Grounds for Optimism…
……..On the difficult journey from Selective to
Comprehensive Primary healthcare
What is the Immediate Context for presenting an introduction to this Regional WHO publication:
In its recent conference at Jakarta, The WHO South-East Asia Region, released its publication: “Positive practices in developing primary health care-oriented health systems- a collection of case stories from the WHO SEAR Region.” This publication addresses the challenges countries face in transitioning from selective to comprehensive primary health care (CPHC) by documenting various interventions aimed at overcoming the “problematiques” that every country is facing on its path for achieving this goal. While countries face similar problems, their approaches vary, offering valuable lessons and opportunities for cross learning. More importantly, this demonstrates that these challenges are not inherent or unique, are not insurmountable and transitioning is possible despite the difficulties.
So, what is selective healthcare- and why did a shift to comprehensive primary healthcare happen?
Selective Primary Health Care refers to a policy introduced in the late eighties and early nineties which essentially stated that governments in Low-and-Middle-Income-Countries (LMICs) cannot and should not attempt to provide all health services, but should limit themselves to only some very selective minimal package of services. The package included services that were essential for a reduction of maternal and under-5 mortality as well as to address tuberculosis, HIV and the vector borne diseases. The understanding was that all the remaining services should be left to the market, with or without making arrangements like insurance. Initially promoted by UNICEF, it became the major feature of health sector reforms under structural adjustment policies introduced by the World Bank in the nineties.(WDR, 1993 pgs) Part of its success in influencing policies was because it was World Bank and IMF loans and developed aid from the US and UK would come with structural reform conditionalities. But an even more powerful driver was the academic discourse that paved the way for legitimation of the selective primary health care approach and its introduction. This discourse also introduced the concept of defining the contents of this package as narrowly as possible based on an index of “dollar spent per DALY saved”. Since under the Millenium Development Goals, the indicators also measured only the outcomes of this minimalist package of services, a country could believe it was doing very well if its under 5 mortality rate or maternal mortality rate came down.
It is worth noting that Thailand’s primary healthcare has always been comprehensive, based on public providers and relatively the most cost-effective system in the world. Thailand itself attributes their success to having been able to resist the pressures to selective healthcare. Thailand in contrast took a health rights approach- as enshrined in their National Health Security Act of 2002 and the National Health Rights Act of 2007. This publication is silent on why other countries did not make this transition earlier.
Then what changed? Why did countries return to the vision of comprehensive primary health care which was what the Health for All declaration had called for?
One of the immediate drivers for the return of comprehensive primary health care (CPHC) was the recognition that because over 85 percent of health care needs were not covered in the selective package, there was a huge increase in out-of-pocket expenditures that led to increasing impoverishment and inequity and undermined any effort to reduce poverty. The other was an increasing public recognition that all the major causes of premature mortality, and the huge costs of hospital care especially on non-communicable diseases, could be addressed by CPHC. There was also the realization that in the absence of a comprehensive health systems strengthening, even the targets of the selective healthcare could not be achieved. Change was also due to considerable rprotest from people’s organizations and civil society that were giving “voice” to the problems of declining access and increasing costs of healthcare as a consequence of “leaving majority of healthcare to the markets” Governments tried to address this by introduction of publicly funded insurance programmes- but these could not be designed to address primary care needs-, especially those related to preventive and promotive care. If UHC came to be associated with the move to insurance, it became necessary to spell out that this had to go along with strengthening comprehensive primary care.
Is this shift from selective to comprehensive primary health care part of official policy?
The adoption of the SDGs and its health targets required CPHC for its implementation. Then, later in an international summit organized by WHO in 2018 in Asthana, Kazakhstan, all countries adopted the Asthana declaration, reaffirming the importance of primary healthcare. . The Delhi Declaration on Strengthening Primary Healthcare, 2023 also affirms this policy at the ministerial level for the South-East Asian Region of WHO.
Now all global institutions including the World Bank have formally accepted the need for comprehensive primary healthcare and the WHO leads in this shift. Some global institutions do favour a shift to purchasing primary healthcare from private providers, instead of government provisioning, but given the lack of successful examples of the former, this insistence remains at the level of discourse.
This shift to CPHC happened in India too. India’s National Health Policy 2017 formally states that one of the major features of the policy is a movement from selective primary health care to comprehensive primary health care. While we estimate that only 15 percent of primary health care needs were covered under earlier decades, the objective was clearly to make it cover over 90 percent of healthcare needs. A task force was set up to plan the roll out of comprehensive primary healthcare programme and it was the proposals of this task-force that were implemented as the Ayushman Bharat Health and Wellness Scheme.
So, what is interesting in this publication?
A PHC Forum was set up by the Regional WHO-SEAR in 2022 to foster learning for better implementation of primary healthcare. This Forum included participants from government, academia and civil society. Over a two-year process, this Forum identified challenges across seven thematic areas, and collected over 211 operational examples of government efforts to address the challenges faced. From these submissions, 20 examples were purposively selected as good case studies to illustrate positive practices that addressed these challenges. The case studies are limited to four areas: challenges on human resources for health, on urban primary health care, on access to technologies and on community engagement. What comes out clearly is that the movement to comprehensive primary care has not been easy, and that every country is facing similar problems, but given their context, path-dependence they are coming up with different ways forward. We briefly introduce each of these case studies below:
Integrated Primary Healthcare approach: Indonesia and Maldives
The case study from Indonesia calls for a fairly comprehensive re-organization of care. The various services are packaged into five clusters, and for each standard treatment guidelines and care pathways are built up, which form the basis for team-based training. Home visits ensure that not only pregnancy and children below 5, but appropriate counselling and support is provided for all age groups. Screening extends to 14 diseases- but not all of it has to be done at the same time. The pilots are reported to have been successful and there is rapid scaling up. The complex of PHC (called Puskesmas) health posts at the village level (Pushtu) and at the hamlet level (posyandu) have each been strengthened with additional human resources including a cadre of community health volunteers, modelled on the ASHAs from India, who make home visits. The government also plans to complement progress at the PHC level with strengthening five pillars. Most of these are as expected- health workforce policies, digitization and strengthening of secondary care, and emergency response. But a relatively unique step is an effort for transitioning to domestic production of 14 routine immunization vaccine antigens, 10 medicinal raw materials and the 10 ten medical equipment by volume and by value.
Maldives has also done something very similar. They too have understood that building capacity is far more than training and requires substantial re-organization of services. They too started with a pilot- the Faafu atoll model- and that is now undergoing nation-wide scaling up.
Addressing Health Workforce requirements of Primary Care: Though primary health care is far more than primary level care, the successful deployment of a network of primary care providers remains a very central element in this transition. Bhutan had different categories of health assistants linked to vertical programmes. Numbers was not the problem but Bhutan’s case study is how they are going about re-skilling them.
In India, this challenge was addressed through the introduction of mid-level healthcare providers- the community health officers. This idea had an incubation period of over a decade and many partly successful and unsuccessful efforts earlier which are not part of this story. The case study from India on scaling up CHOs, describes how starting from almost no deployed CHO in 2017, the country scaled up the programme nation-wide, such that we have close to 120,000 CHOs now. While this is no doubt a huge achievement, the problem of such rapid scaling up is the loss of quality. And one of the really promising narratives in this collection is the case study of rigorous mentoring program developed between NHSRC and CMC Vellore for building up the quality of care provided by CHOs. Despite the robustness of the design, and despite the government’s own recognition of this as a best practice, it will be a challenge to find the administrative will required to scale up and sustain such a design will be available, for this approach is a lot of hard work.
The case study from Timor Leste is fascinating, as it tells the story of how this small country’s transition to a nation-wide health system took off thanks to liberal and continuing support from Cuba, how it was inspired by the Brazilian Family Health Programmes and how it re-learns for itself how some of the medical doctors’ centric models needs to be adapted to their realities.
Finally, from the huge number of performance assessment approaches, two one from Thailand on the challenges of performance based financing and one from India on the Common Review Mission are presented.
Urban Primary Healthcare: There are four case studies related to urban primary health care. Two of these are examples of the Health City Approach that is a WHO intervention that is meant to address the social determinants of health in the urban context. The design of the health city programme in Jaffna is most interesting, but it does not seem to have gone far. The Wajo Regency case study, which is case study of an urban area in a remote Sulawesi island of Indonesia, seems to have done much better and there is a really innovative addition in its approach to engaging the elderly in care for the elderly. Most countries in the region have health city programmes, but there is little heard of it, and probably they have not quite taken off. So, its good that this case study draws some attention to that, since there are few models of integration public health concerns with primary healthcare.
The other two case studies are from Bangkok city- one on public private partnerships in Bangkok city and the other on digital literacy volunteers. But for the most part urban operational examples tend to be ad hoc dispensaries and there are very limited efforts at serious population based, prevention prioritised primary healthcare that can be promoted as positive practices.
Access to quality medicines at affordable prices: The two case studies presented are the Government Pharmaceutical Organization in Thailand and the Essential Drugs Company Limited of Bangladesh. Sri Lanka also has a similar institution but that has not been covered. The importance of these examples of public pharmaceuticals is that by ensuring quality and affordability of the medical products that are consumed in greater volumes, they are able to deliver good health outcomes at much lower per capita public health expenditure. Domestic public sector manufacturing capacity, extending into pooled procurement and distribution is a necessary condition for pandemic preparedness and response. Most essential medicines are off patent. But as the case studies inform us, modernization and expansion of the existing capacity remains a significant challenge.
Community Engagement: Six of the case studies are on this theme, and of these the first three highlight the problems and possibilities of decentralization. Nepal has seen one of the most extensive decentralization efforts in recent times, but it is still work in progress. This case study captures the tension between what must be decentralized, the terms of such decentralization, and what needs to remain central. The case study from Kerala captures how decentralization has helped in effective delivery of quality palliative care services even in rural and remote areas. And from Chhattisgarh in India, there is a case study of how local government institutions can be geared to acknowledge and address intra-village inequities in access to all essential public services.
The next three case studies are of civil society engagement. The first of these is Thailand’s amazing and unparalleled Grievance Redressal system, which is supported both by law and financial allocations. This system not only identifies and acknowledge rather routine instances of sub-optimal care or denials of care, often inadvertent, but pays a monetary compensation for it. Local civil society organizations act informally as advocates, counsellors and arbiters to make the interactions less contested and more positive. It works.
The collection of case studies closes with “two well-known examples of civil society action: one of advocacy and another of service delivery to reach the poor.” The authors note that though the Bangladesh Health Watch is an example of advocacy most of the organizations who participate in it are also involved in service delivery. And the final example is of Gonoshasthaya Kendra, is an example of the major role civil society organizations have played as pioneers, innovators and advocates in advancing the understanding of CPHC and health for all. In both of these domains there are many important examples from India and other countries as well. But it was fitting to take Bangladesh for civil society examples, since the engagement of civil society in the shaping of health systems is much larger and more prominent in Bangladesh as compared to almost any other country. The discussion also pays homage to Dr Zafarullah Choudhury, founder of GK and also of the PHM, as representing the rich history of PHC and Health for All in the WHO Southeast Asia region.
In conclusion:
This collection of case studies is worth noting for a number of reasons. First and foremost, we begin to get a glimpse of the “elephant size” challenge of moving towards comprehensive primary healthcare. Quite often the emphasis goes to one or other aspect, and the need for synergistic intervention on so many fronts are lost. Secondly, we also begin to appreciate that many of the problems that appeared intractable have proven amenable to change. We note that the problematics of financing and digitization have not been addressed in this collection and quality of care is only touched upon. We hope the next reports will tackle with these themes. We also note that all case studies conceptualize health care as common goods and not as market commodities and reform is not a matter of getting the prices right, but rather a problem of institutional design and organizational capacity. We finally conclude with a reflection. It goes without saying that without political will and financial allocations and better terms of employment, none of the efforts will fructify or sustain. However, these are not a given. While critique of the failures and the gaps is necessary, positive case stories generate optimism and confidence and help mobilize the political will and financial allocations that are required.
We hope you do not stop with this introduction and go onto read the case stories in this publication. All of us who were part of writing this collection had over own favourite learning experience from amongst the twenty. It would be interesting to share what you found must interesting.
Acknowledgements:
To Dr. Shalini Singh for her peer review and Ms. Roubitha David and Mr. Hasan for the technical assistance. And of course to Regional WHO and the team who developed this publication.
The views expressed in this introductory piece are attributable to the author and are not necessarily the views of the other contributors or the World Health Organization.
List of case studies:
| S.No. | Theme | Topic | Page No. | Country |
| 1 | Cross-cutting | Transforming primary health care in Indonesia through scale-up of Integrasi Pelayanan Keshatan Primer (ILP): Case study of implementation at Puskesmas Plantungan, Kendal, Central Java (page 14) | 14 | Indonesia |
| 2 | PHC Workforce | Integrated capacity building for primary health care in Faafu Atoll (page 19) | 19 | Maldives |
| 3 | PHC Workforce | Re-skilling and organization of the Health Assistant cadre for comprehensive primary health care | 23 | Bhutan |
| 4 | PHC Workforce | Deploying mid-level healthcare providers at scale for achieving comprehensive primary health care | 26 | India |
| 5 | PHC Workforce | Capacity building for community health officers: The NHSRC-CMC mentoring programme | 30 | India |
| 6 | PHC Workforce | PHC team for the provision of Family Health Care approach | 33 | Timor-Leste |
| 7 | PHC Workforce | Performance incentives linked to quality & outcomes | 36 | Thailand |
| 8 | PHC Workforce | Common Review Mission: Monitoring for building a learning-adaptive system | 40 | India |
| 9 | Urban PHC | Public Private Partnerships under the UCS in Bangkok City and Scale Up | 44 | Thailand |
| 10 | Urban PHC | Bangkok public health and digital health volunteers | 48 | Thailand |
| 11 | Urban PHC | ULAMA: Engaging elderly in the planning and implementation of healthy city programme of Wajo Regency | 51 | Indonesia |
| 12 | Urban PHC | The Jaffna Healthy City programme | 54 | Sri Lanka |
| 13 | Medical Products | Government Pharmaceutical Organization for universal access to essential medicines | 58 | Thailand |
| 14 | Medical Products | State role in manufacture and supply of medicines at affordable cost for primary health care | 61 | Bangladesh |
| 15 | Community engagement | Local government in primary health care and community engagement | 64 | Nepal |
| 16 | Community engagement | Kerala palliative care programme with involvement of local government (Panchayat) | 67 | Kerala/India |
| 17 | Community engagement | Inter-sectoral platform for community action on health and determinants: Swasthya Panchayat Yojana | 70 | Chhattisgarh/ India |
| 18 | Community engagement | Grievance redressal with civil society engagement | 74 | Thailand |
| 19 | Community engagement | Bangladesh Health Watch: Taking voices of the grassroots to policy makers | 77 | Bangladesh |
| 20 | Community engagement | NGO role in providing Primary Health Care: Gonoshasthaya Kendra | 80 | Bangladesh |
Wow! What a wonderful contribution to the healthcare development literature. Congratulations to all involved.