Today, millions of people in low- and middle-income countries do not have access to basic, good quality health services. The author explores the current situation and suggests ways of improving these conditions.
The Alma Ata Declaration in 1978 defined primary health care as basic health care built on technically sound and socially adequate approaches, universally accessible and affordable to all individuals.
Selective primary health care
Soon after the Alma Ata Declaration, the concept of 'selective primary health care' was proposed in an article by Walsh and Warren in 1979, justified on the basis of scarce resources and a need for rationing. It argued that comprehensive primary health care was too idealistic and difficult to achieve. Instead, the idea emerged to concentrate efforts on controlling a few selected infectious diseases through cost-effective interventions, based on disease mortality and morbidity rates.
Cost recovery mechanisms
Similarly, in the 1990s international agencies, led by the World Bank, proposed new mechanisms to organise financial contributions from users towards the cost of care through, for example, user fees and community-based health insurance. These proposals emerged in the context of broader health sector reforms and suggestions to use the private sector in health service provision.
The rationale behind these cost recovery mechanisms was the need to increase healthcare revenues and improve quality and efficiency through greater community involvement in primary health care (PHC) management. Although some studies have shown that this was partially achieved, the main criticism is that cost-recovery also increased inequity in access. As Barbara McPake points out, methods of achieving good quality PHC for those living in poverty have not been identified in most low income countries.
Driven by continuing resource scarcity, international agencies and low- to middle-income country governments continued to look for ways to cut costs in the late 1990s and early 2000s, including basic or essential packages based on a list of cost-effective interventions.
Strengthening health systems
The international community, notably the World Health Organisation, recognised the limits of providing disease specific interventions without a functioning delivery system, and called for greater attention to strengthening the health system as a whole. This led to the creation in 2002 of the Commission on Macroeconomics and Health, which advocated the use of a 'close-to-client' system, including outreach services, health centres and local hospitals most accessible to poor people. It highlighted the various constraints affecting demand and supply which limit the ability of poor people to access such services.
Overcoming barriers to health care
Historically, greater emphasis has been placed on reducing supply side barriers – which negatively affect quality, volume and price of available services – with a focus on key health service inputs, notably human resources and drugs. As Eilish Mcauliffe suggests, staff motivation and ultimately staff performance are associated with the availability of other necessary resources, such as drug supplies, for service delivery.
However, the assumption that free public-sector health services result in universal access to PHC has become less plausible. Growing preferences for non-free over free services, and the resulting growth in providers of differing public and private characteristics, requires strategies that extend beyond public sector provision.
Contracts with the private sector emerged as another supply side strategy that may improve access to PHC. Maureen Lewis indicates that contracting out may increase efficiency (through greater competition), quality (staff morale, for example), and coverage (providing services to high risk groups or people in remote areas). Yet, strong government capacity, often lacking in low- and middle-income countries, is required in order to design and oversee all stages of the contractual arrangement.
Strategies to remove or at least reduce demand side barriers, which disproportionately affect the poorest and most vulnerable in society, also need to be prioritised. Demand side barriers can include physical, financial, cultural and social barriers, such as opportunity costs, lack of knowledge about appropriate care, or distance to the health centre.
The balance between supply and demand is reinforced by research from Indonesia: Tim Ensor provides evidence that improving the availability of trained midwives and emergency obstetric care is not enough to reduce maternal mortality if mothers cannot afford services. And lowering prices for essential health commodities, such as effective anti-malarial drugs, as discussed by Lindsay Mangham and Kara Hanson, needs to be accompanied by community strategies to improve the knowledge of those purchasing the drugs.
Aid harmonisation
Given the high dependency of low income countries on aid, methods of aid delivery are central to the debate on how best to finance PHC. Sector-wide approaches (SWAps) and General Budget Support (GBS) emerged in the late 1980s to 1990s, in response to frustrations with the delivery of aid through 'vertical' projects. Such programmes were problematic because they were defined by donors giving little country ownership. Poor donor coordination lead to fragmentation and duplication of efforts, and governments were unable to respond effectively to different donor requirements.
In 2005, further efforts by the international community to improve aid effectiveness resulted in the Paris Declaration. It highlighted the need for increased donor harmonisation and alignment with recipient governments.
In contrast to vertical projects, the principles behind GBS and SWAps include:
* pooling of government and donor funds to contribute towards nationally agreed policies and expenditure frameworks
* country ownership and leadership
* increased use of government procedures to eventually disburse and account for all funds.
SWAp funds are allocated to a specific sector such as education or health, whilst GBS funds are channelled to the recipient government budget without allocation to a specific sector, programme or activity. PHC funding can benefit from such shifts in resource allocation, when government funds increase due to a change in the donors' method of budget delivery. This happened in Uganda in 2000, as discussed by Freddie Ssengooba, when a SWAp was introduced with other reforms that prioritised PHC services.
Global Health Initiatives
Yet the advantages of vertically delivered donor projects – such as the ability to respond swiftly to urgent health problems and increased flexibility in avoiding recipient countries' capacity problems – continue to make them a popular method of delivery for aid. In the past decade, project-based Global Health Initiatives such as the Presidential Emergency Plan for AIDS Relief and the Global Fund for AIDS, TB and Malaria have posed additional coordination challenges at the national level. This is mainly due to the high volumes of funds they manage and the resulting potential to disrupt existing health system development, and the policy and planning processes of recipient countries.
Conclusion
In the 30 years since the Alma Ata Declaration, there has been tension regarding whether to centre efforts on a few selected interventions or strengthen the health system as a whole. Focusing on a limited disease intervention package or a particular element of the health system, such as human resources, risks neglecting aspects such as management systems and compromising the effective and efficient functioning of health services.
Policymakers in donor agencies and recipient countries need to ensure adequate funding is allocated to the entire health sector. They also need to channel new funding sources through pooled mechanisms, such as SWAps, and use established government processes.
