The role of Primary Health Care, primary care and hospitals in advancing Universal Health Coverage

Primary Health Care (PHC) has re-emerged as a global health priority in recent years. PHC is viewed by many as of the foundation of universal health coverage (UHC). However, recent high-level disagreement has emerged between Lancet editor-in-chief Richard Horton and WHO Director General Tedros Adhanom Ghebreyesus on how much emphasis should be placed on PHC, exposing continuing confusion around what the term actually means.

Ahead of the UN High-Level Meeting on UHC in September 2023, Horton published a commentary entitled ‘Primary Health Care is not enough’, controversially arguing that global health policy-makers’ ‘current preoccupation with PHC condemns millions of people to disease, pain and death’.¹ His premise was that focusing on PHC crowds out funding for secondary care, citing cancer services as an example.

In our view, Horton’s commentary misrepresented the global health community’s motivation; it conflated PHC with primary care service delivery (as does the UHC declaration²); and unfairly implies that primary care services are being pursued at the expense of hospital-based services.

PHC is not only about primary care services: PHC describes a whole-of-society approach to health, including multisectoral action, community empowerment and—crucially—integrated health systems that include all levels of care, but with a central focus on essential public health functions and primary care. PHC-oriented systems offer the most cost-effective, equitable and accessible route to extending health services to unreached populations.³

Focusing on PHC (or primary care services) is not the same as ignoring hospital care. We need action to strengthen all aspects of cancer and other care across all levels of the health system, including prevention, early diagnosis, referral, staging, treatment, rehabilitation and palliative care. Until recently, policy attention and funding had been hospital-centric. Hospitals remain the focus of many health systems around the world and consume an over-riding proportion of healthcare spending in many settings.

In a WHO report titled ‘Making Fair Choices on the Path to Universal Health Coverage’, a group of ethicists recommended prioritising parts of the health system that enhance equity, support the vulnerable and offer the best cost-effectiveness.⁴ Hospitals and curative interventions capture >90% of most health budgets and have done so for decades, despite frequently offering inefficient and inequitable population coverage with relatively poor cost-effectiveness ratios.⁵ The renewed interest in PHC and primary care services is driven by the ethical imperative to maximise the impact of every rupee, naira, yen, peso and shilling.

While PHC and primary care services are increasingly talked about, they remain underfunded, misrepresented and misunderstood.^6–10 Most of the world still lacks access to strong primary care services in their local community i.e. high-quality, first-contact care that is comprehensive, coordinated and continuous.³ Primary and secondary care are generally poorly integrated; and empanelment, gatekeeping, strong referral systems and shared care pathways remain aspirations in most settings. Essential public health functions are routinely underdelivered, and CT and MRI scanners continue to outnumber family physicians in a number of countries.

We do not argue for ignoring hospital-based care. We believe that primary care services can and should amplify the impact of hospital care through detection, referral and shared management, as well as protecting new services from being overwhelmed by undifferentiated demand. Primary and hospital-based care should work synergistically. Balanced investment across the health system is our best chance of minimising human suffering and advancing health for all. Given historic neglect and underinvestment, the nascent recalibration towards primary care services in the context of PHC-oriented health systems should be celebrated.

The official WHO response to Horton took the form of a post published on Tedros’s LinkedIn page, titled ‘There’s perhaps no health topic more important than primary health care’.¹¹ The post notes that PHC is ‘one of the most misunderstood concepts in public health’, and that PHC is commonly conflated ‘with health service delivery at the local level’. We see this all the time. Many international organisations and national health strategies interpret PHC as a direct synonym for primary care service delivery. Indeed, in many languages there is only one term for both primary care services and the broader concept of PHC.¹²

Unfortunately, this particular WHO post inadvertently compounded the confusion by using ‘PHC’ as a synonym for health service delivery at the local level. Furthermore, by making distinctions between PHC, secondary and tertiary care, the post can be interpreted as positing a limited version of PHC where multisectoral action, community engagement and health system integration manifest purely at the level of primary care services.

The Alma-Ata declaration itself seems to provide conflicting definitions of PHC, emphasising a broad whole-of-society approach alongside detailed description of primary care service delivery functions.¹³ However, the Declaration of Astana,¹⁴ the WHO Vision for PHC in the 21st Century,¹⁵ the WHO PHC Measurement Framework¹⁶ and other contemporary supporting documents consistently define PHC as ‘a whole-of-society approach to health’ that includes all aspects of the health system.

In summary, investment in strong primary care (a centrally important subcomponent of PHC-oriented health systems) is the most impactful, equitable and cost-effective way of advancing UHC. Evidence-based investment in primary care is one of the most cost-effective and equitable ways of reducing pain, disease and death around the world. Investment in strong primary care services also supports hospital services by preventing illness, ensuring that the right cases get through to secondary care, and by promoting longitudinal and coordinated management. Now is the time to redouble advocacy for strong primary care; to promote the holistic 'whole-of-society' vision of PHC with consistency and clarity; and to start amplifying synergies between primary care and hospital services for UHC.

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