One of key moment in global health in October 2018 was renewing of commitment of countries for re-positioning and strengthening primary health care (PHC) to mark the 40th anniversary of the 1978 Declaration of Alma-Ata. The Global Conference on Primary Health Care was hosted by the Government of Kazakhstan, WHO and UNICEF, in Astana, Kazakhstan to coincide with the growing momentum for Universal Health Coverage and Sustainable Development Goals.
The voice of experts in this Community of Practice was sought through a flash consultation, so that their opinion can be shared for the session on “Operationalizing Primary Health Care at the Community Level”. We have received good response and valuable suggestions, which we tried to summarise in this blog
The response that we got from the poll (figure1) shows that majority supports strengthening of social structures and networks, which can enable communities to participate meaningfully towards PHC (38.5%), so as the involvement of private sector for service delivery and financing (67%). Community Health workers (CHW) are one of key linkage between the community and service delivery chain and there are global debates about the barriers for their scale-up. In this poll majority (59%) have cited that volunteer and incentivized models are not sustainable for CHWs availability and retention.
FIGURE 1: Approach needed to strengthen PHC, N=27
Formal health sector — 27%
Non-public service — 0%
Social structures and networks — 38.5%
All of the above — 34.5%
Your votes (figure 2) also suggested that maximum investment for PHC needs to be in the domain of strengthening supply chain system and supporting the communities resilience to address emergencies like epidemics, natural disasters, etc.
FIGURE 2: Areas in the PHC that need investments, multiple choice, N-27
Supply chain system strengthening — 55.6%
Resilience to emergencies (epidemics, natural disasters, etc.) — 51.9%
Use of Technology to integrate M & E system — 48.1%
Ownership of community systems and other sectors — 48.1%
Quality of care and effectiveness of CHW — 40.7%
Multifaceted actions are needed from the government, funders and civil society to strengthen the mandate of PHC. A coordinated approach is needed in domains like expanding the service package, availability of human resource and supplies, financial access, improving quality, inclusion of marginalized and vulnerable population, data for decision and a robust public- private- civil society collaborative framework. There are suggestions for moving away from the vertical program of CHW and ensure they are paid well in order to retain them and also they can earn the trust of the communities.
A question, which was raised to the minister in this consultation, was “CHW are basic (unpaid) foundation of PHC. Most of the volunteers have to struggle between their workload burden and family livelihood. Because of this, there are high drop-out rate and non-functioning in some areas. What are the opportunities for CHWs to link their existence in health system that can support their sustainability and functionality?”
Suggestions include the need to expand the PHC package to address issues of non communicable disease and mental health. Also the package needs to be well equipped to take into account of emergencies, natural disasters particularly communities in conflict and fragile settings.
“How can you support an integrated community health system when so much funding and resources are tied to vertical disease programs?” was one of the key issues raised in this group for both the funder and minister.
Suggestion in the form of sufficient budget, which is devoid of leakages and corruption for steady and timely supplies, so as financial access through National health insurance and financing models particularly for marginalized and vulnerable populations, is key for a successful PHC model.
To ensure that PHC works for the communities and to track the progress, there is need for developing a well-designed and structured framework and tools for monitoring the progression of the countries, which should include global set of agreed indicators, flexible and context specific matrix. Empowering communities and involving them in designing PHC program can go a long way for ensuring accountability and sustainability. Community seen as a “First Mile” needs to demand accountability from the health system, which is also echoed in the consultation along with areas of concern.
“One of the possible benefits of community participation is communities and users exerting greater pressure on health facilities for quality services. Given this desirable possible outcome, it not contradictory to entrust the consolidation of community participation to the pyramidal health administration, including health facilities themselves? Who should be tasked with the empowerment of local communities?”
To enhance accountability there is need for a reliable, transparent resources (financial and non financial), utilization tracking system that shows contributions of all stakeholders (Government, donors, non state actors (private sector, communities, NGOs, etc.). The challenge for funders will be to support with long-term commitment and also to work with decentralized system and actors in the community.
But at the same time concern is also raised about how the civil society can be involved: “What strategy will they put in place to ensure that they do not continue to implement donor-centric rather that host country directed PHC programs at community level?”
Action, activism and continuous dialogue through medium like community of practice can lead to a collaborative efforts of bringing the communities, CSO, governments, private sector, donors and development partners. The starting point can be a roadmap for linking communities in broader framework of PHC, test it in different context and scale up the measures.