGINED PHChave broadened the concept of care quality to include criteria such as timeliness, efficiency, equity, and patient centeredness, among many others.88 Some have recommended including quality of inputs as well as patient outcomes as proxy indicators, in addition to measuring quality at the service/output level.89,90A classic definition of comprehensiveness evokes “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs,” within the broader context of primary care.91PHC is the appropriate level to marry the two concepts of quality and comprehensiveness of care. This moves the discussion away from gate keeping towards envisioning a platform to provide a comprehensive set of essential services.92What are the drivers of quality, comprehensive care?Fundamental to building high-quality, comprehensive primary health care is asystems approach.93 WHO experts note that quality improvement efforts oftentend to focus on the “micro” level of local facilities and staff performance. Whilecrucial, this approach needs to be supported by systemic action, since the qualityof local primary health care is deeply affected by the prevailing culture and53environment of the health system. System-level interventions to improve quality ofcare include: national workforce strategies; registration and licensing mechanisms;service delivery and care platform redesigns; external evaluation or accreditation;public reporting and benchmarking mechanisms; and national regulatory bodiesfor medicines, medical devices, and other health products. Health informationsystems to measure and drive quality of care, and financing methods to supportprovision of high-quality care are also essential.94Recent WHO technical guidance on quality in PHC notes that the organization of PHC providers in cohesive multidisciplinary teams is increasingly recognized as a driver of quality, comprehensive care. Effective primary care is now being delivered in many settings by multidisciplinary teams to provide a comprehensive package of services using more holistic models of care. Improving the quality of services requires equal attention to both clinical skills and non-clinical functions such as effective community engagement, leadership, communication, and innovation.95Underpinning all efforts to improve quality across the health system is leadership and governance. Strong commitment to and leadership for quality is required at all levels to ensure all stakeholders work together to create the enabling environment needed to provide high-quality PHC.96 Key characteristics of systems with strong leadership and governance include evidence-based policymaking, efficient and effective service provision arrangements, regulatory frameworks and management systems, responsiveness to public-health needs and the preferences of citizens, transparency, institutional checks and balances, and clear and enforceable accountability.97 Leadership can be cultivated and exercised at all levels of the health system, from ministries of health to local governments and PHC facilities.98WALKING THE TALKBOX 3. WHAT HAS TO CHANGE: DYSFUNCTIONAL GATE KEEPING AND QUALITY GAPSDespite some gains in access to basic services, enormous gaps in the quality and comprehensiveness of primary care persist in many countries. Increasingly, individuals’ most pressing health challenges relate to noncommunicable diseases, mental health, nutritional disorders, and injuries, many of which lie outside the traditional remit of PHC. In LMICs, over three-quarters of diabetes patients99 and 90 percent of individuals with hypertension100 receive zero or inadequate care to control their conditions.101 Sixty percent of healthcare-preventable deaths in these countries can be attributed to poor-quality care—substantially more than the total attributable to non-utilization of the health system.102Unqualified providers have proliferated in unregulated LMIC markets, while adherence of PHC providers to clinical guidelines can also be low. With limited ability to solve patients’ problems and perceived poor quality deterring care-seeking, PHC services can be inefficient and unproductive. Some PHC providers often see extremely low caseloads despite high burdens of disease—just 1.4 outpatient visits per day in Nigeria, 5.2 per day in Madagascar, and 6 per day in Uganda103—while absentee rates frequently exceed 25 percent.104LMICs: In rural India, 76 percent of all primary care providers and 65 percent of self-54identified “doctors” have no formal medical training105 in eight African countries, providerscomplete under half of relevant history and physical examination questions, given apatient’s symptomatic presentation,106 and frequently misdiagnose common conditions.107Among women giving birth in facilities in rural Tanzania, more than 40 percent bypassedtheir local health clinic to seek care in hospitals despite substantially higher costs; theywere more likely to do so if they were relatively wealthy, the local facility was in poorphysical condition, or if the perceived (and actual) quality of care was low.108UMICs: Though major depressive disorder should be treatable in a primary care setting, less than one in ten people with major depression receive minimally adequate treatment in Bulgaria, Lebanon, or Mexico.109HICs: In Riyadh, Saudi Arabia, three-quarters of survey respondents in a sample of PHC centers reported that they do “not make primary health care their first choice,” most frequently citing limited scope of services and mistrust to explain their preferences.110CHAPTER 3: REIMAGINED PHCShift 2: From fragmentation to person-centered integrationBy its nature, healthcare delivery involves an asymmetry of information between those who provide services and those who receive them. Nonetheless, “delivery” of effective care should not be seen as a one-way transfer from provider to patient,111 but instead requires providers to work as partners and collaborators in empowering the people they serve. This in turn often requires a mindset shift, from solving an acute health problem on the patient’s behalf to building long-term, trusting partnerships to strengthen health and wellbeing across the life course.Three global trends in healthcare knowledge and delivery are sharpening thisimperative. First, as noted, patients and populations are increasingly informedabout their own health and therapeutic options. Many enjoy rapid access todata and general information; an extensive understanding of their own medicalconditions; and the ability to triangulate external information and knowledge withthe information shared by their care providers. Second, transparency of providerperformance and patient outcomes is fast becoming the norm, allowing peopleto make an informed choice between providers.112 Finally, increasingly urbanized,educated, and informed populations across the world expect technical excellenceto cure their illness, and also respect for their dignity, wholeness as a person,preferences, and constraints.55These secular trends are particularly relevant for PHC—typically the first point of contact with healthcare outside of emergency settings. PHC practitioners are not only expected to be healers but also managers, coordinating the healthcare needs of the care seeker,113 families, and the entire community in which they reside.What is meant by person-centeredness in PHC?The United States Institute of Medicine (now National Academy of Medicine) classically defined patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”114 As such, patient centeredness comprises eight components: (i) respect for the patient’s values, preferences and expressed needs; (ii) coordination and integration of care; (iii) information and education; (iv) physical comfort; (v) emotional support and alleviation of fear and anxiety; (vi) involvement of family and friends; (vii) continuity and transition; and (viii) access to care, mainly in relation to amenities.115The basic tenet of patient centeredness is that the organizational model of health care, with PHC at the center, revolves around the health, healthcare, and broader psychosocial needs of the person, both as a care seeker and as a member of the community. Health and nutrition promotion and prevention are given as much importance as episodic, curative care, with the goal of enhancing lifelong health and quality of life. This also requires full integration with secondary and tertiaryWALKING THE TALKcare, implying that people centeredness must go hand-in-hand with integrated care. The role of PHC is paramount as first point of care and coordinator across all healthcare levels. Patient centeredness is an evolving concept. An expanded definition includes additional dimensions of structural and interpersonal responsiveness, ensuring that health services are provided without discrimination on the basis of income, ethnicity, language, gender, or other factors.116BOX 4. WHAT HAS TO CHANGE: DISCONTINUOUS DELIVERYOver half of the global disease burden can be attributed to ongoing behavioral or metabolic risks factors occurring in the household or community,117 yet most PHC platforms remain oriented toward episodic disease treatment, not prevention and promotion. Without empowering individuals, families, and communities to take charge of their own health and its determinants—and without serving as a connection point, tracking and managing a patient’s journey across the entire health system—PHC can only address the “tip of the iceberg” of acute disease presentations through interventions that lack the power to drive major population health improvements.Discontinuities in care are associated with departures from clinical best practice,56preventable hospitalizations, and far higher total health care expenditure.118 Lack ofengagement with patients also undermines chronic and infectious disease treatment.WHO estimates that adherence to long-term therapies is just 50 percent in high-income countries, and far lower across LMICs;119 chronic disease patients say mistrust,confusion, and alienation from the treatment planning process are barriers to treatmentadherence.120 Limited information-sharing between providers, including followingdischarge from higher-level care, further exacerbates the risks of fragmentation, leadingto duplication, errors, and patient safety risks.121LMICs: In Sierra Leone, less than one percent of febrile patients completed referrals to health facilities after testing negative for malaria on a rapid diagnostic test.122HMICs: In Peru, just 21 percent of survey respondents report that the last doctor they saw “knows me as a person,” while 34 percent say they “know what to expect from this doctor”, and 31 percent report that they “feel totally relaxed with this doctor.”123HICs: A 2016 survey across 11 high-income countries found that 19-35 percent of all patients had experienced at least one problem with care coordination over the past 2 years—for example, medical records not being shared with a specialist, duplication of testing, or receiving conflicting information from multiple healthcare professionals.124 In Japan, 60 percent of patients reported that their regular doctor had not spent enough time with them during consultations.125 In the United States, half of primary care physicians do not know if their patients have completed referrals.126CHAPTER 3: REIMAGINED PHCWhat are the drivers of person-centeredness in PHC?The mission and values of the health system as a whole, and the PHC network in particular, can be formulated and applied in a way that drives the system towards person-centeredness. This happens when guiding values are egalitarian and inclusive, fully aligned with the aims of optimizing population health outcomes and equitable access to care.Care delivery is fundamental to person-centeredness, and best serves it when care is collaborative, integrated, and coordinated by the PHC team. Along with patients’ medical care needs, practitioners are responsible to give high priority to care-seekers’ physical comfort, emotional well-being, dignity, and care preferences.The PHC team’s willingness to listen and respond to care seekers and families is at the heart of person-centered practice. Care-seeker and family viewpoints need to be, not just heard, but genuinely respected and incorporated in decisions. The physical organization of care settings can also support or undermine person centeredness. Person centeredness is present when basic amenities of the care setting are designed in a way that respects care seekers’ dignity, autonomy, and confidentiality, while enabling prompt provision of health and social support services.A wide range of factors can enable the translation of person-centeredness from57abstract principle into provider behavior and care seekers’ experience. Suchenablers include governance policies and tools, such as the formulation of a PHCmission statement and its rigorous application and establishing performance-based incentives for care providers. Effective incentives can be financial or non-financial. The training of PHC teams is another crucial means to instill people-centeredness as a guiding value and teach team members how they can put itsystematically into practice. Regulatory measures can lend support to person-centered care, for example by ensuring patient confidentiality and establishingenforceable norms for patient safety.Tools that encourage health practitioners to listen to care seekers’ voice and act on their concerns play a key enabling role. These tools may include an accountability framework that gauges people centeredness and empowerment, for example through the Patient reported Indicator Surveys (PaRIS), incorporating patientreported experience measures (PREM) and patient-reported outcome measures (PROM). Community and care seeker information, education, and communication are also crucial. By definition, people-centered communication is not a one-way download of information and instructions from health providers and experts to patients. It is an interactive process that engages people as knowledgeable, responsible agents in their own health. Communication flows both ways, between attentive health professionals and empowered care seekers and communities. Technology and information platforms can enable and accelerate these interactive relationships.WALKING THE TALKShift 3: From inequities to fairness and accountabilitySome inequalities in health are unavoidable, since they stem from genetic differences or other factors beyond humans’ control. Health inequities, in contrast, are defined by WHO as “avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification.”127 The goal of health equity implies that “everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.” Most observed health and healthcare inequities— between individuals and between populations—could be reduced or even eliminated by addressing the structural determinants of health along with disparities in healthcare resource allocation.What is meant by fairness and accountability in PHC?Fairness in health and healthcare refers to the absence of structural and systemicinequities that could be addressed through health promotion, disease prevention,and medical care. Fairness also encompasses the just distribution of the burdenof healthcare costs according to people’s ability to pay—precluding any out-of-58pocket payment, no matter how minimal, at the point of service. Finally, fairnessentails a respectful and appropriate response to the nonmedical needs, rights,and expectations of those seeking and obtaining health care, delivered througha dignified interaction with the provider.128 Fairness is thus closely linked topatient centeredness.Accountability, in its simplest form, is the obligation to ensure that health and health care services are timely, effective, safe, appropriate, cost-conscious and people- and patient-centered. As such it requires a level playing field in the nexus of interactions between communities/care seekers, health care providers, and payers, often mediated through governance, that is, institutions, laws, and regulations.129PHC can address inequities in health and healthcare in multiple ways. One means— limited but important—is through primary care as the preferred first point of patients’ contact with clinical services to address illness, sickness, or disease.130 PHC networks can also deploy, contribute to, or promote a comprehensive set of community-based interventions aimed at reducing socio-economic and cultural disparities that act us distal or proximal determinants of health. However, there are few well-documented instances globally in which PHC services have fully incorporated this function. In many settings, PHC still stands for a limited set of healthcare services, too often provided only to those who can afford to pay and/or who live in close proximity.CHAPTER 3: REIMAGINED PHCBOX 5. WHAT HAS TO CHANGE: HEALTH FINANCING GAPS WIDEN HEALTH CARE INEQUITIESFew governments fund comprehensive, universal PHC services at adequate levels to equitably meet population health needs; most LMIC governments cover well under half of PHC costs through general government revenue.131 Beyond absolute resource constraints, the allocation of scarce resources is often skewed toward hospitals and relatively advantaged urban populations. In this context, patients must often pay out of pocket for critical health needs, pushing about 100 million people into poverty each year.132 Though many associate catastrophic health expenditure with unexpected hospitalization, most out-of-pocket expenses across LMICs and WHO’s European region go toward outpatient care and medicines, both of which fall within the remit of PHC.133 Even when PHC services are financially accessible, patients commonly report disrespectful, impersonal, or even abusive care.134,135,136 This particularly affects marginalized populations, including migrants, racial minorities, sexual minorities, and youth. Financial barriers can also deter poor or marginalized families from seeking care early, leading to preventable hospitalizations and death. LMICs: Among households in rural Malawi where a family member required chronic disease medication, two-thirds incurred at least some out-of-pocket expenditure; the poorest quartile of households spent up to half of monthly income on chronic disease care.13759 UMICs: In Russia, 27 percent of patients report that they were not treated with “respect for [their] values, preferences, and expressed needs” during their last consultation; and 34 percent report that care was not “personalized to reflect [their] needs and choices.”138 HIC: In the United States, over a third of surveyed adults and almost two-thirds of uninsured adults skipped needed medical care in the past year due to cost barriers;139 families under the poverty line are more than three times as likely as the wealthiest families to delay or forego care for their children due to cost or lack of insurance coverage.140What are the drivers of fairness and accountability in PHC?At the PHC level, fairness is achieved by eliminating or at least mitigating avoidable inequities in health and healthcare through accurate targeting of public-health and primary care services to those most in need, while protecting the empaneled population from catastrophic health expenditure or health-related impoverishment. Fairness also means responding to people’s expectations for humane, respectful, and dignified care, without any discrimination based on age, gender, income, area of residence, sexual orientation, disability, or other factors. This would imply not only that PHC is available, but also geographically, socioculturally, economically, and organizationally accessible to all.141Accountability in PHC could be operationalized as the mandate and capacity to hold relevant healthcare institutions, facilities, and health professionals to account for their performance in providing person-centered, appropriate, comprehensive,WALKING THE TALKcontinuous, safe, timely, and cost-conscious care to their empaneled population. As such it would require an accountability “results framework” and a set of metrics mutually agreed by providers, payers, and the empaneled population alike.In this sense, fair and accountable PHC rests on a “social contract” with the community it serves (the empaneled population). It also requires a transparent mechanism to collect, compile, analyze, and interpret data for continuous improvement and summative evaluation. The most useful data will include patientreported experience and outcome measures (PREM and PROM) and input from the community at large. Measures would need to be customized considering community baseline characteristics (epidemiologic, demographic, socio-cultural, and economic), the level of ambition (goals, anticipated health outcomes), the time frame, and the rules and regulations pertaining to broader health-system governance. Most important is a realistic estimation of resource needs—and effective provision of resources based on those estimates. This includes both human resources (numbers, skills mix, and the applicable incentives to recruit and retain) and financial resources for full functionality regardless of short-term surges in demand. Planning and resource estimation need to be demand-oriented, that is, derived through an assessment of a community’s needs and expectations, rather than supply driven.60Shift 4: From fragility to resiliencePandemics like COVID-19—alongside other shocks including conflict or natural disaster—can devastate health systems and reverse years of hard-won health, development, and economic progress. Health security refers to the activities required to minimize the danger and impact of health shocks. Neither health security nor universal health coverage (UHC) can be achieved without building resilient health systems,142 while WHO has reminded countries that the best foundation for resilient systems is PHC.143What is meant by resilience in PHC?There is as yet no universally agreed definition of health system resilience. This report follows the influential definition proposed by Kruk et al. (2015) and widely adopted by the community of organizations working to advance UHC:+Health system resilience can be defined as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it. Health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath.Kruk’s model characterizes resilient systems in terms of five fundamental attributes. Resilient health systems are: (1) “aware,” (2) “diverse,” (3) “self-regulating,” (4) “integrated,” and (5) “adaptable.”144CHAPTER 3: REIMAGINED PHCResilience is closely related to another concept widely discussed in the current health systems literature: preparedness.145 Linguistically and practically, ‘preparedness’ emphasizes pre-crisis actions to anticipate health emergencies, while ‘resilience’ as defined by Kruk encompasses preparation, response, and postcrisis recovery. In this sense, preparedness can be considered as a stage of the continuous cyclical process to improve health system resilience.146The overall definition of health system resilience and its conception as a cyclical process also apply to PHC. A PHC system is resilient if:+ +It is well prepared for health emergencies;It effectively responds to health emergences and maintains access to high-quality routine PHC services as well as to public-health services during an emergency;+It recovers promptly once the health emergency is over by making the necessary adjustments, revising emergency action plans accordingly, and resuming its core functions.A distinctive feature of a resilient PHC system is that, for each stage of thecontinuous cyclical process described above, it maintains and reinforces three61interconnected core functions: service delivery, surveillance, and communications.Service delivery refers to the capacity of PHC to deliver both emergency-related and routine health services. Emergency-related PHC services have included, in the case of the COVID-19 pandemic, basic treatment and follow-up care for patients with mild symptoms, provision or facilitation of laboratory tests, triage, referral to hospitals, and mental health services. Routine PHC services typically include reproductive, maternal, newborn and child health (RMNCH) services, infectious disease services (for example addressing HIV, tuberculosis, and sexually transmitted infections), and noncommunicable disease services. In many countries, COVID-19 forced over-stretched health systems to suspend many PHC-level routine services in order to manage waves of acutely ill coronavirus patients. The result, especially but not only in LMICs, has been large numbers of excess deaths caused not by the virus itself, but by its effects on overall health service provision (Box 6).WALKING THE TALKBOX 6. THE COST OF NOT BUILDING FIT-FOR-PURPOSE PHC: COLLATERAL MORTALITY IN COVID-19Along with COVID-19’s direct health impacts, many low- and middle-income countries have seen a rise in mortality from other causes, associated with the curtailment of health services for non-pandemic-related conditions. Robust, resilient PHC systems would have been able to support the COVID-19 response, while maintaining provision of essential preventive, promotive, and curative care of other kinds. Weak PHC systems in most LMICs have exposed populations to substantial additional risks across a broad range of health conditions:+Vaccine-preventable diseases – Due to COVID-19, 14 major vaccination campaigns for polio, measles, cholera, HPV, yellow fever, and meningitis had already been postponed as of June 2020, resulting in 13.5 million people missing out on vaccinations in 13 of the poorest countries. Across 37 countries, disruptions of measles campaigns could lead to 117 million children missing out on their vaccines, reversing gains in herd immunity.+Nutrition – COVID-19 is interrupting nutritional interventions even as the pandemic is expected to double the number of people facing acute foodinsecurity, from 135 million at end-2019 to 265 million by end-2020. UNICEF62has reported severe disruptions in treatment coverage for acute malnutritionand Vitamin A supplementation.+Maternal Health – A 45% coverage reduction for 6 months would result in 1.16 million additional child deaths and 56,400 additional maternal deaths. This would represent a 9.8% to 44.7% increase in under-5 child deaths per month, and an 8.3% to 38.6% increase in maternal deaths per month.+Malaria – Suspension of distribution campaigns for insecticide-treated nets and disruption of malaria treatment could lead to as many as 225 million additional malaria cases across Sub-Saharan Africa in 2020 alone. This disruption could allow malaria in Sub-Saharan Africa to return to levels seen 20 years ago.+Tuberculosis – MDR-TB incidence is likely to worsen due to delays in TB diagnosis and contact tracing, along with reduced treatment adherence due to access and affordability barriers. TB cases could increase by up to 11% globally between 2020 and 2025 under a 3-month-lockdown, with delays in the resumption of TB services.+HIV - A six-month disruption of ART globally is expected to lead to an approximately 2-fold increase in HIV-related deaths over a one-year period.+Noncommunicable Diseases (NCDs) – While NCDs can be risk factors for COVID-19, reductions in physical activity, patient management, access to fresh food, and isolation due to the pandemic can lead to increased incidence of obesity, cardiovascular disease (CVD), and other chronic NCDs.147,148,149,150Sources: Roberton et al. (2020); WHO (2020); STOP-TB (2020); Jewell et al. (2020). https://www.wfp.org/news/ covid-19-will-double-number-people-facing-food-crises-unless-swift-action-taken ; https://www.unicef.org/ media/82851/file/Global-COVID19-SitRep-11-September-2020.pdf ;CHAPTER 3: REIMAGINED PHCSurveillance mainly relates to the collection and reporting of high-quality and timely data on the disease burden and on the services delivered to the population. Especially for emergencies related to an infectious outbreak, data collection and reporting activities (passive surveillance) are usually accompanied by testing, contact tracing, and isolation management activities (active surveillance).Communications refers to PHC’s capacity to carry on an ongoing dialogue with the community to promote trust, healthy behaviors, and actions for prevention and emergency control (for example, handwashing, physical distancing). It also refers to the ability to communicate with other actors in the health system (e.g., publichealth institutions, hospitals) to maximize coordination along the care pathway, as well as with other sectors involved in the provision of emergency-related services, such as transportation and social protection.BOX 7. WHAT HAS TO CHANGE: FRAGILITY TO SHOCKSDuring natural disasters, outbreaks, or conflict, vulnerabilities in infection control, supplychains, and surveillance can drive up the immediate death toll; in some settings, the63second-order health impact of PHC interruptions can also approach or even exceed thedirect mortality and morbidity caused by the outbreak.LMICs: In Sierra Leone, in addition to the almost 4,000 deaths directly attributed to the 2014-2015 Ebola epidemic,151another 3,600-4,900 stillbirths, neonatal deaths, and maternal deaths can be attributed to decreased utilization of essential maternal and neonatal healthcare,152 along with additional morbidity and mortality from interruptions to HIV, tuberculosis, and malaria programs.153In Nigeria, the COVID-19 pandemic has led to a 50 percent reduction in outpatient visits, antenatal care services, and immunization. In Bangladesh and Guinea-Bissau, vaccination and maternal health services delivered through outreach have been interrupted due to lack of PPE, and telemedicine has not been scaled up. In Papua New Guinea (PNG), immunization rates have declined, and because mobile X-ray machines were reserved for COVID-19 patients, TB screening has also faced significant reductions.154HMICs: Modelling from South Africa shows that even relatively modest and short-lived (three month) COVID-19-related disruptions to HIV treatment enrollment, viral load monitoring, and prevention could lead to over 30,000 excess new infections over the next five years.155HICs: In the US, surveillance data show that routine measles immunization plummeted by over half during the first month of the COVID-19 pandemic, leaving communities vulnerable to measles outbreaks.156WALKING THE TALKWhat are the drivers of resilience in PHC?Resilience in PHC depends on the ability to restructure core service delivery functions during an emergency, then reconfigure again when the crisis is over. During an emergency, resilient PHC systems can adapt and maintain both routine and emergency-related health services. To maintain essential service delivery, PHC systems can provide outreach services through home visits or telemedicine, increase or redistribute health worker roles through task-shifting, remove user fees, and/or extend opening hours.157 In the recovery stage, PHC systems should be prepared to handle a surge in demand due to care needs that were deferred during the emergency or ongoing needs among those who became ill. This may result in an above-normal workload for PHC providers. This also means that resilient PHC systems need the flexibility to rapidly adjust the size, distribution, and skill mix of their workforce based on changing needs.Comprehensive routine data is a cornerstone of resilience, as it enables evidence-based managerial, organizational, and operational decisions. Resilient PHC systemsplay a key role in disease surveillance by collecting and reporting high-quality, timelydata on local disease trends and service provision. The best tools for this purposeare digital data systems that: a) take patients rather than illnesses or services as64their unit of reporting/analysis, b) are integrated into a single platform, and c) feedquality data continuously to health authorities. Well-integrated information systemsallow PHC providers and facilities to closely monitor populations, identifyingchanges in disease patterns and service demand in real time.COVID-19 has underscored the importance of stock management in health emergencies. Effective stock management requires adequate stockpiling plans and processes, strong supply chains and distribution channels, and robust, adaptable stock information systems (for tests, vaccines, medicines, consumables, spare parts, and other inputs). Stocks should reflect forecasted needs for different types of emergencies, be strategically distributed according to risks, and be available regardless of climatic, geographic and other existing or emerging constraints, even during crisis.Communication and engagement with the community have proven to be an effective strategy to change behaviors and so reduce the impact of emergencies. When a crisis strikes, PHC systems with strong communications capacities are able to provide clear, up-to-date information on all aspects of the threat, helping people protect themselves and, in the case of an infectious epidemic, prevent disease spread. PHC systems are able to tailor messaging to the communities they serve, based on characteristics such as language, culture, age, gender, and education.Certain enabling environmental conditions can facilitate the development of a resilient PHC system. The most fundamental of these include a fit-for-purpose governance model for agile response. Such a governance model promotes coordination and local autonomy to rapidly respond to changing population needs. Also essential is the presence of a well-developed, costed, and testedCHAPTER 3: REIMAGINED PHCemergency action plan. Well-developed plans specify clear emergency roles and responsibilities for all health-system actors, including PHC facilities and outreach services in both public and private sectors.158 To be ready to implement the plan, PHC leaders and managers can benefit from complementary training in leadership for crisis management, communication, and safety.The ability to access extra-budgetary funds as required can be catalytic for strong PHC performance under emergency conditions. The extra-budgetary funds could flow from a range of sources, including changes to program budget allocations or external funds from donors or those made available by Ministries of Finance. This ability to adjust funding levels and flows is particularly important in the recovery stage, to manage resurgent demand for non-crisis health services.Building and maintaining trust-based community engagement also supportsresilience in the long term. Community-centered PHC models, in which communityhealth workers (CHWs) often play a key role, can facilitate a resilient PHC system.In an emergency, community-centered PHC models tend to provide more effectiveand clearer messages on emergency status, along with prevention and treatmentrecommendations that people can easily understand and follow. Communityengagement strategies should be tailored to the local context and enhancemessages that promote trust, such as those that highlight facility and health-worker adherence to safety standards and person-centered approaches to care.65Foundations for Change: Enabling Multisectoral Action in PHCThe four fundamental shifts just described map an ambitious change agenda for many PHC systems. The shifts will demand investment and effort from health leaders and stakeholders, sustained over time. Fortunately, as noted at the start of the chapter, policy makers and PHC practitioners in many countries are already engaged in change processes like the ones described, and some countries have achieved impressive advances. Their experiences can enable others to seize opportunities, avoid pitfalls, and accelerate progress. We will shortly turn to analyzing evidence from those country experiences.In closing this chapter, we briefly consider a subject that has potential importance for the four high-level shifts in PHC. It also has a prominent place in the history of PHC. The topic is multisectoral action for health, recently often conceptualized as a “whole-of-government” approach to health action. A strong case can be made that all four shifts described here could be accelerated by forms of collaborative action that reach across sectors of government and society. Country experience suggests that some strategies of this type are feasible under current conditions.Since Alma-Ata, multisectoral action for health has been an enduring concern of the PHC movement, and one of its greatest challenges. Like PHC itself, multisectoral or intersectoral action has suffered from a problem of conceptual tensions and competing definitions.159 Without entering into the details of thoseWALKING THE TALKdebates, it is clear that multisectoral action related to health can take numerous forms and be carried out at many different levels, from the highest tiers of central government to the front lines of community-based health service delivery. However, in part because of the vast range of possible approaches, successfully delivering multisectoral action and measuring its impacts has proven challenging. An influential 2088 study of successes and failures in PHC, written for the 30th anniversary of Alma-Ata, concluded that, among the core components of PHC described at Alma-Ata, two had consistently proven most difficult to implement: intersectoral action for health and community participation.160To systematically analyze the large literature on multisectoral action for health, including One Health, is beyond the scope of this report. Here, we present a short reflection on two aspects of multisectoral stewardship that are pertinent to the high-level PHC shifts. The first concerns linking primary care and public health services at the community level. The second looks at what the concept of multisectoral stewardship entails, as a dimension of leadership in PHC.Linking primary care and public healthDebates on the place of multisectoral action in PHC began even before the Alma-66Ata conference. The distinction between primary care and primary health careemerged in the late 1960s, when the term “primary health care” was first used bythe Christian Medical Commission,161 prior to being adopted by WHO and others.At the time, “primary health care” was meant to replace the existing term “basichealth services” (BHS), while enlarging its meaning.162 The importance assigned tomultisectoral action became a key factor distinguishing PHC from other models ofhealth service provision.The Alma-Ata authors affirmed multisectoral engagement as a central pillar of PHC. Many reasons supported a broader, multisectoral conceptualization. Growing evidence at the time suggested that vertical disease control programs, like the costly and disappointing malaria eradication campaigns of the period, would not succeed in substantially reducing the burden of illness in the developing world. Tackling one disease at a time, such programs could not address the breadth and complexity of health needs in low-income settings. Medical advances alone, in any form, would fall short in these contexts without concomitant improvement in nutrition and living conditions.163Support for multisectoral action was by no means universal. Alma-Ata was rapidly followed by attempts to circumscribe PHC to a limited package of basic services under the rubric “selective PHC.”164 This was presented as a means to make PHC concrete and align it to the healthcare needs and above all the delivery capacities of poor countries. Meanwhile, some high-income countries, especially in North America, embraced their own narrower model of “primary care,” decoupling it from population-based services and limiting it to individualized essential care connected to a gate keeping function. Despite these tensions, the broader concept of PHC, incorporating multisectoral action, has endured, linked to recurrent efforts to integrate primary care with public health.165CHAPTER 3: REIMAGINED PHCIntegrating primary care and public health on the PHC front lines is a foundational step to make multisectoral engagement concrete and support healthier living in communities. For that integration to occur, however, PHC needs to be viewed not only as patients’ first point of contact with health services, but as a “set of values and principles for guiding the development of health systems,” anchored in social justice, solidarity, the right to health, person-centered healthcare, and community participation.166 The emphasis on community participation implies a “bottom-up” approach to multisectoral action, aligned with Alma-Ata principles. The driving force for work across sectors in this approach is community health needs as expressed by communities themselves, not (only) a desire among policy makers to break down ministerial silos and make government work more efficiently.The importance of linking clinical services and public-health action at thegrassroots has practical implications for how local PHC teams are composed, andhow frontline PHC practitioners are trained. Bringing primary care and publichealth together means integrating epidemiologists and disease control specialists,nutritionists, pharmacists, social workers, and community health workers intoexpanded primary health care teams. Bringing collaborators with these skill sets tothe PHC front lines can avoid placing the main burden for managing multisectoralpartnerships on overworked clinicians. Multidisciplinary PHC teams can becomposed, trained, empowered, and compensated to advocate with other sectorsfor healthy public policy and interventions.67Providing the PHC team with capacities and incentives to connect with the empaneled community in a proactive manner further enables multisectoral work at community level. This will allow teams to more accurately track the prevalence and distribution of the main illnesses in the community. It also enables the team to gain understanding of local health determinants, for example lifestyle and behavior patterns, that can be targeted with customized multi-disciplinary action. Proper undergraduate, graduate, and in-service training to raise awareness and build competencies for the latter is key, as are the communication skills and the financial and non-financial incentives for high performance.167 Finally, following the principle that “You manage what you measure,” an expanded accountability framework for health outcomes can facilitate multisectoral initiatives by incorporating outcomes that depend on changes in health determinants, not just on the results of clinical interventions. A framework that highlights outcomes that are sensitive to behavioral change may be especially useful.Multisectoral stewardship in PHCWhile the bottom-up, community-driven dynamic is important, the success and sustainability of local multisectoral initiatives ultimately depend on support from central government. Human, financial, and other resources directed from higher levels of the state to support local efforts can make the difference between promising pilot projects that fade and models that maintain their momentum, steadily improve their procedures and results, and can be taken to scale.WALKING THE TALKConditions for success include values and principles supportive of multisectoral action in PHC, governance structures that reflect them, and leaders who are willing to invest the necessary resources. Ideally, this includes central institutions able to adopt a whole-of-government approach.The most ambitious efforts to advance health goals across sectors involve new partnerships and ways of working at the ministerial level. This in turn requires top health leaders to exercise stewardship in driving these high-level efforts politically. This corresponds to a key dimension of health-system stewardship as defined by WHO: “Beyond the formal health system, stewardship means ensuring that other areas of government policy and legislation promote - or at least do not undermine - peoples’ health.”168In the case of multisectoral action linked to PHC, stewardship is a challengingpolitical art that involves setting ambitious but winnable goals at the centralgovernance level, while ensuring that high-level decisions are informed by theneeds and aspirations of local communities. To practice this art, health leadersneed to persuade partners in other government departments that those partners’own agendas will be served by the results that multisectoral action can bring. Inother words, they need to offer plausible perspectives for “win-win” outcomes.In this sense, stewardship for multisectoral action in PHC involves a distinct68understanding of leadership in health:...to practice this art, health leaders need to persuade partners in other government departments that those partners’ ownone based not on top-down, commandand-control authority, but on partnership building, shared decision making, and the capacity to set policy directions that can align the interests of varied stakeholders, including lowincome and vulnerable communities.agendas will be served by the results...Multisectoral stewardship becomes increasingly vital in the new health ecosystems where globalization,urbanization, population mobility, andageing are prominent. In this context, disease burdens are increasingly driven byfactors including poverty, poor quality of diets, inadequate access to education,and disenfranchisement due to stratifiers such as ethnicity, gender, and rurallocation, among others. These determinants powerfully shape the growing burdenof noncommunicable diseases, in particular. Such shifts in health and healthcareneeds cannot be tackled solely at the point of service delivery, but require actionon distal and proximal determinants of healthy living.CHAPTER 3: REIMAGINED PHCBOX 8. WHAT HAS TO CHANGE: SECTORAL SILOS INHIBIT COLLABORATIONThe structural, social, and behavioral determinants of health span sectoral boundaries; likewise, improved physical and mental health offers cross-sectoral benefits. Housing, traffic, environment, and education policy, among many others, have an important role to play in tackling leading causes of mortality and morbidity. Yet government ministries and the health system are poorly constructed for effective cooperation. Siloed financing flows, organizational hierarchies, and lines of accountability disincentivize joint action. Non-health ministries are tasked with achieving sector-specific goals and granted sectorspecific funds; they may discount the health value of an intervention if it does not relate to the ministry’s core business. The converse also holds true; an over-medicalized health sector may not consider the entire range of non-health benefits offered by health system interventions. Both phenomena can lead to substantial underinvestment and allocative distortions.169 In emergencies, organizational siloes also slow and complicate the effort to mount an effective response, leading to unnecessary health losses.LMICs: The African region is home to only 3 percent of the world’s motor vehicles butaccounts for 20 percent of global road traffic deaths (272,000 each year), due to poorinfrastructure, inadequate vehicle safety standards, and a lack of legislation andenforcement to control speeding, drink-driving, and seatbelt/helmet use.17069HMICs: In China, where 52 percent of men are daily smokers, recent measures haveincreased cigarette taxes to 56 percent of total price—yet taxes are still far below WHO-recommended levels to deter tobacco use, and no complete smoke-free laws have yetbeen applied to public spaces, including healthcare facilities, schools, restaurants, orindoor workplaces.171HICs: In WHO’s European region, over a quarter of childhood asthma deaths and DALYs in children are attributable to poor housing quality (mold and dampness).172As demographic and epidemiological trends drive rising care demands and surging health care costs in many countries, leaders seek a new balance between health promotion, disease prevention, and curative services. Shifting the weight towards prevention and promotion would already enable short-term cost savings, and it is the only way to ensure health systems’ financial sustainability in the longer run. PHC is the platform to make these changes work. PHC’s importance for multisectoral and whole-of-government action will grow as multi-sectorality evolves from predominantly technological interventions in areas like water and sanitation, food security and the food supply chain, and transportation to engage problems driven by complex behavioral determinants, where technology alone will not provide solutions. The costliest of these problems in economic and public-health terms include smoking, poor diet, obesity, harmful alcohol use, and interpersonal violence. Accordingly, some of the most successful recent examples of “win-win” multisectoral policymaking involve measures such as raising excise taxes on health-damaging products, notably tobacco.173*****WALKING THE TALKThis chapter has discussed broad directions for policy action to adapt PHC systems to countries’ new health care ecologies. Fundamental directions include: moving from a gate-keeping model of PHC to a focus on quality, comprehensive care for all; reconnecting fragmented delivery mechanisms around person-centered care; building fairness and accountability into the system’s deep structures to reduce inequities; and making PHC more resilient to future emergencies while boosting its contribution to system-wide crisis response. The chapter has also noted growing interest in some whole-of-government policy models to advance pro-health action across sectors, locally, nationally, and globally.These shifts resonate strongly with other recent proposals for PHC reform and in many cases reflect principles and policy objectives articulated by PHC leaders and implementers throughout PHC’s history. The critical question, now as then, is how these high-level policy directions can be translated into action in countries, especially where health resources are constrained. This chapter has contributed on that question by identifying drivers for each broad shift in PHC. Drivers represent entry points for policy action. However, the diversity of levers raises the problem of how countries can best sequence and coordinate their use. The next chapter takes up the “how” issues that countries will face in setting out to improve PHC. It contains no simple recipes, but it describes a suite of coordinated actions that countries can use to move forward. 70CHAPTER 3: REIMAGINED PHCPHC’s importance for multisectoral and whole-of-government action will grow as multi-sectorality evolves from predominantly technological interventions in areas like water and sanitation, food security and the food supply chain, and transportation to71engage problems driven by complex behavioral determinants, where technology alone will not provide solutions. The costliest of these problems in economic and publichealth terms include smoking, poor diet, obesity, harmful alcohol use, and interpersonal violence.”WALKING THE TALKChapter 4MAKING IT72HAPPENCHAPTER 4: MAKING IT HAPPENThe previous chapter described four high-level shifts to strengthen PHC services. This chapter presents evidence from many countries to show how these shifts can happen— and are already happening—in practice. While large gaps in the evidence base persist, knowledge is available to guide priority reform actions to bring these shifts about in the postCOVID-19 context.This chapter focuses on three priority reform agendas. One concerns the organization of PHC services at community level and in relation to the wider health system. The heart of this agenda is creating a multi-disciplinary team architecture for PHC delivery, tailored to countries’ priorities and available resources. The second reform axis concerns the changes in medical training and health workforce policies needed to support multi-disciplinary PHC practice. The third priority reform area is PHC financing.The chapter is organized according to the framework in Table 1 (page 74). Itrelates the four high-level shifts and outcomes discussed in Chapter 3 to the threepriority reform agendas. Using this framework, this chapter explains how each73of the reforms contributes to advancing each of the four shifts to improve resultsin PHC.174 The chapter unpacks the framework step by step, describing the policyand implementation challenges countries face in each area and summarizing theevidence on practical solutions.WALKING THE TALKTable 1. Reimagining a PHC fit-for-purpose: outcomes and priority reformsMultidisciplinary Team-Based Organization1. From Dysfunctional Gate Keeping to Quality Comprehensive Care for AllMultidisciplinary teams align clinical services to meet full range of local health needs. Clinical services address acute illnesses and injuries and manage chronic conditions, including mental health needs. Teams expand community health education, health and nutrition promotion, and disease prevention.74Multidisciplinary teams build long-term trust2: From Fragmentation to Person-Centered Integrationwith empaneled communities; collaborate and communicate internally; and coordinate patients’ movement through the health system and backto the community.“WHAT?”: OUTCOMES3: From Inequities to Fairness and AccountabilityEmpanelment creates accountability for health outcomes. Financing and other mechanisms reinforce accountability. Team composition reflects local health and healthcare needs and socio-economic determinants. Both patient and health outcomes are embedded in the accountability framework.4: From Fragility to ResiliencePHC teams include public-health surveillance and outreach capacity. Team structure helps buffer provider absences. Service-delivery organization and leadership ensure team capacity to manage the unexpected.CHAPTER 4: MAKING IT HAPPEN“HOW?”: PRIORITY REFORMSMulti-Professional Health Workforce DevelopmentMulti-professional health education builds generalist knowledge, skills, and competencies. Curriculum and practicum reforms facilitate creating multidisciplinary PHC teams.Resource Mobilization for Public-Health-EnabledPrimary CareAllocation of financial and human resources is based on evidence of local disease burden, socio-economic conditions, and demographic characteristics. Financing rewards community engagement and supports a tailored essential service package including primary care and public health.Multi-professional education emphasizes “soft”Data and IT platforms enable telehealth75functions and support electronic healthskills to promote shared medical decision making;empower patients for self-care; contribute torecords for the empaneled community.patient satisfaction; and support teamwork andEHR smoothly exchange data with therest of the healthcare system, and userscare coordination.can access records confidentially.Reformed multi-professional education creates a culture of transparency and social accountability through leadership and team-based performance. PHC teams serve communities without discrimination based on gender, ethnicity, income, sexual orientation, or other factors.Priority-setting through a fair, participatory, and transparent process ensures that the essential service package is equitably and efficiently delivered to all. The service package takes account of socio-economic determinants of health and is not subject to ad hoc or geographic rationing.Health workforce training prepares multidisciplinary PHC teams to prevent, detect, and respond to health emergencies. PHC teams are an effective first level of health-system preparedness and response.Financial and human resource surge capacity is built into health sector planning and resource allocation at the local level.WALKING THE TALKPriority Reform 1: Fit-for-purpose multidisciplinary team-based organization1.1 From dysfunctional gate keeping to quality, comprehensive care for allDedicated multidisciplinary teams for community and primary care: the backboneof a modern PHC Informed by international evidence (Box 1), team-based caremodels are quickly emerging as the preferred PHC service delivery platform,forming the backbone of a PHC system that offers integrated, responsive,continuous, and community-oriented care. Team-based models offer additionalhuman resources, a more robust mix of skills, and a stronger mandate to providea universal, comprehensive package...local teams feed intoof PHC services to an empaneledpopulation.larger clusters that form amore expansive network of Under this model, a dedicated multidisciplinary team of healthservices while maintaining service providers—headquartered at76a team orientation.a PHC hub facility but reaching outactively into the community—workscollaboratively to serve a clearlydefined catchment population. These local teams feed into larger clusters thatform a more expansive network of services while maintaining a team orientation.Specialized services may be located at different nodes in the network rather thanall in one large center. Regional/urban hospitals and specialists assist and supportthe local PHC health team by supplementing the scope of clinical services andoffering continuing education and professional development.CHAPTER 4: MAKING IT HAPPENBOX 9. WHY TEAM-BASED CARE?Multidisciplinary care teams for empaneled populations have been endorsed as the preferred PHC service delivery platform by WHO,175 OECD,176 and UNICEF.177 Intuitively, team-based models offer several advantages over individual providers or less integrated networks. First, the multidisciplinary nature of the team allows for an efficient and appropriate division of labor, with different provider types deploying their complementary skills and competencies to meet the full (and increasingly complex) health and wellness needs of individuals and families. Second, the team offers a supportive and accountable structure for management and supervision. Team members offer each other coaching, encouragement, mentorship, and discipline, while the team as a whole can be held responsible for the health outcomes and satisfaction of the empaneled population. Third, through empanelment to a dedicated care team, individuals and families can build long-term, trusting relationships with their health providers, with continuity of care further enhanced through complete and accessible health records. Finally, team-based organization may offer some structural efficiencies, for example lower overhead, built-in critical mass for quality assurance and improvement, and lower administrative costs.Though the evidence base on multidisciplinary collaborative care is surprisinglysparse,178 emerging evidence appears to confirm these intuitions. A literature reviewon interprofessional collaborative practice identified 20 relevant studies, cumulativelypointing to improvements in chronic disease care, better medication adherence, reduced77hospitalizations, and cost savings.179 Systematic reviews have found that the US-basedPatient-Centered Medical Home (PCMH)—a multidisciplinary team-based modelemphasizing patient-centered, coordinated, and comprehensive care—improvespatient experience, care processes, and clinical outcomes for chronic disease.180,181 Thedeployment of primary care teams within several centers in Canada, based on the PCMH,has been linked in several small studies to less frequent visits to emergency departmentsand reductions in avoidable hospitalization.182 In Brazil, expansion of the Family HealthStrategy team-based care model has been strongly associated with reductions in childmortality and (somewhat more tentatively) linked to reductions in hospitalization forconditions amenable to primary-care-based prevention.183 Several countries in Europeand Central Asia adopted multidisciplinary team-based care models under a family-centered PHC approach in the 1990s.184Patients are assigned (“empaneled”) to dedicated PHC professionals who facilitate access to comprehensive PHC services and coordinate care with the other levels of the health system. Empanelment promotes more proactive management of patients’ and communities’ needs by assigning responsibility to providers regardless of whether the patient seeks care.WALKING THE TALKThe PHC team: roles, composition, and catchment areaAt the local level, the core PHC team consists of at least three categories of members working collaboratively—community health workers (CHWs), registered nurses (RNs), and general practice/family medicine specialists (FPs). Beyond these three core provider types, expanded team-based care models may include other specialized providers, including midwifes, dentists, optometrists, pharmacists, nutritionists, social workers, auxiliary health professionals such as laboratory and radiology technicians, and mental health counsellors, as well as administrative support staff.The PHC team works together in a community clinic setting that provides the fullrange of ongoing community-level care. This includes public-health programs(immunizations, screening, health promotion, and preventive care), as well as allfirst-contact health care for acute and chronic health problems. Mental healthcare and first response to emergencies are provided for the entire empaneledpopulation. The PHC team has primary responsibility for referrals to higher levelsof care, including information-sharing and follow-up after a specialist consultation.Optimal team-based care models require clear role delineation and well-definedscope of practice—both to ensure efficient use of scarce physician time and toensure low- and mid-level cadres deliver care appropriate to their level of training78under supervision.Within this general approach, the specific composition of the care team and the size of the catchment population vary between and within countries and will necessarily reflect local health needs and resource availability. There is limited rigorous evidence to guide optimal construction of the primary care team; however, case studies have highlighted the importance of clear delineation of responsibilities. Different health systems have taken different approaches to construction of care teams and assignment of tasks (Table 2). In Costa Rica, primary health teams (called the Equipos Básicos de Atención Integral de Salud, or EBAIS) consist of a doctor, nurse, CHW, and pharmacist, each with a clearly defined role and set of responsibilities.185 For example, CHWs perform home visits to deliver health promotion and household screening; nurses undertake basic clinical tasks and counselling; and physicians lead management of acute and chronic conditions. In Thailand, primary health “matrix teams” consist of four care providers working at different levels within the health system: a family doctor (district hospital level), nurse (sub-district level), community health worker (village level), and family member/caregiver.186 Recognizing the complexity of community support for chronic disease management, other models have sought to broaden the primary health care team to include allied health practitioners, or to support greater integration with social services. From 2008, for example, the Brazil FHS introduced Family Health Support Centers (NASF), where interdisciplinary teams (including psychologists, for example) deliver extended care to support the family health team.187CHAPTER 4: MAKING IT HAPPENTable 2. Team-based care models around the worldDESCRIPTIONCATCHMENT POPULATIONTEAM COMPOSITIONBrazilThe Family Health Program, launched in 1994, created Family Health teams (FHTs) responsible for the health of residents in a defined territory, including health promotion, education, and control of neglected tropical diseases. By 2015, the FHS covered 63% of the Brazilian population (almost 123 million individuals). Substantial evidence shows the program has improved health outcomes and system efficiency.188 189 190 191Maximum 1,000 households (4,000 residents)At minimum, a physician, nurse, nurse technician, and four to six full-time community health agents. Additional incentives are available for adding other team members, including oral health workers, physiotherapists, and managersCosta Rica192Costa Rica’s Basic Teams for Primary Health Care (EBAIS) began operating in 1994. As of December 2018, the country is organized in 7 regions, 106 health areas, and 1,048 PHC teams. Each PHC team offers health promotion, prevention, treatment, and rehabilitation.Varies according to availability of personnel, sector population, budget and other variables. As of end-2018 an average of 4,474 inhabitants (range: 2,343-7,480) were assigned per PHC team.At least one medical doctor (GP), one nursing assistant, and one technical assistant in primary care.Healthy living centers, introduced in 2017,HLC manager, physician,Turkey193provide multidisciplinary services across health promotion, prevention, and disease management. Healthy living centers complement the family medicine system; family medicine physicians can refer theirAbout 200 HLCs across Turkey each serve a population of about 75,000.dentist, nurse, midwife, medical secretary, social worker, dietician, child development specialist, psychologist, care79patients onward to receive their services.coordinatorOntario (Canada)194Relatively generous capitation-based payment packages encourage family doctors to join Family Health Team group practices. (Some, including the provincial government, now argue that capitation rates were set too high and have resulted in unsustainable overpayment of family medicine physicians.)195Patients voluntarily enroll with Family Health Teams and agree to use their designated provider for all local, non-emergency care. 184 teams currently serve 3 million Ontario residents (about 15,000 patients per practice team).Varies. Typically includes at least doctors, nurse practitioners, and nurses. May also include social workers, dietitians, and other health workers.South AfricaWard-Based Outreach Teams, established in 2020, are linked to PHC facilities and intended to extend care into the community.250-400 households per CHW.196Team leader (typically a professional nurse) plus five or more CHWs.GhanaPreferred Primary Care Provider (PPP) Networks link several Community-based Health Planning and Service (CHPS) compounds to single hub, e.g., a health center or district hospital. Preliminary results suggest the program has improved referral feedback and service delivery coverage.19710 pilot networks (42 health facilities). Size of catchment population for each PPP network varies substantially (from ~5,000 to ~25,000).Varies substantially.WALKING THE TALKThe COVID-19 experience highlights additional roles and competencies that may be desirable within the primary care team—either as permanent members of the care team or as temporary surge capacity during emergencies. Basic laboratory capacity to support diagnosis and surveillance may be brought inhouse, or otherwise assigned to a cluster of PHC teams. PHC teams could also introduce public-health officers tasked with designing and leading public-health campaigns; performing syndromic surveillance and reporting within the catchment areas; and directing contact-tracing efforts during infectious disease outbreaks. A public-health officer should interface closely with the broader PHC team, his or her counterparts in neighboring catchment areas, and central public-health authorities.Empanelment and transition to multidisciplinary care teams in mixed health systemsThe transition from solo practice to empaneled multidisciplinary care teams can be complicated—particularly in mixed health systems, where care is fragmented across a variety of public-sector, for-profit, and not-for-profit private providers. Empanelment, in particular, is often understood as a top-down, public-sector process (for example, applied on a geographic basis); however, alternative empanelment strategies can incorporate private-sector providers.80Geographic empanelment is easily understood in the public-sector context,wherein each public-sector team serves a population within a defined geographiccatchment area. In mixed health systems, it requires a public-private partnershipdesign where patients are identified and assigned to private multidisciplinarycare teams (for example, provider networks) using existing geographic catchmentareas or municipal boundaries, typically as part of a publicly financed strategicpurchasing or contracting arrangement for underserved jurisdictions.198,199 Forexample, Local Health Integration Networks (LHINs) are community-based non-profit organizations that receive funding from the Ministry of Health in Ontario,Canada, to plan, fund, and coordinate public health care services delivered byhospitals, long-term care homes, community care access centers, communitysupport service agencies, mental health and addiction agencies, and communityhealth centers. The LHINs conduct extensive needs mapping of subpopulations ina particular geographic or catchment area (for example, the elderly, the homeless,refugees, immigrants, and the LGBT community) through focus group sessions thatallow the LHINs to identify challenges leading to shortfalls in the health outcomesof these subgroups relative to the rest of the population. Once LHINs identifygaps, they tender requests for proposals from private local health care providers,offering them government funding to provide the missing health care service inunderserved geographies. LHINs outline clear expectations for these contractedhealth care providers to use various team-based care models, which are reinforcedby performance measurement and evaluation systems that are transparent tothe public.200,201CHAPTER 4: MAKING IT HAPPENInsurance-based empanelment involves arrangements where patients are assigned or opt into accredited public or private provider networks or care teams based on their enrollment in specific insurance schemes that may be public (social or national health insurance schemes) or private (for example, through health management organizations).202 The insurer may have a gatekeeping scheme in place that can be used to support the development and implementation of clinical pathways and dual referral systems.203 They may also encourage and incentivize promotive and preventative care through payment models including partial or full capitation or fee-for-service models, among others. This can be coupled with incentives to better use data and patient records for more proactive population management across specific patient populations.204In the United States, for example, patients benefitting from Medicare (a publiclyfinanced insurance program for the elderly) can opt to join an accountable careorganization (ACO), which would subsequently be responsible for the patient’swhole-of-person care and health outcomes—including through financialincentives.205 In Thailand, individuals covered by national health insurance arefree to choose which primary care provider they wish to register with. Providersare then paid on a capitated basis, and patients have four opportunities eachyear to change their provider network, facilitating an element of patient choice,provider accountability, and portability for seasonal migrants. In practice,however, choice in most rural areas is limited by geographic monopoly, as only a81single provider is available within the geographic area.206 In Nigeria, the Hygeiahealth management organizations offer patients access to services through acorporate network of 1,608 hospitals and clinics. The network of private hospitalsand clinics are bound by a capitation model, incentivizing them to provide primary,preventative care through multidisciplinary care teams to a large segment of theNigerian population.207Finally, where population-wide empanelment is not possible in the immediate term, interim policy measures can help make incremental progress toward a teambased care model, for example by incentivizing provider collaboration or forming and integrating networks of individual providers. Private-sector intermediary networks can organize private, independent health care providers and facilities into quality-assured networks of multidisciplinary teams. The networks connect small-scale private providers to interact with governments, patients, and vendors while performing key health-system functions that are challenging for individual private providers to accomplish on their own, for example proactive population management, quality improvement, management capacity, and integration into payment systems and universal health coverage.208Examples abound across highly diverse contexts. In a German pilot project, for example, a third-party health management company works in conjunction with the statutory private insurance companies and providers to offer population-based, integrated care across a specific catchment area; the program is financed by costsavings realized by the insurance providers. The program has improved patient experience and population health outcomes while reducing hospitalizations andWALKING THE TALKhealthcare costs.209,210 In Ghana, where individual Community-Based Health Planning and Services health centers still struggle to provide full PHC services due to lack of infrastructure, medicine, supplies, and human resource capacity, a pilot project (the Preferred Primary Provider Network) links four to five small CHPS zones (spokes) to a larger, more capacitated health center (hub)—thereby forming a decentralized group practice.211 In France, the Communautés Professionnelles Territoriales de Santé program connects geographically proximate health providers into a collaborative network with the “overall objective…to progressively eliminate solo primary health care practices that are often associated with isolation.”212In some settings, where dedicated care teams are not yet the norm, narrowlyconstructed care teams have been stood up to support patients with specifichealth needs. In Kazakhstan, for example, pregnant women are supported by amultidisciplinary team that includes social workers and psychologists in addition tohealth professionals; financial incentives help reinforce strong team performanceas evidenced by maternal and newborn health outcomes.213 Multidisciplinarycare teams are the preferred standard of care for HIV; in the US, inclusion ofpharmacists, care coordinators, social workers, nurses, and non-HIV primarycare providers within the team have been associated with higher adherence toantiretroviral therapy,214 while extensive international evidence associates inclusionof a pharmacist specifically with better adherence and clinical outcomes.215 In the82long run, these teams would ideally be “de-verticalized” from a single disease area/health need and integrated with generalist primary care for all health needs acrossthe life course.1.2 From fragmentation to person-centered integrationEmpanelment to dedicated care teams: a strong foundation for care continuityThe literature distinguishes between three types of care continuity.216 Informational continuity refers to providers’ accumulated understanding of patient history, values, and preferences; such information can be vested in provider memory, written or electronic medical records, or some combination of the two—but it must be easily accessible and applicable at the point of care. Management continuity refers to the coherent and coordinated planning and execution of patient care for complex or chronic disease. Relational continuity, in turn, refers to established interpersonal relationships between specific providers or care-teams and the patients they serve.217Empanelment to dedicated care teams provides a strong foundation for all three types of care coordination and continuity. The effects span patients’ health needs and life course, both within PHC service delivery and across the health system. Empanelment enables continuity by creating a single PHC hub for each patient’s care and disease management; offering an opportunity to build trusted longterm relationships with PHC providers; and building both written and informal repositories of information about patients. This matters because patients withCHAPTER 4: MAKING IT HAPPENaccess to continuous care have been shown to receive better quality care,218 report higher satisfaction with health services,219 and incur lower health expenditures.220 In the United States, increases in the continuity of care have been linked to reductions in the utilization of specialist care,221 reductions in hospitalizations and emergency department use,222 as well as reductions in medical errors.223 In Brazil, in areas with stronger PHC systems, a greater proportion of the population reported having a usual source of care, particularly in the poorest regions in the North and Northeast.224For obvious reasons, care continuity is enhanced by retention of care providers, and compromised by staff (or practice) attrition. High-staff turnover has been shown to reduce the probability of receiving preventive care services, weaken the coordination across different levels of care,225 and lower patient satisfaction scores.226 PHC disruptions due to the retirement of primary care practitioners also led to declines in the use of PHC services and increases in the number of medical tests and hospitalizations.227 In Denmark, the closure of primary care practices has been linked to increased utilization of emergency care,228 suggesting challenges in the transition of patients to new PHC providers.When team-based networks function optimally, non-emergency access tohigher levels of care is based on referral from local PHC teams. PHC teams areaccountable for prompt and appropriate referrals based on a patient’s health83needs and their informed clinical judgment. In turn, regional referral centers acceptresponsibility and accountability for health outcomes within their catchmentareas; they willingly receive requests for assistance and transfers when judgednecessary by local care and take responsibility for communicating the results ofa referral back to the PHC team. This approach fosters respectful and trustingrelationships between PHC team members and specialist service providers. Thisis a true collaborative health-system model that endorses the pre-eminence ofcost-effective local comprehensive PHC services and preserves high-cost specialistservices for those who need this level of care. It also recognizes and values theexpertise of local PHC teams and their communities as being of equal value to thespecialist expertise in regional referral center.Better two-way referrals: from primary care to specialists, and back into the communityThe most effective PHC systems operate not as dysfunctional gatekeepers—a chokepoint before patients can access “real” care from secondary and tertiary providers—but as traffic dispatchers, triaging patients across different levels of care in an agile manner and in accordance with their health needs. The care coordination function helps direct patients to the appropriate care providers within the PHC team, and, as necessary, external specialists. Equally important, it tracks the results of specialist consultations or hospitalizations and ensures appropriate follow-up care upon return to the community.WALKING THE TALKIn some cases, specialist providers may physically co-locate with a PHC team on a part- or full-time basis. In theory, physical co-location of general practitioners with specialist providers extends the benefits of the PHC care team to a broader range of care—helping streamline referral processes, integrate medical records, and create better continuity of care across multiple types of health providers. In Canada, for example, a primary care physician can refer patients to a mental health counselor and/or psychiatrist, who are preferably physically co-located; the different providers then work collaboratively to provide whole-of-person care for low-acuity mental health needs.229 Cross-country survey data in OECD countries finds highly variable rates of co-location between general practitioners and other health professionals; rates of co-location can be as low as 5 or 6 percent (Slovakia, Germany, Denmark, Czech Republic) and as high as 90–99 percent (Iceland, Lithuania).230 Evidence on the results of co-location is limited and mixed. Analysis of survey data suggests that co-location of general practitioners with specialists, midwives, physiotherapists, dentists, or pharmacists is significantly associated with improved coordination with secondary care; however, in countries with weak primary care systems, co-location is significantly associated with worse patient perceptions of care continuity, accessibility, and comprehensiveness.231Some LMICs currently lack capacity to rapidly create dedicated PHC teams ableto work with and track individuals across the life-course. In these settings, end-84to-end same-day services across diagnosis and treatment may offer a stop-gap to increase referral completions and limit attrition. Studies show potentialapplications of same-day services to eye care and diagnosis and treatment ofsexually transmitted infections; however, the approach has not been systematicallyevaluated and may be difficult to finance and integrate within routine services. InIndia, outreach camps provided by the philanthropically-funded Aravind Eye CareSystem offer comprehensive eye exams and same-day provision of nonsurgicaltreatment (for example, glasses or a medicine prescription); patients in needof cataract surgery or other specialty services are counselled and transportedto a nearby hospital for immediate admission.232 In Cameroon, a pilot study forcervical cancer screening returned test results for the human papillomavirus (HPV)within one hour of sample submission, offering same-day coagulation treatmentto eligible patients; loss to follow-up was only 1 percent.233 A similar approachin Tanzania yielded promising results for diagnosis and treatment of syphilis;testing for syphilis jumped more than 12-fold, treatment rates for diagnosedcases increased from 46 to 95 percent, and women reported savings as a result ofaverted transportation costs.234When specialist services are not co-located or provided as integrated single-day services, technological solutions can play a useful role in strengthening referral processes. Though evidence is limited, a few available studies suggest that direct appointment booking services, typically over an online portal, have been associated with substantial reductions in the waiting time for non-urgent specialist services, though not with cost reductions.235 Such platforms are increasingly being adopted at scale within countries in the OECD. In the United Kingdom, all National Health Service providers were required to adopt an e-referral system for specialistCHAPTER 4: MAKING IT HAPPENconsultations (e-RS) by October 2018; the platform enables patients to book a specialist appointment from their general practitioner’s office at the time of referral, or to do so from their personal computer after returning home.236 An initial pilot study suggests that the new system can reduce waiting times for a specialist appointment by an average of eight days.237Electronic consultations (e-consults), defined as “asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform,” can allow general practitioners to directly access specialist expertise and avoid in-person referrals unless necessary.238 Evidence shows generally high provider and patient satisfaction with e-consult platforms; shorter wait times than for traditional in-person referrals; a reduction in face-toface specialist appointments; and potential for reduced cost.239 There is limited rigorous evidence for the effect of e-consults on health outcomes.240Alternatively, telemedicine can allow patients to remotely access medical servicesand complete referrals from the PHC provider—particularly for specialist servicesthat may not otherwise be locally accessible. These initiatives are still largelyunderdeveloped within LMICs, with many nascent (often donor-funded) effortsbut few sustained programs.241 A rare scaled and sustained use of telemedicineis in Brazil, where some states have routinized remote ECG testing, chest x-rayanalysis, and ultrasounds as part of the national Family Health Program.242 By85end-2015, just one Brazilian state had performed almost 2.5 million remote ECGsand 74,000 teleconsultations. Over a five-year period, the state reported netUS$11 million in cost savings.243 In addition, a handful of LMIC telehealth networksfor humanitarian purposes have been sustained at least five years, in some casesoffering general remote consultation for all specialties and in others offeringtargeted support for dermatology, HIV, or trauma. However, evidence in supportof these initiatives is limited.244 Elsewhere, feasibility studies suggest potential,though not scale or sustainability.245Where routine care coordination processes are lacking, dedicated patient navigators can also help patients engage with a complex web of health services. A systematic review defines the patient navigation approach as “trained personnel”—potentially nurses, social workers, community health workers, or volunteers—”who help patients overcome modifiable barriers to care and achieve their care goals by providing a tailored approach to addressing individual needs.”246 Patient navigation services can be quite wide in scope, encompassing all aspects of clinical, logistical, administrative, and emotional support, typically for chronic or life-threatening conditions like cancer.247 The current evidence base is incomplete, but generally suggests that patient navigators can be associated with more complete screening; faster diagnostic resolution; better mental health and quality of life among patients and their caregivers; lower A1C levels among diabetics; and higher clinical attendance and treatment adherence.248WALKING THE TALKIT and digital platforms for integrated careMore developed integrated care and payment models, including those from OECD countries, require interoperable data systems between specialists, hospitals, primary care settings, social service providers and patients. These systems are often in their infancy in LMICs, with several limitations that prevent such platforms for realizing their full potential. First, fragmented donor-supported initiatives and vertical programs have driven a proliferation of health data systems and digital platforms, often with overlapping mandates or scope but limited interoperability and coverage, including for patients who seek care in the private sector. Second, health management information systems (HMIS) typically only capture service delivery data from patients who proactively seek care at a facility equipped to record and report the appropriate data. This excludes individuals within the catchment area who do not visit such a health facility. Third, HMIS typically digitize health data at the district level and do not include patient-level electronic health records with unique patient identifiers, making it difficult to trace patients through the system and from facility to facility.While country information exchange policies can support or detract fromsystem effectiveness (see Box 2), countries can take incremental data-informedapproaches toward more coordinated, transparent, and accountable primary86health care even where data is limited. Data management and storage, patientdata security assurance, and reliable offline and back-up systems suited to low-and lower-middle income countries must all be considered during the design phaseof a digital solution.249BOX 10. HARNESSING TECHNOLOGY TO IMPROVE INFORMATION SHARING IN PHCA recent survey of 13,000 primary care providers across 11 high-income countries – Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States – compares experiences in care coordination between providers and the use of health information technology. Seventyfour percent of physicians in Germany and 65 percent in the U.K. said they frequently coordinated patients with social services or other community providers. In contrast, only about four of 10 in Australia, the US, and Canada reported the same. This is in part because, despite the presence of electronic information, primary care practices in the latter countries are not yet routinely exchanging information outside the practice, while Germany, the U.K. and some other countries have higher levels of interoperability and a two-way exchange of information.250 Even countries that have improved their information-sharing capacities and practices still face challenges. In the U.K., lack of interoperability led to the NHS failing to invite 50,000 women for a cervical screening test.251 Additional promising innovations are underway. Estonia has introduced Blockchain for medical records, allowing patients to access their own medical records and to effectively become active agents in their own care.252 While this application of Blockchain is still in its infancy, the technology may help overcome problems of interoperability and better track health epidemics.253CHAPTER 4: MAKING IT HAPPENWhile integrated data platforms are essential to improve care coherence and enhance patient experience, health data protections and informed consent for the use of personal data are also important. Without strong protections in place, patients may not know how their data is used, the extent to which it is deidentified, who has access to their confidential clinical data, or how public and private providers share sensitive data. Under these conditions, patients are not in a position to determine how their data should be used and to refuse its use for purposes they are not comfortable with. Appropriate regulations should include safeguards that limit how governments link and access clinical data from outside the health sector. Data protection regulations should guard against potential abuses with a clear mandate for an independent body to act as a data steward.At the PHC facility level, data and measurement systems need to be part ofa larger continuous quality-improvement process. Simply having data is notsufficient to improve performance. Team-based network managers must havethe capacity to analyze the data, review performance regularly, and adaptcare processes as needed.254 Facility managers need to strike the right balancebetween collecting the appropriate data and avoiding the administrative burdenon providers that can result from obligatory data reporting.255 Performancemeasurement and management requires establishing targets, monitoringperformance against those targets, and implementing and adapting improvementefforts. Sharing data with staff as part of a continuous quality-improvement87cycle allows countries to move away from inspection and punitive arrangementsto a culture of problem-solving and active collaboration between providers,supervisors, and team members.256 A variety of performance measurement andmanagement tools are available to help with this.257,258,259,260,2611.3 From inequities to fairness and accountabilityExtending care into the community to address health disparitiesWith support from community health workers, the PHC team offers care that extends beyond the static clinic into communities. Proactive frontline strategies can help address disparities in health outcomes by supporting basic health education and promotion; offering nutritional coaching and supplementation; identifying subclinical illness; and helping sustain adherence to treatment, among other strategies. In Brazil, community heath agents are each assigned around 150 households for monthly visits, during which they offer health promotion and support basic health care.262 In Costa Rica, CHWs within broader multidisciplinary teams calculate risk scores for individual households in their catchment areas; these scores are used to determine the frequency of future in-person visits.263 South Africa’s “ward-based outreach teams” (WBOT) likewise consist of a nurse team manager and 5-6 CHWs, all linked to a fixed primary health center, who conduct health promotion, active case finding, and doorstep care within communities. Preliminary reviews of the program have shown significant increases in measles immunization coverage and reductions in severe diarrhea cases inWALKING THE TALKregions served by outreach teams, though formal evaluations are still needed.264,265 In an uncontrolled study in peri-urban Mali, daily door-to-door case detection by CHWs appeared to help double early treatment of malaria, nearly halve the rate of febrile illnesses, and reduce under-5 mortality.266 Pilot studies also support the feasibility (though not necessarily cost-effectiveness) of proactive screening strategies for chronic and more complex diseases: for example stroke detection in Karachi, Pakistan;267 cancer in New Delhi, India;268 and cardiovascular disease risk across four LMICs,269 often led by CHWs.Increasingly, active outreach strategies can be supported by mHealth applications, helping identify chronic conditions even when qualified personnel are unavailable— and potentially helping increase cost-effectiveness of active case finding strategies. In South Africa, for example, CHWs deployed a smartphone-based application (hearScreenTM) to identify adults and children with hearing deficits, subsequently referring them for specialist attention.270 In Madagascar, a cervical cancer screening program used smartphones to take snapshots of the cervix and email the images to remotely located specialists.271 Such strategies have high upside potential in urbanizing centers, where mobile phones are common and network coverage is strong, but current evidence is largely limited to small-scale pilot and efficacy studies.27288Marginalized communities, or individuals facing potential diagnosis of astigmatized disease, may be more likely to receive needed care when they canaccess health services directly within their communities, or even within their ownhomes. In Nigeria, for example, men who have sex with men were 9 times morelikely to accept HIV testing and counselling if the service was directly offeredby a member of the same community vs. referral to a health center; uptakewas 21 times more likely among injection drug users.273 Even for the generalpopulation, systematic review evidence suggests that uptake of HIV testing andcounselling services is far higher in community-based settings than within healthfacilities.274 Increasingly, health services can also target the virtual communitieswhere marginalized populations congregate. In urban China, for example, MSMvolunteers identified members of the MSM community through their profiles ongay social networking sites and recruited them to testing and counselling servicesvia chat rooms, instant messages, and emails.275 Internet-based outreach is stillin its infancy within LMICS, and scale-up will require careful consideration of theprivacy, rights, and safety of marginalized populations.The COVID-19 pandemic has highlighted the importance of proactive communitybased care and case management as a supplement to traditional, facility-based treatment, particularly in the context of limited inpatient capacity for COVID-19 patients and the importance of self-isolation to limit transmission potential. In the United States, the Cambridge Health Alliance (CHA) created multidisciplinary “community management teams” for remote management of high-risk COVID-19 patients (in addition to primary care teams for patients at low or normal risk); the teams check in with the patients regularly by phone or teleconsultation “at points in the disease process associated with significant changes in clinical course, includingCHAPTER 4: MAKING IT HAPPENfour, seven, and 10 days after symptom onset. Patients at highest risk receive calls daily, sometimes multiple times a day. This triage process reserves the respiratory clinic for severely ill patients who have developed dyspnea, or shortness of breath, and enabled CHA to manage most patients without hospitalization.”276 In a small sample of patients, the model was estimated to avert almost half of hospitalizations.277 In South Korea, where individuals who have been exposed to COVID-19 are asked to self-quarantine for two weeks, self-isolation is facilitated by deliveries of food and sanitation supplies, plus twice-daily check-ins from a dedicated case officer.278 In Vietnam, whose successful COVID-19 response has been widely recognized, the commune health station and village health workers played an essential role in raising community awareness about COVID-19 prevention; they also took on contact tracing and self-isolation monitoring on top of their routine responsibilities.279Empanelment and accountabilityThe empanelment process assigns a defined catchment population to a single,cohesive multidisciplinary care team. This process, in turn, creates a naturalstructure for accountability: the care team can be held accountable for the patientexperience and health outcomes of the empaneled population. The focus onwhole-population outcomes, versus patient experience among care seekers alone,reinforces an equity orientation, as PHC teams are held accountable for their89ability to engage, educate, and improve health outcomes even among individualsor families that may feel reluctant or unempowered to seek care, including thepoorest households and other marginalized populations. Care teams can beheld accountable at all levels—by the populations they serve; by their peers andcolleagues within the care team itself; and by payers and regulators at the regionalor national level.Within this general principle—that the care team should be accountable for the experience and outcomes of their empaneled populations—many different accountability mechanisms are available. These mechanisms can be modularly combined in various permutations to reinforce accountability at different levels and from different directions.First, timely data collection and benchmarking can increase PHC professionals’ and managers’ awareness and understanding of their own performance, empowering them to make better decisions. Providing insights into peers’ performance through benchmarking can further inspire emulation and positive reinforcement. In Costa Rica, for example, the Evaluación de la Prestación de Servicios de Salud (EPSS) offers a standardized benchmarking process across different health areas for dimensions of access, continuity, effectiveness, efficiency, and user satisfaction. PHC managers are assessed against targets and the performance of their peers, making them more accountable for their performance. To foster continuous quality improvements, performance targets are slightly increased each year, while health areas in the lowest quintile are required to develop remediation plans.280WALKING THE TALKSecond, public reporting on how different providers perform can help communities hold care teams accountable; they may also induce positive changes in healthworker performance to protect their reputations or to attract additional patients (if empanelment is on a choice or opt-in basis). Rigorous studies of public reporting systems are mostly limited to high-income settings, but systematic review evidence suggests that they are associated with consistent and significant reductions in overall mortality.281 With increasing mobile phone and internet access, web-based quality databases may be more applicable in middle-income countries; for a lowtech solution, performance data can also be posted on bulletin boards or in other public spaces. In China, such reporting has been shown to help reduce antibiotic prescriptions282 and improve rational use of medicines.283Community scorecards and citizen report cards are variants on public reportingthat directly engage citizens to hold health organizations accountable for theservices they provide. In Afghanistan, a community scorecard initiative based onstakeholders’ discussions about performance scores and participatory actionplans contributed to improvements in structural capacity indicators, such aswater and power supply, availability of essential medicines and equipment, andnumber and cadres of service providers.284 In Uganda, report cards were sharedwith citizens and PHC staff through village meetings; PHC staff and citizenrepresentatives worked together to identify strategies for improvement.285 The90intervention led to a 13 percentage point reduction in absentee rates, 12 minuteshorter waiting times, and a statistically significant reduction in the under-fivemortality rates.286 However, other evaluations on citizen report cards found partialor no results,287 suggesting that the impact of this social accountability strategydepends on its implementation.Finally, financial accountability mechanisms connect provider funding and remuneration to their performance. These mechanisms are considered in detail in Section 3.1.4 From fragility to resiliencePreparedness, resilience, and the multidisciplinary platformIntegrated, multidisciplinary team-based PHC platforms also offer important benefits for preparedness, response, and resilience in emergencies—most recently, the COVID-19 pandemic. These benefits can be broadly segmented into three categories.First, integrated and team-based PHC platforms can and should include explicit data collection, public-health, and surveillance functions, integrated with national systems. Syndromic surveillance and close coordination with national publichealth authorities can help identify and contain nascent outbreaks before they spread more widely. Experiences from SARS in East and South-East Asia, Zika in the Caribbean, and Ebola in West Africa, all showed that delayed detectionCHAPTER 4: MAKING IT HAPPENand reporting of cases due to poor surveillance contributed to the escalation of these epidemics.288 Many countries have relied on PHC for effective surveillance and contact tracing during the COVID-19 pandemic, especially coupled with community health workers; an integrated surveillance system appears to be the most important enabling factor. For example, Colombia, North Macedonia, and Vietnam have mobilized their information systems and integrated their COVID-19 surveillance systems with national information systems, with COVID-19 modules included and utilized for surveillance and in contact tracing in certain instances.Second, established relationships and trust between the PHC team and communitycan enable effective communication and behavior change during an emergency.In Liberia, community education on preventive measures was among the mosteffective interventions to fight Ebola.289 During the Ebola and Zika epidemics,CHWs served as community-level communicators and educators, contributingto community health literacy in personal hygiene and other precautionarymeasures.290,291 Resilient PHC platforms can quickly adapt to increase thefrequency of communication, ensuring clarity on emergency status and preventionand treatment recommendations. In partnership with central public-healthauthorities, PHC teams’ deep knowledge of their catchment communities canhelp tailor communication strategies and messaging to the population’s specificconcerns and preferences, building trust, for example, by highlighting facility andhealth-worker adherence to safety standards and person-centered approaches91to care. In Bangladesh, Senegal, Colombia, Vietnam, and Guinea Bissau, PHCplatforms, including CHWs, have helped inform communities about COVID-19symptoms, transmission, and vulnerabilities; they have also helped to counteractsocial stigma. In Nigeria, 230,000 community health workers have been mobilizedto deliver messaging and outreach. In Vietnam, community health stationsand village health workers have played a crucial role in improving communityawareness and enhancing trust. During an emergency recovery phase, resilientPHC facilities can progressively scale-back communication efforts while ensuringcontinued clarity and transparency in communication about service procedures asthe emergency subsides.Third, team-based organizations may be better equipped than other organizational models to maintain essential services and prevent health-system breakdowns during a crisis. Team-based approaches may more effectively sustain continuity of care; demonstrate greater agility in task shifting and alternative service delivery; and offer a first triage point to take stress off overburdened hospitals. Building on the strong foundation of a community-centric healthsystem model to mount an effective response, Italy’s Veneto region was able to prevent overcrowding in hospitals for COVID-19. Authorities required effective and proactive public-health measures to be implemented in the earlier stages of the pandemic, including extensive testing of symptomatic and asymptomatic cases, proactive tracing of potential positives, a strong emphasis on home diagnosis and care, and priority for monitoring and protecting health care personnel and other essential workers. In North Macedonia, the family medicine system delivered most routine care while hospitals focused on COVID-19, including care coordination (forWALKING THE TALKexample, electronic prescription refills). Team-based organizations, enabled by technology, may also be more agile in quickly transitioning to alternative service delivery models, such as telemedicine and home-based care.Priority Reform 2: The fit-for-purpose multi-professional health workforceSection 1 of this chapter presented evidence on the benefits countries can expect if they implement multidisciplinary team-based care in PHC. We showed concrete steps countries can follow to apply this model. Under this form of care organization, patients benefit from dedicated teams of health professionals that offer whole-ofperson care in primary care facilities and extend that care into the community. Yet in many countries and communities, the PHC workforce remains insufficient—in headcount, deployment, competencies, orientation, and/or mandate—to make this vision a reality.In poorer countries, absolute shortages of health workers are common; thereare just 3 physicians and 11 nurses per 10,000 people in WHO’s Africa region,92compared to 34 doctors and 81 nurses per 10,000 Europeans.292 In wealthiercountries the health workforce is often rapidly expanding—yet primary careremains neglected, and the expansion has not been fast enough to effectivelyaddress the burden of chronic disease in aging populations. Further, day-to-daycare for the elderly and people with disabilities has historically been provided byunpaid family members, often women.293 Today, with greater female labor forceparticipation, aging populations will require a larger cohort of home healthcareworkers. Across all countries, inappropriate regulations and lack of trainingpathways limit task-shifting and scope of practice for non-physician health-workers; where there are insufficient primary care doctors to meet patient need,such restrictions can create a significant impediment to access. Clinical staffing inrural communities poses a universal challenge; many health workers reject or leaveunderserved rural areas because of low pay, limited professional opportunities,poor working conditions, and quality of life concerns.2.1. From dysfunctional gate keeping to quality, comprehensive care for allUniversal coverage of comprehensive PHC is not possible without a fit-forpurpose workforce. Significant reforms to workforce training are needed to offer comprehensive PHC services in line with countries’ UHC ambitions. Multiprofessional health education must be embedded within PHC settings; oriented toward generalist practice; and focused on the unique knowledge, skills, and competencies required in a PHC setting. Further, universal provision of wideranging, high-quality PHC services requires the health workforce to be efficiently deployed.294 This means each cadre’s specific scope of practice needs to be alignedCHAPTER 4: MAKING IT HAPPENwith providers’ comparative advantages within the multidisciplinary team unit. In mixed health systems, addressing workforce constraints to quality PHC may also require engaging and contracting private providers with public funds, while ensuring robust quality control.A new paradigm for medical educationIn addition to technical knowledge and skills, PHC team members need a range of non-technical skills grounded in the patient-provider relationship and in the community context. A mutually trusting and respectful relationship is central to high-quality care, no matter the setting or discipline. Health workers require adaptive expertise which involves innovation in addressing uncertain, complex, and novel situations, balanced with efficiency that draws on routine knowledge. Clinical decision making requires skills different from those needed in most large hospitals. Geographic distance from tertiary care centers, inequities in the availability of human and institutional resources, and people’s rising expectations for high-quality comprehensive care, even in economically constrained environments, create a new and challenging environment for PHC. These circumstances necessitate approaches to diagnosis and treatment that are grounded in clinical courage and are at once flexible and innovative, based on selfreliance as well as efficient and effective use of resources.93 The transition to community team-based care models therefore requires a reorientation of the medical education system, particularly for physicians. The culture, pedagogy, and incentive structure of most medical education often work against the development of a fit-for-purpose primary care workforce. In most countries, the bulk of medical education and training is conducted in hospitals and other specialized settings which do not reflect PHC realities and service conditions. Most undergraduate medical education programs begin with a classroombased focus on basic science before progressing to clinical medicine at teaching/ research hospitals. Following graduation, new doctors generally have little or no opportunity to work and train in rural and underserved clinical service settings because most first-year graduate positions are based in urban teaching hospitals.Medical education reforms are required to embed education within community clinical settings and orient medical graduates to generalist/primary care specialization. Case-based learning allows students to explore case scenarios like those in which they will eventually practice, but students should also get direct exposure to community-based clinical settings early in their education. The longitudinal integrated clerkship, for example, is a well-established year-long clinical education model whereby students learn their core clinical knowledge and skills in community settings with skilled PHC team members as their principal clinical teachers and role models, enhanced by integrated clinical learning. Through the program, students become members of the health team; the intense interaction with patients motivates student efforts and supports professional identity formation guided by social accountability.WALKING THE TALKReorientation of medical education toward community-based primary care is also predicated on professional respect, value, and prestige being afforded to local care providers, both as front-line providers of care and as local experts with knowledge and skills to justify academic appointments. Local PHC team members should be engaged as classroom teachers, including for small-group case-based learning, as well as for clinical training. Faculty status for community care providers demonstrates that the institution sees them as equal to campus and hospital-based faculty members and helps to counter the negative perception that community care providers are second class. This in turn raises their standing in the eyes of students, community members, and the providers themselves.Training generalist physiciansAlmost all wealthy countries have a “sufficient” number of health professionals—defined by the WHO as more than 10 medical doctors, 40 nurses/midwiferypersonnel, 5 dentists, and 5 pharmacists per 10,000 people.295 Nonetheless,physicians’ reputational and financial incentives often favor specialization,creating a scarcity of general practitioners. Generalists continue to decline as ashare of all physicians, and in some countries the number of geriatric trainees hasstagnated.296 Medical students face strong financial incentives to avoid generalpractice or geriatrics in favor of more lucrative specialties. In the United States,94doctor surveys show that primary care physicians earn more than $100,000 peryear less than specialists;297 in the United Kingdom physician salaries show moreparity, but generalists nonetheless earn about 11 percent less than their specialistcounterparts.298 Across the OECD, growth in specialist salaries almost alwaysoutpaces growth in generalist pay.299Many OECD countries have introduced initiatives to increase their rates of recruitment and training; however, generalists continue to decline as a proportion of physicians, with many fellowship slots remaining unfilled. The inadequacy of simply expanding generalist training demands alternative approaches to attract medical students to the field. Several incentive approaches can be used, including lower costs to obtain certification, subsidized medical education, or adjusted reimbursement rates from central payers to lower salary differentials.In the United States, where medical school debts can be extremely high, loan forgiveness has been a popular approach with mixed results. The US National Health Service Corps (NHSC) was first created in 1970 to address frontline shortages in rural and underserved areas; the program offers loan forgiveness to primary care clinicians with at least two to three years of service in underserved regions. NHSC has had some success in attracting physicians to underserved areas but fails to fill all available program slots, in part because of competition from other loan forgiveness programs without specialization or service requirements.300 In 2005, South Carolina enacted legislation to create the first loan forgiveness program for trainees in geriatric medicine; in its first year, the program appeared to help attract more qualified applicants to the fellowship.301CHAPTER 4: MAKING IT HAPPENPayers—particularly national health insurance programs—can also use reimbursement rates as a lever to impact staffing levels and specialty choice. Though difficult to directly measure, choice of entry into primary care appears closely related to anticipated income.302 In the United States, historical rates of preference for family medicine closely mirror anticipated income vis-à-vis a specialist career path.303 This suggests that direct financial incentives can be a powerful means to encourage entry into frontline specialties. Economic research has found an association between higher Medicaid reimbursement rates and access to primary care,304 while increases in Medicaid reimbursement rates have also been associated with better staffing levels at US nursing homes.Efficient use of human resourcesOn its face, the team-based care model would appear to require an expansion of human resource capacity. However, team-based models join lay and community health workers, nurses, physicians and potentially other health workers in a single unit. This allows efficient use of each health worker for tasks appropriate for their skills and competencies—thereby avoiding over- or under-qualification for the specific tasks undertaken and optimizing the use of higher-skilled cadres. This approach, where specific care tasks are delegated to non-physician health workers under physician supervision, is known as “task shifting.”95 Evidence shows that CHWs and mid-level cadres can effectively deliver a range of health promotion and basic curative interventions; these include management of common childhood illnesses;305,306,307 promotion of antenatal care and breastfeeding308,309 and support for prevention and treatment of tuberculosis,310 malaria, and HIV.311 Less clear is the ability of CHWs to manage more complex diseases or conduct skilled deliveries; their ability to safely perform these functions is likely to depend on CHW training and experience, which varies across settings.312 For example, Ghana upskilled professional community nurses with midwifery skills to support skilled deliveries at rural health posts;313,314 elsewhere, some CHW cadres receive just weeks of training, implying clear lack of competence to assume such complex tasks.315 CHWs should not be seen as a stop-gap substitute for nurse- or physician-led care, but instead embraced for their unique value-add as community links to health services and in facilitating proactive health promotion and disease prevention within local communities.Further evidence shows that non-physician healthcare workers (NPHWs) can successfully screen individuals for asthma, hypertension, diabetes, and cancer; where NPHWs were also permitted to prescribe medicine, evidence further suggests they can do so effectively for patients with asthma, hypertension, depression, and epilepsy.316 A study in Bangladesh, Guatemala, Mexico, and South Africa, for example, found that community health workers could effectively screen for cardiovascular disease (CVD) and refer people with a moderate to high risk to government clinics.317 A separate systematic review also found evidence that adult diabetic patients who worked with a CHW knew more about their disease and had better self-care skills.318WALKING THE TALKLay workers, including community health workers, have been used extensively to pre-screen potential patients and support adherence to treatment regimes, with mixed results. VisionSpring, for example, trains people without a medical background to distribute oral contraceptives and conduct eye exams.319 Alternatively, lay health workers can focus on non-medical procedures such as managing patient flow and record-keeping, helping reduce the administrative burden on health workers. The Aravind Eye Care System in India, for example, trains high school graduates from rural areas to become patient flow managers.320Telephone-based triage and advice services—wherein a patient can contact a health provider for basic diagnostic services, counselling, and medical advice—is also increasingly used as a substitute for face-to-face consultations, with call services now available in countries like the United Kingdom, Australia, and Denmark.321 Systematic reviews suggest that about half of calls received by such hotlines can be addressed by telephone advice alone, but there is still mixed evidence and many outstanding questions about their safety, cost-effectiveness, and overall impact on health service utilization and outcomes.322 The extreme ease of use for telephone consultations also presents an opportunity for overuse, with recent evidence showing that telephone consultations result in more frequent GPpatient contacts than face-to-face consultations.32396Leveraging and regulating the private-sector workforceHigh rates of private-sector employment in the health field are a reality in many LMICs, especially when offering competitive salaries in the public sector would be prohibitively expensive.324 Recognizing this reality, some strategies—including private-sector empanelment approaches described in section 1—seek to address public-sector workforce gaps by leveraging private-sector health providers for the public interest. Some of the most effective policies use government-funded and administered insurance programs to contract private-sector providers or encourage private providers to work with low-income patients through quotas or expanded coverage in health benefits plans. In the United Kingdom, for example, the government-funded National Health Service commissions privately run practices (“surgeries”) to provide universal primary care; general practitioners are entirely funded by the public sector but often (co-)own and operate their own practices. Strategic purchasing approaches can enable public funds to purchase quality (accredited) PHC services across the public and private sectors, leveraging private-sector capacity while avoiding some common pitfalls, for example quality gaps or impoverishing out-of-pocket expenditure.A key challenge of private-sector engagement is quality assurance. PHC purchasers can create incentives for incremental quality improvement and accreditation among private-sector providers through “carrots,” “sticks,” or some combination of the two. “Carrots” could include access to prestigious or in-demand programs and responsibilities for graduates of accredited medical schools; financial bonuses for accredited providers; or the opportunity to participate in pay-for-performance or voucher schemes. In the Philippines, forCHAPTER 4: MAKING IT HAPPENexample, special administrative and financial autonomy is restricted to accredited institutions,325 while some Indian insurers offer higher reimbursement rates for accredited hospitals.326 “Sticks” could include restrictions on the graduates from non-accredited medical schools, or on the eligibility of non-accredited institutions to receive reimbursement through nationally-funded universal health coverage or social health insurance programs. In Malaysia, for example, graduates of non-accredited schools are not given licenses until they pass exams at accredited schools;327 and in several LMICs—including Kenya, the Philippines, Nigeria, and Thailand—insurers require accreditation as a pre-requisite for reimbursement.328 In some countries where accreditation is not mandatory, use of accreditation to select providers for empanelment-based national health plans can create exceptionally strong financial incentives for accreditation, essentially crowding out non-accredited providers.329Tiered accreditation systems can also help incentivize incremental qualityimprovements in settings where achievement of the highest quality standardsmay seem too costly or unrealistic in the immediate future.330 In the United States,the National Committee for Quality Assurance offered new HMOs the option topursue a separate accreditation on a pass/fail basis,331 while tiered accreditationin Lebanon offers accreditation for different time horizons and levels (3 years; 18months; partially accredited; and failed) based on performance. However, fewstudies empirically evaluate the effects of switching accreditation systems.332 In97Brazil, a health insurance company paired incentives for achieving different tiersof accreditation with support to facilities in navigating the accreditation process.Hospitals received a 7 percent boost in per diem rates simply for beginningthe accreditation process; incentives rose to 9 percent for achieving Level 2accreditation and 15 percent for achieving Level 3 accreditation. By 2009, 19 out of45 in-network hospitals had received accreditation, covering 69 percent of networkhospital admissions.333Social franchising is an alternative approach to accreditation that allows innetwork providers to adopt branding that identifies them as offering qualityassured services or commodities. An estimated 15,000–20,000 individual clinics in Asia, Africa, and Latin America now operate as part of social franchise networks.334 The Janani franchise in Bihar, India, for example, repaints signs and wall advertisements for in-network providers on a yearly basis. Franchisees who are expelled or choose not to re-enroll do not get their signage repainted.335, Social franchising’s emphasis on uniform care can also help introduce a common set of standards across multiple providers. The Greenstar Network in Pakistan provides monthly visits to in-network providers during which they can discuss difficult cases, receive one-on-one training, and learn about new clinical practices.336. Similarly, the Planned Parenthood Federation of America independently evaluates and recertifies its local affiliates every four years.337 A systematic review of clinical social franchising in low- and middle- income countries found that social franchising was associated with increased client satisfaction, but that its effects on health care utilization and outcomes relative to other models of care were mixed.338WALKING THE TALKWhere human and financial resources to enforce quality standards are low, authorities can enlist professional medical groups as partners in the quality control process. In India, for example, professional councils have carried out awareness campaigns against the practice of medicine by unqualified practitioners; investigated complaints about unqualified practitioners; and reported such providers to government departments.339 To ensure complaint mechanisms are used in the future and accountability is maintained, governments need to be prepared to follow up on any tips.Alternatively, to maintain engagement in the public sector, several countries have allowed private sector providers to work in both the public and private sectors (dual practice). However, countries often impose restrictions on those who opt to do so. Costa Rica, for example, mandates that workers cannot engage in private practice during public working hours, while Colombia stipulates that workers cannot have two-full time jobs for the same organization.340 Despite its widespread uptake, several concerns about dual practice remain. Many countries want to avoid a “revolving door,” meaning that providers direct public-sector patients to their own private enterprises, as well as burnout among healthcare workers. Additionally, long clinical and administrative hours have reportedly already started to lessen the appeal of dual practice in Latin America.341982.2. From fragmentation to person-centeredintegrationNew provider competencies for patient-centered, integrated careBeyond clinical knowledge and skills, provision of community-oriented, patientcentered integrated care requires a range of competencies for effective collaboration between the PHC team, the community, and other care providers, for access to care goes beyond physical or geographic and financial accessibility, to include approachability, acceptability for patients and communities to feel comfortable in seeking and obtaining health and healthcare.342 Multidisciplinary teams will need to evaluate local health needs, acquiring knowledge on communities’ state of health and related influencing factors.343 They will also require strategic communications capacity to clearly communicate their vision of PHC and new ways of working, along with interpersonal skills and political savvy to build or strengthen their relationships with other stakeholders that are important for the health of their empaneled population.344,345,346 The team’s population will likely have varying levels of health status, including healthy groups, patients who need specialist intervention, complex patients at risk of hospital admissions, and frail patients discharged from hospitals. Such a diverse spectrum of needs calls for professional management skills to stratify the patient population into risk groups and design targeted management interventions for each cohort.347,348,349CHAPTER 4: MAKING IT HAPPENAt the intervention level, the PHC workforce must acquire new competencies to effectively work within a team-based model and ultimately help patients achieve their health goals. Ability to work and coordinate across boundaries is critical when providing care to an ageing population with multi-morbidity who must interact with multiple providers on a long-term basis. Case management is indispensable for improving quality and efficiency, considering that a small percentage of patients often account for the majority of total health spending.350,351,352 For conditions that involve self-management, the PHC workforce needs to engage and empower patients for joint planning and management around the patients’ health goals.353,354The competencies discussed above, in turn, highlight the importance of capacity touse and interpret data. The interactions between providers and patients generatean enormous amount of data that is then stored in various forms, including files inproviders’ cabinets, electronic health records, and registry systems. (Ideally, thePHC platform should benefit from a single interoperable digital platform withunique patient identifiers; see Section 1). Data about the empaneled population(demographic and socio-economic profiles, health service utilization, costsand outcomes, and other information) that is available to the PHC workforce, ifproperly applied, will be extremely useful for them to evaluate community healthneeds, stratify risk groups, and provide integrated patient-centered care. InTurkey, an enrolment database allows family physicians to identify individuals in ascreening target group and enables community health centers to organize public99campaigns and arrange transport for patients on the day of appointments. Closecollaboration between family practices and the centers resulted in a significantincrease in coverage rates for breast, cervical, and colorectal cancers between2007 and 2014.355Finally, “soft skills” are needed to develop a trusting relationship between providers and patients, improving patient satisfaction and supporting positive health outcomes.356,357,358,359 Such skills can be wide-ranging, including responsiveness, empathy, adaptability, flexibility, time-management, communication and teamwork, cultural sensitivity, collaboration, and brokering partnerships.360,361 More importantly, in reimagined PHC settings, health workers need to develop the skills to act as partners and facilitators, rather than authorities, to empower patients and engage them in a shared decision-making process.362Reorienting medical education and on-the-job training to better prepare the health workforceAppropriate education is essential for ensuring that the PHC workforce has and can demonstrate the competencies necessary for delivering integrated patientcentered care in the community and across health system.363,364 Experts have called for a “third generation” of medical education reform to improve the performance of health systems by adapting core professional competencies to specific local contexts, while drawing on global knowledge. The proposed program emphasizes transformative learning that involves three fundamental shifts: from fact memorization to searching, analysis, and synthesis of information for decisionWALKING THE TALKhealth workers need to develop the skills to act as partners and facilitators, rather than authorities,making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from non-critical adoption of educational models to creative adaptation of global resources to address local priorities.365to empower patients and engage them in a shared decision-making processIn alignment with this transformative vision for medical education, several shifts must take place in the orientation and culture of medical educationand on-the-job training. Training forPHC should not be considered a “specialization”, as this can reinforce health-system silos. Interprofessional educational366 (Box 3), a pedagogical approachthat engages two or more healthcare professions in an integrated learningenvironment,367 has proved useful to ensure professionals value one another’sdisciplines, increase providers’ collaborative knowledge and skills, and improveability to manage people with chronic conditions.368,369,370,371 Creating shared valuesand common goals between primary care providers and other care providershelps trainees internalize integrated care precepts. The asymmetry of information100between providers and patients has a longstanding presence in the health sector,372but these patterns are changing rapidly, as technology enables patients to acquireknowledge more easily.373,374,375 In this context, health workers at the PHC levelmay need to assume the role of advisors, guiding patients to reliable sources ofinformation, more than “experts” who consider themselves the sole authoritativesources of health information. Future PHC workers should be encouraged to take aparticipatory approach to promoting health and wellbeing in the communities theyserve. Further, medical education and training need to prepare the PHC workforceto understand and apply evidence-based medicine principles to a rapidlyexpanding research and evidence base, for example by learning how to follownew algorithms and protocols.CHAPTER 4: MAKING IT HAPPENBOX 11. CORE COMPETENCIES FOR INTERPROFESSIONAL COLLABORATIVE PRACTICEThe core competencies developed through interprofessional education feature the following desired principles: patient and family centered; community and population oriented; relationship focused; process oriented; linked to learning activities, educational strategies, and behavioral assessments that are developmentally appropriate for the learner; able to be integrated across the learning continuum; sensitive to the systems context and applicable across practice settings; applicable across professions; stated in language common and meaningful across the professions; and outcome driven.Competency 1: Work with individuals of other professions to maintain a climate of mutual respect and shared values. (Values/Ethics for Interprofessional Practice)Competency 2: Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. (Roles/Responsibilities)Competency 3: Communicate with patients, families, communities, and professionalsin health and other fields in a responsive and responsible manner that supports a teamapproach to the promotion and maintenance of health and the prevention and treatment101of disease. (Interprofessional Communication)Competency 4: Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/ population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. (Teams and Teamwork)Source: Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.Health professionals will need education, training, and awareness of content not traditionally covered in the medical curriculum, such as community health needs assessment, risk stratification, coordination and case management, and personalized medicine, as well as their impact on practice. In Belgium, for example, one university’s medical, nursing, and social work students undertake a “community diagnosis” exercise as part of the curriculum. The exercise involves analyzing relevant epidemiological, socio-demographic, and other populationbased data on local communities, together with findings from visits to households and care providers, to arrive at a “community diagnosis” and draft an advocacy letter to local authorities recommending actions for improvement. Some countries (for example Hungary and Kazakhstan) have also adjusted medical curriculum for nurses to receive specific training in chronic diseases focused on patient education, prevention of complications, and chronic disease management.376 In addition, coaching for frontline healthcare workers can also be provided to improve their soft skills, for example via in-person and online training, role playing, case studies, guest speakers, and personality assessment tests.377,378,379WALKING THE TALKEducational and accreditation standards should be adjusted and integrated into overall quality assurance mechanisms to support these pedagogical shifts, ensure adequate training in these competencies, and ensure consistency in quality standards from education through to practice.380 Accreditation should also cover the competencies of educators and trainers and the adequacy of infrastructure, equipment, and clinical learning sites.381PHC workforce policies for integrated, patient-centered careCollaborative practice and integrated care across the care continuum require a shared vision on the role of PHC. Mutually accepted interdisciplinary care protocols need to be established between PHC teams and providers or organizations from other settings and levels of care. Based on such protocols, consensus can be achieved on the content of care at each level of provision and on criteria for two-way referrals. Coordination, a key function that connects multiple providers under an integrated patient-centered care model, should be included as part of the PHC work routine.While providing integrated care in the community and across the health system,primary care teams need well-aligned quality measurement that promotes102accountable performance by rewarding team members for managing complexity,solving problems, and thinking creatively when addressing the unique circumstancesof patients with complex needs. Priorities for outcome and performance managementinclude patient-centered reporting and metrics that capture avoidance ofinappropriate testing or treatment, while documenting attributes associated withbetter outcomes, lower costs, and improved patient experiences.382,383PHC workforce performance can be improved through increased use of tools for communication and management. People-centered care can be enhanced through communication tools such as integrated and individualized care plans, structured patient education, decision aids, outreach activities, lifestyle counselling, multidisciplinary assessments and multidisciplinary treatment protocols. Similarly, care integration and population health management can be facilitated by patient registries, health registries, and risk stratification tools, building on health data generated via the empanelment process.384Workforce planning and deployment should align with the reimagined PHC vision and performance management framework. Existing workforce skills and competencies should be carefully reviewed in order to identify any gaps and mismatches, as well as mitigation strategies. As previously discussed, repurposing the current workforce through task shifting is a commonly used strategy to engage existing health workers for new roles.385,386,387 When there is little scope to expand the roles of the existing workforce, creating new care professions/cadres is another option, thought it often takes longer time to show impact. These new cadres can be created to fill new roles, as in the case of care coordinators, self-managementCHAPTER 4: MAKING IT HAPPENcounsellors, and case managers.388,389 Alternatively, new cadres can take over some current activities from existing personnel, as with physician assistants and medical officers.390 In some cases, professional managers can be introduced to manage integrated multidisciplinary teams and coordinate services across the spectrum of prevention, promotion, care, and rehabilitation. Of course, creative workforce policies must still be compatible with the regulatory framework, for example in terms of professional classification and licensing standards.2.3. From inequities to fairness and accountabilityProactive polices for workforce development, deployment, and regulation can help address the maldistribution of health workers across countries and within national borders, creating conditions for more equitable service delivery to those most in need.Engaging health professionals in rural serviceEncouraging rural service requires changing the balance of incentives thatpushes health workers toward urban centers in virtually all countries. Onecommon approach is to offer financial or in-kind benefits to counterbalancehealth workers’ quality of life concerns. Rural health workers receive housingbenefits and electricity in Moldova; allowances in South Africa; and paid tuitionfees for their children along with housing renovations in Zambia. Few studies103have assessed interventions in LMICs empirically and individually (that is, notas part of a package of services). A Cochrane review found that the provision ofbursaries or scholarships had variable success across countries, while increasedfinancial compensation generated more consistently positive results (though withundetermined cost-effectiveness).391 A review of systematic reviews similarly foundthat such policies were effective at attracting practitioners, but that few physiciansstayed in rural areas long-term.392Rural service requirements may also help fill vacant postings, and several countries have made service in resource-constrained areas a prerequisite to graduation or certification. Japan and Lesotho exchange pre-graduation financial aid for postgraduation rural service,393 while other countries, such as Mongolia and Vietnam, have made rural service a prerequisite to certain career changes (for example, entering a postgraduate or specialization program).394 Most of the existing research on compulsory service programs is descriptive and uses stakeholder interviews to document program effects. Anecdotal evidence suggests participants in compulsory service programs often leave soon after the mandatory period ends. Such programs can also be difficult to enforce, particularly for wealthier individuals who can use their financial resources to bypass service requirements. Thailand imposes financial penalties on public medical school graduates who violate their rural service requirements—but many graduates choose to work in the private sector, quickly earning enough to offset the penalty.395WALKING THE TALKStudies from HICs and LMICs identify rural residence or upbringing as a consistent predictor of an applicant’s eventual willingness to accept a post-graduation rural posting.396 Where sensible, medical schools can adjust admissions criteria to prioritize rural applicants, increasing the number of graduates who would be willing to assume rural positions. In addition, opening medical schools or other training facilities in rural areas could reduce the workforce gap via two channels. First, rural medical schools can offer continuing medical education and professional opportunities in rural areas, making rural service more attractive. Second, rural medical schools can attract more students from rural areas, who would be more inclined to remain in rural postings. In Japan, for example, almost 70 percent of graduates from a rurally located medical school remained in their home prefectures for at least six years after the end of their mandatory service periods.397 In the Democratic Republic of the Congo, graduates from a rural medical school were almost four times as likely to practice in rural areas compared to a cohort from an urban medical school;398 and in China, a single rural medical school produced more rural doctors than 12 metropolitan schools combined.399A specific medical education model to encourage rural community service isCommunity Engaged Medical Education (CEME), in which medical schools forman “interdependent and reciprocally beneficial partnership” which the communitiesthey serve,400 creating opportunities for clinical learning in PHC services and other104community clinical settings. CEME programs often recruit primarily local studentsthrough selection and admissions processes that value not only academic abilitybut also other characteristics important to local comprehensive PHC. Studentssupport local PHC team members, who in turn serve as clinical teachers and rolemodels. Trainees come to understand their rural/underserved setting as “homebase,” preparing them to practice in the surrounding areas—with city rotations asa requirement to complete postgraduate training. Trainees undertake additionalspecific skills training relevant to their future practice such as general surgery,anesthesia, procedural obstetrics, endoscopies, indigenous health, and geriatrics.Examples of CEME programs illustrate the potential benefits. In the Philippines, a group of doctors in a highly rural and underserved region founded the Ateneo de Zamboanga University (ADZU) medical school in 1994. The school operates on an almost exclusively volunteer basis; most of its students are drawn from the local community, and the curriculum focuses on case-based learning, problem-solving, and community health, in addition to clinical competency. As of 2011, 80 percent of its graduates were still practicing in the Zamboanga region, and 50 percent were practicing in rural areas.401 Similarly, the Northern Ontario School of Medicine (NOSM) targets health improvement in Northern Ontario, a vast and underserved region of Canada. NOSM’s admissions process selects for a student body that reflects the population distribution of Northern Ontario, while community members help with student selection, education, and support during community placements. 92 percent of NOSM-trained family physicians are practicing in Northern Ontario, while many graduates now serve on faculty.402CHAPTER 4: MAKING IT HAPPENEquitable mobility and cross-jurisdictional solutionsInternational recruitment has been a popular strategy for wealthier countries facing acute PHC workforce shortages, including expanding cohorts like home healthcare workers. However, out-migration of health workers from low- and middle-income countries to high-income countries with far higher compensation can exacerbate existing international inequities in health workforce density and contribute to deepening human resource gaps in the origin country, particularly when training slots for medical education are highly constrained.Smarter processes can increase the benefits of health worker migration for all parties. A Global Skills Partnership (GSP)403 consists of a bilateral agreement in which migrant-destination countries and migrant-origin countries share the benefits and costs of skilled migration. Responding to a nursing shortage in Germany combined with a surplus of recent graduates in China, one pilot program aimed to train and place 150 Chinese nurses within German nursing homes up to five years. Before their migration, the nurses received an 8-month intensive training course and language training to ease their entry into the German health system and society.404Accreditation and licensing differences between states or jurisdictions can makeit challenging for health workers to move to areas of greater need or opportunity,105even within the same country. In Canada, individual provinces set their ownstandards for licensure of foreign medical graduates, with widely varyingprocesses.405 A backlog of applications and bureaucratic processes can also makethe licensure process very lengthy, while qualifying exams and supplementaleducation can be expensive and time-consuming. In the United States, state-levellicensing procedures can often take three to six months, with application feestypically totaling several hundred US dollars.406Regulatory reforms can help increase health worker mobility. In the United States, the Interstate Medical Licensure Compact offers a voluntary statebased approach to reduce licensing barriers by introducing a common licensure application across 29 participating states (though the individual states still issue the licenses);407 the Nurse Licensure Compact (NLC) likewise allows US nurses to obtain a single license for physical, telephone, and electronic practice across any of the participating states.408 Regional efforts also include mutual recognition agreements for three types of health workers under the Association of Southeast Asian Nations Framework Agreement on Services.409Telehealth involves the use of telecommunications and virtual technology to deliver health care outside of traditional health-care facilities;410 it includes virtual home health care, where patients can receive medical advice and guidance in their own homes, plus virtual guidance for health workers in providing diagnosis, care, and referral of patients. Telehealth can connect healthcare providers with remote rural populations and mobility-constrained patients, and offer more efficient routine care in non-emergency situations, for example among patients with chronic conditions. Systematic reviews find that proactive telephone support or caseWALKING THE TALKmanagement over the phone can improve clinical outcomes and reduce symptoms in people with heart disease, diabetes, or asthma,411 while regular phone calls from nurses can reduce hospital admissions and costs.412 A Cochrane review similarly concluded that 50 percent of calls taken by doctors or nurses could be handled over the phone without a subsequent hospital visit.413Regulatory reforms can also help enable telehealth’s potential to at leastpartially break down geographical barriers to care and potentially addressworkforce shortages in specific regions, particularly underserved or remote ruralareas. (However, internet access remains highly correlated with health workerdensity, limiting the applicability of telehealth in some of the most underservedregions and/or countries.414) In some cases, onerous regulatory barriers canstymie efforts to provide telecare when the provider and patient are based indifferent jurisdictions. For example, for different US states or Canadian provinces,providers often must receive licensure in the jurisdiction in which their patient isbased, limiting potential for cross-jurisdiction practice. A few states have eitherestablished registries of qualified out-of-state telehealth providers or offertelemedicine-only medical licenses.415 The European Union takes a more flexibleapproach by defining the relevant jurisdiction as the one in which the provider isbased, allowing a single provider to practice telemedicine with patients across thebloc.416 Likewise, financing reforms can enable reimbursement of a broader range106of telehealth services through public or private insurance packages, facilitatingmore equitable uptake.COVID-19 has accelerated relaxation of many regulatory and financing barriers to telehealth and restrictions regarding practice jurisdiction, at least temporarily. In the US, the Department of Health and Human Services temporarily waived certain privacy requirements related to choice of telehealth platform for the duration of the COVID-19 crisis.417 Several US states and the Center for Medicaid and Medicare Services (CMS) waived state-specific licensing requirements,418 and both the US and France have expanded the range of reimbursable telehealth services.419,420 In South Africa, an extraordinary policy decision authorized the broad use of telemedicine during the COVID-19 pandemic subject to consent and privacy guidance.421Beyond physical mobility, international or private-sector collaborations can help expand countries’ access to specific cadres of healthcare workers in high demand. Several public-private partnerships and regional coordination mechanisms already exist in East Africa. The East Africa Public Health Laboratory Networking Project (EAPHLNP) aims to establish a network of high-quality public-health laboratories in Kenya, Rwanda, Tanzania, Uganda and Burundi; an evaluation of the network in Kenya documented improvements in client satisfaction, test accuracy, and scores on peer audits.422 Other initiatives include the Medical Education Training Partnership Initiative (MEPI), the Nursing Training Partnership Initiative (NEPI), and the Rwanda Human Resources for Health Program (HRH Program). Telemedicine approaches may also offer access to remote expertise for residents of rural villages. For example, in India’s Aravind system, communityCHAPTER 4: MAKING IT HAPPENmembers send photographs of patients’ eyes and information about their symptoms to an Aravind doctor, who then assesses a patient’s need for hospital care via a real-time chat.4232.4. From fragility to resilienceEmergencies require health workers to take on tasks and competencies outside their day-to-day routines; crises can also place enormous stress on health workers’ physical welfare and mental health. Appropriate training, planning, psychosocial assistance, and practical support can ease the burden of crises on the health workforce and help sustain continuity of care.Preparedness: training and contingency planningAn adequate health workforce and appropriate training in outbreak prevention, detection, and response have been identified as a key characteristic of a health system prepared for emerging infectious diseases.424Even with the best planning, emergencies are by their nature unpredictable.Medical education—and training for nonphysician health workers—must thereforeemphasize agility and problem-solving, helping prepare the health workforceto work confidently and capably in unusual conditions. This is consistent with the107expectation that all health workers in PHC have a broad range of knowledge andskills as generalists within their disciplines, including technical capabilities and arange of non-technical and leadership skills.425Consequently, health workforce education and training should encompass mastering technical skills related to managing emergencies in the community, as well as non-technical skills including adaptive expertise and clinical courage. Adaptive expertise involves innovation in addressing uncertain, complex, and novel situations, balanced with efficiency that draws on routine knowledge.426 Clinical courage balances probability and payoff to creatively manage problems in the moment at hand, with whatever resources are available.427 Leadership skills involve inspiring trust and respect, motivating action among team and community members, and allocation of practical, achievable tasks.428 Learning in context through case-based learning (CBL) in the classroom and in community clinical settings is the most effective educational method for developing these generalist knowledge and skills,429,430 including learning the social and environmental determinants of health, including one health431 and integration of the individual and population health domains.432Immersive community-engaged education provides students and trainees with hands-on experience in interprofessional collaborative practice.433,434 Integrated clinical learning (ICL) involves team teaching and team learning, whereby local health team members collaborate in teaching a mix of students of various health care disciplines.435 ICL enriches the experience for all involved and imbeds teamwork in the professional identity of future health workers. To consolidate their learning, it is important that students and trainees are involved in teams that undertake local contingency planning and practice exercises preparing for the management of crises, including infectious disease outbreaks.436WALKING THE TALKAgility, flexibility, and resilience in health emergenciesSome of the most effective workforce responses to the COVID-19 pandemic have required rapid task-shifting, repurposing, or extraordinary deployment of existing health workers. The government of South Africa, for example, mobilized around 60,000 community health workers (CHW)—half of whom were originally trained to trace/test for HIV—to support the COVID-19 response. In Bangladesh, Senegal, Guinea-Bissau, and Nigeria, CHWs and the PHC platform have been effectively deployed to conduct sample collection and case identification/isolation. In Guinea-Bissau, which has a strong community health workforce, CHWs work closely with dedicated contact tracing cadres, contributing their deep knowledge of community context. In Nigeria, over 30,000 PHC providers have been used to identify suspected COVID-19 cases, trace contacts, and conduct referrals.Some countries (including the Netherlands and the UK) postponed re-registrationand revalidation obligations for physicians. This reduced the administrativeburden on practitioners and avoided potentially sidelining key professionals atthe height of the crisis. Provisions have been made to recruit medical and nursingstudents to support health professionals, for instance by allowing (final year)students to graduate early and join the workforce or offering them a gap semesterto support practicing health professionals. Campaigns were launched in several108countries (including Canada, Italy, and the UK) to bring retired or inactive healthprofessionals and foreign-trained but unregistered professionals back into theworkforce. Twinning individual facilities in hotspot area with medical teams fromother provinces also facilitated China’s response to COVID-19. In England, thegovernment brokered an agreement to take over private hospitals and theirstaff for the duration of the crisis, resulting in tens of thousands of clinical staffprovisionally moving to the public sector.437The COVID-19 crisis has also led some countries to empower NPHWs with new responsibilities and authority. Pharmacists, for example, have received extraordinary authorization in several countries to assist in the COVID-19 response and relieve pressure on overburdened hospitals and physicians. For example, pharmacists have been allowed to issue and/or renew prescriptions (e.g., Canada, France, Poland); compound antiseptic solutions or hand sanitizers (e.g., Czech Republic, Germany, Finland, Belgium, Netherlands); and deliver prescriptions to patients’ homes, sometimes including controlled substances, hospital-only drugs, and even oxygen (e.g., Portugal, Italy, Croatia, Canada).438To avoid saturating hospital capacities during the crisis, the broader health workforce, including community-based practitioners, can contribute to emergency-related service provision. Previous outbreaks suggest that task shifting, supported by adequate training, is necessary to cope with emergency challenges.439,440 One of the lessons learned from the SARS outbreak in Hong Kong concerns the need for a wider involvement of General Practitioners (GPs), who could contribute to the response as educators, triage decision makers, and vaccine administrators.441 Patient management and triage strategies need to be adapted; health workers need to be trained in the specifics of the response and appropriateCHAPTER 4: MAKING IT HAPPENpatient care; and heightened safety precautions need to be implemented. Maintaining routine or essential health services (for example, chronic disease management, antenatal care) while delivering emergency-related services requires the availability of inputs such as health workers, medicines, and safety supplies. Management systems must be adjusted to ensure input availability and smooth patient flow. Crucially, public authorities need to provide clear guidelines and adequate financing. Shortages of personal protective equipment (PPE), and insufficient allocation of PPE to PHC systems and in particular community health workers, have reduced PHC platforms’ ability to sustain services during the COVID-19 pandemic.442,443Supplementary training during the crisis may also increase health workers’capacity, confidence, and morale in handling the outbreak. During the Ebolaoutbreak in Sierra Leone, health workers showed lower levels of fear and becamemore confident in providing care after safety training; tentative evidence suggeststhe trainings also prevented further infections among health workers.444 In aCanadian hospital setting, group resilience training substantially increased healthworkers’ self-reported confidence in dealing with the H1N1 virus;445 less costlyand more easily scaled computer-assisted training courses also demonstratedencouraging results in improving confidence and self-efficacy to manage thepandemic.446 In contrast, some essential services were temporarily disrupted inBangladesh because providers were unsure how to comply with social distancing109requirements in their daily jobs.447Social and practical support for a resilient health workforceFinally, health workers need significant social support—both during and in the aftermath of a crisis—to help mitigate resultant stress, exhaustion, and trauma. Burnout is common in health care professionals even during normal times, particularly among family doctors.448 The mental health toll of COVID-19 on frontline health providers has been extensively discussed and well-documented in media reports449 and the academic literature.450 In Wuhan, China, for example, half of frontline nurses reported moderate or high levels of burnout; 91 percent reported moderate or high levels of fear; and almost all had at least one skin lesion caused by long hours in personal protective gear.451 Similarly high levels of stress and fear have been reported in previous viral outbreaks.452Comprehensive and agile psychosocial support to health workers is thus essential to prevent burnout and manage stress.453,454,455 Helplines, for example, can be established so frontline health and social workers can access psychological support from trained professionals and/or referrals to additional mental health services. Depending on the nature of the emergency and the country context, helplines can be set at national or local levels, by professional associations or universities. In the digital era, more health workers can seek guidance and support through apps andWALKING THE TALKonline services. In addition to formal counselling sessions (in-person or remote) with psychiatrists or psychologists, many stress-reducing measures have been tried out during the COVID-19 pandemic. These include buddy systems, whereby health professionals can talk to a matched peer (Norway, China), mindfulness sessions (Malta), and Zumba sessions (Kenya).Practical support to frontline health workers during crises helps workers focus on patients and improve productivity. An important step is making childcare available where facilities would otherwise have been closed. A large number of countries have implemented measures in this area, including Austria, Belgium, Denmark, France, Germany, Malta, the Netherlands, Norway, Portugal, and the UK. Romania has paid health workers allowances for childcare, reducing health professionals’ domestic work burdens. Free accommodation for health workers during a pandemic minimizes their commute times and risk of spreading disease if they become infected. Other practical forms of support can include free access to public transport (Hungary and some parts of the UK) and free parking at health facilities.Finally, special compensation for health workers during emergencies can serve asan extrinsic motivation mechanism, recognizing their sacrifice and contribution.Following the outbreaks of several emerging infectious diseases (e.g., SARS, Ebola,110MERS), many countries have passed regulations to mandate hazard payment/compensation for overtime during public-health crises. This has supported healthprofessionals’ work in fighting COVID-19 in Vietnam and China, for instance.Several Eastern and Southern European countries also have also offered financialsupport to health workers in response to COVID-19, for example one-time bonuspayments (Bosnia and Herzegovina, Greece, Germany, Hungary, Kyrgyzstan,Romania, the Russian Federation), monthly bonus payments for the duration ofthe crisis (Albania, Bulgaria, Latvia), or temporary salary increases (Belarus andLithuania). Meanwhile, in Denmark, COVID-19 has been recognized as a work-related injury for health care staff, enabling them to access associated benefits. InAfrica, many governments have realized the need to improve hazard paymentsand provide insurance for staff on the front lines of the pandemic.Priority Reform 3: Fit-for-purpose financing for public-health-enabled primary careFinancing has a critical role to play in facilitating the transition to high-performing PHC laid out in Chapter 3 and elaborated in Sections 1 and 2 of this chapter. PHC investments yield high returns and promote sustainability but achieving PHC goals requires substantial investment and careful planning across five key areas in health financing.CHAPTER 4: MAKING IT HAPPENFirst, guaranteeing universal coverage of high quality, comprehensive PHC will require governments to raise adequate funding through prepaid, pooled financing, while making explicit efforts to remove financial barriers to care for the entire population. This investment must be guided by clear plans and explicitly defined PHC benefits packages that prioritize prevention and timely treatment at the appropriate level of care, thereby avoiding unnecessary hospitalizations or complications. Second, the shift to effective team-based care models requires innovations in the way providers are paid, accompanied by investments in data and information systems that facilitate closer coordination. Third, financing can address persistent inequities and facilitate accountability through inclusive decision-making processes, explicit removal of financial barriers on both the supply and demand sides, better measurement, and transparent planning and budgeting. Fourth, as demonstrated by COVID-19, countries require agile financing arrangements to adapt to shocks, build resilient systems, and protect spending on essential PHC services during emergencies. Finally, beyond direct health benefits, PHC also offers a best-buy to progress toward many nonhealth SDGs by targeting the social determinants of health across areas including education, housing, transport, and the environment.456,457,458 However, leveraging these synergies will require new models of cross-sectoral prioritization and financing.3.1. From dysfunctional gate keeping to quality,111comprehensive care for allPHC investment should draw from general government revenuesSignificant investments, not just adjustments at the margins, are needed to put PHC at the center of health systems. Substantial resources are required to finance a set of guaranteed services that gives adequate weight to health promotion and disease prevention and includes core public-health and health security functions, including disease surveillance, outbreak response, infection prevention and containment, and monitoring and evaluation. Modelling suggests that an estimated additional US$200 billion per year would be required from 2020 to 2030 in order for 67 low- and middle-income countries to cover basic preventative and outpatient PHC services. Mobilizing these sums would require LMICs (in aggregate) to at least double their total health expenditure. The more ambitious vision described in this report, including a broad PHC package and cross-sectoral investments, would raise the overall price tag in these countries to some US$380 billion annually.459 These are averages and estimates: each country must identify its own locally relevant PHC policies; define a locally-appropriate benefits package; and assess the costs and budgetary implications of its delivery. For the large majority of countries, a strong case can be made that these investments would pay large dividends—by improving population health,460 advancing economic inclusion, and improving countries’ competitiveness.WALKING THE TALKThe source of PHC resources has important implications for whether investmentneeds will be met. Universal coverage of high quality, comprehensive PHC firstrequires mobilizing adequate revenues for health overall through prepaid, pooledfinancing that eliminates out-of-pocket expenditures. Allocations from withinthe pot of pooled health resources must then adequately prioritize PHC. Generalgovernment revenue is increasingly seen as the best mechanism for financing PHC,given the changing nature of work, persistent informality in LICs and LMICs, andthe public-good character of population-based public-health services. Evidencealso shows that financing through general government revenues facilitates accessto health services and improves financial protection for the population.461,462Additionally, many LICs and LMICs arefor the large majority of countries, a strong casestill building health-system foundations for quality PHC, for example including basic infrastructure (for example,can be made that these investments would payrunning water and sanitation), human resources, and reliable supply chains for health products.463 Such fixed-costlarge dividends— by improvinginvestments cannot be readily financed through recurrent health insurance premiums or user fees. Box 4 lays out112population healththe case for PHC financing through general government revenue in detail.CHAPTER 4: MAKING IT HAPPENBOX 12: WHY FINANCE PHC THROUGH GENERAL GOVERNMENT REVENUE?General government revenue is increasingly seen as the best mechanism for financing UHC—and PHC, specifically—for several reasons:Changing nature of work: Demographic shifts and structural changes in employment are challenging the sustainability of employment-based resource mobilization models for the health sector, including labor taxes, employer-provided health insurance, and social health insurance (SHI). Particularly important shifts include population aging (and relatively fewer working-age adults relative to retirees); shrinking labor needs in some industries due to technological transformation (e.g., automation); and the recent rise of the ‘gig’ economy.464,465 Roughly two-thirds of countries with SHI now use government budget transfers, often on top of traditional employment-based resource mobilization, to at least partially finance their health systems.466 For example, France and Estonia, which once relied predominantly on labor taxes to finance their health systems, now use general government revenues to supplement SHI premiums.467Labor informality: In LMICs, preexisting high levels of labor informality further complicateefforts to expand health coverage through employment-linked solutions. Some countrieshave extended SHI to the informal economy by offering the option to join SHI schemesvoluntarily, e.g., in Thailand through the earlier Voluntary Health Insurance Scheme468,or through community-based health insurance. However, countries have been unable to113achieve high levels of coverage without substantial government subsidies and compulsoryenrolment (for example, in Rwanda469). High labor taxes to finance the health sector mayeven exacerbate informality by creating an additional incentive to pay employees “off-book.” Hungary, for example, used government financing to reduce employer payrolltaxes and thereby reduce the incentive for informality.470Reducing financial barriers: Suggestive evidence shows that removing user fees for primary health care in LICs and LMICs results in higher utilization of services and better financial protection;471,472,473 some studies also suggest a link to better health outcomes.474 However, policies to remove user fees are only effective when backed by adequate levels of pooled financing from the government budget.475Financial crises: During financial crises, high unemployment can result in health coverage losses and reduce the system’s ability to mobilize and pool resources.476 In Greece, the 2008 financial crisis resulted in extensive insurance coverage losses due to unemployment; the government subsequently passed legislation to guarantee all Greek citizens the right to primary health care.477 Cumulative income shocks at the individual level can also limit the ability of families to pay out-of-pocket during a financial crisis, creating significant revenue losses for PHC facilities in systems reliant on out-of-pocket payments.Population-based common goods: Public goods, including the public-health and outbreak preparedness functions of PHC, are best financed through general government revenues (supplemented by development financing) to prevent fragmentation and adhere to international standards.478,479WALKING THE TALKExplicit PHC benefits packages for equitable and efficient resource allocationAchieving an ambitious vision for PHC will require new investments, but also the efficient and equitable allocation of all available health resources. All countries, at all levels of wealth, face resource constraints and tradeoffs in the health sector. Best results come from prioritizing investment in the highest-impact health services, within countries’ budget constraints, and ensuring that those services are delivered equitably to the whole population.An explicitly defined and prioritized health benefits package for primary care,customized to local health care needs, burden of disease, citizen values andpreferences, and aligned with local resource constraints, is essential for justifyingallocation of limited resources for PHC and increasing accountability for itsdelivery.480 The explicit character of the benefits creates recognized entitlementsfor patients; empowers the poor to demand equitable access to services; helpsto identify whether funds are being spent wisely on services that create themaximum benefit for society; and facilitates resource allocation decisions andorderly adherence to budget limits. Nationally agreed, prioritized PHC packages,combined with supply-side investments to ensure the package can be implemented,have been identified as a key enabling factor in child mortality reductions across11430 low- and middle-income countries.481Importantly, an explicit PHC benefits package is not necessarily a highly granular or prescriptive benefits package; it can also offer providers space for clinical judgment and “soft” engagement with patients and community members to build relationships and trust. (Too extensive granularity, particularly at the PHC level, risks inhibiting innovation and limiting clinicians’ ability to tailor care to specific patient populations).482 However, granularity is required in developing the list of drugs, devices, vaccines, and other health products and supplies that will be procured with public funds for use in PHC settings, and to which patients can expect access at no cost at the PHC level.Defining a benefit package requires a priority-setting process that is evidencebased, fair, participatory, and inclusive, accounting for various perspectives483 and competing values (e.g., equity, cost-effectiveness, financial protection, scientific community opinion, affordability). The process should promote transparency in decision making; accountability of decision makers to the public; and ownership among those participating.484 To the extent feasible, the process should evaluate potential services for inclusion in the benefits package according to consistent and transparent criteria that are aligned with a health system’s objectives, which in turn make it possible to explain the reasons for adoption or rejection of specific products and services. Transparent criteria also facilitate governance and accountability, allowing proper debate about how priorities are to be set and how performance should be assessed. The process should include a diverse and representative group of stakeholders, including government, public and privateCHAPTER 4: MAKING IT HAPPENsector health care providers, citizens, community representatives, patients, and others, as necessary.485,486 Such an inclusive process can enhance ”procedural justice” and lead to more sustainable and socially acceptable results.Adaptation to local context, both during package definition and implementation, can increase benefits-package impact, transparency, and acceptability. The Local Burden of Disease instrument from the Institute for Health Metrics and Evaluation (IHME), for example, aims to produce estimates of health outcomes and related measures at a granular, local resolution, allowing decision makers to tailor policy decisions about benefits packages and resource allocation to local areas for maximum impact.487 Likewise, the HIV mantra “Know your epidemic; know your response” promoted use of geographical information systems (GIS) to map “hot spots” and target the drivers of HIV infection in concentrated epidemics.488,489 Adapting to local context is also important for ensuring acceptance, ownership, and understanding of decision-making.490 In Kenya, Health Facility Management Committees representing communities were created to enhance community participation in managing funds received and prioritizing funding based on needs to implement the Essential Package of Health. In the United Kingdom, the participatory process led by the National Institute for Health and Clinical Excellence (NICE) has sensitized the public about the rationale for not including particular technologies.491115 Defining a benefits package should not be considered a one-off, static process; the benefits package should be a living document, continuously adjusted as resource availability changes; new data, evidence, and experience sharpen policymaker understanding of local health needs and the value of specific services; the cost/ price of specific health products or services change; and new health technologies or services become available. In countries with weak infrastructure and severe resource constraints, essential packages should start with highly effective interventions that are cost-effective, in line with local health provider capacity, and can be provided with available resources; packages can be gradually expanded as resources increase, capacities improve, innovations emerge, prices fall, and/or disease burden shifts.492 For instance, in the face of rapidly growing prevalence of hypertension and diabetes, China expanded the benefit package of its basic medical insurance scheme to cover prescription drugs related to these two conditions.493Benefits package designers must also pay close attention to how the package affects those who are disadvantaged or vulnerable. For example, it is important to examine how the package may perpetuate or exacerbate existing health inequities across the population; whether certain key benefits for the most disadvantaged are excluded; and in particular whether the package incorporates adequate services for conditions typically affecting rural, poor, or otherwise marginalized groups. This requires understanding patterns of local disease burden and service utilization derived from reliable data, as well as continuous monitoring of benefits distribution across the population over time.WALKING THE TALKRecognizing health system capacity and capabilities can help to effectively define benefits packages and link them explicitly to strategic purchasing and service delivery. In higher-income countries and many middle-income countries such as Thailand, actuarial analysis, costing and cost-effectiveness analysis, and a formal health technology assessment (HTA) process have proven useful for guiding evidence-based decision making around benefits packages. Use of these techniques can lead to a more transparent, efficient system.494 HTA is most useful when making decisions about small expenditure changes that come on top of well-established existing service packages. For example, Thailand’s Health Intervention and Technology Assessment Program (HITAP) initially opted against introduction of the HPV vaccine after its analysis showed it to be less cost-effective than screening;495 following a significant price reduction,496 the vaccine was later deemed cost-effective and subsequently introduced.497However, full HTA requires substantial expertise and capacities which are oftenabsent in LICs and LMICs, where changes are often made at the margin and needto consider implementation factors.498 In these settings, a reasonable optionmay be establishing a fully costed package that considers burden of disease andcost-effectiveness, along with demand for services, while also setting prioritieswithin the constraints of resource availability, human resources and infrastructurecapacity. This approach may be a practical alternative to HTA in the medium116term, as countries build the capacity needed to take on more sophisticatedapproaches to priority setting. For example, Nigeria recently launched a reformto channel federal-level funding through a statutory transfer to finance a BasicMinimum Package of Health Services (BMPHS). The Federal Ministry of Health,with support from development partners, used detailed costing studies to agreeon the composition of the benefits package. This costing informed the economicand financial costs of guaranteeing access for all Nigerians to the BMPHS inthe long term; and built scenarios to consider options for gradual expansion ofthe package, given fiscal constraints in the medium term. The original packageincluded 57 essential interventions covering 60 percent of the disease burden, to beimplemented in rural areas first, then gradually expanded in geography and scope.To set packages and roll-out plans, countries can adapt international estimates, forexample those provided by Disease Control Priorities,499 introducing refinements asthey strengthen their capacity to conduct more sophisticated analyses.Financing upfront investments and routine operationsIn addition to the direct, recurrent costs of service delivery, adequate financing of multidisciplinary PHC must account for upfront investment in system-wide overhead and routine operational costs. At the outset, the PHC system must be endowed with safe and sanitary facilities; equipment; digital platforms; and the drugs and consumables necessary to deliver the PHC package. Upfront investments are also needed for reform and expansion of health workforce training, as described in Section 2. Studies suggest that major investments need to go into system strengthening, with health workforce and infrastructure development jointly accounting for 53–66 percent of additional costs forCHAPTER 4: MAKING IT HAPPENstrengthening PHC measures in LMICs.500 Gaps between the current state of PHC infrastructure and the required levels are likely to be larger in remote and marginalized areas. Brazil, Ethiopia, South Africa, Thailand, Turkey, and Ukraine have all recently increased funding for primary and community health services. These increases were accompanied by supply-side improvements to service quality and accessibility, through improvements in infrastructure, staff training, management, provider-payment mechanisms to encourage quality, and governance.501,502Beyond upfront infrastructure investments, routine funding is required to cover facility overhead (e.g., electricity, water, routine maintenance/cleaning, and similar inputs); staff salaries, including administrative support; and re-supplies of pharmaceuticals and consumables. Input-based budgets must explicitly allocate line items for these anticipated recurrent costs; alternatively, strategic financing arrangements can bundle routine overhead costs into reimbursement or contracting. Shifts towards PHC investment are often facilitated by strong public financial management (PFM) practices that reliably direct adequate funds to PHC facilities for routine operational costs, with sufficient resources for supervision to ensure appropriate use of funds.How primary care is positioned in the government budget, and whether facilitiescan receive funds directly and exercise autonomy in shifting resources to new117needs, plays an important role in securing sufficient routine operational resourcesat the PHC level, particularly in LICs and LMICs.503 In many developing countries,administrative authorities (e.g., districts) act as agents for receiving and managingresources allocated to PHC together with resources for other purposes. Sucharrangements have led to inadequate financing for PHC providers, in particularinadequate resources for operational costs, and hence missed opportunities toaddress community needs.504 In some countries, a shift to a program-based budgetclassification system has helped to allocate resources toward programs that areorganized around policy goals, rather than along administrative and input lines,providing an opportunity to link spending to policy priorities.505 For example, thePrimary Health Care Service Delivery Budget Program in Kyrgyz Republic madethe allocation for PHC at the facility level explicit, facilitating advocacy to increasethis allocation.506 However, gains from such approaches are not automatic andoften require institutional capacity strengthening to realize. When program-basedbudget classification is not feasible, facilities should be explicitly recognized inthe budget such that budget provision can be made to primary care providers,enabling them to receive and spend funds.The donor community has a crucial roleRethinking development assistance can drive the investments and capacity building needed to deliver on the promise of a multisectoral, integrated, peoplecentered PHC system, while also addressing problems with lack of alignment and fragmentation. In LICs and LMICs, where the gap between health needs and current levels of service coverage are high, donor funding accounts forWALKING THE TALK20 percent of health spending in LICs and 3 percent in LMICs.507 Most donor funding is channeled to priority programs such as immunization, HIV, TB, malaria, and maternal and child health (MCH) – the very services that are core to PHC, though in the case of donor-supported programs frequently delivered through vertical structures. A new era of development assistance will require shifting from investing in specific priority programs towards investing in systems, including the capital investments and recurrent operational costs needed for a stronger PHC. Many donors, including Gavi and the Global Fund to Fight AIDS, TB, and Malaria, are signaling increased attention to investment in PHC systems and public financial management. While fundraising through such global initiatives will likely remain disease-specific, funding arrangements at the country level should not duplicate processes across specific programs. A further shift to financing systems rather than programs can lead to cross-programmatic efficiency gains and savings within primary health care.508Donors can also contribute to more resilient health systems by investing insurveillance and public health functions. The Global Action Plan FinancingAccelerator highlights several critical features of a next generation of developmentassistance for health (DAH),509 including enhanced support for fiscal, publicfinancial management, and efficiency reforms, as well as advocacy platforms.The COVID-19 epidemic has already forced donors to become more flexible, for118example by allowing reallocations of their investments to address the COVID-19response, granting flexibilities in donor policies, and looking for opportunities tobuild on existing programmatic infrastructure to address COVID-19 and protectessential services. For example, in LICs and LMICs, Gavi has invested heavily incold chain infrastructure; the cold chain can be used for diagnostic testing andpotentially a COVID-19 vaccine, if and when it becomes available.Alignment of donor financing and concessional lending behind government reforms can strengthen the infrastructure and institutions needed for stronger PHC systems. For example, in Lao PDR, the Government’s Health Sector Reform Strategy (HSRS) focuses on building a people-centered health system that provides equitable access to a prioritized set of essential health services, backed by increases in domestic financing, and delivered through an improved service delivery model that includes strengthening the integrated outreach model for the most remote populations. The World Bank’s Health and Nutrition Services Access Project (HANSA) is designed to strengthen subnational financing, governance and service delivery at the PHC level. It serves as a platform for alignment of development partners in support of sustainable financing for UHC, whereby the Global Fund and the Australia’s Department of Foreign Affairs and Trade provide joint financing of US$36 million through mainstreamed government systems.510CHAPTER 4: MAKING IT HAPPEN3.2. From fragmentation to person-centered integrationPaying providers for care coordination and integrationTraditional fee for service (FFS), line-item budgets or capitation on its own are increasingly seen as poorly aligned with team-based, integrated care models; see Table 3.511 Many countries have adopted financing innovations to foster teambased care, promote coordination and integration, and improve quality, outcomes, and efficiency.512 These emerging models, sometimes referred to as “value-based” payments, shift clinical and financial accountability to providers by adjusting and conditioning reimbursement based on certain cost, quality, and patient experience metrics. Providers are incentivized through these models to innovate and provide high-quality care while minimizing costs.513 Providers are also financially incentivized to work with a defined population group so that they can reap benefits of preventive services and investment in high-quality services.Table 3. Misalignments between traditional payment mechanisms and team-based care modelsIDEALAPPROACH FOR TEAMBASED CAREFEE-FORSERVICEINPUT-BASED FINANCINGCAPITATION119MODELSPayment RecipientA team of providers or Individual provider oran integrated unitunitIndividual unitIndividual provider or unitPayment CriteriaRelevant Time Horizon Beneficiary PopulationIncentives for…Based on health outcomes, value of health carePre-defined fee schedule for specific items (inputs, procedures, etc.)An extended period of time (often multiple years)A defined population group assigned to providers (i.e., empanelment)A visit or an encounterAnyone visiting the concerned providersHealth promotion and preventive careWeak; instead encourages increased activityRetaining patients at the PHC level where appropriateStrong but can create supplierinduced demand and unnecessary careClose coordination across providersWeak; discourages referrals to higher levelsPrices of inputsFixed amount per enrolled patient (sometimes riskadjusted), not always linked to explicit performance standardsPeriodic lump sum (monthly or annual)Periodic (often annual)Anyone visiting the concerned providersA defined population group assigned to providers (i.e., empanelment)Weak; incentivizes low transaction costs; incentivizes reduced quality when demand is highWeak; encourages unnecessary referrals to higher levelsWeak; does not reward good performance or coordinationCan encourage prevention/ promotion depending on the payment agreement but can also lead to avoidance of high-risk patientsCan incentivize improved quality of care and healthier behaviors, but can also lead to under-provision of servicesCan incentivize unnecessary referral to higher levelsWALKING THE TALKDifferent payment mechanisms are often blended together to drive transformations toward a set of policy objectives, as each method may have its own pros and cons.514 Negative effects of a given payment type may be neutralized when blended with other payment methods. For example, FFS payments can encourage increased use of preventative services (e.g. vaccinations, mammograms, screening); they can also encourage (safe) delivery of some services at the primary care level that otherwise might be referred to specialists (e.g., wound care, drainage of abscesses).515 Fee-for-service for preventive care, in combination with capitation payments for everything else, can effectively increase provision of preventative care while maintaining an incentive for efficiency and cost savings.516,517 As of 2016, 25 out of 34 OECD countries use some form of blending, while the other nine use a single payment mechanism for primary health care (either fee-for-service, capitation, or global).518 Many low- and lower-middle income countries also use blended payments to align incentives against competing policy objectives, including Kazakhstan and Myanmar. For example, a capitation payment combined with a small proportion of fee-for-service payment for priority preventive services (e.g., prenatal care and immunization in Estonia) can be adopted to incentivize health promotion.519Team-based care and coordination with other care providers can be explicitly incentivizedthrough direct payment linked to such activities. Pay-for-coordination, for example, offers a lumpsum to a given provider, per chronic patient, to coordinate care across a team of professionalsworking at different levels, e.g., primary care, secondary care, public health, prevention andhealth education.520 The first country to use this payment method was France, where primary120care centers (not health care workers specifically) received payment for coordination of NCDprevention and care, with the flexibility to allocate the additional payment as they see fit. Thepayment represents on average 5 percent of providers’ income and is paid by the social healthinsurance agency (CNAMTS). 521,522 Austria, France, Germany, Hungary and other countries havesince adopted this model.523 The Comprehensive Primary Care Plus (CPC+) model in the UnitedStates also has an element of care management fee, which is non-visit-based and paid perbeneficiary per month.524Alternatively, several payment models can indirectly incentivize or facilitate care coordination and integration—both horizontally and vertically:+Bundled payments provide a single payment for an entire episode of care across multiple types of providers in different settings. This model extends the logic of diagnosis-related group (DRG) payments, which offer a single payment for an acute episode to a single provider, to reimbursing costs related to an entire clinical pathway of care for select conditions—including primary health care, specialists, hospitalization, rehabilitation, and any other care needed during a defined “episode,” that is, over a specified time period for a given disease/condition. The provider delivery group assumes financial risk for the cost of services and costs associated with preventable complications. By design, bundled payments encourage coordination and integration of care across diverse providers and institutions, remove the incentives for cost-shifting to other providers, and encourage implementation of evidence-based clinical pathways.525 For example, the Netherlands and Portugal both use bundled payments for the care of chronic conditions such as HIV/AIDS and diabetes, with quality requirements across service delivery settings.526CHAPTER 4: MAKING IT HAPPEN+Population-based payments are paid per person and cover a wide range of services by various providers, who are in turn encouraged to control costs and meet quality standards (for example in the United States, Germany, Spain). Such population-based payments create a strong financial incentive to integrate a functional network of providers in conjunction with effective health promotion. In Germany, for example, two statutory health insurance funds have contracted a private joint venture, “Gesundes Kinzigtal GmbH” (GK), to run a population-based integrated care model for their insured population; the program is financed by cost savings realized from better prevention and improved efficiency.527 Members of the program are also offered vouchers to be used for participating in health promotion programs. An evaluation shows that the program has improved overall patient experience, quality of care, and population health, while reducing health care costs and emergency hospital admissions.528+Pay-for-performance provides financial incentives for achieving specific objectives, which can either directly or indirectly promote care coordinationand integration, depending on the performance indicators selected. Likepay-for-coordination, it can be used to promote specific functions such asmanagement of chronic disease (e.g., management of diabetes). It can alsobe based on patient experience measures, clinical quality measures, andutilization measures that drive down cost—all of which are facilitated bybetter coordination and integration. Pay-for-performance is used extensively121in OECD countries; in middle-income countries like Brazil, China, and India;and in low-income countries like Rwanda.529 A review of experiences from 10OECD countries found that P4P has helped clarify provider goals, improveprocesses for purchasing health services, improve measurement of provideractivity and performance, and created a more informed dialogue betweenpurchasers and providers—though it has not significantly improved overallhealth outcomes.530+A shared savings approach, often applied in combination with the methods described above, can both promote care integration and strengthen empanelment. Under a shared savings approach, providers bear financial risks subject to their performance in meeting pre-defined quality standards for the patient population. Providers can be initially paid through FFS or capitation, but payments are eventually adjusted based on performance against quality and patient experience metrics. The approach promotes collective accountability of various providers, encourages investment in high-quality and efficient services including PHC, and fosters a long-term relationship between providers and patients. For example, United States Accountable Care Organizations (ACOs) consist of voluntary networks of providers, including primary health care, hospitals, and sometimes specialists and others, who assume financial responsibility and clinical accountability for a defined patient population.531 ACOs typically serve at least 5,000 beneficiaries assigned for at least 3 years. They are primarily paid based on traditional FFS; however, they receive a supplemental reward or penalty based on how their total costs per patient compare with historical references. If costs fall below budgeted targets, ACOs are permitted to keep partial savings, conditional on having met quality targets. These more refined approaches require a threshold capacity of human resource skills (including purchaser and provider administrators), institutional capacity (for correct pricing and negotiating), and governance arrangements.WALKING THE TALKWhile such payment approaches can act as powerful levers for transforming PHC in more developed economies, LICs will require a more gradual process, given the high administrative workload and extensive capacity required to effectively execute payment functions. Payment mechanism discussions are highly political and require consultation with a range of stakeholders to prevent unintended effects. Investment in infrastructure (e.g., interoperable data platforms collecting information on care for empaneled populations) and the health workforce (recruitment and training) will be critical for implementation. Public financial management rules must also be aligned with strategic purchasing goals. For example, providers need sufficient managerial and financial autonomy and capacity to respond to financial incentives.532,533 In many low- and lower-middle income countries, districts (or related government administrative levels) are often allocated a budget for various purposes, including supervision, public-health services and primary care; funds are not disbursed directly to facilities. PFM rules often need to be adjusted to allow providers to change the mix of inputs so that efficiency gains can be realized.534Other recent innovations are also changing the way PHC providers can receivefunds. Mobile money payments, or “e-payments”, reduce dependence onphysical financial interactions and the need for cash and can provide a secureway for providers to both receive and use funds quickly and efficiently, without122compromising accountability. This is important given that primary care facilitiesoften lack access to bank accounts even when they are registered as spendingunits, allowing them to receive a budget allocation. Mobile money transactionsallow a balance to be sent from central-level or district administrations to mobilewallets at remote primary care facilities to be used as part of the operationalbudget. Through such innovations, primary care provider payment reforms canbe operationalized and have the potential for efficiency gains, accountability,transparency, and financial inclusion. Zambia is currently in the process ofpursuing such a reform.535Integrated payment models are facilitated by integrated data platforms, discussed in Section 1. While these platforms are at various stages of maturity, all countries can embark on a strengthening initiative and adapt payment models as more information becomes available and policy makers improve their capacity to generate, analyze, and use data for decision-making.536 For example, verification of claims data and health outcomes can inform a dialogue between purchasers and providers regarding the current performance, opportunities, barriers to improvement, and mechanisms to overcome these barriers, which might include financial incentives.3.3. From inequities to fairness and accountabilityWhen well designed and sufficiently resourced, PHC financing mechanisms play an essential role in promoting and reinforcing values of fairness, equity, and accountability within the overall healthcare system. Value-based payment mechanisms, for example, reinforce provider accountability for population-wideCHAPTER 4: MAKING IT HAPPENhealth outcomes, including for the poor and vulnerable. Sufficient pooled resource mobilization plays a redistributive role, leveraging social resources for equitable service coverage. Likewise, fair, inclusive, and transparent design of explicit health benefits packages creates an equitable entitlement across the entire population; providers and the government, in turn, can be held accountable for ensuring this package is in fact delivered.In this section, we consider four elements of PHC financing for fairness and accountability that this report has not previously discussed: financing to break down demand-side access barriers; pro-equity and accountability in intergovernmental transfers; transparency and accountability in planning and budgeting; and community engagement in resource allocation.Financing to break down demand-side access barriersFor truly equitable access and utilization, all PHC services must be free at the pointof service. There is broad consensus that financial barriers to PHC services in LICsand LMICs (e.g., user fees) should be removed.537 Nonetheless, financing reformsthat are not backed by mobilization of additional resources and careful planningto compensate for simultaneous revenue loss and costs associated with increasedutilization can cause their own problems, for example a shift to informal payments;patients’ foregoing services altogether; or ad-hoc or implicit rationing.538 This123further highlights the importance of defining an explicit benefits package, as wellas a fair and inclusive priority-setting process appropriate for the local context.Even when PHC is free at the point of service, some populations may still face financial or non-financial barriers to access services. These could include migrants or refugees who fall between the cracks of empanelment strategies; marginalized populations who are socially stigmatized or fear judgment or abuse from healthcare providers; rural populations geographically distant even from outlying PHC facilities; or groups where the opportunity cost of accessing services (for example, missed work and wages) may discourage utilization. Understanding the drivers of non-utilization of PHC services is critical for developing targeted interventions to improve equity and fill gaps in financial protection.539Financing mechanisms are not a panacea, but some approaches can ease these broader inequities and demand-side access barriers. Conditional cash transfers, often targeting poorer groups, can improve financial access to care even when the conditions are not explicitly tied to health. Transfer payments are often used for out-of-pocket payments (where they exist), travel costs, or childcare.540 Voucher programs, especially common for antenatal care or delivery, can also help vulnerable groups to receive free care. Evidence shows they are associated with positive impact on the use of maternal and child health services541,542,543 and nutritional status,544 although it is hard to attribute positive effects to these incentives alone, since other components may also contribute.545,546WALKING THE TALKAccountability through intergovernmental transfersIn highly decentralized contexts, conditions on intergovernmental transfers can help create accountability for sufficient financing and/or quality delivery of PHC at subnational levels. In Kenya, for example, the share of the national government budget allocated to health was greatly reduced after devolution of healthcare responsibility to the county level. To restore priority for health in country budgets, the central government established a UHC conditional grant; local authorities (counties) must direct at least 30 percent of the budget to health to receive the grant.547 In Nigeria, a recent reform through the Basic Health Care Provision Fund (BHCPF) finances PHC from the federal government through a statutory transfer, moving away from unconditional block grants which had left PHC underprioritized and facilities with little operational funding. The statutory transfer protects funding for PHC by transferring funds to facilities for a basic package of essential PHC services. The statutory transfer also overcomes the common problem of funds budgeted but not disbursed, while subsidization of enrolment aims to reduce financial barriers for the most vulnerable in a country where 70 percent of total health spending comes from out-of-pocket payments.548,549 Disbursement of funds is subject to receiving financial reports showing the source and use of funds in alignment with the agreed purpose, improvements in monitoring, and quality assurance criteria. 124 Similarly, specific financing mechanisms can ensure equitable nationwide resources for PHC, given regional variations in wealth or other relevant population characteristics. Italy, for example, earmarks 38.5 percent of the VAT for a national equalization fund to help regions with lower revenue-raising ability provide the core benefit package.550 The Philippines uses an earmark on the Sin Tax (levied on alcohol and tobacco) to fully subsidize enrolment of the poorest 40 percent of the population in the National Health Insurance Scheme,551 which includes a benefits package for primary health care.Transparent, participatory, and accountable planning and budgetingImproving allocation of resources will require strong measurement and an understanding of existing performance challenges. Improved budget transparency and better expenditure data can provide a picture of country performance and identify necessary financing reforms. Data on the current level and distribution of health spending are most useful when combined with data on health outcomes, service coverage data, and financial protection, disaggregated across gender and equity markers, where possible.552 Recent global efforts have sought to measure PHC expenditure in a comparative and standardized manner, but implementation and capacity for a standardized methodology is still advancing. One limitation is that the current approach covers only a narrow definition of recurrent expenditure for PHC.553 Continuous investment in data systems, by governments and donors, will therefore be essential for guiding PHC reforms.CHAPTER 4: MAKING IT HAPPENA robust strategic planning process for PHC (articulating a vision and charting a plan for achieving that vision through measurable goals), coupled with strong government leadership, can help shift resource usage towards PHC. For example, Turkey’s Health Transformation Program, launched in 2003, aimed to develop a universal PHC-based delivery system funded through a unified social insurance system. In addition to strong economic growth, a key contributor to success was the iterative planning, implementation, monitoring and evaluation, and refinement of the reform, which drove more spending to health generally and PHC specifically.554 This process allowed the country to adapt to common pitfalls – that policies are not always implemented as planned, and that strategic plans are often wish lists. Over the course of a decade, the program led to improved health outcomes, increased health service utilization (for example, outpatient physician visits per capita rose from 3.1 in 2002 to 8.2 in 2013), and a reduction by 47 percent in out-of-pocket financing between 1999 and 2012.555 See Box 13 for additional examples of how a key donor facility is supporting countries’ strategic planning processes in health.125WALKING THE TALKBOX 13. GLOBAL FINANCING FACILITY AND THE WORLD BANK – A PARTNERSHIP TO SUPPORT PRIMARY HEALTH CAREThirty sixlow- and lower-middle income countries are benefitting from the support of the Global Financing Facility for Women, Children and Adolescents (GFF) – a country-led partnership between country governments, development partners, the private sector, and civil society organizations. Hosted at the World Bank, the partnership focuses on catalyzing high-impact investments for reproductive, maternal, newborn, child and adolescent health and nutrition in the world’s most vulnerable countries, while also strengthening the wider health systems needed to deliver at scale and sustain impact.. The GFF has pioneered a shift from traditional development approaches to a more sustainable way forward where governments lead and bring their global partners together to support prioritized, costed national plans with evidence-driven investments to improve reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH-N) through targeted strengthening of service delivery systems, particularly primary health care—to save lives. By facilitating multi-stakeholder country platforms, the GFF supports its partner governments to mobilize and align both domestic and external funding behind national priorities.As of June 2020, the GFF has directly invested about US$602 million in grants linked toapproximately US$4.7 billion of World Bank International Development Association IDA/126IBRD financing and helped align much larger volumes of domestic public and privateresources as well as external financing in support of GFF partner country investment cases.In line with GFF’s new strategy, it also provides critical technical assistance and supportin key areas such as country leadership & alignment of partners, gender equality, healthsystem redesign, health financing and results.The GFF’s collaborative, country-led approach has already yielded significant results in improving access to PHC-related services by drawing attention to, and funding health system reforms, towards the frontlines and community level delivery. For example, in Côte d’Ivoire, the country’s investment case, which focused on strengthening primary health care, has resulted in the Prime Minister’s decision to increase the health budget by at least 15 percent annually. In Cambodia and Tanzania, the GFF country-driven processes led to the integration of nutrition into the full continuum of essential health services for maternal and child health.Other investment cases in Burkina Faso, Cameroon, Ethiopia, Guinea-Bissau, Liberia, Mozambique and Niger, have focused funding on a prioritized set of high-impact services delivered at the primary care level) and have designed reforms to increase the share of funds that flow to, and are managed by, frontline service providers.CHAPTER 4: MAKING IT HAPPENEngaging communities in resource allocation decisionsEmpowering PHC teams and communities helps to improve participation indecision-making regarding how resources are allocated to respond to populationhealth needs.556 Transferring decision-making to local governments can enablebetter alignment between resource allocation and community needs.557 Forexample, some countries have moved to “participatory budgeting,” which allowscommunities to have direct decision-making powers over the allocation of publicresources in their area.558 The model requires formal evaluations to understandits impact but is gaining popularity as a means of empowering communitiesto adequately fund local priorities. In Brazil, for example, the wide adoption ofthis approach across municipalities has led to increased expenditure on basicsanitation and primary health care services, which were previously underfinanced.An evaluation study also found a significant reduction in infant mortality ratesamong municipalities that adopted participatory budgeting.559 In Nigeria, WardDevelopment Committees (WDCs) were established by volunteer communitymembers to advocate for the health and social needs of their communities andgive them autonomy over the utilization of funds for PHC improvements andoutreach activities. A functioning and responsive complaints mechanism wasalso established. Five percent of the BHCPF was set aside specifically for fundadministration including setting up this robust mechanism to receive and respondto community complaints.5601273.4. From fragility to resilienceAs COVID-19 has made clear, shocks like global pandemics may require considerable additional health service spending, while severely reducing government capacity to raise revenues. Flexible financing systems can enable more resilient systems that can adapt to shocks with appropriate response measures; maintain essential PHC services during a crisis; and rapidly disburse sufficient financial protection to citizens.Surging resources to the frontlinesUnpredictable crises typically require extraordinary resource mobilization and deployment. Experience in past public-health emergencies suggests that additional health-sector funding is often needed for:+Core population-based functions essential for responding to shocks, including comprehensive surveillance, data and information systems; regulation; and communication and information campaigns;+Adaptations to sustain essential routine health services, including use of alternative care models (for example, telehealth, home-based care), reductions in/removal of copayments or user charges, expansion of coverage to previously uncovered populations (for example, migrants), investment in ICT capacity, facility reconfiguration and equipment, hazard pay for health workers, and financial support for facilities to survive through the crisis; andWALKING THE TALK+Clinical and psychosocial care for patients directly affected by the crisis, for example COVID-19 or Ebola patients or persons injured in a natural disaster.The ability to surge the required funding to the front lines must be supported by country legal frameworks. Options can include contingency appropriations within the approved budget; emergency spending provisions that allow for spending in excess of budgeted amounts; expenditure reprioritization through reallocations and virements; supplementary budgets; and external grants/loans. COVID-19 experiences have shown that countries with well-defined and flexible budgetary programs in health are more likely to have a flexible and effective response compared with countries with rigid line-item budgets. New Zealand, France, and to some extent South Africa offer positive examples. Uganda ensures sufficient funding for core population-based functions through a ring-fenced surveillance budget which includes a contingency fund to release money during an outbreak, with distinct funding for routine surveillance and response activities. At the district level, there is also a protected budget from which funding is released when a district officer finds a suspected case of concern. Many countries have also injected additional funding to the health sector during the COVID-19 pandemic by drawing on national reserves, health insurance reserves, or social insurance reserves.128Further, rapid deployment of additional funding to the frontlines may requireadjustments to typical payment mechanisms. For example, several countries arechanneling additional COVID-19 response funds through purchasing agencies,including Austria, Croatia, Estonia, Latvia, Poland, Romania and Serbia. Frontlineproviders can also be granted greater flexibility and spending authority so thatthey can respond more rapidly to key supply shortages or stock-outs, for exampleconcerning soap, medicines, or other materials. Some countries may need toactivate exceptional spending procedures during the first phase of a crisis andthen formalize these procedures using supplementary budget laws. In some cases,declaring a state of emergency can facilitate the release of new funds and speedup public procurement by enabling simplified procedures for trusted suppliers. Inresponse to COVID-19, Italy for example passed a law (“Cure Italy”) to enable sole-source procurement and Lithuania plans to simplify public-health procurement rules.Advance payments can also help bring financial resources to frontline workers quickly. PHC facilities can be adversely impacted as a result of additional expenses that are not part of routine budgeting/purchasing arrangements. Interruptions in routine service demand (due to crisis management measures or public fear) may worsen facilities’ financial situation, which can be exacerbated if case-based or volume-linked payment methods are used. This situation has occurred in PHC facilities of Columbia, North Macedonia and the United States during the COVID-19 pandemic. Advance payments may be in the form of frontloading budgets or capitation payments, or by “pre-funding” payments that would otherwise come through retrospective reimbursement of claims. For long-term resilience, past public-health emergency experience calls for prospective payment mechanisms and delinking payment from service volume with a larger focus instead on service value.CHAPTER 4: MAKING IT HAPPENPurchasing arrangement flexibility assures that frontline providers receive the required resources promptly. Flexibility can be applied to “who provides services”, “what services to provide”, and “to whom to provide services.” For example, some countries established rules to pay for services provided by non-contracted providers during COVID-19: Georgia and Cyprus paid private providers to fill service delivery gaps, while Switzerland mandated service delivery for designated patient groups by acute hospitals that are normally not included in cantonal hospital plans and not reimbursed through DRG-based payment. In England, an agreement has also been brokered for the government to take over private hospitals and their staff for the duration of the crisis, resulting in tens of thousands of clinical staff at the disposal of the public sector.561Resilience and the benefits packageAn explicit health benefits package, defined during a period of relative calm, may need to be rapidly amended so the health system can respond to a crisis. Rules and mechanisms that allow for timely benefit package adjustments can enable provider reimbursement for new or different types of services; remove financial barriers to patient service utilization; and ensure vulnerable groups receive necessary care.During the COVID-19 crisis, many countries have expanded the scope of benefits129packages, ensuring access for and financial protection from the costs of COVID-19diagnosis and care; offering coverage for and incentivizing use of “touchless”teleconsultations or home-based care; and compensating health workers forthe costs of providing these adapted services. For example, the health insurancedepartment in China included eligible online-based medical service expenditurefor primary health care into its package during COVID-19, ensuring continuity ofservice for chronic disease patients.562 In settings where telehealth was alreadycovered by insurance, efforts were made to minimize or eliminate disparity inreimbursement value between in-person and virtual visits. Such efforts were seenacross Europe and North America (Czech Republic, Germany, Luxembourg, theNetherlands, Sweden, Switzerland, Belgium, Canada, and the United States). Insome contexts, free access to health services were provided to vulnerable groups,including migrants in Portugal, France, and Belgium. In Ireland and Belgium,user charges were removed for teleconsultations in primary care, including forsuspected COVID-19 cases.Countries are also making modifications to their governance arrangements to adopt new testing and treatments as they become available, thus ensuring no payment is required by their populations. For example, in China, the drugs and treatments that were listed in the COVID-19 clinical treatment protocol developed by the National Health Commission were added to the health insurance benefits package on a temporary basis. If other types of services need to be put on hold to finance the new interventions, it is critical to anticipate the implications in terms of health impact (current and future), equity, effects on financial protection, and possible implications for public confidence in government.563 In some cases,WALKING THE TALKbuilding out models for countries to rapidly evaluate newly available technologies may help countries to better use scare resources for shock responses without compromising essential services or other priorities.564,565,566Enabling multisectoral engagement through PHC reformChapter 3 discussed multisectoral action for health as a cross-cutting agenda that can accelerate structural shifts toward stronger PHC. This chapter has shown how reforms in care organization, workforce development, and health financing can directly support those shifts. These priority reforms can also contribute to improving PHC through other channels, for example by creating new openings and incentives for multisectoral collaboration. In closing this chapter, we look at specific opportunities and barriers to multisectoral working that are associated with the three priority reforms.Linking clinical care and action on health determinants130A fundamental condition for effective multisectoral engagement is strongintersectoral stewardship at the policy level.567 This central stewardshipfunction then supports the development of needed skills and competenciesat the level of community-based PHC delivery. When appropriately staffed,trained, equipped, and compensated, frontline PHC teams can plan and provideprimary care and public-health services, and also ensure local coordination forintersectoral interventions.568Implementation barriers and the scarcity of good evidence on intersectoral action are widely acknowledged. While compelling evidence exists that the availability of quality PHC services is associated with reduced disparities in health across socioeconomic and ethnic groups in many countries, whether and how multisectoral strategies have contributed to these results is often unclear.569 There is abundant literature on integrating primary care with public or population health,570,571,572 and some on integrating PHC with the rest of the health system,573 but evidence is generally much thinner on how to connect PHC with other sectors of government in pursuing health for all.574However, recent work has begun to strengthen the evidence base supporting some intersectoral policies and interventions as cost-effective means to improve population health. In the third edition of Disease Control Priorities (DCP3), Jamison and collaborators identify 71 proven intersectoral policies, which they divide into financial/fiscal (e.g., excise taxes on tobacco and other harmful products); regulatory (e.g., ambient and indoor air pollution and inadequate or excessive nutrient intakes); built environment (road traffic injuries, water supply and sanitation); and informational (e.g., consumer education). These policies are aimed at reducing/eliminating behavioral and environmental risk factors. TheCHAPTER 4: MAKING IT HAPPENeffectiveness of these policies is solidly backed by evidence. However, they are by definition developed at the central political level rather than locally. That said, successful implementation of many of these policies must be tailored to local conditions. This especially concerns measures related to personal and group behaviors, such as tobacco and alcohol use, salt intake, micronutrient deficiencies, and unsafe sexual behavior. Local PHC teams are well placed to participate in implementing such policies, using socio-culturally acceptable approaches.575One approach that has been widely applied over the past two decades, especiallyin lower-middle-income countries, involves linking health and social protectionagendas to facilitate communities’ expression of their health and healthcareneeds and increase their uptake of some services. Many programs have chosenconditional cash transfers (CCTs) as their main vehicle. CCTs provide cashbenefits to households contingent on their use of essential health services at thePHC level, such as maternal and child health services and immunizations. Someprogram models engage a widening spectrum of determinants of health, includingeducation, water supply and sanitation, food security, and nutrition, amongothers.576,577 Experts have cautioned that, while CCTs may cushion the healthconsequences of poverty and reduce certain health inequalities, by themselvesthese programs are not able to tackle the structural sociocultural and economicinequities that are the root causes of inequities in health.578 However, when theirstrengths and limitations are understood, CCTs can work as complementary131intersectoral interventions in support of people-centered primary health care. Keyconcerns in effective CCT design, such as proper targeting, coverage, scale-up,and longer-term sustainability579 involve skill sets that are not generally present atthe PHC level. However, local implementation and adaptation of these programsalso require specific skills that need to be deliberately instilled in PHC teams. Theseencompass not only technical skills, but also, communications, administrative,managerial, and advocacy capacities. The best-prepared teams will developcapacities to secure appropriate funding and remove bureaucratic hurdles forintersectoral action.Another area of increasing interest is “convergence.” This refers to a strategy of zeroing in on the poorest communities in a given country for simultaneous technical and financial support, often involving International Finance Institutions and their development partners. Support is delivered across several sectors concomitantly, mainly health, education, nutrition, agriculture, and water and sanitation.580 While it is too early to fully assess their effectiveness, such intersectoral interventions, if designed and executed with the full participation of local communities and local government support, could address key social determinants of health while boosting PHC capacities at the local level.In upper-middle-income countries with full population coverage of essential health services, current challenges for PHC are related to noncommunicable diseases, multiple morbidities, and the behavioral determinants of healthier living and aging. Special concerns arise in low-income and/or low-growth “lagging” regions,581 which are often rural. People in these regions often have limited access to comprehensive,WALKING THE TALKquality health care. Indeed, several European countries, along with China, Brazil, Colombia, and Turkey, among others, use metrics or indices to define “lagging” areas that include health and healthy living and ageing.Not surprisingly, these same countries emphasize community- or people-centered health care, with PHC at the center. Their different approaches all highlight the importance of integration across sectors and levels of care, communications strategies, engaging stakeholders, and continuous performance monitoring. All have undertaken or are considering regulatory reforms and workforce measures to facilitate the introduction of multi-disciplinary teams.582,583,584Building skills for multisectoral action among PHC practitionersTraining in advocacy, communication, and resource generation for multisectoral actionIn Chapter 3 we identified proper undergraduate, graduate and in-service training132as essential to building health workers’ skills and competencies for multisectoralengagement.585 We argued that PHC professionals need to expand their skills inpreparation for a range of newer interdisciplinary roles across the care spectrum,from health promotion, disease prevention, and management of chronic diseasesto palliation and social care. Equally important for PHC professionals is acquiringleadership/stewardship, management, and communication skills to be able toconfidently advocate for healthier living in the communities they serve. Suchadvocacy has many facets. It can include reaching out to local practitioners inother sectors whose activities influence health outcomes in the community, andwith whom opportunities for productive intersectoral partnerships may exist. Italso involves sustained dialog with communities themselves, to strengthen healthliteracy, encourage healthy lifestyle choices, and promote greater communityagency and self-reliance in health, often across diverse socio-cultural contexts.This is easier said than done, in a context of rapidly shifting disease burdens and demographics, as well as technological change and evolving social expectations that are challenging health professionals’ traditional status in many settings. Policy makers may encounter substantial opposition to reforms of curriculum and pedagogy in undergraduate medical training, especially if reforms propose to expand already-packed academic programs with new material such as management or advocacy skills that may be perceived as peripheral to many future physicians’ career plans. Factors such as chronic shortages of properly trained health workers, the difficulty of deploying them to underserved areas, the migration of health professionals within and across national borders, and long delays in recouping public investment in the training of health professionals must also be considered, as countries weigh possible changes to health-worker education and training.CHAPTER 4: MAKING IT HAPPENRecognizing these challenges, there are at least three ways countries can address the shortage of skills and competencies in multisectoral engagement. First, in the shorter run, countries can leverage the continuous on-the-job learning that is already part of many PHC professionals’ routine experience, especially in low- and middle-income countries. Conscientious PHC practitioners, whether CHWs or PHC doctors and nurses, already participate in such learning as an integral part of their polyvalent vocation.586 Indeed, PHC professionals themselves increasingly perceive advocacy and communication skills as a key competency in daily PHC practice, but also as a foundation for more ambitious multisectoral engagement at the program-design and policy levels. Action to reinforce their capacities could include not only short-term on-the-job training but also “embedded PHC research”587 to systematically document local health and health care needs and preferences, as well as the broader socio-cultural and economic determinants of health. Frontline PHC workers will be most motivated to build such competencies when they can apply them in the day-to-day practice of their jobs and be recognized and rewarded for doing so.A second, longer-run agenda, is to instill flexibility in existing undergraduateand graduate training courses to encourage pursuit of joint degrees in areaslike business administration (MBA), health or medical administration (MHA,MA), or public health (MPH). The United States has been a recent very rapidincrease in joint degree programs linking an MD degree with a Ph.D., MPH, or MA133qualification. The number of MD/MBA programs in the US alone now exceeds 60,including on-line training, many of them having started since 2000.588,589 Similardual programs are also becoming more common in Canada.590 While many ofthese programs are more attuned to the business side of healthcare in high-income settings, some prepare students for other vocations, including community-based primary care.591 Such dual programs will be more widely on offer in othercountries and to other health professionals over time. A fundamental concernis to customize them to local needs and ensure their accessibility and relevanceto people working in PHC or who aspire to do so. Available tools include tuitionsupport, options for on-the-job and on-line degree acquisition, as well as tangiblebenefits in compensation and career advancement.Last and perhaps most importantly, countries need to build capacities for multisectoral stewardship at the highest policy level. This first involves understanding the training and other requirements for doing so effectively, a question that remains unresolved, despite recurrent efforts in many countries, with varied approaches and uneven results. Top-level multisectoral stewardship must also be mirrored through the successive levels of the health system down to the local administrative level and the PHC front lines. This will involve building into the curricula and pedagogy of health professionals, especially those aiming to work in local PHC, key skills in intersectoral dialogue, advocacy, and communication. This will be a long-term process.The current context may provide an opportunity to launch ambitious reforms in this respect. Along with the global systemic disruption caused by COVID-19, the era of the Sustainable Development Goals (SDGs) is one in which the complexWALKING THE TALKinterplay between health and development progress in other sectors has again come to the fore. There is growing acknowledgement of how action in other sectors influences health, and now an acute awareness that what happens in health can swiftly and overwhelmingly affect countries’ economic performance and every other part of life.592,593,594Financing multisectoral engagementValuing multisectoral benefits in resource allocationThe case for multisectoral action to strengthen PHC is clear. Only throughmultisectoral action can the PHC platform cohesively target the socialdeterminants of health across sectors like education, nutrition, agriculture,housing, transport, and environment.595,596,597 Capitalizing on the synergies acrosshealth and other sectors, however, will require governments to use new ways ofpromoting and financing “win-win” measures that can spur progress on multipledevelopment goals at once.598 There is a growing body of literature on frameworksthat can be used to guide governments on multisectoral investment in health to134support stronger PHC platforms.599,600,601,602,603Win-win taxes, such as those on products that harm health (notably tobacco, alcohol, sugary drinks, and salt in processed food), offer a clear example of an effective multisectoral investment. Such taxes offer one of the most costeffective (and often cost-saving) approaches to reduce health-damaging product consumption, improve population health and individual productivity, and cut future medical treatment costs. These measures complement the promotive/ preventive aspects of the PHC platform while making medium-term health financing more sustainable.604 Although earmarking funds on the expenditure side requires careful consideration of the trade-offs605,606 in some countries, these taxes have contributed directly to PHC. For example, the Philippines’ influential Sin Tax on alcohol and tobacco, discussed above, uses an earmark to fully subsidize enrolment of the poorest 40 percent of the population and senior citizens in the National Health Insurance Scheme,607 which includes a benefits package for primary health care. In the first three years of earmark tax implementation, the budget for the Department of Health tripled.608Countries can also consider joint financing of specific interventions that further the PHC agenda: this modality typically involves one or more non-health sectors investing in health, based on evidence that the investment will also benefit its own sector. This financing model tends to be intervention specific. For example, a randomized controlled trial of school-based deworming treatment, partially supported by the education budget, reduced school absenteeism by one-quarter and was far cheaper than alternative mechanisms to boost school attendance.609,610CHAPTER 4: MAKING IT HAPPENSimilarly, voluntary, school-located programs, which often involve a partnership that includes joint financing between a local school system and health department, have successfully increased uptake for several vaccines.611,612Governments can also explore “integrative financing” by pooling or aligning resources across sectors to better link PHC coordination and other service provision. For example, New Zealand and Canada have implemented various jointly financed integrated health and social care sector models for older adults with complex health needs living in community settings. The evidence suggests that these programs have several positive multisectoral outcomes: they meet the elderly population’s social and health needs, lead to better health outcomes, and reduce costly and often inappropriate hospital and long-term residential care.613,614 Joint financing can take place at various levels (national, regional, local) when two or more budget holders contribute to a single pool for spending on pre-agreed services or interventions, or by aligning resources to ensure joint monitoring of spending and performance but separate management of resources.615Ministers of Health can be at the center of the intersectoral dialogue, togetherwith the Ministry of Finance, as they work together to identify and finance suchinterventions, breaking down the silos typical of more traditional decision makingon resource allocation. In low- and lower-middle income countries, this marks adeparture from a situation where the health sector often struggles to make the135case for investing in health, sometimes because of a failure to highlight non-healthbenefits that might raise other sectors’ interest in health gains.616,617 Cost-benefitanalysis captures human welfare improvement benefits across all sectors inmonetary terms. Thus, it may help make a more effective case for intersectoralpartnership than cost-effectiveness analysis, which is conducted in individualsectors and can undervalue benefits beyond the health sector.618 Intersectoralpriority-setting can also increase the quality and quantity of public spending andensure both value for money and equity.619Finally, with strong Ministry of Finance leadership, governments can facilitate a “whole-of-government” approach to proactively tackle the structural, social, and behavioral determinants of health.620,621,622 This approach can make traditional governmental decision-making mechanisms more reflective of social diversity by promoting greater engagement of the private sector, civil society, communities, and individuals in health-related actions.623 The World Bank’s Human Capital Project consistently highlights the potential benefits whole-of-government approach (Box 14).WALKING THE TALKBOX 14. A WHOLE-OF-GOVERNMENT APPROACH TO STRENGTHENING HUMAN CAPITALThe World Bank’s Human Capital Project (HCP) is a global, multisectoral effort to accelerate more and better investments in people for greater equity and economic growth. The HCP contributes to a “whole-of-government” approach in three ways: by sustaining efforts across political cycles; linking different sectoral programs; and expanding the policy design evidence base.624 This approach recognizes that getting children into school, reducing child mortality, tackling communicable diseases, increasing life expectancy and expanding social safety nets in low- and lower-middle income countries are not just a moral imperative, but also an economic imperative, as this allows people to compete and thrive in a rapidly-changing environment.625 While technology brings opportunity, paving the way to create new jobs, increase productivity and deliver effective public services, it is also changes the skills that employers seek and workers need to be better at complex problem-solving, teamwork, and adaptability.626 The HCP therefore encourages and supports countries to spend on health, education, and social protection programs, in addition to sectors beyond human development. For example, in Nepal, investments in sanitation are contributing significantly to preventing anemia.627136New Zealand offers a suggestive example of an operationalized whole-ofgovernment approach. The country passed a “Well-being Budget” in 2019, whereby all ministries were asked to frame their funding requests based on how that funding would help improve intergenerational well-being. In addition, the budget statement explicitly recognizes that, while Maori and Pacific peoples account for only 22 percent of the population, they make up over 60 percent of avoidable hospitalizations and that many admissions could be prevented by making PHC work better for these minority populations, including by tackling language and cultural barriers.628 Other whole-of-government models target a specific problem. Peru used such an approach to reduce its chronic child malnutrition rate from 28 percent to 13 percent between 2005 and 2016. This success can be largely attributed to strong Ministry of Economy and Finance leadership, lasting through successive changes of political administration. The approach encouraged multi-level, cross-government coordination and used a results-based approach to allocate resources only to evidence-based interventions across sectors. It incorporated a communications strategy, education, and demand-side incentives provided through a conditional cash transfer program.While strong leadership is needed at the national level to ensure effectiveness, whole-of-government PHC strengthening approaches must be supported by bottom-up participation, reliable funding, and a strong accountability structure. Even well-organized efforts at the national level may be limited in their capacity to influence social determinants of health, if they are not aligned with local initiatives that express communities’ concerns, priorities, and preferred solutions.629,630CHAPTER 4: MAKING IT HAPPENConclusionsThis chapter has described three priority reform agendas that can enable countries to improve the performance of their PHC networks. These reforms will prepare PHC to work catalytically in strengthening effectiveness, efficiency, equity, and crisis resilience across the broader health system.The reforms outlined are technically demanding. They require sustained effort, substantial investment, and determined leadership. However, a fundamental lesson from this analysis is that progress toward fit-for-purpose PHC is feasible in virtually all countries. The evidence presented here shows that many economies, including some facing chronic financial challenges and institutional fragility, have already taken impressive strides along the road. The changes needed to get the best from PHC can be achieved, even where resources are highly constrained.The health and economic context shaped by COVID-19 will complicate these efforts. But the pandemic has generated exceptional political and public support for health-system change. COVID-19 has taught bitter lessons about how important strong health systems are, and what happens when they fail. Today, the wounds of the pandemic are still raw. That’s why this is the time to act.137 While implementing fit-for-purpose PHC demands political endurance, measurable health and economic benefits from pro-PHC reforms can emerge in a relatively short timeframe. PHC-level interventions with an intersectoral character, such as school-based deworming programs, can boost school attendance and create conditions for better learning in a matter of weeks.631 Improvements in adult health through PHC-driven interventions in nutrition, malaria treatment, and smoking cessation can spur worker productivity gains within months.632 Lowerincome countries implementing strategies comparable to some described in this chapter have registered impressive gains in child survival and stunting rates in less than five years, saving lives now and laying strong foundations for future human capital and economic growth.633 Community-based mental health delivered through PHC holds promise to reduce a disease burden that weighs heavily on economic performance in virtually all countries; while much remains to be learned, early studies of community-based mental health programs in some low- and middle-income settings have shown promising results in politically acceptable timeframes.634 As the PHC evidence base improves, more examples of health and economic “quick wins” from PHC reforms will emerge.Today, countries are working to recover from COVID-19, rekindle economic growth, and get back on the path of progress toward their most important development goals, including poverty eradication and UHC. Fit-for-purpose primary health care is a powerful resource for this work. As countries continue to walk the talk on PHC reform, their rewards will grow through reduced health care costs, more resilient health systems, stronger human capital, higher productivity, and above all longer, healthier, more satisfying lives for people.WALKING THE TALKChapter 5POLICY RECOMMENDATIONS138CHAPTER 5: POLICY RECOMMENDATIONSThe preceding chapters aimed to: (1) summarize evidence for PHC as the cornerstone of high-performing health systems, while also showing why PHC must evolve; (2) identify structural shifts most PHC models need to undertake to improve outcomes, contain costs, and support system-wide change; (3) propose proven reform steps and implementation strategies that countries can use to drive shifts in care organization, the health workforce, and health financing; and (4) show how countries can optimize domestic and external technical and financial resources to “walk the talk” on reimagined PHC.Reconfiguring health systems around fit-for-purpose PHC poses major technicalchallenges, but it is above all a political problem. Solving that problem will dependon buy-in from influential stakeholders, perhaps especially those identifiedwith the health-system status quo. This, in turn, demands a policy adoption andimplementation road map to engage payers, providers, and patients. The roadmap will vary across countries, reflecting national starting conditions, health and139development priorities, political economy, and the path dependency of changeprocesses within each health system. Systems centered around hospitals andspecialists will pose particular difficulties for PHC-focused redesign. But, in allsettings, PHC reform will be easier said than done.As argued throughout this report, the COVID-19 tragedy may facilitate PHCcentered health system reform. Indeed, it has to do so, or the tragedy is destined to repeat itself. By exposing flaws in health systems worldwide, the pandemic has shown that these systems need to change—profoundly. To those who have traced the COVID-19 crisis to its roots, the importance of PHC for pending health-system reform is clear. As countries complete the emergency phase of pandemic response, both future crisis preparedness and population health outside of crisis times depend on countries’ ability to “integrate core public health functions into a health system based on primary health care with universal health coverage.”635Prerequisites for actionThere are three practical prerequisites for translating reimagined PHC into actionable policies and implementation in the wake of COVID-19:+Whole-of-government commitment and leadership. Building shared political commitment can begin with a data-driven review of the strengths and weaknesses of a country’s existing PHC model.636 A policy paper or White Paper can follow as a basis for consensus building among stakeholders. TheWALKING THE TALKdialogue should encompass actors within the health sector (e.g., hospitals, medical associations, health insurance funds, patients’ organizations) and beyond it (e.g., ministries of finance, agriculture, and the environment and local government authorities). Leaders need both tenacity and tact to maintain momentum for reforms while incorporating diverse viewpoints. Diversity will ultimately enable broad ownership and successful implementation.+Readiness to invest. Implementing reimagined PHC will involve significant upfront investment and recurring costs. The COVID-19 crisis makes mobilizing these investments more challenging but also more important than ever. Resources will need to be secured through additional budgetary allocation, reallocations within the health sector, and/or donor financing. The previous chapter emphasized that general government revenue is the appropriate primary source for PHC financing. In resource-constrained contexts where government funds were already overstretched before COVID-19, external financing from development partners may play a significant role, supporting countries to bridge the gap through interim financing. Long-term sustainability will ultimately require rebalancing resource allocation from hospitals towards PHC.140+Accountability for outcomes. Translating vision into action requires a formal accountability framework that sets out agreed roles and responsibilitiesfor stakeholders. A strong framework incorporates tools to measureand evaluate implementation and outcomes, preferably through a set ofcustomized PHC metrics.With these prerequisites in place, countries can move confidently to design and roll out PHC reforms. What policy actions will governments need to prioritize, and how can development partners help? The remainder of this chapter offers recommendations.The policy guidance formulated here aligns with the reimagined PHC reform matrix in Table 1 (page 74). In the pages below, a first set of recommendations addresses national policy makers. It outlines priority steps for national governments to implement PHC-centered reforms within their health systems. Apart from one consideration about managing the reform process itself, these recommendations are grouped under the three axes discussed in Chapter 4: care organization and delivery, health workforce, and financing.After formulating recommendations for governments, this chapter proposes action priorities for the international health community, in particular the World Bank and its global health partners. These recommendations reflect the strategic directions adopted by the World Bank’s Health, Nutrition and Population (HNP) Global Practice in its 2021 Strategy Refresh.637 At the end of the chapter, an integrated table summarizes the main steps for governments and partners to walk the talk for reimagined PHC.CHAPTER 5: POLICY RECOMMENDATIONSRecommendations for countriesManaging the reform process1Create an inclusive leadership group to drive PHC reforms. The group will be responsible to deliver PHC reform on the path to UHC. It will work through dialogue and seek consensus, while recognizing the imperative for bold decisions and timely action. In most instances, the leadership group will include high-level representation from ministries of finance, health, and planning, among others; members of parliamentary health, finance, and budget committees; and representatives of professional associations, civil society organizations, and other stakeholder groups. Typically, the leadership group will be mandated to set up additional committees, commission reports, conduct public hearings, and initiate other activities to gather data and work toward consensus for decision making.Team-based care organization and delivery models1Assess health workforce strengths and gaps, and plan the transition to teambased delivery. While all countries should aspire to build multidisciplinarycare teams to deliver PHC, specifics of team composition and empanelment141strategies must be tailored to the local context. Contextual factors toconsider include national and local epidemiologic profiles and socioeconomicdeterminants of health.638 To start, each country—supported by technicalpartners and donors, as appropriate—can undertake a situation assessmentencompassing: the current structure and composition of the health workforce;how well the workforce matches health and health care needs; people’scare-seeking patterns across different provider types and levels of care; andpayment/financing mechanisms.Building on the situation assessment, countries can develop a transition plan to organize existing health worker cohorts into teams; establish managerial relationships and reporting chains; and empanel populations to care teams. Empanelment approaches should be responsive to local contexts and engage the private sector depending upon the level of their engagement in PHC which is often socially stratified in LICs with private and deregulated low-tech clinics and pharmacies for the poor and the rural, and higher cost and often insurance driven private care facilities complementing and competing with the public health sector on quality, amenities and more personalized care639 Transition planning may consider short-, medium-, and long-term workforce and financing reforms to expand the comprehensiveness of care, extend PHC teams’ outreach into the community, and support integrated service delivery within care teams and across levels of care.WALKING THE TALK2Equip care teams to engage communities. Reimagined PHC depends on care teams that are able to connect deeply with communities. Dedicated, skilled staff build community connections and trust through outreach and communication activities. These activities clarify local health needs and priorities; boost health literacy; and progressively empower local people to manage their own health. Such efforts may use surveys, community forums, and other tools to understand socio-cultural and economic characteristics of the local population, as well as health-related beliefs, attitudes, and behaviors. Teams use this knowledge to tailor messaging and action in public health, health promotion, and disease prevention.3 Strengthen and integrate information technology on the PHC front lines. Reimagined PHC involves broadening access to digital platforms andleveraging data analysis capabilities to improve outcomes. Interoperable andintegrated digital platforms are needed to create a culture of transparencyand accountability in PHC. This will empower patients and providers alike.The COVID-19 crisis has confirmed the importance of harnessing technologyto monitor population health on the front lines, detect threats early, andfacilitate knowledge sharing and care coordination. These needs are feltwithin local care teams and across levels of care, in both public and privatesectors.640 As empowered co-producers of their own health, patients shouldultimately be able to access, review, and export their personal health data on142demand; in the long-run, they should be able to generate and contribute theirown health data, including through mobile applications and self-monitoringof health indicators.Countries can score efficiency gains by upskilling data analysis capabilities within local care teams. Teams that collect more data and know how to use it can boost care quality for the populations they serve. Better data-analytic capabilities will allow tech-enabled care teams to track and understand population health in real time, including identification of potential outbreaks; undertake risk stratification to inform patient-specific outreach and care strategies; and more actively manage the empaneled patient list.Multi-disciplinary health workforce development1Launch multidisciplinary medical education reforms. Following a workforce needs assessment, countries can develop and implement a multi-pronged, multidisciplinary set of medical education reforms to plug gaps and optimize training for community-focused, team-based care. As described in detail in Chapter 4, countries should address lopsided allocations of human resources for health through educational reforms designed to attract workers where they are needed most. These include strategies to build medical education campuses within rural or underserved areas; recruit local students from those same communities; prioritize and elevate the prestige of community care; and promote generalist practice. A reformed medical curriculum should be designed to prepare health workers for service in the team-based PHC environment by emphasizing collaborative practice. Training programs should also support development of new health workforce competencies,CHAPTER 5: POLICY RECOMMENDATIONSincluding data analysis and interpretation; disease surveillance; risk stratification; team management and coordination; and soft skills for effective patient engagement, outreach, and partnership. Depending on the local context and results of the health workforce assessment, countries may also need to invest in building new medical education programs to expand the health workforce and meet evolving workforce needs. Indeed, reforming the existing medical education platform for the full health work force may be needed, for a fit-for-purpose health workforce for reimagined PHC requires a core team that also includes community health workers (CHWs), registered nurses (RNs) and administrators. The expanded PHC team in more resource rich settings would also involve the same core team albeit with enhanced skills, but also pharmacists, dentists, psychologists and other mental health workers, lab technicians, and a range of other health care providers whose services may be enhanced by the use of information and communications technology (ICT).2 Reform provider compensation models to promote rural practice and generalist care. In addition to medical education reforms, countries canaddress compensation imbalances that exacerbate inequitable allocationof the health workforce, especially in those with a predominant privatesector. Governments should ensure that compensation for health workers(e.g., salaries or reimbursement rates) in rural or underserved areas is at leastequivalent to compensation in more saturated urban regions. Depending on143local context, leaders may also consider additional compensation or in-kindbenefits to offset quality-of-life concerns. Reimbursement and salary reformis also needed to address the substantial differential between generalist andspecialist physicians, thereby encouraging entry into generalist career pathsand addressing the shortage of primary care physicians, and containingperverse and collusive dual practice in loose regulatory settings.3Expand tiered accreditation systems, tied to reimbursement policy. In countries with mixed health systems, governments need to strategically engage with the private sector to leverage its workforce and infrastructure, while improving quality of care and protecting citizens from out-of-pocket expenditures. Governments may leverage reimbursement and strategic purchasing for UHC to incentivize private sector participation in a tiered accreditation system. A minimum accreditation tier would qualify private providers to receive reimbursement with public funds; achieving progressively higher accreditation tiers could be tied to higher reimbursement rates or reimbursement coverage for a broader range of services. Public providers should also be required to participate in the accreditation system and subjected to the same standards.4Reform regulations on telemedicine and labor mobility. To best leverage their entire workforce and promote technology-enabled care, countries can review the regulatory landscape and identify barriers to telemedicine expansion and labor mobility. Once barriers are recognized, countries can critically assess which regulations are necessary and remove or reform those that are not. Countries that have already relaxed such regulations due to COVID-19 can review that experience with the goal of incorporating productive reforms into permanent policy.WALKING THE TALK5Support the frontline workforce. The COVID-19 pandemic has placed extraordinary stress on frontline workers, but work-related stress and burnout are common issues across the health workforce even outside of crises. Governments need to ensure that the PHC workforce receives financial, practical, and psychosocial support to manage the unique pressures of their jobs, both during “normal” times and particularly during emergencies. Governments, care teams, and institutions engaged in medical education should have regular touchpoints to assess the physical and psychosocial welfare of the health workforce and troubleshoot challenges.Financing and resource mobilization1Develop a political strategy to deliver PHC financing goals. While health officials tend to analyze financing options in technical terms, financing andresource allocation are inherently political. Securing funds for reimaginedPHC requires building commitment and buy-in across government. This willnot happen without a deliberate political strategy. Leadership informedby such a strategy is key to translate countries’ formal commitment to UHCunder the SDGs into practical policies and resource allocation. The evidenceis strong that public-health-enabled PHC is the healthcare organizationmodel most apt to improve the efficiency, resilience, and sustainability of144public spending on health, promoting equity and shared prosperity. Suchevidence is vital, but insufficient. A political plan is needed to ensure its uptakeby those with the power to deliver change.2Craft a tailored investment plan. Fit-for-purpose financing for public-healthenabled PHC must be rooted in a comprehensive package of services that meets communities’ priority health needs and is free at the point of service. The benefits package needs to be designed through a participatory and fair process. A gap analysis based on the assessment of existing service delivery capacity (access, quality, and cost) with respect to the defined service package is essential. Such analysis should lead to a country-driven investment plan for strengthening PHC platforms (including infrastructure, human resources, routine operations, overhead, removal of user fees, and other features).3Finance PHC without user fees through general government expenditure. As discussed in Chapter 4, the source of financing for PHC has important implications for equity, financial risk protection, and resilience to financial shocks. To ensure equitable and comprehensive coverage, given existing socioeconomic inequities and widespread labor informality, PHC should be financed through general government revenue. Government efforts to achieve UHC should consider how to transition away from suboptimal sources of PHC financing. These include social health insurance contributions, private insurance premiums, and out-of-pocket healthcare expenditures—the most inefficient and inequitable form of health financing. In most countries, funding from these suboptimal sources can be progressively replaced with routine allocations from the government budget. PHC services should be free at the point of care.CHAPTER 5: POLICY RECOMMENDATIONS4Implement pro-health taxes on tobacco, alcohol, and sugar. Even as countries move to finance PHC from general government revenue, they can often boost tax revenue by implementing or increasing pro-health taxes on harmful products—especially tobacco, alcohol, and sugar. These taxes can create additional fiscal space, including to support PHC, while reducing the burden of common noncommunicable illnesses like hypertension, cancer, and diabetes, along with related health-system costs.5Ensure comprehensive and equitable coverage of PHC services through an affordable benefits package. Countries’ UHC benefits package needs to facilitate equitable provision of comprehensive PHC services. Countries need to reconcile the scope of the benefits package with the available resource pool, moving from implicit rationing to explicit and accountable prioritysetting for sustainability. A participatory benefits package design process offers a lever to rebalance overall health expenditure toward PHC in settings where PHC has been historically under-prioritized.6Leverage payment reform to promote team-based care, coordination, and quality. Countries can expand the use of strategic/value-based purchasing to facilitate team-based care models and incentivize care coordination and quality. (See Chapter 4.)7 Create an accountability framework that links resources to results. Resource mobilization (whether through additional allocations or reprioritization)145tends to be more successful when accompanied by a strong accountabilityframework built on interoperable data platforms. Reliable and transparentmeasurement of PHC financing, which has been a weak link in manycountries, will be critical to hold providers accountable to health systeminvestors—including international and domestic funders and, mostimportantly, a country’s citizens. Results need to be regularly monitored andthe accountability framework itself adjusted to changing circumstances andpriorities, including emergencies.8Explore value-based purchasing. Countries can leverage this approach to promote multi-disciplinary teamwork, encourage collaboration across sectors, and incentivize better care quality and coverage. Patients’ voices should be heard when designing provider payment mechanisms, empowering health service users to participate in decision making. Development partners may support countries to build measurement and monitoring capacity, enhance data platforms, and pilot and incubate innovations to improve accountability in PHC financing.WALKING THE TALKRecommendations for donors and the international health community1Support documentation, evaluation, and learning on country experiences with multidisciplinary team-based care. Despite a consensus favoring team-based care models for PHC, the literature still offers few practical examples and detailed evaluations to guide team design. Donors and the wider international community can enable countries’ reform strategies by supporting systematic documentation, evaluation, and learning around different team-based care models, including transition processes. Donors could finance evaluations or reviews of specific country experiences; they could also support a community of practice for practitioners and policy makers at different stages in the reform process. In the long run, building on a growing donor-supported evidence base, international norm-setting bodies can establish standards and guidelines for PHC care teams, including the size, composition, and catchment population—tailored to local contexts and resource constraints.2Support country-led digital integration. In each country, donors can provide financial and technical support to integrate fragmented health data146platforms and/or ensure their interoperability. Any support donors provide to HMIS should respect the long-term agenda for a single integrated orinteroperable health information platform in each country. In the immediateterm, donors should “walk the talk” by ensuring that any vertically-organizeddata collection platforms are made interoperable with the national HMIS—such that national HMIS systems can access all donor-supported data (whilerespecting patient privacy).3Align behind a WHO-endorsed international standard for community-based medical education. The international community should work collaboratively to raise international recognition of community-based medical education and qualifications. One practical step would be to align behind a set of WHO-endorsed standards and guidelines for community-based medical education and certification. Like existing medical and nursing degrees, these qualifications would be broadly recognized across borders and hold equal prestige—ultimately including earning power—with traditional medical education.4Fund country-led multidisciplinary medical education reform. Developing new norms, content, and pedagogy for multidisciplinary medical education will require investment. Existing institutions will work together in new ways, while in some cases new institutions or facilities will be created. In addition to supporting the normative aspects of reforms, international partners may contribute financial resources to accelerate critical phases of the process. Capital investments in new medical education institutions may be a particularly good fit for multilateral development banks.CHAPTER 5: POLICY RECOMMENDATIONSWhat will the World Bank do?COVID-19 has opened a new era of global uncertainty and risk. Precisely for that reason, now is the time to advocate for, invest in, and work with countries to deliver reimagined PHC—the cornerstone of the health system transformations that the pandemic has shown are needed in countries at all income levels.With its partners, the World Bank is working to meet this challenge. Through its COVID-19 Multiphase Programmatic Approach (MPA) financing facilities, the Bank has accelerated support to countries to tackle the pandemic while strengthening health-systems fundamentals. Now, in a Strategy Refresh for the post-COVID world, the Bank’s Health, Nutrition and Population (HNP) Global Practice has prioritized ensuring universal and equitable access to affordable, people-centered, and integrated quality care with reimagined PHC. This agenda goes hand in hand with strengthening public-health functions, including pandemic preparedness, and investing in health beyond health care under a whole-of-government approach.641In the years ahead, the World Bank will use three main mechanisms to help countriesdeliver the promise of reimagined PHC. These mechanisms match the World Bank’sprincipal areas of added value in health, as identified in the 2021 Strategy Refresh:Lending, Learning, and Leadership. These priorities also underscore the World147Bank’s commitment to partnerships that have proven their value for countries,including the Global Action Plan PHC Accelerator, PHCPI, JLN, and others.642,643,644As countries and partners continue to grapple with the health and economic “doubleshock” of COVID-19,645 the Bank’s approach is parsimonious. It does not aim to createnew structures that might duplicate what already exists. Instead, it seeks to workwithin existing structures and alliances in more effective ways.1Lending: ease access to funding for PHC reforms. The World Bank will work with the Global Finance Facility (GFF) and other partners to make it easier for countries to quickly access the funds they need for PHC-oriented system reforms. Before COVID-19, investment in health system strengthening and public-health enabled PHC was constrained by the difficult transition toward domestic health financing in some countries, together with the continued appeal of donor funding for disease-specific programs. COVID-19 has underscored the limits of such models and the need for new solutions. However, the crisis has also complicated resource mobilization for ambitious PHC-centered system reforms. The World Bank is positioned to help shift this dynamic, drawing lessons from financing and technical support innovations under the COVID-19 MPA.646 As in the case of COVID-19, the World Bank can combine financial backing for PHC reforms with policy and technical advice that will inform leaders on emerging options and equip them to select, finance, and deliver the best approaches for country needs. The Bank can move quickly to initiate conversations with its IDA and IBRD clients and to raise the profile of PHC. Advancing PHC assertively in COVID-19 health system strengthening operations and GFF Essential Services Grants will be a “win-win” for countries and for the World Bank’s programs, as both can achieve desired results more efficiently through PHC.WALKING THE TALK2Learning: mobilize practice-relevant PHC knowledge. Together with analytic and financial partners, the World Bank will strengthen global knowledgehubs for PHC and ensure that they are equipped to deliver the actionableinformation countries need in formats they can use. Since PHCPI’s creation in2015, the initiative’s databases and PHC improvement tools have advancedPHC learning and practice.647 This and other PHC knowledge hubs, such asthat maintained by JLN,648 can achieve even more in the years ahead. Morecan be done to share PHC knowledge in user-friendly forms and to tailorinformation for policy makers and implementers facing specific challengeson the ground. Through collaboration in these efforts, the World Bank willcapture and disseminate learning around PHC “hardware” (e.g., digitaltechnology, tech-equipped PHC workers) and “software” (e.g., team-basedorganizational care models, risk pooling, value-based purchasing). It will helpcompile and assess country experiences and facilitate their disseminationthrough tailored global, regional and country specific training courses andother activities. World Bank technical assistance to countries will supportthe integration and operationalization of PHC knowledge in policies andprograms. Recently, a new PHC performance framework from WHO andUNICEF and OECD’s Patient-Reported Indicator Surveys (PaRIS) haveadvanced PHC performance measurement.649 The World Bank will work withthese and other partners on a country-friendly measurement toolbox forPHC-related inputs, outputs, and outcomes.650 The Bank will also expand the148place of PHC in its learning platforms, such as flagship courses.3Leadership: develop policy options in dialogue with ministers. To support national leadership in PHC reform and facilitate a whole-of-government approach, the World Bank HNP Global Practice will establish a dedicated platform for policy dialogue, advice, and technical assistance to Ministries of Health and Ministries of Finance. The platform will include high-level policy seminars on country-selected topics, linked to the World Bank/IMF Annual Meetings. Flagship courses will be tailored to senior decision makers. The platform’s initial agenda will focus on analyzing the political-economy dynamics of PHC reform in the post-COVID era, capturing the range of country experiences and emerging solutions. Platform dialogue will identify entry points and strengthen relationships for subsequent country-level technical collaboration and financial support. This initiative builds on and further leverages the GFF country leadership program that aims to bolster country leadership to drive transformational changes for health system reforms as well as partner alignment behind government priorities.As the World Bank works with countries to build high-performing, equitable, and resilient PHC systems, it is not about creating new administrative structures, logos, and hashtags, but instead concretely “upping our game” with trusted partners and within structures that are largely in place, so that countries can get the support and the results they need, quickly, and at manageable cost. As with PHC itself, this is easy to say and harder to achieve. We set out together now, with hope and humility, to walk the talk.CHAPTER 5: POLICY RECOMMENDATIONSConclusion: Summary table of policy recommendationsTable 4. presents an integrated overview of the report’s policy recommendations for countries and international partners. The proposed sequencing of the actions is reflected in the order of their presentation (actions at the top of the table occur first).Table 4. Key recommendations for fit-for-purpose PHCSERVICE DELIVERYHEALTH WORKFORCEFINANCING+ Situation+ HRH review2 and gap analysis, + Align HF strategy to team basedassessment (MoH)aligned to team-based servicePHC service model. Prioritize+ Tailor team basedPHC service delivery model to country and local needs1 (MoH)+ Developimplementationmodel (MoH)+ Refresh HRH strategy andpolicies (including M&E) (MoH, MoL, MoF)+ Workforce changes foremergency preparedness and response (MoH, MoF, MoI)financing from general government revenue. Eliminate user fees. Introduce or raise pro-health taxes (MoH, MoF, insurance authority)+ Build emergency planning into HFstrategy (MoH)+ Adapt benefits package forCountriesplan for team-based service delivery model (with M&E) (MoH, MoF, local governments)+ Use data andtechnology to+ Launch multidisciplinarymedical education reforms (MoE, MoH)+ Compensation models topromote generalist care and rural practice (MoH, MoF)equitable PHC coverage (MoH, MoF, insurance)+ Resource mapping and costing forteam-based care and PHC benefits package. Develop political strategy for PHC financing goals (MoH, MoF, insurance)149drive adoption of team-based service delivery model3 (MoH, MoF, insurance, MoT)+ Tiered accreditation, tiedto reimbursement (MoH, insurance authority, MoF, MoE)+ Regulatory reform fortelemedicine and labor mobility (MoH, MoL, MoT, insurance)+ Payment reform to promote team-based care, coordination, and quality (MoH, MoF, insurance).+ Integrate financing and servicedelivery data platforms for accountability (MoH, MoF,insurance, MoT)Global partnership, namely through the SDG3 Global Action Plan (GAP) PHC Accelerator+ Support documentation, measurement, evaluation, and learning on country experiences in teambased PHC service delivery, HRH, and financing+ Support situation assessment and gap analysis in service delivery, HRH, and financing + Support strategy refresh in HRH, health financing, service delivery, and governance + Provide advisory and technical assistance for country reforms. Support design and implementationof team-based service delivery and related HRH and financing solutions+ Align external financing with country-led system-strengthening efforts, on budget toavoid fragmentation+ Foster innovations, technology adoptions, and new initiatives through financial supportand partnership+ Support integrated data platforms to enable team-based service delivery and value-basedpayment, while building in-country analytical capacityWorld Bank+ Lending: easing access to finance for PHC + Learning: curating and mobilizing PHC knowledge and training + Leadership: crafting policy options through dialogueNotes: (1) Key features of a team-based service delivery mode include: team composition, team-member roles, catchment area, empanelment, scope of services, management and reporting, referral mechanism, communication platforms, integration with the community, public health function/surveillance, and the role of the private sector, among others. (2) The HRH review would encompass existing staff numbers, availability, distribution, and competencies. (3) New technologies can facilitate interaction between patients and providers (for example, through e-consultation, patient portals, population health management tools), as well as interactions among providers (through e-referral, communication, integration across providers, and others). HF: Health financing; HRH: Human resources for health; M&E: Monitoring and evaluation; MoE: Ministry of Education; MoF: Ministry of Finance. MoH: Ministry of Health; MoI: Ministry of the Interior; MoL: Ministry of Labor; MoT: Ministry of Technology; PHC: Primary health care; R&D: Research and development.WALKING THE TALK150ENDNOTESENDNOTES1Thomas Hone, James Macinko, and Christopher Millett, “Revisiting Alma-Ata: WhatIs the Role of Primary Health Care in Achieving the Sustainable Development Goals?,”The Lancet (Lancet Publishing Group, October 2018), https://doi.org/10.1016/S0140-6736(18)31829-4.2“Declaration of Astana.,” n.d.3World Health Organization (2019). The Global Action Plan for Healthy Lives and Well-being for All. http://www.who.int/sdg/global-action-plan.4“(WHO and World Bank 2017; World Bank 2019). 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January (2016): 1–9111 “People at the Centre: OECD Policy Forum on the Future of Health,” n.d.112 “This Is Becoming the Case in Most Middle- and Upper- Middle-Income Countries, in Addition to High-Income Countries,” n.d.113 “Health (care) seeker is used instead of ‘patient,’ since all those who seek care are not patients, for example, a healthy individual seeking information before travel, a healthy pregnant woman seeking antenatal care, or a child to be immunized. A distinction also needs to be made between an illness, as perceived by an individual, a sickness as perceived by the care provider and others, and a disease, referring to a medical condition rather than the individual. Finally, we also draw a distinction between health needs, i.e., behavioral input for healthy living, and healthcare needs which are related to a discomfort expressed by an individual requiring medical attention.’ since all those who seek care are not patients, for example, a healthy individual seeking information before travel, a healthy pregnant woman seeking antenatal care, or a child to be immunized. A distinction also needs to be made between an illness, as perceived by an individual, a sickness as perceived by the care provider and others,WALKING THE TALKand a disease, referring to a medical condition rather than the individual. 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Lin, “Dropping the Baton: Specialty Referrals in the United States,” Milbank Quarterly 89, no. 1 (March 2011): 39–68, https://doi.org/10.1111/j.14 68-0009.2011.00619.x.127 WHO, “Social Determinants of Health,” accessed May 10, 2021, https://www.who.int/ health-topics/social-determinants-of-health#tab=tab_1.128 The World Bank, “Fairness and Accountability: Engaging in Health Systems in the Middle East and North Africa,” 2015, 1–67, https://documents.worldbank.org/en/ publication/documents-reports/documentdetail/508181468000283284/a-roadmapto-achieve-social-justice-in-health-care-in-egypt-wds.worldbank.org/external/ default/WDSContentServer/WDSP/IB/2013/10/09/000356161_20131009152447/ Rendered/PDF/817230WP0P12940Box0379842B00PUBLIC0.pdf.129 “As above, We Adhere Here to the Prevailing Terminology Whereby Illness, Sickness and Disease Refer to the Patient’s Society’s and Professionals’ Perspectives.”130 The World Bank, “Fairness and Accountability: Engaging in Health Systems in the Middle East and North Africa.”131 “As above, We Adhere Here to the Prevailing Terminology Whereby Illness, Sickness and Disease Refer to the Patient’s Society’s and Professionals’ Perspectives.”ENDNOTES132 World Health Organization (WHO), “Primary Health Care on the Road to Universal Health Coverage.133 “Primary Health Care on the Road to Universal Health Coverage_ Uhc_report_2019” https://www.who.int/healthinfo/universal_health_coverage/report/uhc_report_2019. pdf.134 Elysia Larson et al., “Disrespectful Treatment in Primary Care in Rural Tanzania: Beyond Any Single Health Issue,” Health Policy and Planning 34, no. 7 (2019): 508–13, https://doi.org/10.1093/heapol/czz071.135 Shannon A. 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