Learning Exchange Guiding Questions
How can we (re)prioritize PHC in the recovery phase of COVID-19? What might shifting resources and incentives to the PHC level look like, and what might be required to achieve this?
How can we generate credible, evidence-based messages to support PHC service delivery innovation and prioritization?
PHCPI, in collaboration with the Joint Learning Network for Universal Health Coverage (JLN), facilitated two Learning Exchanges in 2020 and 2021 under the JLN Network for Open Dialogue and Exchange. The Transforming the Health System to Prioritize PHC Learning Exchange enables sharing of best and promising practices related to PHC prioritization and advocacy.
Participants in the Learning Exchanges meet monthly to learn from experts in plenary and participate in facilitated peer to peer problem-solving, modeled after Feedback Labs LabStorm. Representatives from participating countries bring forward a challenge they are facing and pose 3 questions to the group, who draw on their own knowledge and expertise to provide reflections and possible solutions. Below is a summary of the key takeaways emerging from those discussions.
CHALLENGE: Engaging the Community in Person-Centered Primary Health Care in Chile
The Chilean Ministry of Health is currently engaged in the deployment of a person-centered health care strategy, a shift from disease-oriented healthcare. This effort is a part of the implementation of the national comprehensive health care model (MAIS) that seeks to incorporate health care services based on the needs of the community. Many factors such as the shifting of mindset of local health care authorities and primary health care (PHC) providers, sensitizing and training the health workforce, and community advocacy need to be considered as a person-centered PHC strategy is being introduced. The team from Chile explored the following questions with other participants from the learning exchange:
- What are the key approaches to engage communities in rolling out a person-centered primary health care strategy?
- What are the most common problems that other countries have faced with regard to community engagement, and how have they overcome these problems?
- How to communicate the proposed changes in order to empower people to become the protagonists of their health care?
Identify champions. When engaging with communities, it is essential to build trust and develop an understanding relationship. The strategy can be to customize and approach champions in the communities. For example, in Nigeria, religious leaders were champions and messengers for their communities. A similar approach is to identify liaison between PHC providers and the communities. Community health workers (CHW) are a great resource to bridge this gap. CHWs provide health knowledge and self-sufficiency through outreach and community education efforts and can sensitize community members to the new strategy. Where internet is accessible and smartphones, computers or other similar devices are available, digital health platforms can also serve this function enabling people to adopt self-healthcare attitudes and behaviors, and engage directly with their health care providers.
Create community diaglogue and accountability mechanisms. Shifting from a disease-oriented model to person-centered health care strategy, health care providers and stakeholders need to prioritize community needs, respond to them accordingly and generate opportune accountability actions. Incentivize community to engage with the person-centered strategy and understand what it means are initial steps to get communities interested and allow them to become change agents. There needs to be an increased in investment in community health care units and health application resources so that community members are empowered to take charge of their health care.
engage media and take a strategic communications approach. There are many stakeholders and audiences in implementing a health care strategy, therefore it is important to tailor communication efforts and target each group differently. Clear communication via traditional media and social media can reach many people and would be a great way to introduce this strategy and can importantly serve as a way to neutralize inaccurate coverage and portrayal of the changes in strategy.
Challenge: Effective Participation of NGOs in Addressing Health System Design Challenges
A team of representatives from multiple countries presented the challenges that non-governmental organizations (NGOs) often face in supporting the health system. Though civil society organizations (CSOs) and NGOs have contributed to efforts to address health system challenges, in many countries, their participation has been limited by government agencies. The COVID-19 pandemic presented an opportunity for the government involve and learn from NGOs. The group asked three questions:
- How can NGOs contribute to government efforts to influence patient behavior to seek preventive care?
- How does the government ensure that engagement of CSOs is effective in both planning and execution?
- How can CSOs bring attention to specific issues within this broader landscape without drawing focus away from the larger system/strategic goals?
establish linkages. NGOs are important assets in the community and can motivate constituents to utilize government services. NGOs can additionally serve as an avenue for the community to give feedback on services delivered. It is therefore important for the government to utilize this strategic position of CSOs and involve them from the onset to understand government efforts and structures. A participant also pointed out that understanding government structures can mitigate the risk of creating parallel structures and working in silos. If CSOs are able to work with government on these structures instead, it creates sustainability if the government is able to continue the work once funding ends for the CSOs.
build trust. Participants also pointed out that there is a lack of trust between the government and NGOs/CSOs and discussed strategies to build a relationship between the two. One method includes appointing someone inside the Ministry whose job it is to engage CSOs. This person can support the CSOs and NGOs in navigating bureaucracy but can also help the government understand how best to support these structures. In the Philippines, CSOs and NGOs participate in health partner meetings, thus providing a venue for regular engagement. NGOs can additionally utilize the trust built to negotiate for a seat at the table and be involved in the planning process. A reverse method is to bring government representatives to CSO meetings and invite a Minister to serve on the board. That way, government members can be aware of the work of the CSOs and further build that trust.
Utilize measurement. To assist CSOs in bringing attention to specific issues, participants suggested developing performance measures on key policy initiatives. Data speaks, so it is important for CSOs to conduct research and gather data. Generating this evidence and pinpointing where interventions are going wrong can help in assuring that these issues are priorities to the government.
CHALLENGE: Balancing the PHC workforce across Liberia
Human Resources for Health (HRH) have been recognized as a pre-requisite for an effective and responsive health system. Like many countries in the developing world, Liberia is faced with difficulties in training, distributing and retaining health workers in sufficient number and with the appropriate skills and productivity levels. In Liberia, the geographical distribution of health workers is skewed towards urban and wealthier areas. The geographical imbalances in the health workforce further exacerbate inequities in the health sector, as the services are not available where needs are higher and impact greater. As a result, the team from Liberia delved into the following with the group:
- What strategies can we use to achieve geographical equity of all categories of health workforce?
- What are some of the most common and effective strategies to attract and retain health workers in rural/remote and deprived posts?
- What are some politically-feasible and financially-affordable incentives that policy-makers can put in place to achieve appropriate skill-mix throughout the country?
INCENTIVIZE RURAL AND REMOTE PLACEMENTS. Set a baseline payment amount for health workers throughout the country. Increase the payment for those serving in far-flung areas, while ensuring that the health worker is culturally and religiously appropriate to work in the community, and thus equipped to succeed. In decentralized settings these payments—both baseline and incentives—may vary by state or local governing entity. However, while health worker payment may be made by a local governing entity, additional financial support from the territorial or central level may be beneficial to offset the increased expenses.
EMPOWER THOSE CLOSEST TO THE COMMUNITY TO LEAD THE RECRUITMENT. In countries that run decentralized health systems, recruitment is often a task that is carried out by local government authorities (LGAs). When given the mandate, and supported with the required resources, LGAs are able to tailor recruitment to their needs. When making this shift, it is important that the staffing mandate and budget be flexible so LGAs can implement strategies that will work in their specific contexts—making it possible for rural and remote areas to attract and retain the right mix of health workers.
MAKE LINKAGES WITH TRAINING AND ACCREDITATION OPPORTUNITIES. Some countries require that recent graduates from state universities or certain scholarship recipients serve in rural or remote areas upon graduation. Additionally, some countries are employing “step-ladder” training to build the skills of existing cadres of health workers. For example, a community health worker willing to take on midwifery can receive financial support from their community to pursue training in midwifery. Once trained, they return to their home to continue to serve in the community that supported their education. This can be beneficial in training community members from these same remote areas, who have family and community ties to the area, and are likely to want to stay. Providing a clear roadmap for career development can often serve as an incentive for health workers. In some cases, those who serve in remote areas are able to leverage that experience to have certain requirements waived when applying for paid study leave to pursue higher levels of training.
MOVE FROM STRATEGY TO ACTION. Often, equitable distribution of health workers is included in national strategies and plans, but to make that a reality, investments are needed in development of the health workforce. Many of the strategies require deployment of additional funds—salary increases, scholarships, etc.—to make the plan a reality, HRH needs to be prioritized and funded at the central, and/or local levels—wherever strategic decisions are made. This prioritization can take different forms. It could include increased budget allocations to health worker compensation. Additionally, it could include increasing funding for or coordinating efforts with the Ministry of Education, institutes of higher education, and accreditation to define and promote scholarship opportunities and transparent career pathways that incentivize a balanced distribution of the health workforce across the country.
CHALLENGE: Reforming the PHC service delivery model in Myanmar
While it has been recognized that strong primary health care (PHC) can accelerate progress to universal health coverage and steps have been taken to bring about PHC reforms in Myanmar, there remains a need to adapt the PHC service delivery model to accommodate the realities of the health workforce. There is a limited public sector health workforce for PHC, particularly in growing urban areas, and many patients seek care through the private sector. As a result, participants from Myanmar wanted to explore the following with the group:
- How might we effectively use private general practitioners as gatekeeping mechanism for PHC?
- What might be the most optimal payment mechanism and contracting arrangement when engaging private general practitioners to provide PHC?
- How can we ensure private general practitioners are providing quality PHC services to patients?
Develop inclusive policies. In addition to ensuring PHC policies account for all service providers, given the large number of private general practitioners (GPs), and their envisioned role in the delivery of PHC, it is important to include private GPs in developing those policies. Involving private providers in developing service provision guidelines and quality standards—particularly those required for accreditation—can help ensure that private providers see themselves as a key part of the PHC system.
ALIGN INCENTIVES. In order to attract private GPs to provide primary health care services, it is important to create incentives that are not only supportive of PHC goals but also appealing to private providers. It is important to connect private GPs to the existing payment mechanism. For example, identify PHC services provided by private GPs that can be paid through the national health insurance. Adopting a system that covers the cost of preventive component of PHC can incentivize private GPs who are less likely to focus on preventative health when it is not covered under the national health insurance scheme. Private GPs can also report service delivery data to the public system when they understand clearly what is being asked and getting incentivized to report. In addition to payment, other incentives such as recognition and accreditation can be powerful motivators.
ensure providers are prepared with the right skills. To deliver high-quality, patient-centered PHC services, all practitioners must be equipped with the right skills. Tracking performance indicators can help public sector leaders ensure high-quality services are delivered across the board and respond to any knowledge gaps identified. When dealing with diverse populations, these performance indicators should be flexible and/or tailored to be responsive to the distinct needs of the different populations. With performance data in hand, leaders can work to bridge any divide in performance between public and private PHC providers. Doing so may include investing in in-service training for private GPs on PHC priority health topics or creating a mentoring program to support up-skilling the GPs.
CHALLENGE: Improving Financing for Primary Health Care in Kenya
Universal Health Coverage (UHC) was prioritized within Kenya’s Big 4 Agenda for socio-economic transformation, and primary health care (PHC) was identified to be the driver of UHC. Despite this high-level support, however, PHC financing remains inadequate with most of the funding burden on individuals and donors.
Additionally, although health insurance has been identified as a significant modality for financing UHC, its coverage is inequitable. Only 19% of the population—mostly formal sector workers—are enrolled, and it covers mostly curative services. The team posed three questions that they hoped would elicit insights and proposals to inform actions at the country level.
- What strategies can we use to increase government funding to PHC?
- How can we align the benefits package of the health insurance scheme to care for critical components of PHC other than curative care?
- What strategies can be used to increase informal sector enrolment in existing health insurance schemes?
KEEP AN EXPANSION MINDSET. In resource-constrained environments, it can be difficult to increase funding for specific issues and may require taking new and creative approaches to increase investments and/or diversify funding sources. One group shared how they are building resource mobilization case by identifying specific policies that are currently on the books but are not under-pinned by budget. Since leaders have made high-level statements of commitment to PHC, it may be possible to leverage that political will into targeted additional resources when the gaps between policy and funding are made clear. Another technique to raise additional funds for the health sector—and PHC—is to impose taxes that promote a healthy lifestyle, like sin taxes on tobacco and alcohol and sugar sweetened beverages. Where it is not possible to generate additional resources for PHC, it is always worth remembering that promoting efficiency and avoiding waste can free up resources within the current budget allocation. Additional country examples that may be instructive can be found in the JLN Collaborative on Domestic Resource Mobilization captured in the Health Priority Setting and Resource Allocation (HePRA) Overview and 10 Country Summary.
Tapping into new funding streams can expand service offerings, ensuring components of PHC—such as disease prevention and health promotion—are adequately funded. To do so, countries can look beyond insurance arrangements, which tend to be limited to curative care, to special-purpose funding mechanisms, ensuring they are sustainable, respond to priority health issues at both national and sub-national levels.
Go where the people are. To increase informal sector enrollment in existing health schemes, PhilHealth in the Philippines has used a combination of strategies to increase enrolment in health insurance schemes, including setting up insurance offices where there is high foot traffic (e.g., the mall), offering online and mobile payment systems, linking enrolment/ premium payment with group enrolment for those working in the informal sector and business permits. For instance, small business owners are required by the local government to update their PhilHealth before their business is issued needed permits. One resource of interest for extending coverage to the informal sector are Closing the Gap: Coverage for Non-Poor Informal Sector Workers.
CHALLENGE: Prioritizing Primary Health Care in Nigeria
Nigeria has made significant progress in PHC; however, COVID-19 has exposed weakness of the health system. More resources—both financial and human—are needed to build a resilient and sustainable PHC system. At the same time, governance and accountability, including the meaningful engagement of key stakeholders—especially women and community partners—need to be strengthened across all areas of the PHC program. The team from Nigeria posed three questions for input:
- How do we address the challenges of inadequate health workforce and strengthen existing partnerships, especially at community level?
- How do we develop an effective comprehensive and accountability framework for PHC that is robust, transparent, innovative, and stable over time when applied consistently?
- What innovative financing methods can be adopted for improving PHC financing, outside public budgets?
STRENGTHENING THE HEALTH WORKFORCE REQUIRES BOTH PREPARATION AND FOLLOW THROUGH. Participants noted that increasing the number of health workers and strengthening the health workforce will require clarity around the competencies required for each position. Skilled trainers and pre-service training are crucial in building the skills and confidence needed to deliver high-quality health care, therefore it is important to reach consensus with the educational sector to optimize and customize the training in alignment with the health needs to be met. However, training is just the beginning. Identifying career pathways for community health workers and the health work force as a whole, providing adequate compensation, opportunities for promotion and development, as well as routine feedback, are all elements to consider in building and retaining a quality health workforce.
FEEDBACK IS THE ONLY WAY TO GET THINGS RIGHT. In both increasing accountability and strengthening the health workforce, feedback has a crucial role to play. Participants shared reflections on how collecting, analyzing, and interpreting data at all levels of the health care system—from community to the ministerial—ensures that stakeholders at each level have a role to play in increasing accountability. Assessing data at the first level of care helps program managers quickly understand their needs and empowers them to make better decisions and provide timely and relevant feedback. Having data disaggregated by geography can help national stakeholders with their important roles in priority-setting, resource mobilization and coordination. Increasing the feedback loops in the system can promote accountability among staff at all levels, improve skills among health care workers, and provide opportunities for innovation.
Funding sources for PHC MUST BE Expanded. PHC has been key to properly respond to the COVID-19 pandemic and will continue being crucial in the post-pandemic era. In order to do so, additional funding sources will be required. The group touched briefly on some strategies under review or currently being employed, including resource generation from taxes imposed on individuals for non-vital activities (i.e. telecom surcharge), and taxes on companies resulting from environmental impact assessments of their planned projects.