03 - 487 Primary Care and Global Health

487 Primary Care and Global Health

■ ■FURTHER READING Fauci AS, Morens DM: The perpetual challenge of infectious diseases. N Engl J Med 366:454, 2012. Harper K: Plagues Upon the Earth: Disease and the Course of Human History. Princeton, Princeton University Press, 2023. Keusch GT et al: Pandemic origins and a One Health approach to preparedness and prevention: Solutions based on SARS-CoV-2 and other RNA viruses. Proc Natl Acad Sci USA 119:e2202871119, 2022. Lederberg J et al: Emerging Infections. Microbial Threats to Health in the United States. Washington, DC, National Academies Press, 1992. Menachery VD et al: SARS-like WIV1-CoV poised for human emer­ gence. Proc Natl Acad Sci USA 113: 3048, 2016. Morens DM, Fauci AS: Emerging pandemic diseases: How we got to COVID-19. Cell 182:1077, 2020. Morens DM, Taubenberger JK: Pandemic influenza: Certain uncer­ tainties. Rev Med Virol 21:262, 2011. Parrish C et al: Cross-species virus transmission and the emergence of new epidemic diseases. Microbiol Molec Biol Rev 72:457, 2008. Wasik BR et al: Onward transmission of viruses: How do viruses emerge to cause epidemics after spillover? Philos Trans R Soc Lond B Biol Sci 374:20190017, 2019. Wegner GI et al: Averting wildlife-borne infectious disease epidem­ ics requires a focus on socio-ecological drivers and a redesign of the global food system. EClinicalMedicine 47:101386, 2022. Tim Evans, Kumanan Rasanathan

Primary Care and

Global Health The twentieth century witnessed the rise of an unprecedented global health divide. Industrialized or high-income countries experienced rapid improvement in standards of living, nutrition, health, and health care (Chap. 485). Meanwhile, in low- and middle-income countries with much less favorable conditions, health and health care progressed much more slowly. The scale of this divide is reflected in the cur­ rent extremes of life expectancy at birth, with Japan at the high end (84 years) and Chad at the low end (54 years). This 30-year shortfall in Chad reflects the daunting range of health challenges faced by low- and middle-income countries. These nations must deal not only with a complex mixture of diseases (both infectious and chronic) and illness-promoting conditions but also, and more fundamentally, with the fragility of the foundations underlying good health (e.g., sufficient food, water, sanitation, and education) and of the systems necessary for universal access to good-quality health care and public health. In the last decades of the twentieth century, the need to bridge this global health divide and establish health equity was increasingly recognized. The Declaration of Alma-Ata in 1978 crystallized a vision of justice in health, regardless of income, gender, ethnicity, or education, and called for “health for all by the year 2000” through primary health care. While progress since the declaration is remarkable, >45 years later and in the aftermath of a global pandemic of COVID-19, much remains to be done to achieve global health equity. This chapter looks first at the nature of the health challenges that underlie the health divide in low- and middle-income countries. It then outlines the values and principles of a primary health care approach, with a focus on primary care services. Next, the chapter reviews the experience of low- and middle-income countries in addressing health challenges through primary care and a primary health care approach. Finally, the chapter identifies how current challenges and global context, in particular, the global pandemic, shape an agenda for the

renewal of primary health care and primary care, allied to the move­ ment to achieve universal health coverage. PRIMARY CARE AND PRIMARY HEALTH CARE The term primary care has been used in many different ways: to describe a level of care or the setting of the health system, a set of treat­ ment and prevention activities carried out by specific personnel, a set of attributes for the way care is delivered, or an approach to organizing health systems that is synonymous with the term primary health care. In 1996, the U.S. Institute of Medicine encompassed many of these different usages, defining primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1 We use this definition of primary care in this chapter. Primary care performs an essential function for health systems, providing the first point of contact when people seek health care, dealing with most problems, and referring patients onward to other services when necessary. As is increasingly evident in countries of all income levels, without strong primary care, health systems cannot function properly or address the health challenges of the communities they serve. Primary Care and Global Health CHAPTER 487 Primary care is only one part of a primary health care approach. The Declaration of Alma-Ata, drafted in 1978 at the International Confer­ ence on Primary Health Care in Alma-Ata (now Almaty in Kazakhstan), identified many features of primary care as being essential to achieving the goal of “health for all by the year 2000.” However, it also identi­ fied the need to work across different sectors, address the social and economic factors that determine health, mobilize the participation of communities in health systems, and ensure the use and development of technology that was appropriate in terms of setting and cost. The decla­ ration drew from the experiences of low- and middle-income countries in trying to improve the health of their people following independence. Commonly, these countries had built hospital-based systems similar to those in high-income countries. This effort had resulted in the development of high-technology services in urban areas while leaving the bulk of the population without access to health care unless they traveled great distances to these urban facilities. Furthermore, much of the population lacked access to basic public health measures. Primary health care efforts aimed to move care closer to where people lived, to ensure their involvement in decisions about their own health care, and to address key aspects of the physical and social environment essential to health, such as water, sanitation, and education. After the Declaration of Alma-Ata, many countries implemented reforms of their health systems based on primary health care. Most progress involved strengthening of primary care services; unexpect­ edly, however, much of this progress was seen in high-income coun­ tries, most of which constructed systems that made primary care available at low or no cost to their entire populations and that delivered the bulk of services in primary care settings. This endeavor also saw the reinforcement of family medicine as a specialty to provide primary care services. Even in the United States (an obvious exception to this trend), it became clear that the populations of states with more primary care physicians and services were healthier than those with fewer such resources. Progress was also made in many low- and middle-income countries. However, the target of “health for all by the year 2000” was missed by a large margin. The reasons were complex but partly entailed a general failure to implement all aspects of the primary health care approach, particularly work across sectors to address social and economic fac­ tors that affect health and provision of sufficient human and other resources in order to make possible the access to primary care attained in high-income countries. Furthermore, despite the consensus in Alma-Ata in 1978, the global health community rapidly became frac­ tured in its commitment to the far-reaching measures called for by the 1Institute of Medicine. Primary Care: America’s Health in a New Era (1996).

3860 declaration. Economic recession tempered enthusiasm for primary health care, and momentum shifted to programs concentrating on a few priority measures such as immunization, oral rehydration, breast- feeding, and growth monitoring for child survival. Success with these initiatives supported the continued movement of health development efforts away from the comprehensive approach of primary health care and toward programs that targeted specific public health priorities. This approach was reinforced by the need to address the HIV/AIDS epidemic. By the 1990s, primary health care had fallen out of favor in many global-health policy circles, and low- and middle-income countries were being encouraged to reduce public sector spending on health and to focus on cost-effectiveness analysis to provide a package of health care measures thought to offer the greatest health benefits. PART 17 Global Medicine HEALTH CHALLENGES IN LOW- AND MIDDLE-INCOME COUNTRIES Low- and middle-income countries, defined by a per-capita gross national income of <$12,535 (U.S.) per person per year, account for

85% of the world’s population. Average life expectancy in these coun­ tries lags far behind that in high-income countries: whereas the average life expectancy at birth for a girl in high-income countries is 83 years, it is only 65 years for a girl in low-income countries. This discrepancy has received growing attention over the past 50 years. Initially, the situation in poor countries was characterized primarily in terms of high fertility and high infant, child, and maternal mortality rates, with most deaths and illnesses attributable to infectious or tropical diseases among remote, largely rural populations. With growing adult (and especially elderly) populations and changing lifestyles linked to global forces of urbanization, a new set of health challenges characterized by chronic diseases, environmental overcrowding, and road traffic injuries has emerged rapidly (Fig. 487-1). The majority of tobacco-related deaths globally now occur in low- and middle-income countries, and the

Deaths (millions)

Year/countries grouped by income per capita FIGURE 487-1  Projections of disease burden to 2030 for high-, middle-, and low-income countries (left, center, and right, respectively). TB, tuberculosis. (Reproduced with permission from World Health Organization: The Global Burden of Disease 2004 Update, 2008.)

risk of a child’s dying from a road traffic injury in Africa is more than twice that in Europe. Thus, low- and middle-income countries in the twenty-first century face a full spectrum of health challenges—infectious, chronic, and injury-related—at much higher incidences and preva­ lences than are documented in high-income countries and with many fewer resources to address these challenges. Addressing these challenges, however, does not mean simply waiting for economic growth. Analysis of the association between wealth and health across countries reveals that, for any given level of wealth, there is a substantial variation in life expectancy at birth that has persisted despite overall global progress in life expectancy during the past 40 years (Fig. 487-2). Health status in low- and middle-income countries varies enormously. Nations such as Cuba and Costa Rica have life expectan­ cies and childhood mortality rates similar to or even better than those in high-income countries; in contrast, countries in Sub-Saharan Africa and the former Soviet bloc have at times experienced significant reversals in these health markers, particularly in the 1990s. As Angus Deaton stated in the World Institute for Development Economics Research annual lecture on September 29, 2006, “People in poor countries are sick not primarily because they are poor but because of other social organizational failures, including health delivery, which are not automatically ameliorated by higher income.” This analysis concurs with classic studies of the array of societal factors explaining good health in poor settings such as Cuba and Kerala State in India in the 1980s. Analyses conducted over the past 4 decades indeed show that rapid health improvement is possible in very different contexts. That some countries continue to lag far behind can be understood through a comparison of regional differences in progress in terms of life expec­ tancy over this period (Fig. 487-3). As average levels of health vary across regions and countries, so too do they vary within countries (Fig. 487-4). Indeed, disparities within countries are often greater than those between high-income Intentional injuries Other unintentional injuries Road traffic accidents Other noncommunicable diseases Cancers Cardiovascular disease Maternal, perinatal, and nutritional conditions Other infectious diseases HIV/AIDS, TB, and malaria

Life expectancy at birth (years)

Namibia South Africa

Botswana Swaziland

10,000 15,000 20,000 25,000 30,000 35,000 40,000 GDP per capita, constant 2000 international $ FIGURE 487-2  Gross domestic product (GDP) per capita and life expectancy at birth in 169 countries, 1975 and 2005. Only outlying countries are named. (Reproduced with permission from World Health Organization: Primary Health Care: Now More Than Ever. World Health Report 2008.) and low-income countries. For example, if low- and middle-income countries could reduce their overall childhood mortality rate to that of the richest one-fifth of their populations, global childhood mortality could be decreased by 40%. Disparities in health are mostly a result of social and economic factors such as daily living conditions, access to resources, and ability to participate in life-affecting decisions. In most countries, the health care sector actually tends to exacerbate health inequalities (the “inverse-care law”); because of neglect and discrimination, poor and marginalized communities are much less likely to benefit from public health services than those that are better off. Reforming health systems toward people-centered primary care provides an opportunity to reverse these negative trends. Health services have failed to make their contribution to reducing these pervasive social inequalities by ensuring universal access to existing, scientifically validated, low-cost interventions such as insecticide-treated bed nets for malaria, taxes on cigarettes, short-course chemotherapy for tuberculosis, antibiotic treatment for pneumonia, dietary modification and secondary prevention measures for high blood pressure and high 1970–1975 2000–2005 52.1 66.9 Arab states 60.5 70.4 East Asia and Pacific Latin America and Caribbean 61.1 71.7 50.1 63.2 South Asia 45.8 46.1 Sub-Saharan Africa

68.1 CEE and CIS 71.6 78.8 High-income OECD

Life expectancy (years) FIGURE 487-3  Regional trends in life expectancy. CEE, Central and Eastern Europe; CIS, the Commonwealth of Independent States; OECD, Organization for Economic Cooperation and Development. (Reproduced with permission from World Health Organization: Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Commission on Social Determinants of Health Final Report, 2008.)

Primary Care and Global Health CHAPTER 487

Rural Urban

Under 5 mortality rate per 1000

A Haiti Nigeria Pakistan Philippines Rwanda Lowest quintile Quintile 2 Quintile 3 Quintile 4 Highest quintile

Bangladesh

Colombia

Indonesia 2002–2003 Mozambique

B FIGURE 487-4  A. Mortality of children under 5 years old, by place of residence, in five countries. (Reproduced with permission from World Health Organization: Data from the World Health Organization.) B. Full basic immunization coverage (%), by income group. (Reproduced with permission from World Health Organization: Primary Health Care: Now More Than Ever. World Health Report 2008.)

3862 cholesterol levels, and water treatment and oral rehydration therapy for diarrhea. Despite decades of “essential packages” and “basic” health cam­ paigns, the effective implementation of what is already known to work with requisite scale and quality appears (deceptively) to be difficult. Recent analyses have begun to focus on “the how” (as opposed to “the what”) of health care delivery, exploring why health progress is slow and sluggish despite the abundant availability of proven inter­ ventions for health conditions in low- and middle-income countries. Three general categories of reasons are being identified: (1) shortfalls in performance of health systems; (2) stratifying social conditions; and (3) skews in science. PART 17 Global Medicine ■ ■SHORTFALLS IN PERFORMANCE

OF HEALTH SYSTEMS Specific health problems often require the development of specific health interventions (e.g., tuberculosis requires short-course chemotherapy). However, the delivery of different interventions is often facilitated by a common set of resources or functions: money or financing, trained health workers, and facilities with reliable supplies fit for multiple pur­ poses. Unfortunately, health systems in most low- and middle-income countries are largely dysfunctional across these core functions. In the large majority of low- and middle-income countries, the level of public financing for health is woefully insufficient: whereas high-income countries spend, on average, >7% of the gross domestic product on health, middle-income countries spend <3%, and lowincome countries <2%. External financing for health through various donor channels grew rapidly in the first decade of the twenty-first century but has grown more slowly in the second decade to its current level of $37 billion. While these funds for health are significant, they represent <2% of total health expenditures in low- and middle-income countries and therefore are neither a sufficient nor a long-term solution to chronic underfinancing. In Africa, 70% of health expenditures come from domestic sources. The predominant form of health care financing—charging patients at the point of service—is the least efficient and the most inequitable, tipping millions of households into poverty annually. Health workers, who represent another critical resource, are often inadequately trained and supported in their work, especially in locations with the greatest needs. Recent estimates indi­ cate a shortage of >18 million health workers, constituting a crisis that is greatly exacerbated by the migration of health workers from low- and middle-income countries to high-income countries. Sub-Saharan Africa carries 24% of the global disease burden but has only 3% of the health workforce (Fig. 487-5). Critical diagnostics and drugs often do not reach patients in need because of supply-chain failures. Moreover, facilities fail to provide good-quality and safe care: new evidence suggests much higher rates of adverse events among hospitalized patients in low- and middle-income countries than in high-income countries. Weak government planning,

South-East Asia % of global burden of disease Africa

Western Pacific Europe Americas

Eastern Mediterranean

% of global workforce FIGURE 487-5  Global burden of disease and health workforce. (Reproduced with permission from World Health Organization: Working Together for Health, 2006.)

regulatory, monitoring, and evaluation capacities are associated with rampant, unregulated commercialization of health services and cha­ otic fragmentation of these services as donors “push” their respective priority programs. With such fragile foundations, it is not surprising that low-cost, affordable, validated interventions are not reaching those who need them. ■ ■STRATIFYING SOCIAL CONDITIONS Health care delivery systems do not exist in a vacuum but rather are embedded in a complex of social and economic forces that often stratify opportunities for health unfairly. Most worrisome are the pervasive forces of social inequality that serve to marginalize popula­ tions with disproportionately large health needs (e.g., the urban poor; illiterate mothers). Why should a poor slum dweller with no income be expected to come up with the money for a bus fare needed to travel to a clinic to learn the results of a sputum test for tuberculosis? How can a mother living in a remote rural village and caring for an infant with febrile convulsions find the means to get her child to appropriate care? Shaky or nonexistent social security systems, dangerous work environments, isolated communities with little or no infrastructure, and systematic discrimination against racialized minorities are among the myriad forces with which efforts for more equitable health care delivery must contend. ■ ■SKEWS IN SCIENCE While science has yielded enormous breakthroughs in health in highincome countries, with some spillover to low- and middle-income countries, many important health problems continue to affect primar­ ily low- and middle-income countries whose research and develop­ ment investments are deplorably inadequate. The past two decades have seen growing efforts to right this imbalance with research and development investment for new drugs, vaccines, and diagnostics that effectively cater to the specific health needs of populations in low- and middle-income countries. For example, the TB Alliance has revitalized a previously “dry” pipeline for new tuberculosis drugs. In 2019, their new drug (pretomanid) received U.S. Food and Drug Administration approval as part of a triple oral regimen (bedaquiline, pretomanid, and linezolid [BPaL]) that treats extensively drug-resistant tuberculosis faster, better, and cheaper. Nevertheless, the global vaccine inequity witnessed during the COVID-19 pandemic is indicative of the need for further efforts to right the research and development balance globally. As discussed above, the primary constraint on better health in low- and middle-income countries is related less to the availability of health technologies and more to their effective delivery. Underlying these health delivery challenges is a major bias regarding what consti­ tutes legitimate “science” to improve health equity. The lion’s share of health research financing is channeled toward the development of new technologies—drugs, vaccines, and diagnostics; in contrast, virtually no resources are directed toward research on how health care delivery systems can become more reliable and overcome adverse social condi­ tions. The complexity of systems and social context is such that this issue of delivery requires an enormous investment in terms not only of money but also of scientific rigor, with the development of new research methods and measures and the attainment of greater legiti­ macy in the mainstream scientific establishment. These common challenges to low- and middle-income countries partly explain the resurgence of interest in the primary health care approach and the emergence of a global movement toward universal health coverage, now enshrined as one of the Sustainable Develop­ ment Goal targets adopted in Agenda 2030 by all countries at the United Nations in September 2015. In some countries (mostly middleincome), significant progress has been made in expanding coverage by health systems based on primary care and even in improving indicators of population health. More countries are embarking on the creation of primary care services despite the challenges that exist, particularly in low-income countries. Even when these challenges are acknowledged, there are many reasons for optimism that low- and middle-income countries can accelerate progress in building primary care as a key vehicle toward achieving universal health coverage.

PRIMARY HEALTH CARE IN THE

TWENTY-FIRST CENTURY The new millennium has seen a resurgence of interest in primary health care as a means of addressing global health challenges but also of familiar obstacles to its implementation. This interest has been driven by many of the same issues that led to the Declaration of Alma-Ata: rapidly increasing disparities in health between and within countries; spiraling costs of health care at a time when many people lack qual­ ity care; dissatisfaction of communities with the care they are able to access; and failure to address changes in health threats, especially noncommunicable diseases, pandemics, and challenges arising from accelerated climate change. These challenges require a comprehensive approach and strong health systems with effective primary care. Global health development agencies have partially recognized that sustaining gains in public health priorities such as HIV/AIDS and pandemic pre­ paredness requires not only robust health systems but also the tackling of social and economic factors related to disease incidence and progres­ sion. Weak health systems have proved a major obstacle to delivering new technologies, such as COVID-19 vaccines and antiretroviral therapy, to all who need them. We discuss experiences in low- and middle-income countries in relation to primary care in greater detail below. First, we consider the features of primary health care and pri­ mary care as currently understood. ■ ■REVITALIZATION OF PRIMARY HEALTH CARE At the 2019 World Health Assembly (an annual meeting of all coun­ tries to discuss the work of the World Health Organization [WHO]), a resolution was passed reaffirming the principles of the Declaration of Alma-Ata and the need for national health systems to be based on pri­ mary health care. This resolution reframed primary health care as three components: (1) primary care and essential public health functions as the core of integrated health services; (2) empowered people and com­ munities; and (3) multisectoral policy and action. This reframing itself drew on the 2008 WHO World Health Report, which asserted that a primary health care approach was necessary “now more than ever” to address global health priorities, especially in terms of disparities and new health challenges. The 2008 World Health Report highlighted four broad areas for reform (Fig. 487-6). One of these areas—the need to organize health care so that it places the needs of people first—relates to the necessity SERVICE DELIVERY REFORMS UNIVERSAL COVERAGE REFORMS to make health systems people-centered to improve health equity LEADERSHIP REFORMS PUBLIC POLICY REFORMS to make health authorities more reliable to promote and protect the health of communities FIGURE 487-6  The four reforms of primary health care renewal. (Reproduced with permission from World Health Organization: Primary Health Care: Now More Than Ever. World Health Report 2008.)

for strong primary care in health systems and what this requirement entails. The other three areas also relate to primary care. All four areas require action to move health systems in a direction that will improve health, reduce disparities, and increase satisfaction. Universal Coverage Reforms to Improve Health Equity   Despite progress in many countries, most people in the world can receive health care services only if they can pay at the point of service. Disparities in health are caused not only by a lack of access to necessary health services but also by the impact of expenditure on health. More than 100 million people are still being driven into extreme poverty each year by health care costs, with countless others deterred from accessing services at all. Moving toward prepayment financing systems for universal coverage, which ensure access to a comprehensive package of services according to need without precipitating economic ruin, has therefore emerged as a major priority in low- and middleincome countries. Increasing coverage of health services can be consid­ ered in terms of three axes: the proportion of the population covered, the range of services underwritten, and the percentage of costs paid (Fig. 487-7). Moving toward universal health coverage requires ensur­ ing the availability of health care services to all, eliminating barriers to access, and organizing pooled financing mechanisms, such as taxation or insurance, to remove user fees at the point of service. It also requires measures beyond financing, including expansion of health services in poorly served areas, improvement in the quality of services provided to marginalized communities, and increased coverage of other social services that significantly affect health (e.g., education). Primary Care and Global Health CHAPTER 487 Service Delivery Reforms to Make Health Systems PeopleCentered   Health systems have often been organized around the needs of those who provide health care services, such as clinicians and policymakers. The result is a centralization of services or the provi­ sion of vertical programs that target single diseases. The principles of primary health care, including the development of primary care, reori­ ent care around the needs of the people to whom services cater. This “people-centered” approach aims to provide health care that is both more effective and appropriate. The increase in noncommunicable diseases in low- and middleincome countries offers a further stimulus for urgent reform of service delivery to improve chronic disease care. As discussed above, large numbers of people currently fail to receive relatively low-cost interven­ tions that have reduced the incidence of these diseases in high-income countries. Delivery of these interventions requires health systems that can address multiple problems and manage people over a long period within their own communities, yet many low- and middle-income countries are only now starting to adapt and build primary care ser­ vices that can address noncommunicable diseases and communicable diseases requiring chronic care. Even some countries (e.g., Iran) that have had significant success in reducing communicable diseases and improving child survival have been slow to adapt their health systems to rapidly accelerating noncommunicable disease epidemics. Total health expenditure Height: what proportion of the costs is covered? Reduce cost sharing Include other services Public expenditure on health Extend to uninsured Depth: which benefits are covered? Breadth: who is insured? FIGURE 487-7  Three ways of moving toward universal coverage.

People-centered care requires a safe, comprehensive, and integrated response to the needs of those presenting to health systems, with treat­ ment at the first point of contact or referral to appropriate services. Because no discrete boundary separates people’s needs for health promotion, curative interventions, and rehabilitation services across different diseases, primary care services must address all present­ ing problems in a unified way. Meeting people’s needs also involves improved communication between patients and their clinicians, who must take the time to understand the impact of the patients’ social context on the problems they develop. This enhanced understanding is made possible by improvements in the continuity of care so that responsibility transcends the limited time people spend in health care facilities. Primary care plays a vital role in navigating people through the health system; when people are referred elsewhere for services, primary care providers must monitor the resulting consultations and perform follow-up. All too often, people do not receive the benefit of complex interventions undertaken in hospitals because they lose con­ tact with the health care system once discharged. Comprehensiveness and continuity of care are best achieved by ensuring that people have an ongoing personal relationship with a care team. PART 17 Global Medicine Public Policy Reforms to Promote and Protect the Health of Communities   Public policies in sectors other than health care are essential to reduce disparities in health and to make progress toward global public health targets. The 2008 final report of the WHO Commission on Social Determinants of Health provided an exhaus­ tive review of the multisectoral policies required to address health inequities at the local, national, and global levels. Advances against major challenges such as HIV/AIDS, tuberculosis, emerging infec­ tions, cardiovascular disease, cancers, and injuries require effective collaboration with sectors such as transport, housing, labor, agricul­ ture, urban planning, trade, and energy. The COVID-19 pandemic has underscored the importance of multisectoral action to protect health; countries that have been most successful in managing the pandemic have been those best able to coordinate across their societies to imple­ ment nonpharmaceutical health measures and build social solidarity. Similarly, while tobacco control provides a striking example of what is possible if different sectors work together toward health goals, the lack of implementation of many evidence-based tobacco control measures in most countries just as clearly illustrates the difficulties encountered in such multisectoral work and the unrealized potential of public poli­ cies to improve health. Leadership Reforms to Make Health Authorities More Reliable   The Declaration of Alma-Ata emphasized the importance of participation by people in their own health care. In fact, participa­ tion is important at all levels of decision-making. Contemporary health challenges require models of leadership that acknowledge the role of government but also the many types of organizations involved in health care delivery. Governments need to engage, guide, negotiate, and regulate among these diverse actors, including but not limited to nongovernmental organizations (NGOs), the private sector, pro­ fessional societies, academia, and patient groups. This difficult task requires concerted investment in leadership and governance capacity, especially if action requires the engagement of different sectors such as local government and education. The complex landscape for leadership at the national level extends to the international level. The increasing transnational character of health as seen by the interdependence of countries with respect to pandemics, climate change, health worker migration, and food security emphasizes the need for more effective global health governance mechanisms. EXPERIENCES WITH PRIMARY CARE IN LOW- AND MIDDLE-INCOME COUNTRIES Aspects of the primary health care approach described above, with an emphasis on primary care services, have been implemented to varying degrees in many low- and middle-income countries over the past halfcentury. As discussed above, some of these experiences inspired and informed the Declaration of Alma-Ata, which itself led many more

countries to attempt to implement primary health care. This section describes the experiences of a selection of low- and middle-income countries in improving primary care services that have enhanced the health of their populations. Before Alma-Ata, few countries had attempted to develop pri­ mary care on a national level. Rather, most focused on expanding primary care services to specific communities (often rural villages), making use of community volunteers to compensate for the absence of facility-based care. In contrast, in the post–World War II period, China invested in primary care on a national scale, and life expectancy doubled within roughly 20 years. The Chinese expansion of primary care services included a massive investment in infrastructure for pub­ lic health (e.g., water and sanitation systems) linked to innovative use of community health workers. These “barefoot doctors” lived in and expanded care to rural villages. They received a basic level of training that enabled them to provide immunizations, maternal care, and basic medical interventions, including the use of antibiotics. Through the work of the barefoot doctors, China brought low-cost universal basic health care coverage to its entire population, most of which had previ­ ously had no access to these services. In 1982, the Rockefeller Foundation convened a conference to review the experiences of China along with those of Costa Rica, Sri Lanka, and the state of Kerala in India. In all of these locations, good health care at low cost appeared to have been achieved. Despite lower levels of economic development and health spending, all of these juris­ dictions, along with Cuba, had health indicators approaching—or in some cases exceeding—those of developed countries. Analysis of these experiences revealed a common emphasis on primary care services, with expansion of care to the entire population free of charge or at low cost, combined with community participation in decision-making about health services and coordinated work in different sectors (espe­ cially education) toward health goals. During the more than three decades since the Rockefeller meeting, some of these countries have built on this progress, while others have experienced setbacks. Recent experiences in developing primary care services show that the same combination of features is necessary for success. For example, Brazil— a large country with a dispersed population—made major strides in increasing the availability of health care from 1980 to 2010. The Brazilian Family Health Program expanded progressively across the country to reach universal coverage. This program provided communities with free access to primary care teams made up of primary care physicians, community health workers, nurses, dentists, obstetricians, and pedia­ tricians. These teams were responsible for the provision of primary care to all people in a specified geographic area—not only those who access health clinics. Moreover, individual community health workers were responsible for a named list of people within the area covered by the primary care team. Solid evidence indicated that the Family Health Program has contributed to impressive gains in population health, particularly in terms of childhood mortality and health inequities (Fig. 487-8). Nevertheless, systemic inequalities, magnified during the COVID-19 crisis, highlight how continued progress is not guaranteed, and efforts to implement and expand a primary health care approach need to adapt to new health and political challenges. Chile has also built on its existing primary care services in the past two decades, aiming to improve the quality of care and the extent of coverage in remote areas, above all for disadvantaged populations. This effort has been made in concert with measures aimed at reducing social inequalities and fostering development, including social welfare benefits for families and disadvantaged groups and increased access to early-childhood educational facilities. As in Brazil, these steps have improved maternal and child health and have reduced health inequi­ ties. In addition to directly enhancing primary care services, Brazil and Chile have instituted measures to increase both the accountability of health providers and the participation of communities in decisionmaking. In Brazil, national and regional health assemblies with high levels of public participation are integral parts of the health policymaking process. Chile has instituted a patient’s charter that explicitly specifies the rights of patients in terms of the range of services to which they are entitled.

3.96 Mean annual change (since 1998)

–2 –2.08 –4 –4.24 –6 –6.82 –6.97 –6.77 –8 –10 0–20 21–50 51–70 71+ PSF coverage (% population covered) FIGURE 487-8  Improvements in childhood mortality following the Family Health Program in Brazil. HDI, Human Development Index; PSF, Program Saúde da Família (Family Health Program). (Source: Ministry of Health, Brazil.) Other countries that have made recent progress with primary health care include Bangladesh, once one of the poorest countries in the world. Since achieving its independence from Pakistan in 1971, Bangladesh has seen a dramatic increase in life expectancy, and child­ hood mortality rates are now lower than those in neighboring nations such as India and Pakistan. The expansion of access to primary care services has played a major role in these achievements. This progress has been spearheaded by a vibrant NGO community that has focused its attention on improving the lives and livelihoods of poor women and their families through innovative and integrated microcredit, educa­ tion, and primary care programs. The above examples, along with others from the past 40 years in countries such as Thailand, Rwanda, Ethiopia, Turkey, Vietnam, and Oman, illustrate how the implementation of a primary health care approach, with a greater emphasis on primary care, has led to bet­ ter access to health care services—a trend that has not been seen in many other low- and middle-income countries. This trend, in turn, has contributed to improvements in population health and reductions in health inequities. However, as these nations have progressed, other countries have shown how previous gains in primary care can easily be eroded. In Sub-Saharan Africa, undermining of primary care services contributed to catastrophic reversals in health outcomes catalyzed by the HIV/AIDS epidemic. Countries such as Botswana and Zimbabwe implemented primary health care strategies in the 1980s, increasing access to care and making impressive gains in child health. Both coun­ tries were severely affected by HIV/AIDS, with pronounced decreases in life expectancy. However, Zimbabwe has also seen political turmoil,

Percentage of total health expenditure

FIGURE 487-9  Changes in source of health expenditure in China over the past 40 years. (Reproduced with permission from World Health Organization: Primary Health Care: Now More Than Ever. World Health Report 2008.)

a decline of health and other social services, and the flight of health personnel, whereas Botswana has maintained primary care services to a greater extent and has managed to organize widespread access to antiretroviral therapy for people living with HIV/AIDS. High HDI Low HDI China provides a particularly striking example of how changes in health policy relevant to the organization of health systems (Fig. 487-9) can have rapid, far-reaching consequences for population health. Even as the 1982 Rockefeller conference was celebrating China’s achievements in primary care, its health system was unraveling. The deci­ sion to open up the economy in the early 1980s led to rapid privatization of the health sector and the breakdown of universal health coverage. As a result, by the end of the 1980s, most people, especially the poorer segments of the population, were paying directly out of pocket for health care, and almost no Chinese had insurance—a dramatic transformation. The “barefoot doctor” schemes collapsed, and the population either turned to care paid for at hospitals or simply became unable to access care. This undermining of access to primary care ser­ vices in the Chinese system and the resulting increase in impoverish­ ment due to illness contributed to the stagnation of progress in health in China at the same time that incomes in that country increased at an unprecedented rate. Reversals in primary care have meant that China now increasingly faces health care issues similar to those faced by India, although the country has more recently implemented measures to restore universal health coverage, with significant success. In both countries, rapid economic growth has been linked to lifestyle changes and noncommunicable disease epidemics. The health care systems of the two nations share two negative features that are common when primary care is weak: a disproportionate focus on specialty services provided in hospitals and unregulated commercialization of health ser­ vices. China and India both saw expansion of private hospital services that cater to middle-class and urban populations who can afford care; at the same time, hundreds of millions of people in rural areas struggled to access basic services. Even in the wealthier groups, a lack of primary care services has been associated with late presentation with illness and with insufficient investment in primary prevention approaches. This neglect of prevention poses a risk of large-scale epidemics of cardio­ vascular disease, which could endanger continued economic growth. In addition, the health systems of both countries now depend for the majority of their funding on out-of-pocket payments by people when they use services. Thus, substantial proportions of the population must sacrifice other essential goods as a result of health expenditure and Primary Care and Global Health CHAPTER 487 –5.64 –8.38 Out-of-pocket expenditure Prepaid private expenditure Social security expenditure Other general government expenditure

3866 may even be driven into poverty by this cost. The commercial nature of health services with inadequate or no regulation has also led to the proliferation of charlatan providers, inappropriate care, and pressure for people to pay for expensive and sometimes unnecessary care. Faced with these problems, China and India have implemented measures to strengthen primary health care. China has increased gov­ ernment funding of health care, has taken steps toward restoring health insurance, and has enacted a target of universal access to primary care services. India has similarly mobilized funding to greatly expand pri­ mary care services in rural areas and in urban settings. Both countries are increasingly using public resources from their growing economies to fund primary care services. PART 17 Global Medicine These encouraging trends are illustrative of new opportunities to implement a primary health care approach and strengthen primary care services in low- and middle-income countries. Linked to goal number 3 of the UN Sustainable Development Goals, Over the past decade, nearly all countries have adopted universal health coverage—the provision of quality health services in a timely manner at affordable cost—and the primary health care approach remains key to achieving this. ■ ■OPPORTUNITIES TO BUILD PRIMARY CARE IN LOW- AND MIDDLE-INCOME COUNTRIES To reach global health targets, health systems must be strengthened. More money is currently being spent on health than ever before. In 2020, global health spending totaled $9 trillion (U.S.)—more than double the amount spent a decade earlier. Although most expendi­ ture occurs in high-income countries, spending in many emerging middle-income countries has rapidly accelerated, as has the allocation of monies for this purpose by both governments in, and donors to, lowincome countries. These twin trends—greater emphasis on building health systems based on primary care and allotment of more money for health care—provide opportunities to address many of the challenges discussed above in low- and middle-income countries. Accelerating progress requires a better understanding of how global health initiatives (GHIs) can more effectively facilitate the development of primary care in low-income countries. Recent reviews including the WHO Maximizing Positive Synergies Collaborative Group and the Wellcome Trust Future of GHIs have assessed the impact on coun­ try health systems of diverse GHIs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunization; the U.S. President’s Emergency Plan for AIDS Relief; and the Global Financing Facility of the World Bank. While evidence of improved access to targeted health services is encouraging, systemic concerns related to increasing domestic resources for health and accel­ erating comprehensive primary care remain. If GHIs implement pro­ grams that work in tandem with other components of national health systems without undermining staffing and procurement of supplies, they have the potential to contribute substantially to the capacity of health systems to provide comprehensive primary care services. In the context of the recent pandemic, GHIs appear even more important. The imperative of vaccinating the world’s population against SARS-CoV-2 led to the creation of the multi-billion-dollar COVAX facility that failed to ensure equitable access to COVID-19 vaccines. After the pandemic, the need to recover essential health ser­ vices, particularly for mothers and children, underlines the importance of GHIs like the Global Financing Facility for every mother and child as catalysts for universal access to life-saving services. The general trend is to coordinate this funding in order to reduce fragmentation of national health systems and to concentrate more on strengthening these systems. Comprehensive primary care in low-income countries must inevitably deal with the rapid emergence of chronic diseases and the growing prominence of injury-related health problems; thus, inter­ national health development assistance must become more responsive to these needs. Beyond funding for health services, other opportunities exist. Increased social participation in health systems can help build pri­ mary care services. In many countries, political pressure from com­ munity advocates for more holistic and accountable care as well as

entrepreneurial initiatives to scale up community-based services through NGOs have accelerated progress in primary care without major increases in funding. Participation of the population in the provision of health care services and in relevant decision-making often drives services to cater to people’s needs as a whole rather than to nar­ row public health priorities. Participation and innovation can help address critical issues related to the health workforce in low- and middle-income countries by estab­ lishing effective people-centered primary care services. Many primary care services do not need to be delivered by a physician or a nurse. Multidisciplinary teams can include paid community workers who have access to a physician if necessary but who can provide a range of health services on their own. In Ethiopia, >38,000 community health workers have been trained and deployed to improve access to primary care services, and there is increasing evidence that this measure is contributing to better health outcomes. In India, >600,000 community health advocates have been recruited as part of expanded rural primary care services. In Niger, the deployment of community health work­ ers to deliver essential child health interventions (as a component of integrated community case management) has had impressive results in reducing childhood mortality and decreasing disparities. After the Declaration of Alma-Ata, experiences with community health work­ ers were mixed, with particular problems regarding levels of training and lack of payment. Current endeavors are not immune from these concerns. However, with access to physician support and the deploy­ ment of teams, some of these concerns may be addressed. Growing evidence from many countries indicates that shifting appropriate tasks to primary care workers who have had shorter, less expensive training than physicians will be essential to address the human resources crisis. Finally, recent improvements in information and communication technologies, particularly mobile phone and Internet systems, have cre­ ated the potential for systematic implementation of e-health, telemedi­ cine, and improved health data initiatives in low- and middle-income countries. These developments raise the tantalizing possibility that health systems in these countries, which have long lagged behind those in high-income countries but are less encumbered by legacy systems that have proved hard to modernize in many settings, could leapfrog their wealthier counterparts in exploiting these technologies. Although the challenges posed by poor or absent infrastructure and investment in many low- and middle-income countries cannot be underestimated and will need to be addressed to make this possibility a reality, the rapid rollout of mobile networks and their use for health and other social services in many low-income countries where access to fixed telephone lines was previously very limited offer great promise in building pri­ mary care services in low- and middle-income countries. To a partial extent, this potential has been demonstrated and even realized in many countries during the COVID-19 pandemic, with greatly increased uptake of the use of telemedicine and clinical support via digital means. CONCLUSION As concern continues to mount about glaring inequities in global health, there is a growing commitment to redress these egregious shortfalls, as exemplified by the central place of equity in the United Nations’ Sustainable Development Goals adopted in 2015, including a specific target on the achievement of universal health coverage in all countries by 2030. This commitment begins first and foremost with a clear vision of the fundamental importance of health in all countries, regardless of income. The values of health and health equity are shared across all borders, and primary health care provides a framework for their effective translation across all contexts. The translation of these fundamental values has its roots in four types of reform that reflect the distinct but interlinked challenges of (re)orienting a society’s resources on the basis of its citizens’ health needs: (1) organizing health care services around the needs of people and communities; (2) harnessing services and sectors beyond health care to promote and protect health more effectively; (3) establishing sustainable and equitable financing mechanisms for universal health coverage; and (4) investing in effective leadership to steward change locally, nationally and across borders. This common primary health

care agenda highlights the striking similarity, despite enormous dif­ ferences in context, in the nature and direction of the reforms that national health systems must undertake to promote greater equity in health. This shared agenda is complemented by the growing reality of global health interconnectedness due, for example, to shared microbial threats, bridging of ethnolinguistic diversity, flows in migrant health workers, and mobilization of global funds to support the neediest populations. Embracing solidarity in global health while strengthening health systems through a primary health care approach is fundamental to sustained progress in global health. The shortfalls in health system performance, stratification of social conditions leading to unfair differences in health, and skews in science that undermine the realization of “Health for All” have never been more glaringly visible than during the COVID-19 pandemic. But they also have never commanded such global political attention at the high­ est level. Out of this crisis, then, is a once-in-a-lifetime opportunity to recast global and national systems to enable the genuine implementa­ tion of the primary health care approach in all countries. ■ ■FURTHER READING Aquino R et al: Impact of the family health program on infant mortal­ ity in Brazilian municipalities. Am J Public Health 99:87, 2009. Commission on Social Determinants of Health: Closing the Gap in a Generation: Health Equity through Action on the Social

Determinants of Health: Commission on Social Determinants of Health Final Report. Geneva, World Health Organization, 2008. Kruk ME et al: The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives. Soc Sci Med 70:904, 2010. Li X et al: The primary health-care system in China. Lancet 390:2584, 2017. Macinko J et al: The impact of primary healthcare on population health in low- and middle-income countries. J Ambul Care Manage 32:150, 2009. Rasanathan K, Evans T: Primary health care, the Declaration of Primary Care and Global Health CHAPTER 487 Astana and COVID-19. Bulletin of the World Health Organization 98:801, 2020. Rasanathan K et al: Primary health care and the social determinants of health: Essential and complementary approaches for reducing inequities in health. J Epidemiol Community Health 65:656, 2011. Starfield B et al: Contribution of primary care to health systems and health. Milbank Q 83:457, 2005. Tangcharoensathien V et al: Health systems development in Thailand: A solid platform for successful implementation of universal health coverage. Lancet 391:1205, 2018. Van Lerberghe W et al: Primary Health Care: Now More Than Ever. World Health Report 2008. Geneva, World Health Organization, 2008.