Data Insight

PHCPI Data Insight: Primary Health Care Spending

Bill & Melinda Gates Foundation/Prashant Panjiar
Before leaving home for a trip to the market, you likely know how much you plan to spend and how much food you will get for your money. This basic understanding of how much food your money will buy allows you to budget effectively and makes your shopping experience much less stressful. For most purchases, it is critical to understand how much money you have and what that money will purchase,  Unfortunately, this basic concept is all too often absent in health systems, particularly in primary health care (PHC) systems.

While countries are pledging for increasing external and, most importantly, domestic funding for health, global commitment to support countries to track health spending has also progressively increased. As an example, thanks to the global resource mobilization for vertical diseases spurred by the Millennium Development Goal’s, $11 billion was spent on HIV/AIDS, $2.4 billion on TB, and $6.6 billion on child health in 2014 alone [1]. Despite undoubtedly bringing the countries much-needed resources to fight these epidemics, to some extent vertical spending has fragmented the efforts of countries to manage at their primary health care system in a coherent and comprehensive way and account for resources spent at the first level of care. In this respect, WHO and major global health agencies, including USAID and the World Bank, have worked on coordinating and standardizing reporting based on the System of Health Accounts (SHA). However, much more work is needed to help countries track overall spending on a regular basis, as well as to conduct more detailed resource tracking by functions to evaluate how effectively they are spending their resources.

As countries pursue the ambitious agenda laid out in the Sustainable Development Goals, they will have to make difficult choices about how they spend their money. To ensure they are investing in the most impactful interventions, decision makers must know where their money is flowing and the resulting impact.

Why do we need to track PHC spending?

In PHCPI we talk a lot about the “black box” of service delivery. But there are other areas that countries have equally limited insight into, including PHC spending. In September 2015, PHCPI released new internationally-comparable data on PHC spending per capita and the percent of government health spending dedicated to PHC for over 20 countries based on Systems of Health Accounts (SHA) data. These new data are revealing. They show us that, of the countries we have data for, 80% spend less than $100 (PPP) on PHC per capita and only two direct over 50% of government health spending to PHC.

These PHC spending indicators, particularly government spending on PHC, are an important barometers of a country’s commitment to resilient, cost-effective and equitable health systems. PHC spending also reflects progress toward Universal Health Coverage (UHC); in countries with low PHC spending, individuals often bear the financial burden of out of pocket (OOP) payments, which restrict access for all and weigh particularly heavily on the poorest populations. Finally, the PHC spending indicators show us just how large the variation in PHC spending is between countries; for example, the country with the highest PHC spending per capita spends 26 times more than the country with the lowest level of spending. However, these data are the tip of the iceberg, as they tell us how much a country is spending on PHC but not how efficient that spending is.

What are the common challenges associated with tracking PHC spending data?

It is not only low- and middle income countries (LMIC) that lack PHC spending insights; high-income countries also do not have consistent metrics they apply to PHC spending. Insights from LMIC data collection can grant insight into potential methodologies, critical challenges. 

Nigeria Health Visit Bill & Melinda Gates Foundation/Prashant Panjiar

One of the reasons PHC spending data is sparsely available is that it is inherently difficult to measure. The paradox is that the stronger a PHC system is, the more difficult it is to extract PHC spending data from health system records. At their best, PHC systems provide people with high-quality care at the right place, at the right time, and by the right person. This means PHC is a common thread throughout patients’ interactions with the health system, not isolated to specific care providers, facilities, or disease areas, which is how spending data is often classified. However, this makes quantifying PHC much more difficult.

To further compound the complexity of isolating PHC spending, there is no homogenous definition of PHC across countries, as country-specific benefits packages often drive spending categorization. To overcome some of the challenges incumbent in quantifying PHC spending, SHA established a common definition of PHC spending that underlies its calculations. This standard is necessary to ensure that data is accurately comparable across countries. However, this standard PHC definition may not align with how countries define PHC for their specific contexts, so additional country-level PHC spending data is needed to inform policy and decisions. Additionally, countries may calculate PHC spending based on their own definition of PHC, but the differences in calculation mean these figures may not be comparable to other countries. Coming soon on the PHCPI blog, we will explore how countries are gathering and using PHC spending data to inform their improvement efforts.

What do the Vital Sign Indicators Tell Us

Let’s look at some of the PHC Vital Signs outcome indicators as an example. Both maternal and under 5 mortality go down as PHC spending per capita increases; while we can’t directly attribute these improvements to spending alone, there is indeed correlation. However, the picture is much less clear when we compare adult mortality from NCDs against PHC spending per capita. There doesn’t appear to be any relationship. Is this because more primary care funding is diverted to maternal and child health interventions? Could it be because there are many tried-and-true MCH standards, but providers aren’t as well trained to manage NCDs? Or could it be that care providers know how to manage NCDs, but lack the means to do so? The bottom line is that without more and better data, we still do not have the full picture.

To bridge this evidence gap, PHCPI is dedicated to unlocking the information needed to truly understand PHC systems and enabling well-informed investments for improvement.

Federica Secci is a Health Specialist in the Health, Nutrition, & Population division at the World Bank Group. 


1. Institute for Health Metrics and Evaluation. Global Burden of Disease.