Public financing for primary health care is the key to universal health coverage and strengthening health security

The last time global leaders met in person to discuss health issues was at the UN high-level meeting on universal health coverage (UHC) in New York, NY, USA in September, 2019. At this gathering, heads of government re-committed themselves to the Sustainable Development Goal 3, which aims to ensure that everyone can receive the health services they need without suffering financial hardship.

But in listening to heads of government deliver their speeches, it was striking how many of them said that their strategy to reach UHC was based on giving people better access to expensive hospital services, rather than to primary health-care (PHC) services. This was a phenomenon I also witnessed when I visited India in 2018, where I was told that one of the primary objectives of their health reforms was to increase hospitalisation rates among poor people.¹

Speaking as a member of The Elders and as a former WHO Director-General at the high-level meeting, I proposed that a more efficient and equitable route to UHC would be achieved through PHC reforms that were publicly financed. I also used this opportunity to highlight the findings of the first report of the Global Preparedness Monitoring Board,² that the world was at great risk from a pandemic of an airborne pathogen due to alarming gaps in global preparedness against health emergencies. This danger was due to a chronic underinvestment in public health services at both a national and global level. Of course, none of us realised just how quickly these gaps would be exposed by COVID-19, which struck just 3 months later.

Given the devastating impact the pandemic has had over the last 2 years, the publication of the Lancet Global Heath Commission on financing primary health care³ is most timely and welcome. This excellent report argues strongly that the COVID-19 crisis shows that we need to invest more in health, but that as well as spending more, we need to spend better.

Building on the seminal World Health Report of 2010,⁴ the Commission³ shows that in raising financing for a nation's health system, pooled public financing mechanisms are superior to private voluntary mechanisms such as health-care user fees and private insurance schemes. This is because only public financing can ensure that everybody, including the poor, receives the health services they need.

With all countries facing constraints in public financing, it is essential that pooled public funds are spent as efficiently and equitably as possible, to maximise health benefits for the most people. To do this, it is necessary to invest in the most cost-effective health interventions that prevent people from becoming ill or enable them to be treated quickly in the community or a primary care setting, before they require costly hospital care.

Over recent decades, extensive research has shown that better value for money is achieved from public health spending, in terms of higher health outcomes, when it is allocated to PHC services. As well as services provided by health centres, this should include investing in community-based services delivered by publicly-financed community health workers, whose value has been shown since the days of China's famous barefoot doctors.

Over the last 2 years, community-health workers have also proved extremely effective in tackling the pandemic by mobilising communities and providing preventive and curative services. It is therefore encouraging to see more countries, such as South Africa,⁵ recognising the value of community health workers and formalising their employment by the state.

As well as improving people's access to health services, public investment PHC services also fulfils an important role in protecting vulnerable people from the potentially high costs of health care, which is an explicit objective of UHC.

Whereas some might think that financial protection is best achieved by protecting people from the sudden high costs of inpatient hospital care, there is evidence from many countries⁶ that the highest burden of out-of-pocket expenditure is actually from people purchasing medicines, often from private drug stores. Therefore, potentially the best way to reduce impoverishing health-care costs would be to publicly finance the provision of medicines in PHC and community settings.

Moreover, as there is strong evidence that private financing of medicines (often spent on inappropriate use of antibiotics) is highly correlated with growing levels of antimicrobial resistance, this points to the need to publicly finance medicines to reduce the threat of antimicrobial resistance.

This latter point also shows that as well as helping improving the health of individuals, investing in PHC also helps strengthen our collective health security. PHC is the foundation of a strong health system and is where a lot of infectious disease interventions (eg, surveillance, prevention, and treatment) are delivered.

As we rebuild after COVID-19 and countries aim to strengthen their preparedness against future pandemics, it is essential that vital public health services are funded properly and integrated into broader UHC reforms that are PHC-led. Ultimately this will prove the most efficient and equitable way to simultaneously strengthen health security and accelerate progress towards UHC.

Gro Harlem Brundtland is a former Director-General of the World Health Organization and a founding member of The Elders.