Measuring primary health care expenditure in low and lower-middle income countries

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    The 1978 Alma Ata Declaration on Primary Health Care (PHC) was touted as an integral step to achieving health for all (WHO, 1978). More recently, the 2008 World Health Report, WHA following resolutions, and the Sustainable Development Goals (SDG5) re-emphasized the importance of PHC in recognition that regardless of a country's income status, the majority of health conditions can be addressed via primary care interventions (Kruk, Porignon, Rockers, & Van Lerberghe, 2010; Starfield, Shi, & Macinko, 2005; WHO, 2008). PHC is recognized as the foundation of any health system and as the most effective, efficient, and equitable approach to delivering essential health services to the majority of the population for the lowest cost (Atun, 2004; Bitton et al., 2017; Engstrom, Foldevi, & Borgquist, 2001; Kringos et aL, 2013; Kruk et al., 2010; Phillips & Bazemore, 2010; Rao & Pilot, 2014; Starfield et al., 2005; Stigler, Macinko, Pettigrew, Kumar, & van Weel, 2016; Veillard et al., 2017).

    Today PHC is considered as the trajectory to UHC and to achieving SDGs. Increasing spending on PHC services (especially from domestic sources to improve the sustainability of financing) is a mounting priority (Bitton et al., 2017; Ly et al., 2016; Nayyar & Chatterjee, 2018, 2018; Stigler et al., 2016). Yet, there is considerable global debate about how to define PHC, how PHC service delivery should be structured and organized (Macinko, Starfield, & Shi, 2003; OECD, 2016; Starfield et al., 2005; Stigler et al., 2016). Measuring PHC expenditure in a comparative and standard manner is a critical first step to understanding why some countries are doing better than others and where extra efforts can be made to gain better performance. However, there is no framework for countries to use to guide data collection or routine tracking of the resources spent specifically on PHC in a systematic way (Gurkan, Kaiser, & Voorbraak, 2009; Maeda, Harrit, Mabuchi, Siadat, & Nagpal, 2012; OECD/Eurostat/WHO, 2017; Pradhan, 1996; UNAIDS, 2009). The System of Health Accounts 2011 (SHA 2011) is commonly used as the global standard in tracking health expenditure (OECD/Eurostat/WHO, 2017), but PHC is not a category under any of the classifications. The components of PHC are included under different classifications (OECD, 2016).

    The objective of this paper is to develop a standardized methodology to measure PHC expenditure using SHA 2011; provide comparative PHC expenditure estimates for the first time for a sizable number of countries; and formulate recommendations for future PHC expenditure tracking. The paper is structured in four sections with a section on the problem statement, section 2 on methods and data, section 3 on descriptive analysis of preliminary results, and section 4 on discussion and recommendations.