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.

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.

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.

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.

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.