Country representatives from Ghana, India, Indonesia, and Malaysia have successfully piloted the UHC Primary Health Care Self-Assessment Tool to assess whether their health financing approaches are well-aligned with their primary health care (PHC) service delivery goals.
The Tool, which was collaboratively designed with input from 50 representatives from JLN member countries and global partners, is a rapid diagnostic instrument that helps countries identify practical policy opportunities in the health system to improve the relationship between health financing and PHC efforts. To achieve this goal, the Tool is designed to capture the different perspectives of stakeholders regarding the alignment of health financing strategies with the provision of PHC. The process of capturing these areas of misalignment creates the space to discuss the roles of the individual stakeholders and modify these roles to improve delivery of care.
“[In India] providers in the tertiary care level also understand the importance of primary care in ensuring effective health care delivery to the community,” says Dr. T. S. Selvavinayagam. “As such, they must be involved in dialogues around integrating primary health care into larger frameworks of the health system”.
The four member countries that adapted and piloted the Tool have documented their experience in a new report with the goal of sharing their experiences with global audiences and contributing new evidence on implementing reforms for PHC improvement to achieve universal health coverage (UHC).
Country experiences: UHC PHC Tool easily adapts to fit local context
The Ghana, India, Indonesia, and Malaysia teams adapted the Tool to ensure its relevance to their local settings and stakeholders. While the teams from Ghana, India, and Indonesia made only slight adjustments to the terminology of the Tool, the team from Malaysia made significant changes to the team from Malaysia made significant changes to the health financing sections to align with the Malaysian public health system’s organization. Overall, the pilots demonstrated that countries could adapt and rapidly implement the Tool in a variety of settings, either at the national or sub-national level.
For example, India chose to pilot the Tool in two states: Kerala and Tamil Nadu. The pilots revealed several areas of misalignment between PHC objectives and health financing policies. In Kerala state, the need to develop incentive structures that motivate health workers to provide primary care, and to use evidence to promote PHC as a priority emerged. In Tamil Nadu, members of the country team noted health education and behavior change communication as major barriers to achieving UHC. Health education, a critical component of PHC, is noted in Tamil Nadu’s states health policies but is not prioritized. Though different stakeholders noted local government funds were set aside to provide health education, the funding has been insufficient.
“The State is really interested in understanding the alignment of PHC towards UHC, which will reflect the aspirations of the public”, says Dr. T. S. Selvavinayagam, Additional Director of Public Health in the Government of Tamil Nadu, India.
Following the pilot, the Tamil Nadu country team proposed running a similar pilot at the district level to better understand the severity of misalignments across the spectrum of well to poor performing districts, with the aim of devising district-level interventions for improvement. This bottom-up approach will allow the state to identify potential areas to better align PHC goals at a smaller subunit that can be scaled at the state and even national level.
In contrast to India, Malaysia piloted the Tool with national-level stakeholders, including the Ministry of Health (MOH) that serves as the primary funder, provider and regulator of the health system. The MOH delivers health services through an extensive network of primary care clinics, and many Malaysians also rely on private clinics for primary care. While the utilization rates of public and private PHC facilities is near equal, the services provided differ; public sector PHC facilities treat more chronic illnesses, whereas private facilities treat acute illnesses and provide curative care.
Malaysia’s government faces two main challenges regarding delivery of PHC—the population’s rising expectations for the scope of public sector health service delivery, and the increasing costs of health services. The Tool presented Malaysia’s MOH with the opportunity to identify misalignments between UHC and PHC goals which could help mitigate these challenges, and also informed an assessment of the effectiveness of its health system and ongoing design of system reforms.
“Alignment of the disparate actors working directly on primary health care towards achieving UHC in Malaysia has not been assessed before,” says Dr. Kamaliah Deputy Director, Primary Care Section, Family Health Development Division, Ministry of Health Malaysia. “The JLN UHC-PHC Self-Assessment Tool provides the means to understand the interaction between them in promoting primary health care and has the potential to assist policymakers in aligning incentives to PHC goals.”
Among the insights resulting from application of the Tool, the pilot revealed private PHC providers lacked awareness of national health policies and health priorities, yet they provide 51 per cent of PHC services and approximately 60 per cent of primary health care expenditures were non-government funds. This finding and other evidence generated by the Tool enabled the Malaysia team to present recommendations for reform to the MOH. The Malaysian government is using the findings from the report to inform ongoing health financing and system reforms.
Next steps for the pilot countries
The pilot teams who administered the Tool and engaged in follow up discussions identified findings and misalignments related to UHC and PHC in their countries and have developed a set of recommended actions to address these misalignments. The teams of JLN members who carried out the pilots reported that the process of engaging and involving different stakeholders in discussions about the tool and reporting their findings was valuable and set the stage for future discussions about PHC-oriented UHC. Each country’s pilot team provided recommendations for next steps for their countries to take to follow up their main findings.
Dr. Kamaliah advises other JLN members who are interested in applying the Tool to, “Go for it! This Tool not only can identify areas of missed opportunities and misaligned incentives in UHC PHC alignment, it helps understand how the various actors interact with each other. If you have mixed financing mechanisms like Malaysia, we hope you will learn from our adaptation of the Tool to reflect this, as the original Tool is focused towards a single payer financing mechanism.”
The Technical Facilitation team from Results for Development Institute, who worked closely JLN member countries to develop the tool and synthesize the report, are interested in helping other countries pilot the Tool in their respective countries.
Click here to download the UHC Primary Health Care Self-Assessment Tool Summary Report, or contact Cynthia Charchi at firstname.lastname@example.org to inquire about piloting the tool.
Cynthia Charchi is a Program Associate at Results for Development Institute.
Nathan Blanchet is a Program Director at Results for Development Institute.