Q&A: How to leapfrog progress in primary health care

According to the World Health Organization, primary health care — a person’s first point of contact with the health care system — can meet 80-90 percent of an individual’s health needs over the course of their life. However, for many in a low- or middle-income setting that infrastructure is not in place. When it is there, it’s often inadequate in successfully meeting a patient’s needs and potentially means further, yet avoidable, health consequences. If the 2030 sustainable development agenda is to be met, that needs to change.

“We have to avoid the trap of assuming that health care in low resource settings should be inferior to what’s on offer elsewhere in the world. We have means to put quality care services in proximity to just about everybody in the world and we ought to try and do that,” said Karl Hofmann, president and CEO of PSI — a global health organization dedicated to improving the health of people in developing countries.

What exactly are those means, who is best placed to implement them, and is there a way progress can be sped up to provide sustainable solutions?

“The problem for all of us — policymakers, implementers, funders, thinkers — is how to do that in a way that’s financially sensible,” Hofmann said. “The answer to the challenge of global health is not to provide second-class health to the poorly resourced parts of the world; we can do better than that.”

In an interview with Devex, Hofmann explained how he believes progress in primary health care can be “leapfrogged,” what technology is already allowing for that, and what lessons the development community can take from the private sector in terms of meeting people where they are.

This conversation has been edited for length and clarity.

You previously mentioned at Devex World 2018 that we’re potentially at a leapfrog moment in terms of primary health care. What do you mean by that?

It’s a combination of things. First, you’ve got tremendous technological advancements being made in things such as diagnostics, self-administrative therapies, rapid diagnostic kits for malaria, and HIV self-testing, you’re putting more information into the hands of health consumers. That’s one phenomenon that’s underway.

The other that’s a well-established trend line is progress in connectivity around the world. There are vanishingly few places left on the map, rich or poor, that don’t have access to cell phones, information, and to the referral networks that come with that. By combining diagnostics and the ability to connect people to information through cell phone technology and the ability to put more care into consumers’ hands, it gives us the opportunity to leapfrog over something that has been a real bottleneck for decades in global health — primary health care, which we all recognize as critical to global health progress. But despite decades of investment, still doesn’t meet the needs of the people it’s designed to serve. With technology, improved diagnostics, access to referral networks, and a recognition that consumers have the ability to control their own health, we can leapfrog over many of those problems.

What examples can you give of technology providing that leapfrog opportunity?

I mentioned HIV self-testing, which is something PSI and others are involved in scaling across sub-Saharan Africa with funding from UNITAID and the Children’s Investment Fund Foundation. The evidence makes it quite clear that it’s a very sought after and successful product and it’s going to help reach the first 90 of the 90-90-90 goals in HIV control, which is getting people to know their status. It’s particularly useful technology for groups that have been underrepresented in the past, for example, men who don’t want to go to health care facilities in general.

Or you can look at something such as Sayana Press, which is a long-acting contraceptive. In some regulatory environments it’s possible to self-administer and in others, it requires a provider. The technology is designed for women to inject themselves and get multiple months of prevention against unwanted pregnancy.

A third and very powerful one is medical abortion. This, increasingly everywhere, is becoming a more prominent means for women to access safe abortion care as opposed to surgical abortion. The beauty of the new technology is not only that it’s highly effective, but it can be used at home, managed without heavy care infrastructure, and is highly safe.

What opportunities for investments in local communities do you think could help speed progress in health and embrace the idea of consumer-powered health care?

There’s an on and off again fascination with community health workers. In many places, that potential has been realized, but in many other places, it is still unrealized. Ethiopia has had significant investment by government and partners in building out a community-level health infrastructure and this has led to dramatic progress in terms of health for the population.

Rwanda is another great example where government investment in primary health care at the community-level health infrastructure has yielded great progress. In every village there is now a semitrained health professional who can provide referrals and basic information. These are low cost but high pay-off public investments.

We know there’s a lot of private sector money looking for opportunities to invest in primary health care in integrated health systems in Africa. There are private and social investors who see the power of a model connecting tertiary and referral hospitals down to primary health care community-level infrastructure. In a handful of places in Africa, including Kenya, you can already see that beginning to emerge.

What can the development and health care community learn from the private sector in terms of meeting people where they are?

Social marketing organizations, such as ours and others from the beginning — for over 50 years — have been excited by the concept that the private sector tends to reach people more effectively and consistently than the public sector does, even in low resource settings. Eliminating issues around supply chain and constant contact with the consumer are learnings from the private sector that are increasingly embraced by the public sector and those looking to build out a comprehensive health infrastructure.

PSI‘s trying to double down on that concept with a recognition that there is tremendous power in the hands of consumers once they’re recognized as people with choices, people with agency, people who, once they have access to quality products and services, can do much for their own health.

I think the one way in which the private sector really excels — and you could debate whether it’s for social good or not — is at understanding and bringing a solution to what their consumer perceives as a problem. We could all learn from that. We all think to a great degree about our beneficiaries, recipients, the people we’re trying to serve — at PSI we think of them as consumers — but do we all do enough to really understand the reality and shape our responses to their needs, through their eyes? I think we have a lot to learn from the private sector in that regard.