EXECUTIVE SUMMARY 1 WALKING THE TALK Reimagining Primary Health Care After COVID-19 © 2021 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This 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. 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WALKING THE TALK Reimagining Primary Health Care After COVID-19 WALKING THE TALK Contents Executive Summary 12 Chapter 1. Introduction: Primary Health Care: Time to Deliver An unfinished journey 21 The shock of COVID-19 22 This report: practical options for stronger PHC 23 Chapter 2: Challenges for Health Systems: COVID-19 and Beyond Health-system ecologies: trends for the coming decade 31 Trends in health care delivery and financing 41 Implications for primary health care 43 Chapter 3. Reimagined PHC: What Will It Look Like? Four high-level shifts for stronger PHC 50 2 Chapter 4. Making It Happen Priority Reform 1: Fit-for-purpose multidisciplinary team-based organization 76 1.1. From dysfunctional gate keeping to quality, comprehensive care for all 76 1.2. From fragmentation to person-centered integration 82 1.3. From inequities to fairness and accountability 87 1.4. From fragility to resilience 90 Priority Reform 2: The fit-for-purpose multi-professional health workforce 92 2.1. From dysfunctional gate keeping to quality, comprehensive care for all 92 2.2. From fragmentation to person-centered integration 98 2.3. From inequities to fairness and accountability 103 2.4. From fragility to resilience 107 TABLE OF CONTENTS Priority Reform 3: Fit-for-purpose financing for public-health- enabled primary care 110 3.1. From dysfunctional gate keeping to quality, comprehensive care for all 111 3.2. From fragmentation to person-centered integration 119 3.3. From inequities to fairness and accountability 122 3.4. From fragility to resilience 127 Enabling multisectoral engagement through PHC reform 130 Conclusions 137 Chapter 5: Policy Recommendations Prerequisites for action 139 Recommendations for countries 141 3 Recommendations for donors and the international health community 146 What will the World Bank do? 147 Conclusion: Summary table of policy recommendations 149 Endnotes 150 WALKING THE TALK 4 FOREWORD The Universal Health Coverage (UHC) agenda has reached a crucial crossroad. FOREWORD The 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 post- pandemic 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 similar catastrophes from future occurrence. To be clear, we do not claim that COVID crisis was entirely or mostly the result of weak or non-functional PHC services. Yet PHC was often the weakest link in the national and community response, despite 5 its critical importance as a backstop to “flatten the curve” and prevent hospital saturation. Core PHC functions like surveillance, testing, and contact tracing first fell through the cracks, then were ultimately assumed by newly created teams or hospitals. And now we will again need PHC to close the COVID-19 chapter and make up for lost time—by administering vaccines against COVID-19; recouping losses to reproductive health, preventive care, and mental health; and building back 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 TALK Acknowledgements This 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 HNP leadership team and HNP colleagues throughout the process, as well as written 6 comments provided for the decision meeting from Daniel Dulitzky (Regional Director), Gayle Martin (Country Manager), Susanna Hayrapetyan (Program Leader), Mark E. Cackler (Lead Agriculture Specialist), John Paul Clark (Lead Health Specialist), Sherin Varkey (Senior Health Specialist). Chapters 3 and 4 have incorporated content from the World Bank’s internal Frontlines First (FLF) series, developed in 2018 to commemorate the 40th anniversary of the Alma Ata Declaration. The team is also grateful to David Wilson (Program Director) and Mickey Chopra (Lead Health Specialist), Rachel Silverman (Consultant, lead author); Kojo Nimako (Consultant), and Danielle Fitzpatrick (Consultant) for their roles in compiling the FLF framework and briefs that have fed into this Flagship 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. ABBREVIATIONS Abbreviations ACO Accountable Care Organization ADZU Ateneo de Zamboanga University ART Anti-Retroviral Therapy BHS Basic Health Services BMPHS Basic Minimum Package of Health Services BHCPF Basic Health Care Provision Fund CBL Case-based Learning CCTs Conditional Cash Transfers CEME Community Engaged Medical Education CHA Cambridge Health Alliance CHPS Community-based Health Planning and Service CHWs Community Health Workers CMS Center for Medicaid and Medicare Services CNAMTS Caisse Nationale d’Assurance Maladie des Travailleurs Salariés CPC+ Comprehensive Primary Care Plus 7 CVD Cardiovascular Disease DAH Development Assistance for Health DCP3 Disease Control Priorities (3rd edition) DRG Diagnosis-related Group EAPHLNP The East Africa Public Health Laboratory Networking Project EBAIS Equipos Básicos de Atención Integral de Salud EHR Electronic Health Record EPSS Evaluación de la Prestación de Servicios de Salud e-RS E-referral System for Specialist Consultations FFS Fee for Service FHTs Family Health teams FPs Family Practitioners GAP Global Action Plan for SDG3 GFF The Global Finance Facility for Women, Children and Adolescents GIS Geographical Information Systems GK Gesundes Kinzigtal GmbH GP General Practitioner GPs General Practitioners GSP Global Skills Partnership HANSA The World Bank’s Health and Nutrition Services Access Project HCP Human Capital Project WALKING THE TALK HF Health financing HITAP Thailand’s Health Intervention and Technology Assessment Program HMIS Health Management Information Systems HNP Health, Nutrition and Population HPV Human Papillomavirus HRH Program Rwanda Human Resources for Health Program hearScreenTM Smartphone-based Application HSRS Health Sector Reform Strategy HTA Health Technology Assessment ICT Information and Communications Technology IHME The Institute for Health Metrics and Evaluation JLN The Joint Learning Initiative for Universal Health Coverage LHINs Local Health Integration Networks LMICs Low- and Middle-income Countries MA Medical Administration MBA Business Administration 8 MCH Maternal and Child Health MHA Health Administration MEPI The Medical Education Training Partnership Initiative MoH Ministry of Health MoF Ministry of Finance MoE Ministry of Education MoL Ministry of Labor MoI Ministry of the Interior MoT Ministry of Technology MPA Multiphase Programmatic Approach MPH Public Health Administration M&E Monitoring and evaluation NASF Family Health Support Centers NCDs Noncommunicable Diseases NEPI The Nursing Training Partnership Initiative NHSC The US National Health Service Corps NICE The National Institute for Health and Clinical Excellence NLC The Nurse Licensure Compact NOSM The Northern Ontario School of Medicine NPHWs Non-physician Healthcare Workers PaRIS The Patient reported Indicator Surveys ABBREVIATIONS PCMH The US-based Patient-Centered Medical Home PFM Public Financial Management PHC Primary Health Care PHCPI Primary Health Care Performance Initiative PNG Papua New Guinea PPE Personal Protective Equipment PPP Preferred Primary Care Provider PREM Patient-reported Experience Measures PROM Patient-reported Outcome Measures RMNCH Reproductive, Maternal, Newborn and Child Health Services RNs Registered Nurses RMNCAH-N Improve Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition R&D Research and development SDGs Sustainable Development Goals SHI Social Health Insurance UHC Universal Health Coverage 9 WBOT Ward-based Outreach Teams WDCs Ward Development Committees WALKING THE TALK Figures Figure 1. Policy choices will be critical for health goals and economic recovery 32 Figure 2. Percentage of working age population (15-64 years of age) by income group and geographic location, 1950-2100 34 Figure 3. Percentage of population 65+ years of age by income group and geographic location, 34 Figure 4. Living longer, living sicker: years lived in poor health, 1990 and 2019 36 Figure 5. Noncommunicable diseases will test already-fragile health systems 37 Figure 6. Urban populations continue to surge 39 10 Figure 7. Service coverage and financial protection worldwide: slow progress even before COVID-19 41 Tables Table 1. Reimagining a PHC fit-for-purpose: outcomes and priority reforms 74 Table 2. Team-based care models around the world 79 Table 3. Misalignments between traditional payment mechanisms and team-based care models 119 Table 4. Key recommendations for fit-for-purpose PHC 149 BOXES Boxes Box 1. PHC and health-system reform in the 21st century: a growing convergence and strong alliances 49 Box 2. Four shifts to improve performance in PHC 51 Box 3: What has to change: dysfunctional gate keeping and quality gaps 54 Box 4. What has to change: discontinuous delivery 56 Box 5. What has to change: health financing gaps widen health care inequities 59 Box 6. The cost of not building fit-for-purpose PHC: collateral mortality in COVID-19 62 Box 7. What has to change: fragility to shocks 63 11 Box 8. What has to change: sectoral silos inhibit collaboration 69 Box 9. Why team-based care? 77 Box 10. Harnessing technology to improve information sharing in PHC 86 Box 11. Core competencies for interprofessional collaborative practice 101 Box 12. Why finance PHC through general government revenue? 113 Box 13. Global Financing Facility and the World Bank – a partnership to support Primary Health Care 126 Box 14. A Whole-of-government approach to strengthening human capital 136 WALKING THE TALK 12 EXECUTIVE SUMMARY EXECUTIVE SUMMARY The 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 systems matter 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 now can prepare health systems for future crises and bring goals like universal health coverage (UHC) within reach. PHC holds the key to these transformations. But to fulfill that promise, the walk has to finally match the talk. This report charts an agenda toward reimagined, fit-for-purpose PHC. It asks three questions about 13 health-systems reform built around PHC: “Why?”, “What?”, and “How?” The “Why?” of PHC reform: confronting complex change Since 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 lower- income 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 TALK The “What?” of PHC reform: four structural shifts So, 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 fragmented and impersonal. Strong local PHC teams can fix this. Accountable teams build care around patients’ needs and preferences; treat all patients with respect; collaborate and communicate internally; and coordinate patients’ movement 14 through 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 action After 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 SUMMARY Priority reform 1: multidisciplinary team-based care Delivering 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 affect vulnerable constituencies. Engaging directly with communities, local teams 15 can deliver health education and promotion; offer nutritional coaching and supplementation; identify subclinical illness; and help sustain adherence to treatment 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 workforce In 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 strategic WALKING THE TALK communication 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 task- shifting, 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 performance evaluation and compensation. Primary care teams need quality measurement tools that promote accountable performance by rewarding team members for managing complexity, solving problems, and thinking creatively to address patients’ unique circumstances. Priorities for outcome and performance 16 management include patient-centered reporting and metrics. Priority reform 3: financing public-health-enabled PHC Financing 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. These EXECUTIVE SUMMARY emerging 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 recommendations Each country will have its own road map for PHC reform, reflecting national starting conditions, health and development priorities, and political economy. However, some policy priorities will apply across settings. This report formulates 17 broad policy recommendations for governments, then proposes actions for the global health community, including the World Bank. TEAM-BASED CARE ORGANIZATION + Assess health workforce strengths and gaps, and plan the transition to team- based 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 TALK FINANCING 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 do 18 The World Bank will use its lending, learning, and leadership to support countries in delivering 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 country- level technical collaboration and financial support, building on and further leveraging the GFF country leadership program. EXECUTIVE SUMMARY Conclusions With 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 talked enough about PHC? Clearly not, because PHC’s proven benefits have still not reached hundreds of millions of people who urgently need them. And because, when COVID struck, PHC’s power to protect communities in health emergencies was not used. We need to keep talking about PHC. But above all we need to walk the talk—fast. The distinctive strengths of PHC are vital to “build back better” in health after the pandemic. Countries that choose the path of ambitious PHC reform will reap powerful rewards: through lower health care costs, more resilient systems, stronger human capital, increased health literacy, higher economic 19 productivity, and above all longer, healthier, more satisfying lives for people. WALKING THE TALK Chapter 1 Introduction: Primary Health Care: TIME TO 20 DELIVER CHAPTER 1: INTRODUCTION The 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. 21 An unfinished journey Since 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.2 Yet, 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 essential WALKING THE TALK health 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.5 Countries 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 greater challenges lie ahead for health systems. Populations are rising fast in some of the poorest countries and aging rapidly in higher-income settings. Many countries face a protracted epidemiologic transition, where stunting coexists with obesity, and surging noncommunicable disease burdens come atop persistent infectious 22 threats. Rising citizen expectations for health care have followed urbanization and globalization, even as climate change, economic crises, institutional fragility, and conflict 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-19 COVID-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: INTRODUCTION Amid 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 for stronger PHC 23 While 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 far- reaching 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 TALK This 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. Audiences The report is addressed primarily to governments, in particular policy makers and technical advisers in ministries of finance and ministries of health. Since PHC is most 24 effective when supported by a whole-of-government approach to policy making, the report also aims to engage leaders in other government departments, clarifying how the recommended actions can advance some of those sectors’ priority agendas. The report’s recommendations prioritize options that are realistic for most low- and lower-middle-income countries. Adapted versions of these approaches are likely to yield 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 paths CHAPTER 1: INTRODUCTION described 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 timeframe This 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 offers 25 specific recommendations for leveraging the distinctive capabilities of high- performing PHC in this context of urgent action. The report’s technical and policy recommendations also look beyond crisis response and early-stage recovery to consider a longer timeframe appropriate for structural change in PHC systems. The report discusses actions and outcomes through 2030, the target year for the Sustainable Development Goals, including countries’ pledge to achieve UHC. Limitations It 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 TALK Chapter 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-level change goals for stronger PHC and charting three priority reform axes that countries can use to reach those goals (Table 1, page 74). Both the change goals 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 recognize broad alignment between the conceptual architecture developed here and existing, widely cited frameworks for understanding and improving PHC. However, 26 it is important to be explicit on two points. First, while this report’s agenda for fit-for-purpose PHC builds on and benefits from previous frameworks, research, and country experience, the fit-for-purpose PHC program is a new framing and therefore subject to caution. It is derived from ongoing original work, such that responsibility for its shortcomings rests entirely with the report team, not with our sources. Second, the construction of the fit-for-purpose PHC agenda is based on a primarily qualitative approach to prior frameworks and evidence. In foregrounding the promise of team-based PHC service delivery models, for example, we have not attempted to generate original quantitative estimates of the benefits that such models could produce in terms of population health indicators and health-system cost savings in specific settings. This is another important frontier 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: INTRODUCTION Panel 1. Defining primary health care WHO definition The 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, as 27 co-developers of health and social services, and as self-carers and care-givers to others.8 What PHC is not Related 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 health- service 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 fully WALKING THE TALK encompass 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 the concept of PHC by focusing on selected diseases rather than the whole person 28 and the full spectrum of services from promotive to palliative.12 Defining 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 Alma- Ata. 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.14 Reimagining PHC In 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 by CHAPTER 1: INTRODUCTION this 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 report The remainder of this report proceeds as follows. The report asks “Why?”, “What?” and “How?” questions about PHC-driven health-system reform. Chapter 2 29 shows why these reforms are urgent now. It analyzes trends in demographics, epidemiology, technology, and citizens’ expectations for health care that pose daunting challenges for health systems today—challenges to which systems built around strong PHC will be best able to respond. Chapter 3 describes what PHC reforms aim to achieve. It identifies four systemic shifts that characterize fit-for-purpose PHC: boosting service quality while expanding coverage; achieving greater integration of patient-centered care; enhancing fairness and accountability in PHC; and preparing PHC networks to tackle emergencies with resilience. Chapter 4 summarizes evidence on how countries can deliver these shifts. It describes three priority reform agendas: developing a multidisciplinary, team-based PHC platform; building a multi-professional health workforce; and creating PHC financing solutions that can bring public-health crisis response capabilities to the front lines, while strengthening routine PHC services. Finally, Chapter 5 offers recommendations for countries and development partners to deliver PHC reforms and strengthen health-system performance in the post- COVID world. It also explains how the World Bank is changing its work to support countries as they walk the talk on PHC. WALKING THE TALK Chapter 2 CHALLENGES 30 FOR HEALTH SYSTEMS COVID-19 and Beyond CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMS The 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 health- system 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 health policy must now aim to achieve. The rationale, the “Why?” of health-system reform, is more complex, because the challenges that health systems face extend far beyond the threat of future infectious outbreaks. To better understand the rationale for ambitious health-system reform now, we need a broader sense of the key forces that will influence population health needs and health-system response options in the coming years. To provide a portion of this background, this chapter 31 asks two questions: (1) What are the forces that are likely to shape the evolution of countries’ health ecosystems in the coming decade? (2) Are current health-service delivery and financing models ready to manage those forces? The chapter does not try to answer these broad questions comprehensively across all levels of care but focuses on selected aspects that are especially relevant to the discussion of health-system reform led by PHC. Health-system ecologies: trends for the coming decade Health 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 economies WALKING THE TALK worldwide.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 low- and 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.18 Figure 1. Policy choices will be critical for health goals and economic recovery Performance score of the UHC Effective Coverage Index 2030 target Global average Better scenario Reference scenario 32 Worst scenario 2019 100 100 90 62 80 70 69 63 60 60 50 40 30 20 10 0 1990 2000 2010 2020 2030 Source: Gates Foundation. 2020 Goalkeepers Report. https://ww2.gatesfoundation.org/goalkeepers/ downloads/2020-report/report_letter_en.pdf Demographic and epidemiological trends Today, 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 diseases CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMS of 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 rich The 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.24 The bulk of the global population growth is projected to take place in LMICs, concentrating in the poorest countries across the globe. Populations of many Sub-Saharan countries are expected to double by 2050. Eight of the nine countries that will account for more than half of global population growth in this period are 33 LMICs (India, Nigeria, Pakistan, Democratic Republic of Congo, Ethiopia, Tanzania, Indonesia, Egypt). Meanwhile, many high-income countries are projected to experience modest growth or a decline in their populations.25 Populations in many high-income countries (HICs) are growing older. Since the early 2000s, high-income countries have seen drops in the proportion of working- age 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 Sub- Saharan 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 TALK Figure 2. Percentage of working age population (15-64 years of age) by income group and geographic location, 1950-2100 70 70 (% of working age population) 60 60 50 50 1950 2000 2050 2100 1950 2000 2050 2100 LMICs UMICs Africa Asia UICs LICs Europe Latin America North America Oceania Notes: Data extracted from the World Population Prospects 2019 website curated by the United Nations, 34 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. Figure 3. Percentage of population 65+ years of age by income group and geographic location, 1950-2100 30 30 (% of population 65+ years of age) 20 20 10 10 0 0 1950 2000 2050 2100 1950 2000 2050 2100 LMICs UMICs Africa Asia UICs LICs Europe Latin America North America Oceania Notes: 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 SYSTEMS The 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 sure that limited health resources are used efficiently. The promotion and prevention logic applies still more strongly in these contexts. So, increasingly, does the imperative to manage chronic conditions in community settings where costs are much lower. This argument gains strength as the absolute numbers of older citizens rise, together with the prevalence of multi-morbidities and “lifestyle” diseases 35 (obesity, diabetes) once seen largely in rich countries. In LMICs with rapidly growing younger populations, another key advantage of PHC is its capacity to efficiently deliver key maternal and child health services, along with promotive, preventative, and curative services that can boost the productivity of working-age populations (for example, nutritional supplementation, malaria prevention and treatment, treatment of minor injuries, routine monitoring of vision and hearing). Such PHC services are critical to build and protect the human capital embodied in LMICs’ young people and working adults—the cornerstone of these countries’ economic future. Longer, healthier lives—but not for all Global 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.30 Healthy 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 a WALKING THE TALK substantial 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 low- income 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.33 Figure 4. Living longer, living sicker: years lived in poor health, 1990 and 2019 15.0 GBD super-region Central Europe, eastern Europe, and central Asia High income Latin America and Caribbean North Africa and Middle East Years lived in poor health, 2019 South Asia 12.5 Southeast Asia, east Asia, and Oceania Sub-Saharan Africa 10.0 Nicaragua 36 Philippines Tajikistan 7.5 Uzbekistan Zimbabwe Lesotho 5.0 0 0 5.0 7.5 10.0 12.5 15.0 Years lived in poor health, 1990 Notes: 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)30977-6 The changing burden of disease calls for reinforced PHC and action across sectors The 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 SYSTEMS neonatal, 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.37 Despite gains during the MDG period, preventable diseases remain a major driver of mortality and morbidity in developing countries. Between 2000 and 2017, the proportion of global population with at least basic drinking water services increased from 82% to 90%. This trend was coupled with a rise in access to basic sanitation services from 56% to 74% of the population.38 Despite these improvements, globally, 12.6 million deaths – corresponding to 23% of all deaths -- are attributable to environmental risk factors modifiable by multisectoral policies such as investment in water and sanitation services. Children under 5 years of age are particularly vulnerable, with mortality due to environmental risk factors 37 constituting 28% of global deaths for this age group. Figure 5. Noncommunicable diseases will test already-fragile health systems Projected change from 2015 to 2040 in percentage of disease burden due to noncommunicable diseases (NCDs), by score on the health system capacity index Change in share of disease burden due to NCDs 35% Central Europe, eastern Europe, and central Asia Ethiopia High income countries Rwanda 30% Latin America and Caribbean Botswana Tanzania North Africa and Middle East South Asia 25% Zambia Southeast Asia, east Asia, India Bangladesh and Oceania Turkmenistan Sub-Saharan Africa 20% Haiti South Nigeria 19,410 Size of noncommu- Africa nicable disease 15% Indonesia Mali 15,000 health burden in 10,000 2040 measured in Kazakhstan 5,000 disability-adjusted 10% Brazil 138 life-years China Russia United 5% States Chile 0% 0 50 100 150 200 Score on health system capacity index Source: 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.2017.0708 For 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 sanitation WALKING THE TALK has 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 opportunities for intersectoral action in areas critical for countries’ human capital and economic development. For instance, over the last three decades, many countries made important strides in improving the food security for young children.40 The percentage 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 of 2019, globally, an estimated 149 million children under 5 were stunted, 49.5 million suffered from wasting, and 40 million were overweight.41 Rigorous evidence is mounting on the close links between health outcomes and a range of socioeconomic and environmental determinants, including housing security,42,43 access to water, sanitation, and hygiene,44 and vector control.45 Intersectoral action on health determinants has historically proven to be among the most difficult components 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 can be an effective way to tackle risk factors and other social determinants of health, 38 which in turn improves equity of health outcomes.46 Urbanization brings new challenges for health service delivery The 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 high- income countries live in urban centers, compared with almost 6 out of 10 in middle- income 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.49 CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMS Figure 6. Urban populations continue to surge Urban and rural population projected to 2050, World Total 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 billion Urban 6 billion 4 billion 2 billion Rural 0 1500 1600 1700 1800 1900 2000 2050 Source: OWID based on UN World Urbanization Prospects 2018 and historical sources Rapid urbanization poses major challenges for traditional models of health care delivery, especially in slums. In 2014, almost 30% of urban populations lived in slums.50 People living in slum areas face multiple health threats related to socioeconomic and environmental factors including housing insecurity, 39 overcrowding, and absent or insufficient access to clean water, sanitation, and other essential services. Slum conditions pose new organizational and logistic challenges for PHC systems. Meanwhile, slum populations face disproportionate risks for some childhood diseases and greater prevalence of water-borne diseases (e.g., cholera and typhoid), among others health problems.51 Migration and forced displacement increase people’s vulnerability and make them harder to reach with services Migration 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 TALK In 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.56 New technologies can connect people—but only if they are widely accessible By many measures, the world is becoming increasingly connected. Yet the digital divide between under-connected and highly digitalized countries threatens to deepen existing inequities. In the world’s least-developed countries, only 20% of 40 people are online, compared to about 80% in developed countries. Exacerbating cross-country variation in digital connectivity, disparities exist within countries based on gender, income, geographic location, and level of education. For instance, on average, only about 63% of rural households in the least developed countries have access to a mobile phone, compared to 89% of urban households. Similar connectivity gaps exist between genders. Globally, the share of women with online access is 12% lower than for men, with this gap reaching 30% in the least developed countries.57,58 Disparities 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 performance In 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 high- quality public services, as well as demand for better governance, transparency, and control of corruption. CHAPTER 2: CHALLENGES FOR HEALTH SYSTEMS In some settings, the COVID-19 pandemic may have accelerated these shifts, prompting citizens to look to their governments for reliable information, public- health 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 high- quality 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.60 Trends in health care delivery and financing As 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. 41 Prior to COVID-19, many countries had registered progress in the two key domains of universal health coverage: coverage with quality essential health services and financial protection from excessive health care costs. But even before the pandemic struck, gains had not been sufficient to keep most LMICs on track to achieve UHC and other SDG health targets by 2030 (Figure 7).61 Figure 7. Service coverage and financial protection worldwide: slow progress even before COVID-19 Service coverage index (SDG 3.8.1, 2015) 90 Quadrant I Quadrant II 80 70 Average 60 50 40 30 Average Quadrant IV Quadrant III 20 0 5 10 15 20 25 30 Incidence of catastrophic spending [SDG 3.8.2 – 10% threshold, latest year] Low Lower middle Upper middle High Source: 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/report/uhc_report_2019.pdf?ua=1 WALKING THE TALK On 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.63 Before 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 that financial protection against debilitating health care costs worsened between 2000 and 2015. Globally, the number of people with out-of-pocket health expenditures exceeding 10% of their household income increased by 3.6% during this period, 42 reaching 927 million in 2015. Similarly, the number of people who spent more than 25% of their household income on health was estimated at around 210 million.65 A closer look at the data reveals that progress towards providing better financial protection differed across the development continuum. For instance, between 2000 and 2015, the sharpest increase in out-of-pocket expenditures occurred among upper-middle-income countries. In contrast, low-income countries started out in 2000 with the highest numbers of people spending 10% or 25% of their household budgets on health services, but subsequently saw declines in this indicator. Importantly, these declines could stem from a variety of causes, including better coverage of basic health services, but also foregone health care because 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 SYSTEMS Implications for primary health care Vast 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, approaches that succeeded in the Alma-Ata period or even the MDG era cannot simply be transposed to today’s health-system contexts. The powerful trends just described are shaping a novel global health landscape with new risks and new rules, but 43 also new opportunities with advanced technology. COVID-19 embodies these transformations. The pandemic has also provided an opportunity to rethink established health-system paradigms, including the role of PHC. Strengthening governance and accountability in PHC systems Demographic 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 TALK Building 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. 44 Reorganizing care delivery Many people across the globe are living longer and healthier lives—and all aspire to do so. Rapid urbanization and increased digital connectivity will continue to fuel 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, already struggle with poor infrastructure and digital connectivity, stark human resource gaps, and weak supply chains, fueling shortfalls in service coverage, quality, efficiency, and equity. Many LMICs need new solutions to expand coverage of essential services while improving financial protection—the pillars of UHC. This new 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 SYSTEMS These 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 pressures on health systems. While some high-income countries are already scaling up long-term care programs, substantial work remains to be done to address the high degree of fragmentation, low-quality and low-value care, and waste. In many UMICs, efforts are needed to integrate primary care with other levels of care; address the chasm between service coverage and quality; and improve inefficiencies in service provision. Meanwhile, health systems in many LMICs are unprepared to address the needs of their aging populations. Long-term care arrangements in these settings remain weak and poorly integrated with social services, placing elderly people and their families at high risk for catastrophic out- 45 of-pocket health care expenditures. The 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 emergencies Among 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 also WALKING THE TALK 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. 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 in the decade leading to 2030, the goal-line year for major global health and development targets, including universal health coverage under Sustainable Development Goal 3. But already, for health policy makers in countries facing the impacts 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 even necessarily the most devastating health problem many of their countries face. The pandemic is part of a broader and more complex ecology of health risks and opportunities in the advancing 21st century. It is that ecology as a whole that policy 46 makers 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 low- income 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 SYSTEMS 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 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 TALK Chapter 3 Reimagining PHC 48 WHAT WILL IT LOOK LIKE? CHAPTER 3: REIMAGINED PHC The 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. 49 BOX 1. PHC AND HEALTH-SYSTEM REFORM IN THE 21ST CENTURY: A GROWING CONVERGENCE AND STRONG ALLIANCES A 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.80 WALKING THE TALK Four high-level shifts for stronger PHC To 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. 50 CHAPTER 3: REIMAGINED PHC BOX 2. FOUR SHIFTS TO IMPROVE PERFORMANCE IN PHC The 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 countries alike, patients often experience the search for health care as a solitary, bewildering journey. Many patients must patch together their care from multiple institutions and providers who are physically dispersed and systemically uncoordinated, practice 51 inconsistent pricing regimes, may give different answers to the same diagnostic and therapeutic questions, and provide services of variable quality. Health service fragmentation and the absence of stable, trusting patient-provider relationships that results are cited in many surveys as key reasons for people’s dissatisfaction with health care. This situation demands a shift toward cohesive local PHC teams that build care around patients’ needs and preferences; treat all patients with respect; collaborate and communicate internally; and coordinate patients’ movement through the health system and 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 TALK Shift 1: From dysfunctional gate keeping to quality comprehensive care for all The 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 authors CHAPTER 3: REIMAGINED PHC have 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.89,90 A 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.91 PHC 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.92 What are the drivers of quality, comprehensive care? Fundamental to building high-quality, comprehensive primary health care is a systems approach.93 WHO experts note that quality improvement efforts often tend to focus on the “micro” level of local facilities and staff performance. While crucial, this approach needs to be supported by systemic action, since the quality of local primary health care is deeply affected by the prevailing culture and 53 environment of the health system. System-level interventions to improve quality of care 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 bodies for medicines, medical devices, and other health products. Health information systems to measure and drive quality of care, and financing methods to support provision of high-quality care are also essential.94 Recent 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.95 Underpinning 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.98 WALKING THE TALK BOX 3. WHAT HAS TO CHANGE: DYSFUNCTIONAL GATE KEEPING AND QUALITY GAPS Despite 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.102 Unqualified 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.104 LMICs: In rural India, 76 percent of all primary care providers and 65 percent of self- 54 identified “doctors” have no formal medical training105 in eight African countries, providers complete under half of relevant history and physical examination questions, given a patient’s symptomatic presentation,106 and frequently misdiagnose common conditions.107 Among women giving birth in facilities in rural Tanzania, more than 40 percent bypassed their local health clinic to seek care in hospitals despite substantially higher costs; they were more likely to do so if they were relatively wealthy, the local facility was in poor physical condition, or if the perceived (and actual) quality of care was low.108 UMICs: 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.109 HICs: 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.110 CHAPTER 3: REIMAGINED PHC Shift 2: From fragmentation to person-centered integration By 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 this imperative. First, as noted, patients and populations are increasingly informed about their own health and therapeutic options. Many enjoy rapid access to data and general information; an extensive understanding of their own medical conditions; and the ability to triangulate external information and knowledge with the information shared by their care providers. Second, transparency of provider performance and patient outcomes is fast becoming the norm, allowing people to make an informed choice between providers.112 Finally, increasingly urbanized, educated, and informed populations across the world expect technical excellence to cure their illness, and also respect for their dignity, wholeness as a person, 55 preferences, and constraints. These 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.115 The 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 tertiary WALKING THE TALK care, 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.116 BOX 4. WHAT HAS TO CHANGE: DISCONTINUOUS DELIVERY Over 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, 56 preventable hospitalizations, and far higher total health care expenditure.118 Lack of engagement 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 treatment adherence.120 Limited information-sharing between providers, including following discharge from higher-level care, further exacerbates the risks of fragmentation, leading to duplication, errors, and patient safety risks.121 LMICs: 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.122 HMICs: 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.”123 HICs: 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.126 CHAPTER 3: REIMAGINED PHC What 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. 57 A wide range of factors can enable the translation of person-centeredness from abstract principle into provider behavior and care seekers’ experience. Such enablers include governance policies and tools, such as the formulation of a PHC mission 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 it systematically into practice. Regulatory measures can lend support to person- centered care, for example by ensuring patient confidentiality and establishing enforceable 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 patient- reported 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 TALK Shift 3: From inequities to fairness and accountability Some 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 systemic inequities that could be addressed through health promotion, disease prevention, and medical care. Fairness also encompasses the just distribution of the burden of healthcare costs according to people’s ability to pay—precluding any out-of- 58 pocket payment, no matter how minimal, at the point of service. Finally, fairness entails a respectful and appropriate response to the nonmedical needs, rights, and expectations of those seeking and obtaining health care, delivered through a dignified interaction with the provider.128 Fairness is thus closely linked to patient 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.129 PHC 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 PHC BOX 5. WHAT HAS TO CHANGE: HEALTH FINANCING GAPS WIDEN HEALTH CARE INEQUITIES Few 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.137 59 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.140 What 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, socio- culturally, economically, and organizationally accessible to all.141 Accountability 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 TALK continuous, 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 patient- reported 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. 60 Shift 4: From fragility to resilience Pandemics 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.143 What 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.”144 CHAPTER 3: REIMAGINED PHC Resilience 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 post- crisis recovery. In this sense, preparedness can be considered as a stage of the continuous cyclical process to improve health system resilience.146 The 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 the continuous cyclical process described above, it maintains and reinforces three 61 interconnected 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 TALK BOX 6. THE COST OF NOT BUILDING FIT-FOR-PURPOSE PHC: COLLATERAL MORTALITY IN COVID-19 Along 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 food insecurity, from 135 million at end-2019 to 265 million by end-2020. UNICEF 62 has reported severe disruptions in treatment coverage for acute malnutrition and 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.147,148,149,150 Sources: 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 PHC Surveillance 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., public- health 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 SHOCKS During natural disasters, outbreaks, or conflict, vulnerabilities in infection control, supply chains, and surveillance can drive up the immediate death toll; in some settings, the 63 second-order health impact of PHC interruptions can also approach or even exceed the direct 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.153 In 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.154 HMICs: 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.155 HICs: 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.156 WALKING THE TALK What 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 systems play a key role in disease surveillance by collecting and reporting high-quality, timely data on local disease trends and service provision. The best tools for this purpose are digital data systems that: a) take patients rather than illnesses or services as their unit of reporting/analysis, b) are integrated into a single platform, and c) feed 64 quality data continuously to health authorities. Well-integrated information systems allow PHC providers and facilities to closely monitor populations, identifying changes 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 tested CHAPTER 3: REIMAGINED PHC emergency 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 supports resilience in the long term. Community-centered PHC models, in which community health workers (CHWs) often play a key role, can facilitate a resilient PHC system. In an emergency, community-centered PHC models tend to provide more effective and clearer messages on emergency status, along with prevention and treatment recommendations that people can easily understand and follow. Community engagement strategies should be tailored to the local context and enhance messages that promote trust, such as those that highlight facility and health- worker adherence to safety standards and person-centered approaches to care. 65 Foundations for Change: Enabling Multisectoral Action in PHC The 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 those WALKING THE TALK debates, 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.160 To 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 health Debates on the place of multisectoral action in PHC began even before the Alma- 66 Ata conference. The distinction between primary care and primary health care emerged in the late 1960s, when the term “primary health care” was first used by the 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 “basic health services” (BHS), while enlarging its meaning.162 The importance assigned to multisectoral action became a key factor distinguishing PHC from other models of health 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.163 Support 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.165 CHAPTER 3: REIMAGINED PHC Integrating 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 the grassroots has practical implications for how local PHC teams are composed, and how frontline PHC practitioners are trained. Bringing primary care and public health together means integrating epidemiologists and disease control specialists, nutritionists, pharmacists, social workers, and community health workers into expanded primary health care teams. Bringing collaborators with these skill sets to the PHC front lines can avoid placing the main burden for managing multisectoral partnerships on overworked clinicians. Multidisciplinary PHC teams can be composed, trained, empowered, and compensated to advocate with other sectors 67 for healthy public policy and interventions. Providing 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 PHC While 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 TALK Conditions 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.”168 In the case of multisectoral action linked to PHC, stewardship is a challenging political art that involves setting ambitious but winnable goals at the central governance level, while ensuring that high-level decisions are informed by the needs and aspirations of local communities. To practice this art, health leaders need to persuade partners in other government departments that those partners’ own agendas will be served by the results that multisectoral action can bring. In other words, they need to offer plausible perspectives for “win-win” outcomes. In this sense, stewardship for multisectoral action in PHC involves a distinct 68 understanding of leadership in health: one based not on top-down, command- ...to practice this art, and-control authority, but on health leaders need to partnership building, shared decision making, and the capacity to set policy persuade partners in other directions that can align the interests government departments of varied stakeholders, including low- income and vulnerable communities. that those partners’ own agendas will be served by Multisectoral stewardship becomes increasingly vital in the new health the results... ecosystems where globalization, urbanization, population mobility, and ageing are prominent. In this context, disease burdens are increasingly driven by factors including poverty, poor quality of diets, inadequate access to education, and disenfranchisement due to stratifiers such as ethnicity, gender, and rural location, among others. These determinants powerfully shape the growing burden of noncommunicable diseases, in particular. Such shifts in health and healthcare needs cannot be tackled solely at the point of service delivery, but require action on distal and proximal determinants of healthy living. CHAPTER 3: REIMAGINED PHC BOX 8. WHAT HAS TO CHANGE: SECTORAL SILOS INHIBIT COLLABORATION The 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 sector- specific 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 but accounts for 20 percent of global road traffic deaths (272,000 each year), due to poor infrastructure, inadequate vehicle safety standards, and a lack of legislation and enforcement to control speeding, drink-driving, and seatbelt/helmet use.170 69 HMICs: In China, where 52 percent of men are daily smokers, recent measures have increased 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 yet been applied to public spaces, including healthcare facilities, schools, restaurants, or indoor workplaces.171 HICs: 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).172 As 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 TALK This 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. 70 CHAPTER 3: REIMAGINED PHC 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 71 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.” WALKING THE TALK Chapter 4 MAKING IT HAPPEN 72 CHAPTER 4: MAKING IT HAPPEN The 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 post- COVID-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). It relates the four high-level shifts and outcomes discussed in Chapter 3 to the three priority reform agendas. Using this framework, this chapter explains how each 73 of the reforms contributes to advancing each of the four shifts to improve results in PHC.174 The chapter unpacks the framework step by step, describing the policy and implementation challenges countries face in each area and summarizing the evidence on practical solutions. WALKING THE TALK Table 1. Reimagining a PHC fit-for-purpose: outcomes and priority reforms Multidisciplinary Team-Based Organization Multidisciplinary teams align clinical services to meet full range of local health needs. Clinical 1. From Dysfunctional services address acute illnesses and injuries and Gate Keeping to Quality manage chronic conditions, including mental Comprehensive Care for All health needs. Teams expand community health education, health and nutrition promotion, and disease prevention. 74 Multidisciplinary teams build long-term trust with empaneled communities; collaborate and 2: From Fragmentation to communicate internally; and coordinate patients’ “WHAT?”: OUTCOMES Person-Centered Integration movement through the health system and back to the community. Empanelment creates accountability for health outcomes. Financing and other mechanisms reinforce accountability. Team composition 3: From Inequities to Fairness reflects local health and healthcare needs and and Accountability socio-economic determinants. Both patient and health outcomes are embedded in the accountability framework. PHC teams include public-health surveillance and outreach capacity. Team structure helps 4: From Fragility to Resilience buffer provider absences. Service-delivery organization and leadership ensure team capacity to manage the unexpected. CHAPTER 4: MAKING IT HAPPEN “HOW?”: PRIORITY REFORMS Resource Mobilization Multi-Professional Health Workforce for Public-Health-Enabled Development Primary Care Allocation of financial and human resources is based on evidence of local disease burden, socio-economic Multi-professional health education builds generalist conditions, and demographic knowledge, skills, and competencies. Curriculum and characteristics. Financing rewards practicum reforms facilitate creating multidisciplinary community engagement and PHC teams. supports a tailored essential service package including primary care and public health. Data and IT platforms enable telehealth 75 Multi-professional education emphasizes “soft” functions and support electronic health skills to promote shared medical decision making; records for the empaneled community. empower patients for self-care; contribute to EHR smoothly exchange data with the patient satisfaction; and support teamwork and rest of the healthcare system, and users care coordination. can access records confidentially. Priority-setting through a fair, Reformed multi-professional education creates a participatory, and transparent culture of transparency and social accountability process ensures that the essential service through leadership and team-based performance. package is equitably and efficiently PHC teams serve communities without discrimination delivered to all. The service package based on gender, ethnicity, income, sexual orientation, takes account of socio-economic or other factors. determinants of health and is not subject to ad hoc or geographic rationing. Health workforce training prepares multidisciplinary Financial and human resource surge PHC teams to prevent, detect, and respond to health capacity is built into health sector emergencies. PHC teams are an effective first level of planning and resource allocation at the health-system preparedness and response. local level. WALKING THE TALK Priority Reform 1: Fit-for-purpose multidisciplinary team-based organization 1.1 From dysfunctional gate keeping to quality, comprehensive care for all Dedicated multidisciplinary teams for community and primary care: the backbone of a modern PHC Informed by international evidence (Box 1), team-based care models 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 additional human resources, a more robust mix of skills, and a stronger mandate to provide a universal, comprehensive package ...local teams feed into of PHC services to an empaneled population. larger clusters that form a more expansive network of Under this model, a dedicated multidisciplinary team of health services while maintaining service providers—headquartered at 76 a team orientation. a PHC hub facility but reaching out actively into the community—works collaboratively to serve a clearly defined catchment population. These local teams feed into larger clusters that form a more expansive network of services while maintaining a team orientation. Specialized services may be located at different nodes in the network rather than all in one large center. Regional/urban hospitals and specialists assist and support the local PHC health team by supplementing the scope of clinical services and offering continuing education and professional development. CHAPTER 4: MAKING IT HAPPEN BOX 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 surprisingly sparse,178 emerging evidence appears to confirm these intuitions. A literature review on interprofessional collaborative practice identified 20 relevant studies, cumulatively pointing to improvements in chronic disease care, better medication adherence, reduced 77 hospitalizations, and cost savings.179 Systematic reviews have found that the US-based Patient-Centered Medical Home (PCMH)—a multidisciplinary team-based model emphasizing patient-centered, coordinated, and comprehensive care—improves patient experience, care processes, and clinical outcomes for chronic disease.180,181 The deployment 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 departments and reductions in avoidable hospitalization.182 In Brazil, expansion of the Family Health Strategy team-based care model has been strongly associated with reductions in child mortality and (somewhat more tentatively) linked to reductions in hospitalization for conditions amenable to primary-care-based prevention.183 Several countries in Europe and Central Asia adopted multidisciplinary team-based care models under a family- centered PHC approach in the 1990s.184 Patients 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 TALK The PHC team: roles, composition, and catchment area At 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 full range of ongoing community-level care. This includes public-health programs (immunizations, screening, health promotion, and preventive care), as well as all first-contact health care for acute and chronic health problems. Mental health care and first response to emergencies are provided for the entire empaneled population. The PHC team has primary responsibility for referrals to higher levels of care, including information-sharing and follow-up after a specialist consultation. Optimal team-based care models require clear role delineation and well-defined scope of practice—both to ensure efficient use of scarce physician time and to ensure low- and mid-level cadres deliver care appropriate to their level of training 78 under 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.187 CHAPTER 4: MAKING IT HAPPEN Table 2. Team-based care models around the world CATCHMENT TEAM DESCRIPTION POPULATION COMPOSITION The Family Health Program, launched in At minimum, a physician, 1994, created Family Health teams (FHTs) nurse, nurse technician, responsible for the health of residents and four to six full-time in a defined territory, including health community health promotion, education, and control of Maximum 1,000 agents. Additional Brazil neglected tropical diseases. By 2015, households (4,000 incentives are available the FHS covered 63% of the Brazilian residents) for adding other team population (almost 123 million individuals). members, including Substantial evidence shows the program oral health workers, has improved health outcomes and system physiotherapists, and efficiency.188 189 190 191 managers Varies according to Costa Rica’s Basic Teams for Primary availability of personnel, Health Care (EBAIS) began operating in At least one medical sector population, budget 1994. As of December 2018, the country doctor (GP), one nursing and other variables. As Costa Rica192 is organized in 7 regions, 106 health assistant, and one of end-2018 an average areas, and 1,048 PHC teams. Each PHC technical assistant in of 4,474 inhabitants team offers health promotion, prevention, primary care. (range: 2,343-7,480) were treatment, and rehabilitation. assigned per PHC team. Healthy living centers, introduced in 2017, HLC manager, physician, provide multidisciplinary services across dentist, nurse, midwife, About 200 HLCs across health promotion, prevention, and disease medical secretary, social 79 Turkey each serve a Turkey193 management. Healthy living centers worker, dietician, child population of about complement the family medicine system; development specialist, 75,000. family medicine physicians can refer their psychologist, care patients onward to receive their services. coordinator Patients voluntarily enroll Relatively generous capitation-based with Family Health Teams payment packages encourage family and agree to use their Varies. Typically includes doctors to join Family Health Team group designated provider for at least doctors, nurse Ontario practices. (Some, including the provincial all local, non-emergency practitioners, and nurses. (Canada)194 government, now argue that capitation care. 184 teams currently May also include social rates were set too high and have resulted serve 3 million Ontario workers, dietitians, and in unsustainable overpayment of family residents (about 15,000 other health workers. medicine physicians.)195 patients per practice team). Ward-Based Outreach Teams, established Team leader (typically a in 2020, are linked to PHC facilities 250-400 households per South Africa professional nurse) plus and intended to extend care into the CHW.196 five or more CHWs. community. Preferred Primary Care Provider (PPP) Networks link several Community-based 10 pilot networks (42 Health Planning and Service (CHPS) health facilities). Size of compounds to single hub, e.g., a health catchment population for Ghana Varies substantially. center or district hospital. Preliminary each PPP network varies results suggest the program has improved substantially (from ~5,000 referral feedback and service delivery to ~25,000). coverage.197 WALKING THE TALK The 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 in- house, 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 systems The 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. 80 Geographic empanelment is easily understood in the public-sector context, wherein each public-sector team serves a population within a defined geographic catchment area. In mixed health systems, it requires a public-private partnership design where patients are identified and assigned to private multidisciplinary care teams (for example, provider networks) using existing geographic catchment areas or municipal boundaries, typically as part of a publicly financed strategic purchasing or contracting arrangement for underserved jurisdictions.198,199 For example, 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 by hospitals, long-term care homes, community care access centers, community support service agencies, mental health and addiction agencies, and community health centers. The LHINs conduct extensive needs mapping of subpopulations in a particular geographic or catchment area (for example, the elderly, the homeless, refugees, immigrants, and the LGBT community) through focus group sessions that allow the LHINs to identify challenges leading to shortfalls in the health outcomes of these subgroups relative to the rest of the population. Once LHINs identify gaps, they tender requests for proposals from private local health care providers, offering them government funding to provide the missing health care service in underserved geographies. LHINs outline clear expectations for these contracted health care providers to use various team-based care models, which are reinforced by performance measurement and evaluation systems that are transparent to the public.200,201 CHAPTER 4: MAKING IT HAPPEN Insurance-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.204 In the United States, for example, patients benefitting from Medicare (a publicly financed insurance program for the elderly) can opt to join an accountable care organization (ACO), which would subsequently be responsible for the patient’s whole-of-person care and health outcomes—including through financial incentives.205 In Thailand, individuals covered by national health insurance are free to choose which primary care provider they wish to register with. Providers are then paid on a capitated basis, and patients have four opportunities each year to change their provider network, facilitating an element of patient choice, provider accountability, and portability for seasonal migrants. In practice, 81 however, choice in most rural areas is limited by geographic monopoly, as only a single provider is available within the geographic area.206 In Nigeria, the Hygeia health management organizations offer patients access to services through a corporate network of 1,608 hospitals and clinics. The network of private hospitals and clinics are bound by a capitation model, incentivizing them to provide primary, preventative care through multidisciplinary care teams to a large segment of the Nigerian population.207 Finally, where population-wide empanelment is not possible in the immediate term, interim policy measures can help make incremental progress toward a team- based 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.208 Examples 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 cost- savings realized by the insurance providers. The program has improved patient experience and population health outcomes while reducing hospitalizations and WALKING THE TALK healthcare 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.”212 In some settings, where dedicated care teams are not yet the norm, narrowly constructed care teams have been stood up to support patients with specific health needs. In Kazakhstan, for example, pregnant women are supported by a multidisciplinary team that includes social workers and psychologists in addition to health professionals; financial incentives help reinforce strong team performance as evidenced by maternal and newborn health outcomes.213 Multidisciplinary care teams are the preferred standard of care for HIV; in the US, inclusion of pharmacists, care coordinators, social workers, nurses, and non-HIV primary care providers within the team have been associated with higher adherence to antiretroviral therapy,214 while extensive international evidence associates inclusion of a pharmacist specifically with better adherence and clinical outcomes.215 In the 82 long 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 across the life course. 1.2 From fragmentation to person-centered integration Empanelment to dedicated care teams: a strong foundation for care continuity The 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.217 Empanelment 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 long- term relationships with PHC providers; and building both written and informal repositories of information about patients. This matters because patients with CHAPTER 4: MAKING IT HAPPEN access 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.224 For 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 to higher levels of care is based on referral from local PHC teams. PHC teams are accountable for prompt and appropriate referrals based on a patient’s health 83 needs and their informed clinical judgment. In turn, regional referral centers accept responsibility and accountability for health outcomes within their catchment areas; they willingly receive requests for assistance and transfers when judged necessary by local care and take responsibility for communicating the results of a referral back to the PHC team. This approach fosters respectful and trusting relationships between PHC team members and specialist service providers. This is a true collaborative health-system model that endorses the pre-eminence of cost-effective local comprehensive PHC services and preserves high-cost specialist services for those who need this level of care. It also recognizes and values the expertise of local PHC teams and their communities as being of equal value to the specialist expertise in regional referral center. Better two-way referrals: from primary care to specialists, and back into the community The 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 TALK In 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.231 Some LMICs currently lack capacity to rapidly create dedicated PHC teams able to work with and track individuals across the life-course. In these settings, end- 84 to-end same-day services across diagnosis and treatment may offer a stop- gap to increase referral completions and limit attrition. Studies show potential applications of same-day services to eye care and diagnosis and treatment of sexually transmitted infections; however, the approach has not been systematically evaluated and may be difficult to finance and integrate within routine services. In India, outreach camps provided by the philanthropically-funded Aravind Eye Care System offer comprehensive eye exams and same-day provision of nonsurgical treatment (for example, glasses or a medicine prescription); patients in need of cataract surgery or other specialty services are counselled and transported to a nearby hospital for immediate admission.232 In Cameroon, a pilot study for cervical cancer screening returned test results for the human papillomavirus (HPV) within one hour of sample submission, offering same-day coagulation treatment to eligible patients; loss to follow-up was only 1 percent.233 A similar approach in Tanzania yielded promising results for diagnosis and treatment of syphilis; testing for syphilis jumped more than 12-fold, treatment rates for diagnosed cases increased from 46 to 95 percent, and women reported savings as a result of averted transportation costs.234 When 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 specialist CHAPTER 4: MAKING IT HAPPEN consultations (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.237 Electronic 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-to- face specialist appointments; and potential for reduced cost.239 There is limited rigorous evidence for the effect of e-consults on health outcomes.240 Alternatively, telemedicine can allow patients to remotely access medical services and complete referrals from the PHC provider—particularly for specialist services that may not otherwise be locally accessible. These initiatives are still largely underdeveloped within LMICs, with many nascent (often donor-funded) efforts but few sustained programs.241 A rare scaled and sustained use of telemedicine is in Brazil, where some states have routinized remote ECG testing, chest x-ray analysis, and ultrasounds as part of the national Family Health Program.242 By 85 end-2015, just one Brazilian state had performed almost 2.5 million remote ECGs and 74,000 teleconsultations. Over a five-year period, the state reported net US$11 million in cost savings.243 In addition, a handful of LMIC telehealth networks for humanitarian purposes have been sustained at least five years, in some cases offering general remote consultation for all specialties and in others offering targeted support for dermatology, HIV, or trauma. However, evidence in support of these initiatives is limited.244 Elsewhere, feasibility studies suggest potential, though not scale or sustainability.245 Where 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.248 WALKING THE TALK IT and digital platforms for integrated care More 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 from system effectiveness (see Box 2), countries can take incremental data-informed approaches toward more coordinated, transparent, and accountable primary 86 health care even where data is limited. Data management and storage, patient data security assurance, and reliable offline and back-up systems suited to low- and lower-middle income countries must all be considered during the design phase of a digital solution.249 BOX 10. HARNESSING TECHNOLOGY TO IMPROVE INFORMATION SHARING IN PHC A 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. Seventy- four 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.253 CHAPTER 4: MAKING IT HAPPEN While 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 de- identified, 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 of a larger continuous quality-improvement process. Simply having data is not sufficient to improve performance. Team-based network managers must have the capacity to analyze the data, review performance regularly, and adapt care processes as needed.254 Facility managers need to strike the right balance between collecting the appropriate data and avoiding the administrative burden on providers that can result from obligatory data reporting.255 Performance measurement and management requires establishing targets, monitoring performance against those targets, and implementing and adapting improvement 87 efforts. Sharing data with staff as part of a continuous quality-improvement cycle allows countries to move away from inspection and punitive arrangements to a culture of problem-solving and active collaboration between providers, supervisors, and team members.256 A variety of performance measurement and management tools are available to help with this.257,258,259,260,261 1.3 From inequities to fairness and accountability Extending care into the community to address health disparities With 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 in WALKING THE TALK regions 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.272 88 Marginalized communities, or individuals facing potential diagnosis of a stigmatized disease, may be more likely to receive needed care when they can access health services directly within their communities, or even within their own homes. In Nigeria, for example, men who have sex with men were 9 times more likely to accept HIV testing and counselling if the service was directly offered by a member of the same community vs. referral to a health center; uptake was 21 times more likely among injection drug users.273 Even for the general population, systematic review evidence suggests that uptake of HIV testing and counselling services is far higher in community-based settings than within health facilities.274 Increasingly, health services can also target the virtual communities where marginalized populations congregate. In urban China, for example, MSM volunteers identified members of the MSM community through their profiles on gay social networking sites and recruited them to testing and counselling services via chat rooms, instant messages, and emails.275 Internet-based outreach is still in its infancy within LMICS, and scale-up will require careful consideration of the privacy, rights, and safety of marginalized populations. The COVID-19 pandemic has highlighted the importance of proactive community- based 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, including CHAPTER 4: MAKING IT HAPPEN four, 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.279 Empanelment and accountability The empanelment process assigns a defined catchment population to a single, cohesive multidisciplinary care team. This process, in turn, creates a natural structure for accountability: the care team can be held accountable for the patient experience and health outcomes of the empaneled population. The focus on whole-population outcomes, versus patient experience among care seekers alone, reinforces an equity orientation, as PHC teams are held accountable for their 89 ability to engage, educate, and improve health outcomes even among individuals or families that may feel reluctant or unempowered to seek care, including the poorest households and other marginalized populations. Care teams can be held accountable at all levels—by the populations they serve; by their peers and colleagues within the care team itself; and by payers and regulators at the regional or 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.280 WALKING THE TALK Second, public reporting on how different providers perform can help communities hold care teams accountable; they may also induce positive changes in health- worker 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 low- tech 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.283 Community scorecards and citizen report cards are variants on public reporting that directly engage citizens to hold health organizations accountable for the services they provide. In Afghanistan, a community scorecard initiative based on stakeholders’ discussions about performance scores and participatory action plans contributed to improvements in structural capacity indicators, such as water and power supply, availability of essential medicines and equipment, and number and cadres of service providers.284 In Uganda, report cards were shared with citizens and PHC staff through village meetings; PHC staff and citizen representatives worked together to identify strategies for improvement.285 The 90 intervention led to a 13 percentage point reduction in absentee rates, 12 minute shorter waiting times, and a statistically significant reduction in the under-five mortality rates.286 However, other evaluations on citizen report cards found partial or no results,287 suggesting that the impact of this social accountability strategy depends 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 resilience Preparedness, resilience, and the multidisciplinary platform Integrated, 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 public- health 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 detection CHAPTER 4: MAKING IT HAPPEN and 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 community can enable effective communication and behavior change during an emergency. In Liberia, community education on preventive measures was among the most effective interventions to fight Ebola.289 During the Ebola and Zika epidemics, CHWs served as community-level communicators and educators, contributing to community health literacy in personal hygiene and other precautionary measures.290,291 Resilient PHC platforms can quickly adapt to increase the frequency of communication, ensuring clarity on emergency status and prevention and treatment recommendations. In partnership with central public-health authorities, PHC teams’ deep knowledge of their catchment communities can help tailor communication strategies and messaging to the population’s specific concerns and preferences, building trust, for example, by highlighting facility and 91 health-worker adherence to safety standards and person-centered approaches to care. In Bangladesh, Senegal, Colombia, Vietnam, and Guinea Bissau, PHC platforms, including CHWs, have helped inform communities about COVID-19 symptoms, transmission, and vulnerabilities; they have also helped to counteract social stigma. In Nigeria, 230,000 community health workers have been mobilized to deliver messaging and outreach. In Vietnam, community health stations and village health workers have played a crucial role in improving community awareness and enhancing trust. During an emergency recovery phase, resilient PHC facilities can progressively scale-back communication efforts while ensuring continued clarity and transparency in communication about service procedures as the 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 health- system 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 (for WALKING THE TALK example, 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 workforce Section 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-of- person 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; there are just 3 physicians and 11 nurses per 10,000 people in WHO’s Africa region, 92 compared to 34 doctors and 81 nurses per 10,000 Europeans.292 In wealthier countries the health workforce is often rapidly expanding—yet primary care remains neglected, and the expansion has not been fast enough to effectively address the burden of chronic disease in aging populations. Further, day-to-day care for the elderly and people with disabilities has historically been provided by unpaid family members, often women.293 Today, with greater female labor force participation, aging populations will require a larger cohort of home healthcare workers. Across all countries, inappropriate regulations and lack of training pathways 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 in rural communities poses a universal challenge; many health workers reject or leave underserved 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 all Universal coverage of comprehensive PHC is not possible without a fit-for- purpose workforce. Significant reforms to workforce training are needed to offer comprehensive PHC services in line with countries’ UHC ambitions. Multi- professional 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 wide- ranging, 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 aligned CHAPTER 4: MAKING IT HAPPEN with 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 education In 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 self- reliance 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 classroom- based 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 TALK Reorientation 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 physicians Almost all wealthy countries have a “sufficient” number of health professionals— defined by the WHO as more than 10 medical doctors, 40 nurses/midwifery personnel, 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 a share of all physicians, and in some countries the number of geriatric trainees has stagnated.296 Medical students face strong financial incentives to avoid general practice or geriatrics in favor of more lucrative specialties. In the United States, 94 doctor surveys show that primary care physicians earn more than $100,000 per year less than specialists;297 in the United Kingdom physician salaries show more parity, but generalists nonetheless earn about 11 percent less than their specialist counterparts.298 Across the OECD, growth in specialist salaries almost always outpaces growth in generalist pay.299 Many 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.301 CHAPTER 4: MAKING IT HAPPEN Payers—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 resources On 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.318 WALKING THE TALK Lay 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.320 Telephone-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 GP- patient contacts than face-to-face consultations.323 96 Leveraging and regulating the private-sector workforce High 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, for CHAPTER 4: MAKING IT HAPPEN example, 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.329 Tiered accreditation systems can also help incentivize incremental quality improvements in settings where achievement of the highest quality standards may 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 to pursue a separate accreditation on a pass/fail basis,331 while tiered accreditation in Lebanon offers accreditation for different time horizons and levels (3 years; 18 months; partially accredited; and failed) based on performance. However, few 97 studies empirically evaluate the effects of switching accreditation systems.332 In Brazil, a health insurance company paired incentives for achieving different tiers of accreditation with support to facilities in navigating the accreditation process. Hospitals received a 7 percent boost in per diem rates simply for beginning the accreditation process; incentives rose to 9 percent for achieving Level 2 accreditation and 15 percent for achieving Level 3 accreditation. By 2009, 19 out of 45 in-network hospitals had received accreditation, covering 69 percent of network hospital admissions.333 Social franchising is an alternative approach to accreditation that allows in- network providers to adopt branding that identifies them as offering quality- assured 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 re- certifies 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.338 WALKING THE TALK Where 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.341 98 2.2. From fragmentation to person-centered integration New provider competencies for patient-centered, integrated care Beyond clinical knowledge and skills, provision of community-oriented, patient- centered 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.347,348,349 CHAPTER 4: MAKING IT HAPPEN At 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.353,354 The competencies discussed above, in turn, highlight the importance of capacity to use and interpret data. The interactions between providers and patients generate an enormous amount of data that is then stored in various forms, including files in providers’ cabinets, electronic health records, and registry systems. (Ideally, the PHC platform should benefit from a single interoperable digital platform with unique patient identifiers; see Section 1). Data about the empaneled population (demographic and socio-economic profiles, health service utilization, costs and outcomes, and other information) that is available to the PHC workforce, if properly applied, will be extremely useful for them to evaluate community health needs, stratify risk groups, and provide integrated patient-centered care. In Turkey, an enrolment database allows family physicians to identify individuals in a 99 screening target group and enables community health centers to organize public campaigns and arrange transport for patients on the day of appointments. Close collaboration between family practices and the centers resulted in a significant increase in coverage rates for breast, cervical, and colorectal cancers between 2007 and 2014.355 Finally, “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 team- work, 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.362 Reorienting medical education and on-the-job training to better prepare the health workforce Appropriate education is essential for ensuring that the PHC workforce has and can demonstrate the competencies necessary for delivering integrated patient- centered 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 decision WALKING THE TALK making; from seeking professional credentials to achieving core health workers need to competencies for effective teamwork develop the skills to act as in health systems; and from non-critical adoption of educational models to partners and facilitators, creative adaptation of global resources rather than authorities, to address local priorities.365 to empower patients and In alignment with this transformative engage them in a shared vision for medical education, several shifts must take place in the orientation decision-making process and culture of medical education and on-the-job training. Training for PHC should not be considered a “specialization”, as this can reinforce health- system silos. Interprofessional educational366 (Box 3), a pedagogical approach that engages two or more healthcare professions in an integrated learning environment,367 has proved useful to ensure professionals value one another’s disciplines, increase providers’ collaborative knowledge and skills, and improve ability to manage people with chronic conditions.368,369,370,371 Creating shared values and common goals between primary care providers and other care providers helps trainees internalize integrated care precepts. The asymmetry of information 100 between providers and patients has a longstanding presence in the health sector,372 but these patterns are changing rapidly, as technology enables patients to acquire knowledge more easily.373,374,375 In this context, health workers at the PHC level may need to assume the role of advisors, guiding patients to reliable sources of information, more than “experts” who consider themselves the sole authoritative sources of health information. Future PHC workers should be encouraged to take a participatory approach to promoting health and wellbeing in the communities they serve. Further, medical education and training need to prepare the PHC workforce to understand and apply evidence-based medicine principles to a rapidly expanding research and evidence base, for example by learning how to follow new algorithms and protocols. CHAPTER 4: MAKING IT HAPPEN BOX 11. CORE COMPETENCIES FOR INTERPROFESSIONAL COLLABORATIVE PRACTICE The 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 professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment 101 of 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 population- based 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.377,378,379 WALKING THE TALK Educational 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.381 PHC workforce policies for integrated, patient-centered care Collaborative 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 promotes 102 accountable performance by rewarding team members for managing complexity, solving problems, and thinking creatively when addressing the unique circumstances of patients with complex needs. Priorities for outcome and performance management include patient-centered reporting and metrics that capture avoidance of inappropriate testing or treatment, while documenting attributes associated with better outcomes, lower costs, and improved patient experiences.382,383 PHC 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.384 Workforce 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-management CHAPTER 4: MAKING IT HAPPEN counsellors, 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 accountability Proactive 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 service Encouraging rural service requires changing the balance of incentives that pushes health workers toward urban centers in virtually all countries. One common approach is to offer financial or in-kind benefits to counterbalance health workers’ quality of life concerns. Rural health workers receive housing benefits and electricity in Moldova; allowances in South Africa; and paid tuition fees for their children along with housing renovations in Zambia. Few studies 103 have assessed interventions in LMICs empirically and individually (that is, not as part of a package of services). A Cochrane review found that the provision of bursaries or scholarships had variable success across countries, while increased financial compensation generated more consistently positive results (though with undetermined cost-effectiveness).391 A review of systematic reviews similarly found that such policies were effective at attracting practitioners, but that few physicians stayed in rural areas long-term.392 Rural 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 post- graduation 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.395 WALKING THE TALK Studies 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.399 A specific medical education model to encourage rural community service is Community Engaged Medical Education (CEME), in which medical schools form an “interdependent and reciprocally beneficial partnership” which the communities they serve,400 creating opportunities for clinical learning in PHC services and other 104 community clinical settings. CEME programs often recruit primarily local students through selection and admissions processes that value not only academic ability but also other characteristics important to local comprehensive PHC. Students support local PHC team members, who in turn serve as clinical teachers and role models. Trainees come to understand their rural/underserved setting as “home base,” preparing them to practice in the surrounding areas—with city rotations as a requirement to complete postgraduate training. Trainees undertake additional specific 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.402 CHAPTER 4: MAKING IT HAPPEN Equitable mobility and cross-jurisdictional solutions International 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.404 Accreditation and licensing differences between states or jurisdictions can make it challenging for health workers to move to areas of greater need or opportunity, 105 even within the same country. In Canada, individual provinces set their own standards for licensure of foreign medical graduates, with widely varying processes.405 A backlog of applications and bureaucratic processes can also make the licensure process very lengthy, while qualifying exams and supplemental education can be expensive and time-consuming. In the United States, state-level licensing procedures can often take three to six months, with application fees typically totaling several hundred US dollars.406 Regulatory reforms can help increase health worker mobility. In the United States, the Interstate Medical Licensure Compact offers a voluntary state- based 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.409 Telehealth 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 case WALKING THE TALK management 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.413 Regulatory reforms can also help enable telehealth’s potential to at least partially break down geographical barriers to care and potentially address workforce shortages in specific regions, particularly underserved or remote rural areas. (However, internet access remains highly correlated with health worker density, limiting the applicability of telehealth in some of the most underserved regions and/or countries.414) In some cases, onerous regulatory barriers can stymie efforts to provide telecare when the provider and patient are based in different jurisdictions. For example, for different US states or Canadian provinces, providers often must receive licensure in the jurisdiction in which their patient is based, limiting potential for cross-jurisdiction practice. A few states have either established registries of qualified out-of-state telehealth providers or offer telemedicine-only medical licenses.415 The European Union takes a more flexible approach by defining the relevant jurisdiction as the one in which the provider is based, allowing a single provider to practice telemedicine with patients across the bloc.416 Likewise, financing reforms can enable reimbursement of a broader range 106 of telehealth services through public or private insurance packages, facilitating more 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.421 Beyond 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, community CHAPTER 4: MAKING IT HAPPEN members 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.423 2.4. From fragility to resilience Emergencies 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 planning An 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.424 Even with the best planning, emergencies are by their nature unpredictable. Medical education—and training for nonphysician health workers—must therefore emphasize agility and problem-solving, helping prepare the health workforce to work confidently and capably in unusual conditions. This is consistent with the 107 expectation that all health workers in PHC have a broad range of knowledge and skills as generalists within their disciplines, including technical capabilities and a range of non-technical and leadership skills.425 Consequently, 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.432 Immersive 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.436 WALKING THE TALK Agility, flexibility, and resilience in health emergencies Some 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-registration and revalidation obligations for physicians. This reduced the administrative burden on practitioners and avoided potentially sidelining key professionals at the height of the crisis. Provisions have been made to recruit medical and nursing students to support health professionals, for instance by allowing (final year) students to graduate early and join the workforce or offering them a gap semester to support practicing health professionals. Campaigns were launched in several 108 countries (including Canada, Italy, and the UK) to bring retired or inactive health professionals and foreign-trained but unregistered professionals back into the workforce. Twinning individual facilities in hotspot area with medical teams from other provinces also facilitated China’s response to COVID-19. In England, the government brokered an agreement to take over private hospitals and their staff for the duration of the crisis, resulting in tens of thousands of clinical staff provisionally moving to the public sector.437 The 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).438 To 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 appropriate CHAPTER 4: MAKING IT HAPPEN patient 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.442,443 Supplementary training during the crisis may also increase health workers’ capacity, confidence, and morale in handling the outbreak. During the Ebola outbreak in Sierra Leone, health workers showed lower levels of fear and became more confident in providing care after safety training; tentative evidence suggests the trainings also prevented further infections among health workers.444 In a Canadian hospital setting, group resilience training substantially increased health workers’ self-reported confidence in dealing with the H1N1 virus;445 less costly and more easily scaled computer-assisted training courses also demonstrated encouraging results in improving confidence and self-efficacy to manage the pandemic.446 In contrast, some essential services were temporarily disrupted in 109 Bangladesh because providers were unsure how to comply with social distancing requirements in their daily jobs.447 Social and practical support for a resilient health workforce Finally, 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.452 Comprehensive 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 and WALKING THE TALK online 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 as an extrinsic motivation mechanism, recognizing their sacrifice and contribution. Following the outbreaks of several emerging infectious diseases (e.g., SARS, Ebola, 110 MERS), many countries have passed regulations to mandate hazard payment/ compensation for overtime during public-health crises. This has supported health professionals’ work in fighting COVID-19 in Vietnam and China, for instance. Several Eastern and Southern European countries also have also offered financial support to health workers in response to COVID-19, for example one-time bonus payments (Bosnia and Herzegovina, Greece, Germany, Hungary, Kyrgyzstan, Romania, the Russian Federation), monthly bonus payments for the duration of the crisis (Albania, Bulgaria, Latvia), or temporary salary increases (Belarus and Lithuania). Meanwhile, in Denmark, COVID-19 has been recognized as a work- related injury for health care staff, enabling them to access associated benefits. In Africa, many governments have realized the need to improve hazard payments and provide insurance for staff on the front lines of the pandemic. Priority Reform 3: Fit-for-purpose financing for public-health-enabled primary care Financing 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 HAPPEN First, 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 non- health 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, 111 comprehensive care for all PHC investment should draw from general government revenues Significant 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 TALK The source of PHC resources has important implications for whether investment needs will be met. Universal coverage of high quality, comprehensive PHC first requires mobilizing adequate revenues for health overall through prepaid, pooled financing that eliminates out-of-pocket expenditures. Allocations from within the pot of pooled health resources must then adequately prioritize PHC. General government revenue is increasingly seen as the best mechanism for financing PHC, given the changing nature of work, persistent informality in LICs and LMICs, and the public-good character of population-based public-health services. Evidence also shows that financing through general government revenues facilitates access to health services and improves financial protection for the population.4 61,462 Additionally, many LICs and LMICs are still building health-system foundations for the large majority of for quality PHC, for example including countries, a strong case basic infrastructure (for example, running water and sanitation), human can be made that these resources, and reliable supply chains investments would pay for health products.463 Such fixed-cost investments cannot be readily financed large dividends— through recurrent health insurance by improving premiums or user fees. Box 4 lays out the case for PHC financing through 112 population health general government revenue in detail. CHAPTER 4: MAKING IT HAPPEN BOX 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.467 Labor informality: In LMICs, preexisting high levels of labor informality further complicate efforts to expand health coverage through employment-linked solutions. Some countries have extended SHI to the informal economy by offering the option to join SHI schemes voluntarily, e.g., in Thailand through the earlier Voluntary Health Insurance Scheme468, or through community-based health insurance. However, countries have been unable to 113 achieve high levels of coverage without substantial government subsidies and compulsory enrolment (for example, in Rwanda469). High labor taxes to finance the health sector may even exacerbate informality by creating an additional incentive to pay employees “off- book.” Hungary, for example, used government financing to reduce employer payroll taxes and thereby reduce the incentive for informality.470 Reducing 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.475 Financial 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.478,479 WALKING THE TALK Explicit PHC benefits packages for equitable and efficient resource allocation Achieving 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 and preferences, and aligned with local resource constraints, is essential for justifying allocation of limited resources for PHC and increasing accountability for its delivery.480 The explicit character of the benefits creates recognized entitlements for patients; empowers the poor to demand equitable access to services; helps to identify whether funds are being spent wisely on services that create the maximum benefit for society; and facilitates resource allocation decisions and orderly 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 across 114 30 low- and middle-income countries.481 Importantly, 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 evidence- based, 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 private CHAPTER 4: MAKING IT HAPPEN sector 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.491 115 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.493 Benefits 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 TALK Recognizing 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.497 However, full HTA requires substantial expertise and capacities which are often absent in LICs and LMICs, where changes are often made at the margin and need to consider implementation factors.498 In these settings, a reasonable option may be establishing a fully costed package that considers burden of disease and cost-effectiveness, along with demand for services, while also setting priorities within the constraints of resource availability, human resources and infrastructure capacity. This approach may be a practical alternative to HTA in the medium 116 term, as countries build the capacity needed to take on more sophisticated approaches to priority setting. For example, Nigeria recently launched a reform to channel federal-level funding through a statutory transfer to finance a Basic Minimum Package of Health Services (BMPHS). The Federal Ministry of Health, with support from development partners, used detailed costing studies to agree on the composition of the benefits package. This costing informed the economic and financial costs of guaranteeing access for all Nigerians to the BMPHS in the long term; and built scenarios to consider options for gradual expansion of the package, given fiscal constraints in the medium term. The original package included 57 essential interventions covering 60 percent of the disease burden, to be implemented in rural areas first, then gradually expanded in geography and scope. To set packages and roll-out plans, countries can adapt international estimates, for example those provided by Disease Control Priorities,499 introducing refinements as they strengthen their capacity to conduct more sophisticated analyses. Financing upfront investments and routine operations In 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 for CHAPTER 4: MAKING IT HAPPEN strengthening 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.501,502 Beyond 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 facilities can receive funds directly and exercise autonomy in shifting resources to new 117 needs, plays an important role in securing sufficient routine operational resources at the PHC level, particularly in LICs and LMICs.503 In many developing countries, administrative authorities (e.g., districts) act as agents for receiving and managing resources allocated to PHC together with resources for other purposes. Such arrangements have led to inadequate financing for PHC providers, in particular inadequate resources for operational costs, and hence missed opportunities to address community needs.504 In some countries, a shift to a program-based budget classification system has helped to allocate resources toward programs that are organized around policy goals, rather than along administrative and input lines, providing an opportunity to link spending to policy priorities.505 For example, the Primary Health Care Service Delivery Budget Program in Kyrgyz Republic made the allocation for PHC at the facility level explicit, facilitating advocacy to increase this allocation.506 However, gains from such approaches are not automatic and often require institutional capacity strengthening to realize. When program-based budget classification is not feasible, facilities should be explicitly recognized in the 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 role Rethinking development assistance can drive the investments and capacity building needed to deliver on the promise of a multisectoral, integrated, people- centered 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 for WALKING THE TALK 20 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.508 Donors can also contribute to more resilient health systems by investing in surveillance and public health functions. The Global Action Plan Financing Accelerator highlights several critical features of a next generation of development assistance for health (DAH),509 including enhanced support for fiscal, public financial management, and efficiency reforms, as well as advocacy platforms. The COVID-19 epidemic has already forced donors to become more flexible, for 118 example by allowing reallocations of their investments to address the COVID-19 response, granting flexibilities in donor policies, and looking for opportunities to build on existing programmatic infrastructure to address COVID-19 and protect essential services. For example, in LICs and LMICs, Gavi has invested heavily in cold chain infrastructure; the cold chain can be used for diagnostic testing and potentially 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.510 CHAPTER 4: MAKING IT HAPPEN 3.2. From fragmentation to person-centered integration Paying providers for care coordination and integration Traditional 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 team- based 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 models IDEAL APPROACH 119 FEE-FOR- INPUT-BASED   FOR TEAM- CAPITATION SERVICE FINANCING BASED CARE MODELS Payment A team of providers or Individual provider or Individual unit Individual provider or unit Recipient an integrated unit unit Fixed amount per enrolled Pre-defined fee Based on health patient (sometimes risk- Payment schedule for specific outcomes, value of Prices of inputs adjusted), not always linked Criteria items (inputs, health care to explicit performance procedures, etc.) standards Relevant An extended period Periodic lump sum Time of time (often multiple A visit or an encounter Periodic (often annual) (monthly or annual) Horizon years) A defined population A defined population group Beneficiary group assigned Anyone visiting the Anyone visiting the assigned to providers (i.e., Population to providers (i.e., concerned providers concerned providers empanelment) empanelment) Weak; incentivizes Can encourage prevention/ low transaction Weak; instead promotion depending on the Health promotion and costs; incentivizes encourages increased payment agreement but can preventive care reduced quality activity also lead to avoidance of when demand is high-risk patients high Incentives Strong but can Weak; encourages Can incentivize improved Retaining patients at for… create supplier- unnecessary quality of care and healthier the PHC level where induced demand and referrals to higher behaviors, but can also lead appropriate unnecessary care levels to under-provision of services Weak; does not Weak; discourages Close coordination reward good Can incentivize unnecessary referrals to higher across providers performance or referral to higher levels levels coordination WALKING THE TALK Different 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.519 Team-based care and coordination with other care providers can be explicitly incentivized through direct payment linked to such activities. Pay-for-coordination, for example, offers a lump sum to a given provider, per chronic patient, to coordinate care across a team of professionals working at different levels, e.g., primary care, secondary care, public health, prevention and health education.520 The first country to use this payment method was France, where primary 120 care centers (not health care workers specifically) received payment for coordination of NCD prevention and care, with the flexibility to allocate the additional payment as they see fit. The payment represents on average 5 percent of providers’ income and is paid by the social health insurance agency (CNAMTS). 521,522 Austria, France, Germany, Hungary and other countries have since adopted this model.523 The Comprehensive Primary Care Plus (CPC+) model in the United States also has an element of care management fee, which is non-visit-based and paid per beneficiary per month.524 Alternatively, 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.526 CHAPTER 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 coordination and integration, depending on the performance indicators selected. Like pay-for-coordination, it can be used to promote specific functions such as management of chronic disease (e.g., management of diabetes). It can also be based on patient experience measures, clinical quality measures, and utilization measures that drive down cost—all of which are facilitated by better coordination and integration. Pay-for-performance is used extensively 121 in OECD countries; in middle-income countries like Brazil, China, and India; and in low-income countries like Rwanda.529 A review of experiences from 10 OECD countries found that P4P has helped clarify provider goals, improve processes for purchasing health services, improve measurement of provider activity and performance, and created a more informed dialogue between purchasers and providers—though it has not significantly improved overall health 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 TALK While 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.534 Other recent innovations are also changing the way PHC providers can receive funds. Mobile money payments, or “e-payments”, reduce dependence on physical financial interactions and the need for cash and can provide a secure way for providers to both receive and use funds quickly and efficiently, without 122 compromising accountability. This is important given that primary care facilities often lack access to bank accounts even when they are registered as spending units, allowing them to receive a budget allocation. Mobile money transactions allow a balance to be sent from central-level or district administrations to mobile wallets at remote primary care facilities to be used as part of the operational budget. Through such innovations, primary care provider payment reforms can be operationalized and have the potential for efficiency gains, accountability, transparency, and financial inclusion. Zambia is currently in the process of pursuing such a reform.535 Integrated 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 accountability When 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-wide CHAPTER 4: MAKING IT HAPPEN health 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 barriers For truly equitable access and utilization, all PHC services must be free at the point of service. There is broad consensus that financial barriers to PHC services in LICs and LMICs (e.g., user fees) should be removed.537 Nonetheless, financing reforms that are not backed by mobilization of additional resources and careful planning to compensate for simultaneous revenue loss and costs associated with increased utilization can cause their own problems, for example a shift to informal payments; patients’ foregoing services altogether; or ad-hoc or implicit rationing.538 This 123 further highlights the importance of defining an explicit benefits package, as well as 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.539 Financing 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.545,546 WALKING THE TALK Accountability through intergovernmental transfers In 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 budgeting Improving 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 HAPPEN A 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. 125 WALKING THE TALK BOX 13. GLOBAL FINANCING FACILITY AND THE WORLD BANK – A PARTNERSHIP TO SUPPORT PRIMARY HEALTH CARE Thirty 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 to approximately US$4.7 billion of World Bank International Development Association IDA/ 126 IBRD financing and helped align much larger volumes of domestic public and private resources 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 support in key areas such as country leadership & alignment of partners, gender equality, health system 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 HAPPEN Engaging communities in resource allocation decisions Empowering PHC teams and communities helps to improve participation in decision-making regarding how resources are allocated to respond to population health needs.556 Transferring decision-making to local governments can enable better alignment between resource allocation and community needs.557 For example, some countries have moved to “participatory budgeting,” which allows communities to have direct decision-making powers over the allocation of public resources in their area.558 The model requires formal evaluations to understand its impact but is gaining popularity as a means of empowering communities to adequately fund local priorities. In Brazil, for example, the wide adoption of this approach across municipalities has led to increased expenditure on basic sanitation and primary health care services, which were previously underfinanced. An evaluation study also found a significant reduction in infant mortality rates among municipalities that adopted participatory budgeting.559 In Nigeria, Ward Development Committees (WDCs) were established by volunteer community members to advocate for the health and social needs of their communities and give them autonomy over the utilization of funds for PHC improvements and outreach activities. A functioning and responsive complaints mechanism was also established. Five percent of the BHCPF was set aside specifically for fund administration including setting up this robust mechanism to receive and respond to community complaints.560 127 3.4. From fragility to resilience As 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 frontlines Unpredictable 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; and WALKING 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. Further, rapid deployment of additional funding to the frontlines may require 128 adjustments to typical payment mechanisms. For example, several countries are channeling additional COVID-19 response funds through purchasing agencies, including Austria, Croatia, Estonia, Latvia, Poland, Romania and Serbia. Frontline providers can also be granted greater flexibility and spending authority so that they can respond more rapidly to key supply shortages or stock-outs, for example concerning soap, medicines, or other materials. Some countries may need to activate exceptional spending procedures during the first phase of a crisis and then formalize these procedures using supplementary budget laws. In some cases, declaring a state of emergency can facilitate the release of new funds and speed up public procurement by enabling simplified procedures for trusted suppliers. In response 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 front- loading 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 HAPPEN Purchasing 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.561 Resilience and the benefits package An 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 benefits 129 packages, ensuring access for and financial protection from the costs of COVID-19 diagnosis and care; offering coverage for and incentivizing use of “touchless” teleconsultations or home-based care; and compensating health workers for the costs of providing these adapted services. For example, the health insurance department in China included eligible online-based medical service expenditure for primary health care into its package during COVID-19, ensuring continuity of service for chronic disease patients.562 In settings where telehealth was already covered by insurance, efforts were made to minimize or eliminate disparity in reimbursement value between in-person and virtual visits. Such efforts were seen across Europe and North America (Czech Republic, Germany, Luxembourg, the Netherlands, Sweden, Switzerland, Belgium, Canada, and the United States). In some 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 for suspected 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 TALK building 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.564,565,566 Enabling multisectoral engagement through PHC reform Chapter 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 determinants 130 A fundamental condition for effective multisectoral engagement is strong intersectoral stewardship at the policy level.567 This central stewardship function then supports the development of needed skills and competencies at the level of community-based PHC delivery. When appropriately staffed, trained, equipped, and compensated, frontline PHC teams can plan and provide primary care and public-health services, and also ensure local coordination for intersectoral interventions.568 Implementation 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.574 However, 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. The CHAPTER 4: MAKING IT HAPPEN effectiveness 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.575 One approach that has been widely applied over the past two decades, especially in lower-middle-income countries, involves linking health and social protection agendas to facilitate communities’ expression of their health and healthcare needs and increase their uptake of some services. Many programs have chosen conditional cash transfers (CCTs) as their main vehicle. CCTs provide cash benefits to households contingent on their use of essential health services at the PHC level, such as maternal and child health services and immunizations. Some program models engage a widening spectrum of determinants of health, including education, water supply and sanitation, food security, and nutrition, among others.576,577 Experts have cautioned that, while CCTs may cushion the health consequences of poverty and reduce certain health inequalities, by themselves these programs are not able to tackle the structural sociocultural and economic inequities that are the root causes of inequities in health.578 However, when their strengths and limitations are understood, CCTs can work as complementary 131 intersectoral interventions in support of people-centered primary health care. Key concerns in effective CCT design, such as proper targeting, coverage, scale-up, and longer-term sustainability579 involve skill sets that are not generally present at the PHC level. However, local implementation and adaptation of these programs also require specific skills that need to be deliberately instilled in PHC teams. These encompass not only technical skills, but also, communications, administrative, managerial, and advocacy capacities. The best-prepared teams will develop capacities to secure appropriate funding and remove bureaucratic hurdles for intersectoral 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 TALK quality 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.582,583,584 Building skills for multisectoral action among PHC practitioners Training in advocacy, communication, and resource generation for multisectoral action In Chapter 3 we identified proper undergraduate, graduate and in-service training 132 as essential to building health workers’ skills and competencies for multisectoral engagement.585 We argued that PHC professionals need to expand their skills in preparation for a range of newer interdisciplinary roles across the care spectrum, from health promotion, disease prevention, and management of chronic diseases to palliation and social care. Equally important for PHC professionals is acquiring leadership/stewardship, management, and communication skills to be able to confidently advocate for healthier living in the communities they serve. Such advocacy has many facets. It can include reaching out to local practitioners in other sectors whose activities influence health outcomes in the community, and with whom opportunities for productive intersectoral partnerships may exist. It also involves sustained dialog with communities themselves, to strengthen health literacy, encourage healthy lifestyle choices, and promote greater community agency 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 HAPPEN Recognizing 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 undergraduate and graduate training courses to encourage pursuit of joint degrees in areas like business administration (MBA), health or medical administration (MHA, MA), or public health (MPH). The United States has been a recent very rapid increase in joint degree programs linking an MD degree with a Ph.D., MPH, or MA 133 qualification. 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 Similar dual programs are also becoming more common in Canada.590 While many of these 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 other countries and to other health professionals over time. A fundamental concern is to customize them to local needs and ensure their accessibility and relevance to people working in PHC or who aspire to do so. Available tools include tuition support, options for on-the-job and on-line degree acquisition, as well as tangible benefits 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 complex WALKING THE TALK interplay 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.592,593,594 Financing multisectoral engagement Valuing multisectoral benefits in resource allocation The case for multisectoral action to strengthen PHC is clear. Only through multisectoral action can the PHC platform cohesively target the social determinants of health across sectors like education, nutrition, agriculture, housing, transport, and environment.595,596,597 Capitalizing on the synergies across health and other sectors, however, will require governments to use new ways of promoting and financing “win-win” measures that can spur progress on multiple development goals at once.598 There is a growing body of literature on frameworks that can be used to guide governments on multisectoral investment in health to support stronger PHC platforms.599,600,601,602,603 134 Win-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 cost- effective (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.608 Countries 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.609,610 CHAPTER 4: MAKING IT HAPPEN Similarly, 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.611,612 Governments 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.615 Ministers of Health can be at the center of the intersectoral dialogue, together with the Ministry of Finance, as they work together to identify and finance such interventions, breaking down the silos typical of more traditional decision making on resource allocation. In low- and lower-middle income countries, this marks a departure from a situation where the health sector often struggles to make the 135 case for investing in health, sometimes because of a failure to highlight non-health benefits that might raise other sectors’ interest in health gains.616,617 Cost-benefit analysis captures human welfare improvement benefits across all sectors in monetary terms. Thus, it may help make a more effective case for intersectoral partnership than cost-effectiveness analysis, which is conducted in individual sectors and can undervalue benefits beyond the health sector.618 Intersectoral priority-setting can also increase the quality and quantity of public spending and ensure both value for money and equity.619 Finally, 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 TALK BOX 14. A WHOLE-OF-GOVERNMENT APPROACH TO STRENGTHENING HUMAN CAPITAL The 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.627 136 New Zealand offers a suggestive example of an operationalized whole-of- government 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.629,630 CHAPTER 4: MAKING IT HAPPEN Conclusions This 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 Lower- income 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 TALK Chapter 5 POLICY RECOMMENDATIONS 138 CHAPTER 5: POLICY RECOMMENDATIONS The 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 technical challenges, but it is above all a political problem. Solving that problem will depend on buy-in from influential stakeholders, perhaps especially those identified with the health-system status quo. This, in turn, demands a policy adoption and implementation road map to engage payers, providers, and patients. The road 139 map will vary across countries, reflecting national starting conditions, health and development priorities, political economy, and the path dependency of change processes within each health system. Systems centered around hospitals and specialists will pose particular difficulties for PHC-focused redesign. But, in all settings, PHC reform will be easier said than done. As argued throughout this report, the COVID-19 tragedy may facilitate PHC- centered 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.”635 Prerequisites for action There 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. The WALKING THE TALK dialogue 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 responsibilities for stakeholders. A strong framework incorporates tools to measure and evaluate implementation and outcomes, preferably through a set of customized 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 RECOMMENDATIONS Recommendations for countries Managing the reform process 1 Create 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 models 1 Assess health workforce strengths and gaps, and plan the transition to team- based delivery. While all countries should aspire to build multidisciplinary care teams to deliver PHC, specifics of team composition and empanelment 141 strategies must be tailored to the local context. Contextual factors to consider include national and local epidemiologic profiles and socioeconomic determinants of health.638 To start, each country—supported by technical partners and donors, as appropriate—can undertake a situation assessment encompassing: the current structure and composition of the health workforce; how well the workforce matches health and health care needs; people’s care-seeking patterns across different provider types and levels of care; and payment/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 TALK 2 Equip 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 and leveraging data analysis capabilities to improve outcomes. Interoperable and integrated digital platforms are needed to create a culture of transparency and accountability in PHC. This will empower patients and providers alike. The COVID-19 crisis has confirmed the importance of harnessing technology to monitor population health on the front lines, detect threats early, and facilitate knowledge sharing and care coordination. These needs are felt within local care teams and across levels of care, in both public and private sectors.640 As empowered co-producers of their own health, patients should ultimately be able to access, review, and export their personal health data on 142 demand; in the long-run, they should be able to generate and contribute their own health data, including through mobile applications and self-monitoring of 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 development 1 Launch 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 RECOMMENDATIONS including 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 can address compensation imbalances that exacerbate inequitable allocation of the health workforce, especially in those with a predominant private sector. Governments should ensure that compensation for health workers (e.g., salaries or reimbursement rates) in rural or underserved areas is at least equivalent to compensation in more saturated urban regions. Depending on 143 local context, leaders may also consider additional compensation or in-kind benefits to offset quality-of-life concerns. Reimbursement and salary reform is also needed to address the substantial differential between generalist and specialist physicians, thereby encouraging entry into generalist career paths and addressing the shortage of primary care physicians, and containing perverse and collusive dual practice in loose regulatory settings.  3 Expand 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. 4 Reform 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 TALK 5 Support 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 mobilization 1 Develop a political strategy to deliver PHC financing goals. While health officials tend to analyze financing options in technical terms, financing and resource allocation are inherently political. Securing funds for reimagined PHC requires building commitment and buy-in across government. This will not happen without a deliberate political strategy. Leadership informed by such a strategy is key to translate countries’ formal commitment to UHC under the SDGs into practical policies and resource allocation. The evidence is strong that public-health-enabled PHC is the healthcare organization model most apt to improve the efficiency, resilience, and sustainability of 144 public spending on health, promoting equity and shared prosperity. Such evidence is vital, but insufficient. A political plan is needed to ensure its uptake by those with the power to deliver change. 2 Craft a tailored investment plan. Fit-for-purpose financing for public-health- enabled 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). 3 Finance 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 RECOMMENDATIONS 4 Implement 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. 5 Ensure 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 priority- setting 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. 6 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 and incentivize care coordination and quality. (See Chapter 4.) 7 Create an accountability framework that links resources to results. Resource 145 mobilization (whether through additional allocations or reprioritization) tends to be more successful when accompanied by a strong accountability framework built on interoperable data platforms. Reliable and transparent measurement of PHC financing, which has been a weak link in many countries, will be critical to hold providers accountable to health system investors—including international and domestic funders and, most importantly, a country’s citizens. Results need to be regularly monitored and the accountability framework itself adjusted to changing circumstances and priorities, including emergencies. 8 Explore 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 TALK Recommendations for donors and the international health community 1 Support 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.  2 Support country-led digital integration. In each country, donors can provide financial and technical support to integrate fragmented health data platforms and/or ensure their interoperability. Any support donors provide 146 to HMIS should respect the long-term agenda for a single integrated or interoperable health information platform in each country. In the immediate term, donors should “walk the talk” by ensuring that any vertically-organized data collection platforms are made interoperable with the national HMIS— such that national HMIS systems can access all donor-supported data (while respecting patient privacy).  3 Align 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.  4 Fund 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 RECOMMENDATIONS What 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.641 In the years ahead, the World Bank will use three main mechanisms to help countries deliver the promise of reimagined PHC. These mechanisms match the World Bank’s principal areas of added value in health, as identified in the 2021 Strategy Refresh: Lending, Learning, and Leadership. These priorities also underscore the World 147 Bank’s commitment to partnerships that have proven their value for countries, including the Global Action Plan PHC Accelerator, PHCPI, JLN, and others.642,643,644 As countries and partners continue to grapple with the health and economic “double shock” of COVID-19,645 the Bank’s approach is parsimonious. It does not aim to create new structures that might duplicate what already exists. Instead, it seeks to work within existing structures and alliances in more effective ways. 1 Lending: 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 TALK 2 Learning: mobilize practice-relevant PHC knowledge. Together with analytic and financial partners, the World Bank will strengthen global knowledge hubs for PHC and ensure that they are equipped to deliver the actionable information countries need in formats they can use. Since PHCPI’s creation in 2015, the initiative’s databases and PHC improvement tools have advanced PHC learning and practice.647 This and other PHC knowledge hubs, such as that maintained by JLN,648 can achieve even more in the years ahead. More can be done to share PHC knowledge in user-friendly forms and to tailor information for policy makers and implementers facing specific challenges on the ground. Through collaboration in these efforts, the World Bank will capture and disseminate learning around PHC “hardware” (e.g., digital technology, tech-equipped PHC workers) and “software” (e.g., team-based organizational care models, risk pooling, value-based purchasing). It will help compile and assess country experiences and facilitate their dissemination through tailored global, regional and country specific training courses and other activities. World Bank technical assistance to countries will support the integration and operationalization of PHC knowledge in policies and programs. Recently, a new PHC performance framework from WHO and UNICEF and OECD’s Patient-Reported Indicator Surveys (PaRIS) have advanced PHC performance measurement.649 The World Bank will work with these and other partners on a country-friendly measurement toolbox for PHC-related inputs, outputs, and outcomes.650 The Bank will also expand the 148 place of PHC in its learning platforms, such as flagship courses. 3 Leadership: 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 RECOMMENDATIONS Conclusion: Summary table of policy recommendations Table 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 PHC SERVICE HEALTH WORKFORCE FINANCING DELIVERY + Situation + HRH review2 and gap analysis, + Align HF strategy to team based assessment (MoH) aligned to team-based service PHC service model. Prioritize model (MoH) financing from general government + Tailor team based revenue. Eliminate user fees. PHC service delivery + Refresh HRH strategy and Introduce or raise pro-health taxes model to country policies (including M&E) (MoH, (MoH, MoF, insurance authority) and local needs1 MoL, MoF) (MoH) + Workforce changes for + Build emergency planning into HF strategy (MoH) + Develop emergency preparedness and implementation response (MoH, MoF, MoI) + Adapt benefits package for plan for team-based equitable PHC coverage (MoH, service delivery + Launch multidisciplinary MoF, insurance) medical education reforms model (with M&E) Countries (MoH, MoF, local (MoE, MoH) + Resource mapping and costing for team-based care and PHC benefits governments) + Compensation models to package. Develop political strategy 149 promote generalist care and + Use data and rural practice (MoH, MoF) for PHC financing goals (MoH, MoF, technology to insurance) drive adoption + Tiered accreditation, tied + Payment reform to promote team- of team-based to reimbursement (MoH, based care, coordination, and service delivery insurance authority, MoF, MoE) quality (MoH, MoF, insurance). model3 (MoH, MoF, insurance, MoT) + Regulatory reform for + Integrate financing and service telemedicine and labor mobility delivery data platforms for (MoH, MoL, MoT, insurance) accountability (MoH, MoF, insurance, MoT) + Support documentation, measurement, evaluation, and learning on country experiences in team based PHC service delivery, HRH, and financing Global + Support situation assessment and gap analysis in service delivery, HRH, and financing partnership, + Support strategy refresh in HRH, health financing, service delivery, and governance namely through the + Provide advisory and technical assistance for country reforms. Support design and implementation SDG3 Global of team-based service delivery and related HRH and financing solutions Action Plan + Align external financing with country-led system-strengthening efforts, on budget to (GAP) PHC avoid fragmentation Accelerator + Foster innovations, technology adoptions, and new initiatives through financial support and partnership + Support integrated data platforms to enable team-based service delivery and value-based payment, while building in-country analytical capacity + Lending: easing access to finance for PHC World Bank + Learning: curating and mobilizing PHC knowledge and training + Leadership: crafting policy options through dialogue Notes: (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. 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January (2016): 1–9 111 “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 atten- tion.’ 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 TALK and a disease, referring to a medical condition rather than the individual. 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Forrest, and Caroline Y. 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-roadmap- to-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.” ENDNOTES 132 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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Responsiveness is understood to include quality of basic amenities, choice, access to social support networks, and prompt attention as structural domains, while dignity, autonomy, communication, and confidentiality are seen as interpersonal domains of responsiveness.” 142 UHC2030 and Sustainable Health Financing Accelerator (SHFA, “How COVID-19 Is Reshaping Priorities for Both Domestic Resources and Development Assistance in the Health Sector - UHC2030,” accessed May 11, 2021, https://www.uhc2030.org/blog- news-events/uhc2030-blog/how-covid-19-is-reshaping-priorities-for-both-domestic- resources-and-development-assistance-in-the-health-sector-555362/. 143 World Health Organization, “Primary Health Care and Health Emergencies,” 2020, 1–62, https://www.who.int/docs/default-source/primary-health-care-conference/ emergencies.pdf?sfvrsn=687d4d8d_2. 144 Margaret E. Kruk et al., “What Is a Resilient Health System? 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(UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark, 2020). ENDNOTES 168 World Health Organization, “WHO | Health Systems; Stewardship,” WHO, 2010. 169 Finn McGuire et al., “Financing Intersectoral Action for Health: A Systematic Review of Co-Financing Models,” Globalization and Health 15, no. 1 (December 2019): 1–18, https://doi.org/10.1186/s12992-019-0513-7. 170 WORLD HEALTH ORGANIZATION–REGIONAL OFFICE FOR AFRICA, “STATUS OF ROAD SAFETY IN THE AFRICAN REGION,” no. 1 (2018): 1–4 171 World Health Organization, “WHO Report on the Global Tobacco Epidemic, 2019 - Country Profile,” 2019, 17–19, https://doi.org/10.1787/b0801bd1-en. 172 Matthias Braubach, David E Jacobs, and David Ormandy, “Environmental Burden of Disease Associated with Inadequate Housing: Summary Report,” World Health Organisation Europe, 2011, 1–13. 173 M. Bloomberg, M. R., Summers, L. 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Meanwhile, readers primarily interested in policy and practice solutions supporting one particular outcome (for example, crisis resilience in PHC systems) can quickly find the subsections where the impacts of each main reform thrust on this outcome are discussed,” n.d. 175 World Health Organization (WHO), “Framework on Integrated, People-Centred Health Services: Report by the Secretariat.” 176 OECD, “Realising the Potential of Primary Health Care,” OECD Health Policy Studies 159 (Paris: OECD Publishing, May 30, 2020), https://doi.org/10.1787/a92adee4-en. 177 World Health Organization, “A VISION FOR PRIMARY HEALTH CARE IN THE 21ST CENTURY,” 2018, 64. 178 May Nawal Lutfiyya et al., “The State of the Science of Interprofessional Collaborative Practice: A Scoping Review of the Patient Health-Related Outcomes Based Literature Published between 2010 and 2018,” PLoS ONE 14, no. 6 (2018): 1–18, https://doi. org/10.1371/journal.pone.0218578. 179 May Nawal Lutfiyya et al., “The State of the Science of Interprofessional Collaborative Practice: A Scoping Review of the Patient Health-Related Outcomes Based Literature Published between 2010 and 2018,” PLoS ONE 14, no. 6 (2018): 1–18, https://doi. org/10.1371/journal.pone.0218578. 180 James Rufus John et al., “The Effectiveness of Patient-Centred Medical Home-Based Models of Care versus Standard Primary Care in Chronic Disease Management: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Controlled Trials,” International Journal of Environmental Research and Public Health 17, no. 18 (2020): 1–50, https://doi.org/10.3390/ijerph17186886. 181 George L. Jackson et al., “The Patient-Centered Medical Home: A Systematic Review,” Annals of Internal Medicine (American College of Physicians, February 2013), https:// doi.org/10.7326/0003-4819-158-3-201302050-00579. 182 Renee Carter et al., “The Impact of Primary Care Reform on Health System Perfor- mance in Canada: A Systematic Review,” BMC Health Services Research 16, no. 1 (2016), https://doi.org/10.1186/s12913-016-1571-7. 183 Mayara Lisboa Bastos et al., “The Impact of the Brazilian Family Health on Selected Primary Care Sensitive Conditions: A Systematic Review,” PLoS ONE 12, no. 8 (August 2017): e0182336, https://doi.org/10.1371/journal.pone.0182336. 184 World Bank Group, “Review of Experience of Family Medicine in Europe and Central Asia.” I, no. 32354 (2005). 185 Madeline Pesec et al., “Primary Health Care That Works: The Costa Rican Experience,” Health Affairs 36, no. 3 (2017): 531–38, https://doi.org/10.1377/hlthaff.2016.1319. 186 Alliance for Health Policy and Systems Research and Bill and Melinda Gates founda- tion, “Report of the Expert Consultation on Primary Care Systems Proiles and Perfor- mance (PRIMASYS),” 2015, 0–34. WALKING THE TALK 187 James Macinko, Matthew J. Harris, and Marcia Gomes Rocha, “Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ) Fulfilling the Poten- tial of the World’s Largest Payment for Performance System in Primary Care,” Journal of Ambulatory Care Management 40, no. 2 (2017): S4–11, https://doi.org/10.1097/ JAC.0000000000000189. 188 James Macinko et al., “Major Expansion of Primary Care in Brazil Linked to Decline in Unnecessary Hospitalization,” Health Affairs 29, no. 12 (December 2010): 2149–60, https://doi.org/10.1377/hlthaff.2010.0251. 189 Davide Rasella et al., “Impact of Primary Health Care on Mortality from Heart and Cerebrovascular Diseases in Brazil: A Nationwide Analysis of Longitudinal Data,” BMJ (Online) 349 (July 2014), https://doi.org/10.1136/bmj.g4014. 190 Rosana Aquino, Nelson F. De Oliveira, and Mauricio L. Barreto, “Impact of the Family Health Program on Infant Mortality in Brazilian Municipalities,” American Journal of Public Health 99, no. 1 (January 2009): 87–93, https://doi.org/10.2105/ AJPH.2007.127480. 191 Romero Rocha and Rodrigo R. Soares, “Evaluating the Impact of Community-Based Health Interventions: Evidence from Brazil’s Family Health Program,” Health Economics (John Wiley & Sons, Ltd, September 2010), https://doi.org/10.1002/ hec.1607. 192 “ Https://Www.Ccss.Sa.Cr/Est_areas_cantones,” n.d. 193 Safir Sumer, Joanne Shear, and Ahmet Levent Yener, “Building an Improved Primary Health Care System in Turkey through Care Integration,” Building an Improved Primary Health Care System in Turkey through Care Integration, 2019, https://doi. org/10.1596/33098. 194 Ministry of Health and Long-Term Care Government of Ontario, “Q&A : Under- 160 standing Family Health Teams - Family Health Teams - Ministry Programs - Health Care Professionals - MOHLTC,” n.d. 195 Theresa Boyle, “Ontario Family Doctors Average $400,000-plus for Part-Time Hours. Province Wants to Claw Back Pay | TheSpec.Com,” n.d. 196 Tracey Naledi, Peter Barron, and Helen Schneider, “Primary Health Care in SA since 1994 and Implications of the New Vision for PHC Re-Engineering,” South African Health Review, 2011, 17–28. 197 Chris Atim, Koku Awoonor, Elizabeth Hammah, “UHC through PHC: Piloting Preferred Primary Care Provider Networks in Ghana - Securing PHC for All: The Foundation for Making Progress on UHC in Africa,” in Journal of Chemical Information and Modeling (Kempinski Hotel Gold Coast City (Accra-Ghana), 2019), 218–19, https://afhea.org/ docs/afhea2019/EN-Abstract book Accra Conference (VF).pdf. 198 Ariadne Labs; Comagine Health, “Empanelment: A Foundational Component of Primary Health Care” (Washington DC : Joint Learning Network for Universal Health Coverage, 2019. 6. 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(2019). 203 Ariadne Labs; Comagine Health, “Empanelment: A Foundational Component of Primary Health Care.” 204 Aiyenigba et al., “Results for Development - Intermediaries: The Missing Link in Improving Mixed Market Health Systems?” 205 Centers for Medicare & Medicaid Services, “Shared Savings Program | CMS,” n.d. ENDNOTES 206 Viroj Tangcharoensathien et al., “Achieving Universal Health Coverage Goals in Thailand: The Vital Role of Strategic Purchasing,” Health Policy and Planning 30, no. 9 (2015): 1152–61, https://doi.org/10.1093/heapol/czu120. 207 Aiyenigba et al., “Results for Development - Intermediaries: The Missing Link in Improving Mixed Market Health Systems?” 208 Aiyenigba et al., “Results for Development - Intermediaries: The Missing Link in Improving Mixed Market Health Systems?” 209 Alexander Pimperl et al., “Duke Authors Accountable Care in Practice : Global Perspectives Case Study : Gesundes Kinzigtal , Germany Overview,” n.d. 210 Reinhard Busse and Juliane Stahl, “Integrated Care Experiences and Outcomes in Germany, the Netherlands, and England,” Health Affairs 33, no. 9 (2014): 1549–58, https://doi.org/10.1377/hlthaff.2014.0419. 211 Chris Atim Tamara Chikhradze, Elizabeth Hammah, Ezinne Ezekwem, “5 Principles for Building an Innovative Primary Health Care Model | Results for Development,” n.d. 212 OECD, “Realising the Potential of Primary Health Care,” OECD Health Policy Studies (Paris: OECD Publishing, May 30, 2020), https://doi.org/10.1787/a92adee4-en. 213 Kanat Sukhanberdiyev and Larissa Tikhonova, “Kazakhstan,” Kazakhstan Case Study: Fostering Cooperation between the Health and Social Sectors to Deliver Better Nurturing Care Services., 2017, 1–4, https://nurturing-care.org/resources/nurturing- care-case-study-kazakhstan.pdf. 214 Michael A. Horberg et al., “Determination of Optimized Multidisciplinary Care Team for Maximal Antiretroviral Therapy Adherence,” Journal of Acquired Immune Deficiency Syndromes 60, no. 2 (June 2012): 183–90, https://doi.org/10.1097/ QAI.0b013e31824bd605. 215 Parya Saberi et al., “The Impact of HIV Clinical Pharmacists on HIV Treatment 161 Outcomes: A Systematic Review,” Patient Preference and Adherence (Dove Press, 2012), https://doi.org/10.2147/PPA. 216 Jeannie L. Haggerty et al., “Continuity of Care: A Multidisciplinary Review,” British Medical Journal (BMJ Publishing Group, November 2003), https://doi.org/10.1136/ bmj.327.7425.1219. 217 Jeannie L. Haggerty et al., “Continuity of Care: A Multidisciplinary Review,” British Medical Journal (BMJ Publishing Group, November 22, 2003), https://doi.org/10.1136/ bmj.327.7425.1219. 218 Max J. Romano, Jodi B. Segal, and Craig Evan Pollack, “The Association between Continuity of Care and the Overuse of Medical Procedures,” JAMA Internal Medicine 175, no. 7 (July 2015): 1148–54, https://doi.org/10.1001/jamainternmed.2015.1340. 219 Ashok Reddy et al., “The Effect of Primary Care Provider Turnover on Patient Experi- ence of Care and Ambulatory Quality of Care,” JAMA Internal Medicine 175, no. 7 (July 2015): 1157–62, https://doi.org/10.1001/jamainternmed.2015.1853. 220 Peter S. Hussey et al., “Continuity and the Costs of Care for Chronic Disease,” JAMA Internal Medicine 174, no. 5 (2014): 742–48, https://doi.org/10.1001/jamaint- ernmed.2014.245; Andrew Bazemore et al., “Higher Primary Care Physician Continuity Is Associated with Lower Costs and Hospitalizations,” Annals of Family Medicine 16, no. 6 (2018): 492–97, https://doi.org/10.1370/afm.2308. 221 David J. Nyweide et al., “Continuity of Care and the Risk of Preventable Hospitaliza- tion in Older Adults,” JAMA Internal Medicine 173, no. 20 (November 2013): 1879–85, https://doi.org/10.1001/jamainternmed.2013.10059. 222 Nadereh Pourat et al., “In California, Primary Care Continuity Was Associated with Reduced Emergency Department Use and Fewer Hospitalizations,” Health Affairs 34, no. 7 (2015): 1113–20, https://doi.org/10.1377/hlthaff.2014.1165. 223 Tejal K. Gandhi et al., “Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims,” Annals of Internal Medicine 145, no. 7 (October 2006): 488–96, https://doi.org/10.7326/0003-4819-145-7-200610030-00006. 224 Inês Dourado, Maria Guadalupe Medina, and Rosana Aquino, “The Effect of the Family Health Strategy on Usual Source of Care in Brazil: Data from the 2013 National Health Survey (PNS 2013),” International Journal for Equity in Health (BioMed Central Ltd., November 2016), https://doi.org/10.1186/s12939-016-0440-7. WALKING THE TALK 225 Carmen Juliani, Maura MacPhee, and Wilza Spiri, “Brazilian Specialists’ Perspectives on the Patient Referral Process,” Healthcare 5, no. 1 (January 2017): 4, https://doi. org/10.3390/healthcare5010004. 226 Reddy et al., “The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care.” 227 Yi Zhang, Martin Salm, and Arthur van Soest, “The Effect of Retirement on Healthcare Utilization: Evidence from China,” Journal of Health Economics 62 (November 2018): 165–77, https://doi.org/10.1016/j.jhealeco.2018.09.009. 228 Marianne Simonsen et al., “Discontinuity in Care: Practice Closures among Primary Care Providers and Patient Health,” no. September (2019). 229 Realising the Potential of Primary Health Care. 230 M. Bonciani et al., “The Benefits of Co-Location in Primary Care Practices: The Perspectives of General Practitioners and Patients in 34 Countries,” BMC Health Services Research 18, no. 1 (February 2018): 1–22, https://doi.org/10.1186/s12913-018- 2913-4. 231 M. Bonciani et al., “The Benefits of Co-Location in Primary Care Practices: The Perspectives of General Practitioners and Patients in 34 Countries,” BMC Health Services Research 18, no. 1 (February 21, 2018): 1–22, https://doi.org/10.1186/s12913- 018-2913-4. 232 Aravind Eye Care System, “A Trip to an Eye Camp - Aravind Eye Care System,” 2015. 233 Margot Kunckler et al., “Cervical Cancer Screening in a Low-Resource Setting: A Pilot Study on an HPV-Based Screen-and-Treat Approach,” Cancer Medicine 6, no. 7 (July 2017): 1752–61, https://doi.org/10.1002/cam4.1089. 234 Soori Nnko et al., “Perceptions, Attitude and Uptake of Rapid Syphilis Testing Services 162 in Antenatal Clinics in North-Western Tanzania,” Health Policy and Planning 31, no. 5 (June 2016): 667–73, https://doi.org/10.1093/heapol/czv116. 235 Brigham R Frandsen et al., “Care Fragmentation, Quality, and Costs among Chron- ically Ill Patients - PubMed,” The American Journal of Managed Care, n.d., 355-362. 236 National Health Service (NHS), “Joint Guidance on the Use of the NHS E-Referral Service 2018 - NHS Digital,” n.d. 237 Sunil Kripalani et al., “Deficits in Communication and Information Transfer between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care,” Journal of the American Medical Association (JAMA, February 2007), https://doi.org/10.1001/jama.297.8.831.Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Study Selection: Observational studies investigating communication and information transfer at hospital discharge (n=55 238 Varsha G. Vimalananda et al., “Electronic Consultations (e-Consults) to Improve Access to Specialty Care: A Systematic Review and Narrative Synthesis,” Journal of Telemedicine and Telecare 21, no. 6 (September 2015): 323–30, https://doi. org/10.1177/1357633X15582108. 239 Clare Liddy et al., “A Systematic Review of Asynchronous, Provider-to-Provider, Electronic Consultation Services to Improve Access to Specialty Care Available Worldwide,” Telemedicine and E-Health 25, no. 3 (March 2019): 184–98, https://doi. org/10.1089/tmj.2018.0005. 240 Clare Liddy et al., “A Systematic Review of Asynchronous, Provider-to-Provider, Electronic Consultation Services to Improve Access to Specialty Care Available Worldwide,” Telemedicine and E-Health 25, no. 3 (March 1, 2019): 184–98, https://doi. org/10.1089/tmj.2018.0005. 241 Maurice Mars, “Telemedicine and Advances in Urban and Rural Healthcare Delivery in Africa,” Progress in Cardiovascular Diseases 56, no. 3 (November 2013): 326–35, https://doi.org/10.1016/j.pcad.2013.10.006. 242 Jose Manuel Santos de Varge Maldonado, Alexandre Barbosa Marques, and Antonio Cruz, “Telemedicine: Challenges to Dissemination in Brazil,” Cadernos de Saude Publica 32 (2016), https://doi.org/10.1590/0102-311X00155615. 243 Richard Scott and Maurice Mars, “Telehealth in the Developing World: Current Status and Future Prospects,” Smart Homecare Technology and TeleHealth 3 (February 2015): 25, https://doi.org/10.2147/shtt.s75184. ENDNOTES 244 World Health Organization (WHO), “Long-Running Telemedicine Networks Delivering Humanitarian Services: Experience, Performance and Scientific Output,” WHO (World Health Organization, 2012). 245 Mars, “Telemedicine and Advances in Urban and Rural Healthcare Delivery in Africa.” 246 Kerry A. McBrien et al., “Patient Navigators for People with Chronic Disease: A Systematic Review,” PLoS ONE (Public Library of Science, February 2018), https://doi. org/10.1371/journal.pone.0191980. 247 National Cancer Institute, “NCI Dictionary of Cancer Terms: Patient Navigator,” n.d. 248 Alain B. Labrique et al., “Best Practices in Scaling Digital Health in Low and Middle Income Countries 11 Medical and Health Sciences 1117 Public Health and Health Services,” Globalization and Health (BioMed Central Ltd., November 2018), https:// doi.org/10.1186/s12992-018-0424-z. 249 Alain B. Labrique et al., “Best Practices in Scaling Digital Health in Low and Middle Income Countries 11 Medical and Health Sciences 1117 Public Health and Health Services,” Globalization and Health (BioMed Central Ltd., November 3, 2018), https:// doi.org/10.1186/s12992-018-0424-z. 250 Michelle M. Doty et al., “Primary Care Physicians’ Role in Coordinating Medical and Health-Related Social Needs in Eleven Countries,” Health Affairs 39, no. 1 (January 2020): 115–23, https://doi.org/10.1377/hlthaff.2019.01088. 251 Gareth Iacobucci, “Cervical Screening: GP Leaders Slam Capita over Failure to Send up to 48 500 Letters,” BMJ (Clinical Research Ed.) 363 (November 2018): k4832, https:// doi.org/10.1136/bmj.k4832. 252 Anuraag A. Vazirani et al., “Blockchain Vehicles for Efficient Medical Record Management,” Npj Digital Medicine (Nature Research, December 2020), https://doi. org/10.1038/s41746-019-0211-0. 163 253 Primary Health Care Performance Initiative, “Improvement Strategies Model : Facility Organization and Management : Team-Based,” 2018, 13. 254 Primary Health Care Performance Initiative, “Improvement Strategies Model : Facility Organization and Management : Team-Based,” 2018, 13. 255 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016. 256 Primary Health Care Performance Initiative, “Improvement Strategies Model : Facility Organization and Management : Team-Based,” 2018, 13. 257 Laura Lee Hall, “Plan-Do-Study-Act ( PDSA ) Four STEPS to Using PDSA within Your Practice :,” 2019, 1–11. 258 IHI - Institute for Healthcare Improvement, “SBAR Tool: Situation-Background-As- sessment-Recommendation,” n.d. 259 Robert Kane, “How to Use the Fishbone Tool for Root Cause Analysis,” Qapi, 2012, 1–3. 260 IHI - Institute for Healthcare Improvement;, “5 Whys: Finding the Root Cause,” n.d. 261 Edgar Necochea and Debora Bossemeyer, Standards-Based Management and Recog- nition: A Field Guide, 2005. 262 James Macinko and Matthew J. Harris, “Brazil’s Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System,” New England Journal of Medicine 372, no. 23 (June 2015): 2177–81, https://doi.org/10.1056/nejmp1501140. 263 Pesec et al., “Primary Health Care That Works: The Costa Rican Experience.” 264 T Assegaai, G Reagon, and H Schneider, “Evaluating the Effect of Ward-Based Outreach Teams on Primary Healthcare Performance in North West Province, South Africa: A Plausibility Design Using Routine Data,” South African Medical Journal 108, no. 4 (March 2018): 329, https://doi.org/10.7196/samj.2017.v108i4.12755. 265 Alliance for Health Policy and Systems Research -, “Primary Health Care Systems (PRIMASYS) - New Case Studies Available,” n.d. 266 Ari D. Johnson et al., “Proactive Community Case Management and Child Survival in Periurban Mali,” BMJ Global Healt h 3, no. 2 (2018): 1–10, https://doi.org/10.1136/ bmjgh-2017-000634 . WALKING THE TALK 267 Maria Khan et al., “Can Trained Field Community Workers Identify Stroke Using a Stroke Symptom Questionnaire as Well as Neurologists?: Adaptation and Validation of a Community Worker Administered Stroke Symptom Questionnaire in a Peri-Urban Pakistani Community,” Journal of Stroke and Cerebrovascular Diseases 24, no. 1 (January 2015): 91–99, https://doi.org/10.1016/j.jstrokecerebrovasdis.2014.07.030. 268 Krithiga Shridhar et al., “Cancer Detection Rates in a Population-Based, Opportu- nistic Screening Model, New Delhi, India,” Asian Pacific Journal of Cancer Prevention 16, no. 5 (2015): 1953–58, https://doi.org/10.7314/APJCP.2015.16.5.1953. 269 Thomas A. Gaziano et al., “An Assessment of Community Health Workers’ Ability to Screen for Cardiovascular Disease Risk with a Simple, Non-Invasive Risk Assessment Instrument in Bangladesh, Guatemala, Mexico, and South Africa: An Observational Study,” The Lancet Global Health 3, no. 9 (2015): e556–63, https://doi.org/10.1016/ S2214-109X(15)00143-6. 270 Shouneez Yousuf Hussein et al., “Smartphone Hearing Screening in MHealth Assisted Community-Based Primary Care,” Journal of Telemedicine and Telecare 22, no. 7 (October 2016): 405–12, https://doi.org/10.1177/1357633X15610721. 271 Rosa Catarino et al., “Smartphone Use for Cervical Cancer Screening in Low-Resource Countries: A Pilot Study Conducted in Madagascar,” PLoS ONE 10, no. 7 (July 2015): e0134309, https://doi.org/10.1371/journal.pone.0134309. 272 Kate Michi Ettinger et al., “Building Quality MHealth for Low Resource Settings,” Journal of Medical Engineering and Technology (Taylor and Francis Ltd, November 2016), https://doi.org/10.1080/03091902.2016.1213906; David Peiris et al., “Use of MHealth Systems and Tools for Non-Communicable Diseases in Low- and Middle-In- come Countries: A Systematic Review,” Journal of Cardiovascular Translational Research 7, no. 8 (November 2014): 677–91, https://doi.org/10.1007/s12265-014-9581- 5. 164 273 Sylvia Adebajo et al., “Evaluating the Effect of HIV Prevention Strategies on Uptake of HIV Counselling and Testing among Male Most-at-Risk-Populations in Nigeria; A Cross-Sectional Analysis,” Sexually Transmitted Infections 91, no. 8 (2015): 555–60, https://doi.org/10.1136/sextrans-2014-051659. 274 Jaelan Sumo Sulat et al., “The Impacts of Community-Based HIV Testing and Coun- selling on Testing Uptake: A Systematic Review,” Journal of Health Research 32, no. 2 (2018): 152–63, https://doi.org/10.1108/JHR-01-2018-015. 275 Huachun Zou et al., “Internet-Facilitated, Voluntary Counseling and Testing (VCT) Clinic-Based HIV Testing among Men Who Have Sex with Men in China,” PLoS ONE 8, no. 2 (February 2013): 51919, https://doi.org/10.1371/journal.pone.0051919. 276 Schweich Emily, “Cambridge Health Alliance Develops COVID-19 Community Management Model - America’s Essential Hospitals,” Cambridge Health Alliance COVID-19 Infectious Disease Telehealth, 2020. 277 John Janice, Zallman Leah, and Blau Jessamyn, “Our Hospital’s Community Manage- ment Strategy for Covid-19 Works - STAT,” STAT, 2020. 278 Marie Genries, “Food, Water and Masks: South Korea’s COVID-19 Quarantine Kits,” Observers.france24, March 2020. 279 Nhan Phuc Thanh Nguyen et al., “Preventive Behavior of Vietnamese People in Response to the COVID-19 Pandemic,” PLoS ONE 15, no. 9 September (September 1, 2020): e0238830, https://doi.org/10.1371/journal.pone.0238830. 280 PHCPI, “IMPROVEMENT STRATEGIES MODEL : ADJUSTMENT TO POPULATION HEALTH MANAGEMENT : INNOVATION & LEARNING,” n.d. 281 Paolo Campanella et al., “The Impact of Public Reporting on Clinical Outcomes: A Systematic Review and Meta-Analysis,” BMC Health Services Research 16, no. 1 (2016), https://doi.org/10.1186/s12913-016-1543-y. 282 Lianping Yang et al., “Public Reporting Improves Antibiotic Prescribing for Upper Respiratory Tract Infections in Primary Care: A Matched-Pair Cluster-Randomized Trial in China,” Health Research Policy and Systems 12, no. 1 (2014): 1–9, https://doi. org/10.1186/1478-4505-12-61. 283 Xuan Wang et al., “Effect of Publicly Reporting Performance Data of Medicine Use on Injection Use: A Quasi-Experimental Study,” PLoS ONE 9, no. 10 (2014): 1–7, https:// doi.org/10.1371/journal.pone.0109594. ENDNOTES 284 Anbrasi Edward et al., “Enhancing Governance and Health System Accountability for People Centered Healthcare: An Exploratory Study of Community Scorecards in Afghanistan,” BMC Health Services Research 15, no. 1 (2015): 1–15, https://doi. org/10.1186/s12913-015-094 6-5. 285 PHCPI, “IMPROVEMENT STRATEGIES MODEL : ADJUSTMENT TO POPULATION HEALTH MANAGEMENT : INNOVATION & LEARNING.” 286 Martina Björkman and Jakob Svensson, “Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda,” Quar- terly Journal of Economics 124, no. 2 (May 2009): 735–69, https://doi.org/10.1162/ qjec.2009.124.2.735. 287 Great Barrier Reef and World Migatory Bird, “Transparency for Development Proposals,” no. January (2020): 4–5. 288 World Bank Group, “The World Bank Group’s Response to the COVID-19 Pandemic,” n.d. 289 Thomas D. Kirsch et al., “Impact of Interventions and the Incidence of Ebola Virus Disease in Liberia - Implications for Future Epidemics,” Health Policy and Planning 32, no. 2 (March 2017): 205–14, https://doi.org/10.1093/heapol/czw113. 290 Matthew R. Boyce and Rebecca Katz, “Community Health Workers and Pandemic Preparedness: Current and Prospective Roles,” Frontiers in Public Health 7, no. MAR (2019): 62, https://doi.org/10.3389/fpubh.2019.00062. 291 Community Health Impact Coalition, “Priorities for the Global COVID-19 Response,” April 2020. 292 World Health Organization, World Health Statistics 2019: Monitoring Health for the SDGs, Sustainable Development Goals, vol. 8 (Geneva, Switzerland., 2019). 293 Shereen Hussein and Jill Manthorpe, “An International Review of the Long-Term Care 165 Workforce: Policies and Shortages,” Journal of Aging and Social Policy 17, no. 4 (2005): 75–94, https://doi.org/10.1300/J031v17n04_05; Robyn Stone and Mary F. Harahan, “Improving the Long-Term Care Workforce Serving Older Adults,” Health Affairs 29, no. 1 (2010): 109–15, https://doi.org/10.1377/hlthaff.2009.0554. 294 World Health Organization, “Building the Primary Health Care Workforce of the 21st Century (Technical Series on Primary Health Care),” WHO Report, 2018, 1–29. 295 A. H. Roberts, “Life Expectancy and Causes of Death,” Severe Accidental Head Injury, no. 2018 (1979): 140–51, https://doi.org/10.1007/978-1-349-04787-1_12. 296 OECD, “Realising the Potential of Primary Health Care,” OECD Health Policy Studies (Paris: OECD Publishing, May 30, 2020), https://doi.org/10.1787/a92adee4-en. 297 Kane 2018 Leslie, “Medscape Physician Compensation Report 2018,” 2018. 298 Locke Tim and Véronique Duquéroy, “UK Doctors’ Salary Report,” 2018. 299 OECD, “Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places ,” March 2016. 300 Douglas B. Kamerow, “Is the National Health Service Corps the Answer? (For Placing Family Doctors in Underserved Areas),” Journal of the American Board of Family Medicine 31, no. 4 (2018): 499–500, https://doi.org/10.3122/jabfm.2018.04.180153. 301 Victor A. Hirth, G. Paul Eleazer, and Maureen Dever-Bumba, “A Step toward Solving the Geriatrician Shortage,” American Journal of Medicine 121, no. 3 (2008): 247–51, https://doi.org/10.1016/j.amjmed.2007.10.030. 302 OECD, “Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places ,” March 15, 2016, https://www.oecd.org/publications/health-workforce-poli- cies-in-oecd-countries-9789264239517-en.htm.” 303 Council On Graduate Medical Education, “Twenty-First Report: Improving Value in Graduate Medical Education,” 2013. 304 D. 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Yazbeck et al., “The Case against Labor-Tax-Financed Social Health Insur- ance for Low-and Low-Middle-Income Countries,” Health Affairs (Project HOPE, May 1, 2020), https://doi.org/10.1377/hlthaff.2019.00874. 477 World Bank, “High-Performance Health Financing for Universal Health Coverage. Driving Sustainable, Inclusive Growth in the 21st Century,” World Bank, 2019, 1–82, http://documents.worldbank.org/curated/en/641451561043585615/Driving-Sustain- able-Inclusive-Growth-in-the-21st-Century. 478 Abdo S. Yazbeck and Agnès Soucat, “When Both Markets and Governments Fail Health,” Health Systems and Reform 5, no. 4 (October 2019): 268–79, https://doi.org/1 0.1080/23288604.2019.1660756. 479 Susan P. Sparkes, Joseph Kutzin, and Alexandra J. Earle, “Financing Common Goods for Health: A Country Agenda,” Health Systems and Reform 5, no. 4 (October 2019): 322–33, https://doi.org/10.1080/23288604.2019.1659126. 480 Amanda Glassman, Ursula Giedion, and Peter C. Smith, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, 2017.} ENDNOTES 481 Jon Rohde et al., “30 Years after Alma-Ata: Has Primary Health Care Worked in Coun- tries?,” The Lancet (Elsevier B.V., 2008), https://doi.org/10.1016/S0140-6736(08)61405-1. 482 Peter C. Smith and Kalipso Chalkidou, “Should Countries Set an Explicit Health Bene- fits Package? The Case of the English National Health Service,” Value in Health 20, no. 1 (January 2017): 60–66, https://doi.org/10.1016/j.jval.2016.01.004. 483 Lydia Kapiriri and Douglas K. Martin, “Priority Setting in Developing Countries Health Care Institutions: The Case of a Ugandan Hospital,” BMC Health Services Research (BMC Health Serv Res, October 2006), https://doi.org/10.1186/1472-6963-6-127. 484 Amanda Glassman, Ursula Giedion, and Peter C. Smith, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, 2017.} 485 Frank Terwindt, Dheepa Rajan, and Agnes Soucat, “Priority-Setting for National Health Policies , Strategies and Plans,” Strategizing National Health in the 21st Century: A Handbook, 2016, 71. 486 N. Daniels, “Accountability for Reasonableness,” British Medical Journal (BMJ Publishing Group, November 2000), https://doi.org/10.1136/bmj.321.7272.1300. 487 “Institute for Health Metrics and Evaluation,” n.d. 488 David Wilson and Daniel T. Halperin, “‘Know Your Epidemic, Know Your Response’: A Useful Approach, If We Get It Right,” The Lancet (Elsevier B.V., 2008), https://doi. org/10.1016/S0140-6736(08)60883-1. 489 Danielle C. Boyda et al., “Geographic Information Systems, Spatial Analysis, and HIV in Africa: A Scoping Review,” PLoS ONE 14, no. 5 (2019): 1–22, https://doi.org/10.1371/ JOURNAL.PONE.0216388. 490 Ernesto Báscolo and Natalia Yavich, “Governance and the Effectiveness of the Buenos Aires Public Health Insurance Implementation Process,” Journal of Ambu- 175 latory Care Management 32, no. 2 (April 2009): 91–102, https://doi.org/10.1097/ JAC.0b013e31819941bb. 491 Amanda Glassman, Ursula Giedion, and Peter C. Smith, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, 2017. 492 Amanda Glassman, Ursula Giedion, and Peter C. Smith, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, 2017. 493 Southern Metropolis Daily Client, “Outpatient Drugs for Hypertension and Diabetes Are Included in Medical Insurance, and the Reimbursement Ratio Is at Least 50%, Benefiting 300 Million People,” n.d. 494 Amanda Glassman, Ursula Giedion, and Peter C. Smith, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, What’s In, What’s Out: Designing Benefits for Universal Health Coverage, 2017. 495 Yot Teerawattananon and Nattha Tritasavit, “A Learning Experience from Price Nego- tiations for Vaccines,” Vaccine (Elsevier Ltd, May 2015), https://doi.org/10.1016/j. vaccine.2014.12.050. 496 Jon Kim Andrus and Damian G. Walker, “Perspectives on Expanding the Evidence Base to Inform Vaccine Introduction: Program Costing and Cost-Effectiveness Anal- yses,” Vaccine 33, no. 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December (2018), https://doi. org/10.1596/31784 . 505 Melitta Jakab, Tamas Evetovits, and David McDaid, “Health Financing Strategies to Support Scale-up of Core Noncommunicable Disease Interventions and Services,” LSE Research Online, 2018. 506 P Gottret, G J Schieber, and H R Waters, Good Practices in Health Financing: Lessons from Reforms in Low- and Middle-Income Countries, Good Practices in Health Financing Lessons from Reforms in Low and Middle Income Countries, vol. 530, 2008. 507 The Nation, “400,000 Schoolgirls to Be Vaccinated against Human Papilloma Virus,” March 2017. 508 Susan Sparkes, Antonio Durán, and Joseph Kutzin, A System-Wide Approach to Analysing Efficiency across Health Programmes, Health Financing Diagnostics & Guidance No. 2, 2017. 509 Yazbeck et al., “The Case against Labor-Tax-Financed Social Health Insurance for Low-and Low-Middle-Income Countries.” 510 World Bank, “Lao PDR - Health Governance and Nutrition Development Project- Additional Financing,” 2017. 176 511 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 512 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 513 Mark McClellan et al., “Achieving Universal Health Coverage through Value-Based Care and Public-Private Collaboration,” n.d. 514 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 515 Langenbrunner J.C., Cashin C., and Sheila O’Dougherty, Designing and Implementing Health Care Provider Payment Systems - How-to Manuals, World Bank Publications, 2009. 516 James C. 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ENDNOTES 522 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 523 A. Tandon and Adrien Dozol, “Purchasing Integrated Care: Concepts, Trends and Policy Implications.,” World Bank (2019). 524 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 525 Anissa Afrite et al., “The Impact of Multi-Professional Group Practices. Evaluation Aims and Methods for ‘Maisons’, ‘Pôles de Santé’ and ‘Centres de Santé’ within the Framework of Experiments with New Mechanisms of Remuneration,” Questions d’économie de La Santé., no. 189 (2013): 1–6. 526 Melitta Jakab, Tamas Evetovits, and David McDaid, “Health Financing Strategies to Support Scale-up of Core Noncommunicable Disease Interventions and Services,” LSE Research Online, 2018, http://eprints.lse.ac.uk/90269/. 527 CMS Innovation Center, “Comprehensive Primary Care Plus,” n.d. 528 David Blumenthal and David Squires, “The Promise and Pitfalls of Bundled Payments,” Commonwealth Fund, n.d. 529 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 530 Helmut Hildebrandt et al., “Gesundes Kinzigtal Integrated Care: Improving Population Health by a Shared Health Gain Approach and a Shared Savings Contract,” Interna- tional Journal of Integrated Care 10, no. 2 (2010), https://doi.org/10.5334/ijic.539. 531 Helmut Hildebrandt et al., “Pursuing the Triple Aim: Evaluation of the Integrated Care 177 System Gesundes Kinzigtal: Population Health, Patient Experience and Cost-Effec- tiveness,” Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 58, no. 4–5 (April 2015): 383–92, https://doi.org/10.1007/s00103-015-2120-y. 532 Cheryl Cashin Y-Ling Chi Peter Smith Michael Borowitz and Sarah Thomson Cashin, “Paying for Performance in Health Care Implications for Health System Performance and Accountability European Observatory on Health Systems and Policies Series” (Open Universtiy Press, Maidenhead, 2014). 533 Cheryl Cashin Y-Ling Chi Peter Smith Michael Borowitz and Sarah Thomson Cashin, “Paying for Performance in Health Care Implications for Health System Performance and Accountability European Observatory on Health Systems and Policies Series” (Open Universtiy Press, Maidenhead, 2014). 534 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 535 OECD, “Better Ways to Pay for Health Care,” OECD Publishing, 2016, https://www. oecd-ilibrary.org/social-issues-migration-health/better-ways-to-pay-for-health- care_9789264258211-en. 536 Andrew J. Barnes et al., “Accountable Care Organizations in the USA: Types, Develop- ments and Challenges,” Health Policy 118, no. 1 (2014): 1–7, https://doi.org/10.1016/j. healthpol.2014.07.019. 537 WHO, “Budget Matters for Universal Health Coverage: Key Formulation and Classifi- cation Issues,” WHO, no. 4 (2018): 25 538 Piatti-Fünfkirchen and Schneider, “From Stumbling Block to Enabler: The Role of Public Financial Management in Health Service Delivery in Tanzania and Zambia.” 539 WHO, “Budget Matters for Universal Health Coverage: Key Formulation and Classifi- cation Issues.” 540 Moritz Piatti-Funfkirchen, Ali Hashim, and Khuram Farooq, “Balancing Control and Flexibility in Public Expenditure Management: Using Banking Sector Innovations for Improved Expenditure Control and Effective Service Delivery,” Balancing Control and Flexibility in Public Expenditure Management: Using Banking Sector Innovations for Improved Expenditure Control and Effective Service Delivery, no. September (2019), https://doi.org/10.1596/1813-9450-9029. WALKING THE TALK 541 Elina Dale Inke Mathauer, “Purchasing Health Services for Universal Health Coverage: How to Make It More Strategic?,” WHO, 2019. 542 World Health Organization, “Health Systems Financing: The Path to Universal Coverage,” WHO, 2016, http://www.who.int/whr/2010/en/7. 543 Barbara McPake et al., “Removing User Fees: Learning from International Experience to Support the Process,” Health Policy and Planning 26, no. SUPPL. 2 (2011): 104–17, https://doi.org/10.1093/heapol/czr064. 544 Cristine Villena Amurao, “Closing the Gap,” Fuels and Lubes International 22, no. 4 (2016): 16–19. 545 Mylene Lagarde, Andy Haines, and Natasha Palmer, “Conditional Cash Transfers for Improving Uptake of Health Interventions in Low- and Middle-Income Countries” 298, no. 16 (2014): 1900–1910. 546 M Lagarde, A Haines, and N Palmer, “The Impact of Conditional Cash Transfers on Health Outcomes and Use of Health Services in Low and Middle Income Countries,” Cochrane Database Syst, no. 4 (2009), https://doi.org/10.1002/14651858.CD008137 547 Alan de Brauw and Amber Peterman, “Can Conditional Cash Transfers Improve Maternal Health Care? Evidence from El Salvador’s Comunidades Solidarias Rurales Program,” Health Economics (United Kingdom) 29, no. 6 (2020): 700–715, https://doi. org/10.1002/hec.4012. 548 Benjamin M. Hunter et al., The Effects of Cash Transfers and Vouchers on the Use and Quality of Maternity Care Services: A Systematic Review, PLoS ONE, vol. 12, 2017, https://doi.org/10.1371/journal.pone.0173068 549 Richard de Groot et al., “Cash Transfers and Child Nutrition: Pathways and Impacts,” Development Policy Review 35, no. 5 (2017): 621–43, https://doi.org/10.1111/dpr.12255. 178 550 Lagarde, Haines, and Palmer, “The Impact of Conditional Cash Transfers on Health Outcomes and Use of Health Services in Low and Middle Income Countries.” 551 Amanda Glassman et al., “Impact of Conditional Cash Transfers on Maternal and Newborn Health,” Journal of Health, Population, and Nutrition 31, no. 4 (2013): S48– S66.. 552 WHO, “Global Spending on Health: A World in Transition 2019,” Global Report, 2019, 49. 553 Ke Xu et al., “Global Spending on Health: A World in Transition” (Geneva, 2019). 554 Johanson A.S, “Strategic Planning for Health: A Case Study from Turkey,” WHO Regional Office for Europe, 2015, 72.. 555 “Turkish Health Transformation Program and Beyond,” World Bank Group, 2018. 556 World Health Organization, “From Alma-Ata to Astana:Primary Health Care – Reflecting on the Past, Transforming for the Future,” Global Conference on Primary Health Car, 2018, 68. 557 World Health Organization, “From Alma-Ata to Astana:Primary Health Care – Reflecting on the Past, Transforming for the Future,” Global Conference on Primary Health Car, 2018, 68, https://www.who.int/docs/default-source/prima- ry-health-care-conference/phc-regional-report-europe.pdf?sfvrsn=cf2badeb_2. 558 Mhairi Campbell et al., “The Impact of Participatory Budgeting on Health and Wellbeing: A Scoping Review of Evaluations,” BMC Public Health 18, no. 1 (2018): 1–11, https://doi.org/10.1186/s12889-018-5735-8. 559 Sónia Gonçalves, “The Effects of Participatory Budgeting on Municipal Expenditures and Infant Mortality in Brazil,” World Development 53 (2014): 94–110, https://doi. org/10.1016/j.worlddev.2013.01.009. 560 Reem Hafez, “Nigeria Health Financing System Assessment,” Nigeria Health Financing System Assessment, no. 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