How to achieve universal health coverage? Focus on primary care

Doctor Ismail Abdurrahman attends to a child at a temporary clinic for internally displaced persons in North Darfur, Sudan. Photo by: Albert González Farran / UNAMID / CC BY-NC-ND

BARCELONA — At least 400 million people globally lack access to essential health services such as immunization, family planning services and primary care hospitals, according to the World Health Organization, resulting in the unnecessary deaths of millions of men, women and children every year. That’s why Sustainable Development Goal 3 — to ensure healthy lives and promote well-being for all at all ages — includes a target to achieve universal health coverage by 2030. This includes financial risk protection, access to quality essential health care services and access to safe, effective and affordable medicines and vaccines for all.

In order to achieve UHC, experts have suggested that we need to start by revolutionizing primary health care. The good news is that more players than ever are engaging in global health. Private sector actors such as Philips are innovating around health technology solutions for the developing country context. For example, it has produced fetal health monitors that work independently of power supply, and handheld technological devices that health care workers can take with them to remote and rural areas. And a multitude of corporations, philanthropic foundations and large international nongovernmental organizations are partnering to invest in and deliver improved health systems.

However, achieving UHC is easier said than done, and many challenges remain — such as training and maintaining health care staff, financing, and making medicines affordable and available.    

Devex looks at what it will take to overcome these challenges and achieve universal health coverage, including how to strengthen primary health care facilities, how to make such facilities more accessible, and the role that innovation can play in creating and delivering more sustainable systems.

Strengthening primary health care systems

“If you really want to improve the quality of primary care, you have to take a very holistic approach to the issue. You can’t just look at what devices a center might need — but everything else that is necessary to make it function sustainably.”

— Christoph Castellaz, head of strategy and new business development, Africa at Philips

Primary health care systems are the first line of contact for most people into the health care system. It’s the first place people go when they feel unwell, and where diseases are detected and diagnosed. As such, a well-run, functioning primary care system must be accessible and affordable and have the trust of the population. In short, patients need to know where to go to seek care and be confident about the quality of care they will receive. It also requires that providers know and understand the populations they serve, serve them in a timely way, and have access to a well-functioning referral system, so that the patients who need it are able to access higher levels of care, according to Christoph Castellaz, head of strategy and new business development in Africa at Philips.

“Primary care is really ground zero for a functioning health care system,” said Castellaz.

Despite that key role that primary health care systems play in providing UHC, millions of people worldwide lack access to primary care hospitals, particularly in the developing world. According to Castellaz, some of the main challenges that stakeholders need to overcome to bridge that gap include geographical and infrastructural constraints — for example, ensuring sustainable power sources to health centers in remote areas, as well as ensuring that health centers are properly staffed, equipped and stocked.

Philips has worked in the Republic of South Africa, the Democratic Republic of the Congo and Kenya, and is currently developing projects in four sub-Saharan countries to launch Community Life Centers, which aim to provide underserved populations with primary care services — and they believe they have found a formula that works.

The first step, according to Castellaz, is to bring together all stakeholders, including local community leaders, the national government, international and local partners, to identify the specific community needs, challenges and constraints, and put together a plan.

“If you really want to improve the quality of care, you have to take a very holistic approach to the issue,” he said. “You can’t just look at what devices a center might need — but everything else that is necessary to make it function sustainably, including how to ensure it will have sustainable access to power and water, and how to make sure you have the right personnel and training.”

For example, Philips recently helped to launch a CLC in the Democratic Republic of the Congo in a rural area where few had access to electricity, let alone medical coverage.

“In this case, one of the first things we had to think about was infrastructure. Health centers use a lot of medical devices, so we needed to find a way to ensure a reliable power source,” said Castellaz, adding that this then meant there was also maintenance to consider.

In the DRC example, Philips was able to form a partnership with a nearby engineering school, which helped them to identify a power source and agreed to help with the installation and servicing of medical devices.

“We always look for local partners, and collaboratively decide from the beginning who can do what,” continued Castellaz. “It’s important that the entire process is very community driven or it just doesn’t work in the long run.”

Increasing accessibility and coverage outcomes

Increasing accessibility and coverage are also critical components of achieving UHC. Some of the primary factors limiting access include geography, in particular, how to ensure access for people in rural areas, remote areas and fragile states, as well as affordability.

According to Jim Campbell, executive director of the global health workforce alliance and department at WHO, one key strategy to increase both the accessibility and coverage of primary care is to ensure the sustainable availability, training and retention of health care workers. This requires knowledge of which professional profiles are most needed at the state and local levels, and ensuring a steady stream of students and training programs. While this might seem straightforward, matching supply to demand can be tricky.  

“In order to ensure high-quality coverage, you have to have a workforce with the right mix, distribution and composition — including community health workers, nurses, pharmacists and specialists, as well as doctors,” said Campbell. “To do that in rural settings, you need to be able to identify the future health care workers from the community and then provide them with an education and vocational training.”

This is often hard to achieve in practice.

“The health economy isn’t always straightforward,” said Campbell. “First, you have to train people, then you have to make sure that jobs are available in the right places when they graduate. It’s a matter of crafting the right policies to ensure both supply and demand, and those two factors don’t always meet up.”

Working to ensure access to high-quality and affordable pharmaceuticals and medicine is another critical component of UHC, according to Thomas Cueni, director general of the International Federation of Pharmaceutical Manufacturers & Associations.

This can also be major challenge in developing countries, which often face problems such as inefficient customs processing, poor storage facilities and bureaucratic bottlenecks, both in terms of approving clinical trials and new life-saving medicines.  

One way that IFPMA has succeeded in addressing many of the challenges blocking both access and coverage is by forming 300 innovative multi-stakeholder partnerships around achievable goals. One of the most ambitious and recent partnerships, called Access Accelerated, brings together 23 different pharmaceutical companies, the World Bank and the Union for International Cancer Control to improve access to treatment for noncommunicable diseases.

“Bringing so many companies under one umbrella lets us tackle big health issues,” said Cueni. “It also means you can use the group as a convener to have some good policy discussions.”  

Other pharmaceutical partnerships led or co-led by IFPMA address other issues in health care systems, including improving access to and quality of health care and medicines by training health workers, contributing to disease awareness campaigns, investing in health infrastructure and improving point-of-care service delivery. According to Cueni, many of these partnerships are quite innovative.

For example, GSK’s 20 percent reinvestment program puts profits directly back into participating countries’ health care systems and human resources for health, and also trains health care workers. The program has so far reinvested $30 million and trained 25,000 health care workers, reaching 6.5 million people in 34 countries since 2011.

Another partnership, the Neglected Tropical Disease Drug Supply Chain Forum, brings together a number of pharmaceutical companies and large international organizations to improve supply chain management for NTDs, including the creation of a logistics “control tower,” forecasting and planning tools, and statistical modeling of supply chains. The partnership’s efforts have resulted in a 36 percent increase in donated treatment by participating companies.

IFPMA’s Cueni also said that addressing inefficiencies in approving clinical trials, as well as regulatory hurdles to approve new drugs for sales and distribution, would go a long way in increasing access to life-saving medicines for millions of people around the world.

“Right now, it can take up to five years to get changes in formulations approved by regulatory authorities,” adding that this meant five years that potentially life-saving drugs were not available to the people who needed them. 

Innovation in primary care financing, management and delivery

One of the key factors as to whether or not UHC remains merely a goal or becomes reality is dependent on finding innovative and sustainable financing mechanisms to fund it. To address the funding gap for reproductive, maternal and newborn child and adolescent health in low- and middle-income countries alone would require an additional $33.3 billion dollars in funds.  

This is why large international organizations, such as the World Bank, International Monetary Fund and WHO, are working to identify innovative financing options — for example, social impact bonds, which pay partners based on measurable outcomes, or grants to pay down interest on large health-related loans, to name just a few.

The Global Financing Facility, a multi-stakeholder partnership launched by the World Bank Group and the United Nations, supports country-led efforts to improve the health of women, children and adolescents. It has shown that leveraging domestic financing options, concessional financing, and aligning external financing and crowd funding in private capital may hold the key to the challenge of funding UHC.  

According to Mariam Claeson, director of GFF, the first step towards achieving sustainable financing for UHC, is to empower countries to identify their highest health priorities informed by data, equity analysis and by an evidence-based approach — involving and unifying stakeholders, including bilateral donors and other investors, around common goals.  
“One of the big challenges is a fragmented marketplace between sectors, donors and actors,” said Claeson. “So bringing together the partners through the one country-driven platform with the aim of achieving critical health results for women, children and adolescents, and mobilizing resources in support of those results, is essential.”

Once stakeholders are unified behind clearly outlined and evidence-based goals, the GFF finds that outside donors from large international organizations, other governments and the private sector are more willing to commit funding, particularly when outcomes are carefully measured.    

“We’ve found that this model has been extremely successful,” said Claeson. “Right now, it’s available in 16 countries, but there are 67 that are eligible — so if we put more financing behind it, we’ll see real accelerated progress in achieving UHC.”         

While it may seem like a monumental task, development professionals across the health sector agree that the Sustainable Development Goal of universal health coverage for all by 2030 is achievable if approached strategically by collaborating closely with other stakeholders and communities, innovating around financing solutions and addressing key challenges as they emerge.

How do we ensure that people worldwide get the care they need without the risk of being pushed further into poverty? Devex explores the path to universal health coverage. Join us as we ask what it will take to achieve UHC for all by visiting our Healthy Horizons site and tagging #HealthyHorizons, #Health4All and @Devex.

The content, information, opinions and viewpoints in this Healthy Horizons content series are those of the authors or contributors of such materials. Content produced as part of the series does not represent an endorsement of the contributing institutions or their positions, nor does it imply the existence of any relationship or engagement among them in connection with this series.

About the author

  • Malia Politzer

    Malia Politzer is an award-winning long-form journalist who specializes in international development, human rights issues and investigative reporting. She recently completed a fellowship from the Institute of Current World Affairs in India and Spain. For three years, she worked as a feature-writer at Mint, India’s second-largest financial newspaper, where she wrote about international development, strategic philanthropy and impact investing. She holds an M.S. journalism from Columbia University Graduate School of Journalism, where she was a Stabile Fellow for Investigative Journalism, and a B.A. from Hampshire College.