Expert Insight

Quality: A Catalyst for PHC-Driven UHC

Tanzania Paediatric Ward Bill & Melinda Gates Foundation/Frederic Courbet
What is a young mother looking for when seeking health care for her child, her elderly father or herself? Quality primary health care. Health care that is centred on her needs, her family and her community without having to reach into her pocket. This is where the current intense global dialogue on universal health coverage (UHC) and primary health care (PHC) needs to converge – people. Quality can drive this necessary convergence, as a sharp entry point to catalyzing change at the frontline of service delivery. But how?

We need a clear recognition that effective PHC is foundational to achieving a people-centred approach in pursuit of quality UHC. And here we should be deliberate in our focus on primary health care as opposed to simply primary care, thus emphasizing the pivotal role of communities in defining their health, their development, their future. The connection point with UHC is clearly evident.

We have, however, been somewhat remiss by not placing a strong enough emphasis on quality within the UHC agenda. Increasing financial protection, population coverage or even expanding the range of available services means little if the quality of these services is poor or even – at times – unsafe. Focusing on quality can make a clear case for PHC-driven integration of health services, designed to perform not for some, but for all. Moves to improve quality can lead to integration. Moves to improve integration can lead to quality. The two are mutually supportive.

Improving PHC has long been recognized as key to achieving health for all, and several global platforms have called for strong, accessible PHC systems, including the World Health Organization [2008 World Health Report: ‘Primary Health Care (Now More Than Ever)’], asserting that PHC reforms can deliver equitable health services that focus on people’s needs and expectations. More recently, the WHO Integrated People-Centred Health Strategy (IPCHS), launched in March 2015, highlights an important new way to empower patients, combat health system fragmentation and both engage and incentivize providers across care settings. The central features of this global framework are essential if the goals of quality UHC are to be realized at the frontline. Indeed, quality can be the litmus test in the success of moves towards integration and people-centeredness.

A strong PHC system is the foundation for a resilient health system. People, communities, community health workers, district health managers and PHC providers are the front-line responders to health system shocks."

Indeed, the Ebola epidemic shone a light on how fragile health systems in vulnerable parts of the world struggle when faced with a shock, in this case a communicable disease. Yet the PHC workforce were the change agents who responded to the outbreak and played a critical role in building trust with local communities even in the midst of profound challenges. The need to prioritize PHC improvement to empower these front-line responders with the tools and knowledge to provide basic services while responding to a shock is a practical means towards achieving quality UHC.  

But how will the success of these efforts be tracked? Tools that focus on measurement as a means towards improvement will be critical to empower local providers, district health managers and national-level stakeholders towards PHC-driven quality UHC. One example of an initiative focusing on PHC performance improvement is the Primary Healthcare Performance Initiative (PHCPI).  Taking a practical approach towards data-driven change, PHCPI focuses on integrated, effective primary health care across the continuum of care that includes health promotion, prevention, treatment, rehabilitation and palliative care services.  This practical approach to PHC performance will be critical as countries rapidly shift gears towards quality UHC. The success of the approach will be dependent on ensuring a firm commitment to iterative prospective learning from the frontline, particularly focused on the linkage between measurement and improvement.

The action that follows will need to be multi-pronged. First, there is a clear need to support countries to strengthen national policies on quality within the context of UHC utilizing PHC performance improvement as a key driver for change.  Second, mechanisms to capture, share and learn from field experiences on PHC quality improvement – a global learning laboratory approach – need to be embedded within the fabric of the evolving dialogue on PHC-driven quality UHC. Third, tools and resources to support frontline efforts to improve PHC need to be co-developed at the frontline, in order to harness their wisdom. Fourth, patient and community perspectives on the quality of PHC – the foundation of trust in local systems – need to be the primary driver of local change as part of national movement towards UHC. Finally, focused efforts on improving the quality of PHC within the context of UHC should be considered the touch point to reality in the evolving and influential discussions on global health security. Boardrooms can only get you so far. 

Nearly forty years ago a godfather of PHC – Carl Taylor – highlighted three PHC pillars: infrastructure for peripheral health services; community participation; and intersectoral cooperation. He also underlined the importance of a genuine three-way partnership among people in the community, experts from outside and government officials in achieving just and lasting change. Can we imagine PHC-driven quality UHC as a realization of these ideas that echo through decades of time?

Dr. Shams Syed currently coordinates the new World Health Organization Unit on UHC & quality, within the WHO Department of Service Delivery & Safety at WHO Headquarters in Geneva.