What it is
What others have done
What to ask
How to succeed

What are primary health care policies and why are they important?

The content below is grouped within three central questions stakeholders should consider for strengthening PHC policies and leadership in their health system:

  • What are the steps to PHC policy reform?
  • What are some key pathways to developing policies that ensure quality and improve PHC functions and outcomes?
  • What are some challenges to developing and implementing effective PHC policies?

There are several tools, guides, and example policy documents listed in the resources section of this module and referenced below, which go into great detail on the steps to planning and undertaking policymaking and policy reform including potential challenges and how to meet them. We highlight some of the critical steps and considerations here, and encourage readers to make use of the resources compiled and described in the resources section to assist with these efforts.  

  •  

    Ensure mechanisms for a participatory process (WHO) and legal framework are built into the policy reform process.2

    • Health and health equity are values in their own right and policy reform processes should reflect principles of legitimacy, transparency, accountability, access to information, and collaboration in order to respect these values.2

    Create a culture of shared accountability and engage (WHO) service providers and the population in the decision-making process.45 Good policy engages a very broad group of stakeholders including the workforce, district level managers, and others who will have to operate under it. This involves:

    • Ensuring that any member of an affected program team can identify quality improvement initiatives through direct communication with leadership, and shares in responsibility of identified improvement initiatives.6
    • Legitimizing the roles of community networks to facilitate local health system accountability to users and communities through effective participation, prioritizing transparency and equity.5

    Make PHC a priority (national policy document) of the National Strategic Plan (WHO) and ensure the PHC quality policy (WHO) is linked to the strategic vision of the National Health Plan.457 

    • Making PHC a priority does not require a standalone policy. Policies designed around PHC put PHC at the core of a country’s health strategy. They emphasize the five key functions of primary health care: first point of contact, continuity, comprehensiveness, coordination, and patient-centered care.8 They integrate primary care with other service delivery structures and other policy aims and objectives, and emphasize the individual and community at the center of policy and implementation.9 
    • A National Health Plan (national policy document) is a dynamic medium-term national strategic plan that looks 3-7 years into the future and guides overall strategic reforms in a country.410 
    • A National Strategic Plan (national policy document) links with operational planning to provide the roadmap (national policy document) for how the health plan will be carried out.111213 
    • National health policy should include explicit statements (WHO) regarding:14 
      • necessary framework for policies, laws, and regulations concerning quality;
      • equity, affordability, sustainability, and efficiency;
      • factors (medical, technical, or organizational) that influence quality of care;
      • active involvement of consumers in developing indicators and standards for quality assurance in health care; 
      • appropriate incentives for participation in quality improvement;
      • requirement of quality improvement systems as a condition for funding contracts with practitioners, hospitals, and health care organizations.

    Designate PHC institutional structures (national policy document) including a national body to coordinate, monitor, integrate, and implement national PHC policy and policy frameworks that enable a balance of local autonomy and central direction in particular areas of decision-making.13

    • For example, the Joint Consultative Forum is the highest governance body in Ethiopia charged with overseeing and facilitating the implementation of the country’s Health Sector Transformation Plan. Its membership includes the MOH, other relevant government bodies, development partners, NGOs, and others.13 
    • Further, it is important to ensure the national coordinating body has adequate authority, budget, and staff to successfully conduct its mandate.9 

    Use operational planning (WHO) to develop a detailed framework for action based on strategic vision, defining key tasks, assigning responsibilities, identifying milestones, and considering practical aspects of implementation.411

    Define clear structure, roles, and responsibilities (WHO) within policies for key individuals and organizations charged with overseeing specific elements of strategy implementation.11 Build in joint review of the progress towards PHC-related objectives with a broad range of stakeholders.9

    • This can help ensure the capacity of individuals and groups are fully utilized and can help identify where responsibilities can be shared more broadly across the health sector.11
    • The joint review process should include assessments of situational analysis and programming; process, costs, and financing; implementation and management arrangements; and results, monitoring, and review mechanisms. With inclusive participation, this process can help improve the quality of and confidence in strategies, and improve coordination.9
  • Ground PHC policy in data and facility-based evidence (Health Finance & Governance Project, WHO), with PHC stakeholders as partners and a feedback process to make sure data inform steps for improvement.711

    • Effective national health strategy relies on data to inform selection of priorities, clarify governance and structures, to develop interventions and define a service package, and to craft a practical framework for monitoring and evaluation.11

    Ensure policies around PHC include the fundamentals: that a service package is defined, that mechanisms for financing PHC are identified, and that a system for monitoring and evaluation is established.9

    Strengthen policy implementation (WHO) to address health inequity with legislation and funding, clear health equity goals (national policy document) to guide implementation, and a learning approach to implementation, monitoring, and evaluation.2 Some steps to achieving this include:

    • Developing legislation and funding for policies including the right to health;2 
    • Establishing clear health equity goals that will guide implementation and enable equity-based evaluation;2 and
    • Monitoring and evaluating the experiences of implementation and use those lessons to inform future iterations of policy and programming.4

    Create demand from the bottom-up (Health Finance & Governance Project) to ensure a unified vision and priority for high-quality PHC as a public right in the face of changes in political leadership.7 

    • Educating and engaging communities to understand high quality care as a right, and working with facilities to ask for the support and resources they need to provide that quality care, can help provide the demand and prioritization of quality care at the national level that is needed to make it a sustained priority.7 

    Aim for health in all policies (HiAP) where appropriate (WHO), to increase accountability of policymakers for health impacts at all levels.2 

    1. Establish the need and priorities for HiAP
    2. Frame planned action
    3. Identify supportive structures and processes
    4. Facilitate assessment and engagement
    5. Ensure monitoring, evaluation, and reporting
    6. Build capacity
  • Gaps between written policy and implementation capacity (peer-reviewed article), due to politics, public trust and perception, competing economic incentives, corruption, and other potential realities. 15

    • For example, Thailand’s experience (peer-reviewed article) of a politically-motivated policy that attempted to rapidly scale up a health screening program without ensuring that it could be effectively implemented, leading to an unsuccessful program outcome. 16
    • It can be a delicate balance to take advantage of a national political window of opportunity for policy development while also ensuring time for the planning and preparation needed to support implementation.15 Being aware and proactively planning for such windows can help facilitate successful implementation.

    Quality data for decision-making (Health Finance & Governance Project) is often lacking, but it is important for ensuring politicians and policy makers to have access to data that can facilitate strategic decisions for improving service quality.7 

    • It is generally known that evidence is critical for informed policy development and prioritization, yet progress towards efficient data collection and utilization has been slow. According to Tarantino and colleagues7, “in the majority of the countries, monitoring and evaluation of quality is conducted by ministries of health or by quality assurance units or programs. However, quality monitoring data are rarely published or made widely available…we found evidence of data being used to inform quality improvement in only five countries.”
    • Approaches to strengthening data quality and access by decision makers include developing data training for people at every level in the system, creating special teams to focus on collecting and validating data within different levels of the health care system, simplifying the data required to be collected, and supporting efforts to collect and track data in real time.7 

    Generating political priority (peer-reviewed article) and sustained support (Health Finance & Governance Project), including connecting national plans to global agendas.57 17 These are critical components to developing sustainable and supported PHC policies, but can be hampered by lack of understanding or appreciation for quality care, inadequate advocacy, and insufficient data among other things.7 

    • Some solutions that planners and implementers in an array of LMICs have had successes with include using data, including dashboards and infographics, for lobbying; prioritizing quality in national health strategies to help streamline political support; using global statements, resolutions, and commitments to garner national and local political will; and encouraging benchmarking and peer-to-peer accountability within regions to facilitate competition for improved quality. 7
    • Successful policy reform involves advocacy from political leaders who think an issue is worthy of sustained attention.17 Use of data to illustrate the need for reform, and finding the right people help drive policy change, can help establish a policy environment more receptive to change.

    Unforeseen challenges (WHO) that require amendments to the policies. These can be mitigated by building in additional vetting and consultation during the policy development process, through tools like formal process evaluation and committees for strategy oversight. It is important to plan for how to monitor and troubleshoot early challenges during the policy implementation process, and ensure processes for feedback to overseeing individuals and agencies responsible for correction.11

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.

What has been done elsewhere to improve primary health care policies?

  • Indonesia is a country that has historically experienced high levels of geographic inequality in terms of levels of poverty, range in health care access, and in household burden of health care expenses.18 19 20 For much of the late 20th century, the country’s large population was ruled by a strong central government, which often did not prioritize the needs or conditions of its far-flung citizens.18 The country underwent decentralization starting in 2001, which allowed for greater policy experimentation at local levels. This created opportunities for communities to try to improve access to primary health care services, and locally elected leaders began to link promises for expanded health care coverage to election campaigns.18 Over time, successful policies developed at the local level were adopted nationally18, while the national government also began expanding single-payer health coverage. Initially only civil servants, the police, and the military were covered by national health care, which progressively expanded to include the country’s poorest citizens, and then to bring in coverage for pregnant women.19 21This incremental progress allowed the government to gradually develop and implement laws and regulations, and respond to challenges as they arose, particularly in trying to integrate its many programs into one place.19 20 

    In Indonesia, successful health system reforms have been underpinned by a strong legal and regulatory framework.22 The country’s new single-payer national health insurance scheme was put into place over a period of two decades. When it takes full effect in 2019 it is likely to become the biggest single payer system in the world.20 23The country has faced challenges to the health reform agenda. Worker shortages in parts of the country, poor quality of care, inequitable access, and high maternal mortality rates are all major hurdles.24 The health reform process, combined with the decentralized nature of service delivery, has created communication and management challenges across the health system, which potentially limited efforts to strengthen the quality of health care.22 However, planners and implementers took steps to anticipate these challenges. A former Health Minister, who helped to lead the reform process, wrote that “we tried hard to create the best system possible…but we also knew that we would need to make adjustments as we implemented” 19. Critical elements to creating the framework for successful reform included strong political commitment and buy-in from partners inside and outside of health sectors, including the national planning board, Parliament, and ministries of finance and home affairs.25 Additionally, comprehensive analysis of the national health system - in terms of both coverage and quality - along with multiparty participation in developing and implementing the plans that included national and local-level authorities and input from provider associations; and systematic, continuous monitoring and evaluation that included technical and administrative perspectives and helped ensure successful reform.19

  • Peru has achieved major increases in health coverage in recent decades, especially for the poor.26 Health sector reform began in the 1990s, and health service coverage rose above 80% of the population by 2014.27Along the way, successful steps toward scaling up were supported by broad political consensus along the way. Health reform measures were introduced by the country's ruling political party in 1998 but eventually gained the cross-party approval of a Universal Health Insurance scheme.28 This bipartisan support was particularly important in a decentralizing health system where the national government sets overall policies and frameworks, to be carried out by local and regional authorities.29 Peru’s progress towards universal health coverage was initially based on pilot schemes, which it scaled up over time, eventually expanding health legislation to include full population coverage.28 In the early 2000s efforts were made to promote policy dialogue and consensus around health sector reform, helping to strengthen the foundation for this progress. These were followed by efforts to strengthen capacity and governance capabilities of the Peruvian Ministry of Health as well as within regional and local entities.27 

    Peru’s progress towards comprehensive health care began seriously in the late 1990s. In 1999 specific categories of workers were guaranteed health coverage. This was expanded in 2002 to include informal sector workers and the poor. Over the next few years, public health services provision began to be regionalized, moving management of public health centers, supervision and control of production, and organization of levels of care from the central to regional governments.30 In 2007, a semi-contributory regime was introduced, in which public funds were combined with private contributions.31 Finally, in 2009, legislation instituting universal health insurance was passed32 and in 2010 the Universal Health Insurance Law was created in 2010 as a regulatory framework to achieve universal health coverage by integrating the two main social insurance funds that had been established in prior years.19 Following this, in 2012 the president requested health reform guidelines be developed to ensure access and quality of health services.32 Peru’s policy successes have resulted from a strong emphasis on planning, consensus-building, inclusive participation by the public and private health sectors, and progressive legislative reforms.27

  • Background

    In Malawi, policymakers have used data and statistics on reproductive health practices to make gradual changes to the primary health care system through policy development. Over two-thirds of Malawi’s population is under 25, and many young people begin having sex before age 18.33 In 2015, just about half of sexually active young men ages 15-24 reported using condoms, while one in three unmarried sexually active girls ages 15-19 reported using contraception.34 Low educational attainment is an ongoing challenge with only 37% of 15-19-year-olds reporting completion of primary education, and a high proportion of adolescent women marry and have children before age 18.35 Almost 30% of all pregnancies in 2016 were unintended 36, and three in 10 teenage girls in Malawi reported dropping out of school due to teen pregnancy. 34 Comprehensive knowledge about HIV/AIDS was low among young people, and data from 2008 showed that just under half of maternal deaths in Malawi were among girls and young women ages 14-23.

    Evidence-based policy development to promote reproductive health and family planning

    In Malawi, the government focused on improving access to the underserved youth population, finding that often services were not available, convenient, or acceptable. Young people needed basic information about their bodies and about prevention of pregnancy and sexually transmitted infections, but they also needed services that would address gender inequality and empowerment, their rights and responsibilities, and sexual and reproductive decision making.37 In 2013, Malawi’s government passed the Gender Equality Act, giving young people the right to high-quality, accessible, and acceptable sexual and reproductive health services.34 Public health facilities were mandated to provide free care for youth aged 24 and under.34 New policies on youth and population linked adolescent family planning services to policies around adolescent development, and Malawi became a signatory to all major international agreements and treaties focused on supporting adolescent access to family planning.33 

    Focus on equity and broad stakeholder engagement

    The government worked with stakeholders across the Ministry of Health and other ministries, regulatory bodies, development partners, implementing partners and NGOs, and networks and associations including youth councils 36 to develop policies tailored to the family planning needs of adolescents and sexually active, unmarried young people.33 These included policies to promote male involvement in family planning behaviors, such as the National Sexual and Reproductive Health and Rights Policy (2015-2020) whose guiding principles included community participation, evidence-based decision making, and equity-based approach, partnership and multisectoral collaboration, and accountability.37 Male involvement is being viewed by Malawi’s government as “a new health or social and behavioural change activity,” having found that “male unfriendly infrastructure at the health facilities, illiteracy, ignorance, poverty, increasing rural urban migration, and cultural beliefs contribute to lack of male involvement” in sexual and reproductive health issues.37

    Progress tailoring PHC policies, but still more to be done

    Between 2010 and 2015, Malawi’s total fertility rate was reduced from 5.7 to 4.4, but age-specific reductions showed still more needs to be done to decrease rates among young women between ages 15-19 and 20-24.38 Many of the evidence-based policy changes are still too recent to show profound changes. However, a 2018 focus group study of youth and their parents or guardians found that while awareness of the different types of contraceptive options were high, misconceptions of their mechanisms were common – and that youth who had dropped out of school had lower knowledge about family planning than those who were still in school.38 Primary health care facilities are an important route to improving knowledge and equitable access, but support and time are needed to turn national policy commitments into programs implemented in a standardized way across communities and health care facilities nationwide.39

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.

What questions should be considered to begin improvements?

The questions below may be a useful starting place for determining if Primary Health Care Policies are an appropriate area of focus for a given context and how one might begin to plan and enact reforms:

Who is in charge of implementing the policy, knowing if it is working, and subsequently taking action to improve upon it?

Identify the key stakeholders by name or role, ensure that people are clear on their responsibilities, and that all the stakeholders are educated on and have a shared understanding, and definition, of quality. Make sure operational planning and detailed implementation planning are part of the policy planning process to avoid challenges stemming from policies that are out of alignment with practical realities.

Is there appetite for policy reform in the government and among stakeholders? Are there structures in place to ensure decision makers have access to quality data?

Stakeholder engagement supports policy development by fostering dialogue and discussion, which can create a more welcoming environment for legitimizing and implementing policy.7 Advocacy plays an important role in developing and sustaining political priority. Cohesion in the policy community, identification of individuals who will champion policy change, and advocacy for clear policy proposals have proven to be important steps to creating an environment that supports reform.17 Quality data is another important element to legitimizing policy, but can be more challenging. Measuring quality, determining which data to use, and connecting the data that is needed to the appropriate users are important steps. Integrating the use of data into decision making, accountability mechanisms, and policy decisions are important elements that many governments still struggle to put in place.7 Some potential approaches to strengthening data quality and access by decision makers include data training for people at every level in the system, development of special teams to focus on collecting and validating data within different levels of the health care system, simplification of the data that is required to be collected, and support for efforts to collect and track data in real time.7

What are the accountability mechanisms in place or available to ensure a transparent, equitable, and participatory policy making process?

Approaches include peer monitoring, in which neighboring decision makers or stakeholders who have gone through similar processes and can share their experience and help bolster the process are brought in. Another approach is to make sure that broad stakeholder participation is part of the process from the planning stage. It is important to plan for the unexpected in order to have a process in place for how to resolve unanticipated challenges without derailing the policy process.

Is there sufficient engagement and capacity within the ministry of health to lead or be instrumentally involved in reforms – and are there links to other government sectors, or opportunities to develop them?

Health in all policies approaches require engagement of relevant actors within and beyond the health sector – as well as the promotion of actions that take health implications into consideration at every level of government.2 Structures like interdepartmental committees can help to support the implementation process and develop broader networks to help with policy planning and development.2 At the same time, it is helpful to develop capacity in other ministries, so that stakeholders across sectors understand the contribution of health impacts to their own work.2

What are the mechanisms for engagement from civil society stakeholders? Is there demand for reform or policy development from this community? If not, what are the opportunities to strengthen awareness and involvement from these stakeholders?

Civil society engagement is a vital element of growing and sustaining a culture of quality. Patients, communities, and the media must have access to information and resources to shape their preferences and develop strategies in order to hold providers accountable and demand higher quality services.22 Community engagement can be time-intensive, and it can be challenging to determine how best to use feedback gained through this process, but participation is critical and should be planned into the process and accommodated for.7 More information can be found in the social accountability module.

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.

What elements should be in place to support effective improvements?

In order for interventions aimed at improving Primary Health Care Policies and leadership to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously:

  • Social accountability is a measure of whether a country is held accountable to existing and emerging social concerns and priorities based on need relevant to PHC of internal and external stakeholders. It is a key element to have in place or actively strengthen as a mechanism to ensure appropriate actions to develop or reform PHC policies and leadership. In the same way that PHC policies are best when incorporating the experience and priorities of the full spectrum of stakeholders, social accountability involves close collaboration among citizen groups, marginalized populations, private sector, civil society organizations, non-governmental organizations, non-health actors, and other stakeholders in health care planning, policy formation, monitoring, and evaluation.

    Learn more in the Social Accountability Improvement Strategies module.

  • Health financing and particularly the availability of funding for PHC is a vital aspect to creating an environment for successful PHC policy development and, crucially, operationalization of such policies. This subdomain addresses the efficacy of health systems to mobilize adequate funds for health in order to ensure access to PHC in a financially sustainable manner. It can also ensure equitable and efficient use of resources, both of which are critical to fostering strong PHC governance elements.

    Learn more in the Health Financing: Spending on Primary Health Care Improvement Strategies module.

  • This includes surveillance and routine information collection of information about population health status and needs in order to support priority setting, innovation, and learning. These are essential processes that feed back into strong PHC policies and leadership informed by accurate and up-to-date evidence.

    Learn more in the Adjustment to Population Health Needs Improvement Strategies module.

  • Communities are an important part of the PHC policy development and implementation process as users – the rightful recipients of quality primary health care. As individuals in leadership positions change, often more quickly than policy development and implementation processes occur, ongoing community engagement can help to guarantee sustained oversight and demand for the policies that are developed. Community engagement is critical to strengthening appropriate health care policies and ensuring that social accountability needs are met.

    Learn more in the Community Engagement Improvement Strategies module.

References:

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  2. Health in all policies: Framework for Action. Geneva: World Health Organization; 2014. https://www.who.int/cardiovascular_diseases/140120HPRHiAPFramework.pdf
  3. Kickbusch I and Szabo MMC. A new governance space for health. Glob Health Action 2014, 7: 23507. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925805/ 
  4. Strategizing national health in the 21st century: a handbook. World Health Organization; 2016. https://www.who.int/healthsystems/publications/nhpsp-handbook/en/
  5. Technical series on Primary Health Care. Primary health care: transforming vision into action: Operational Framework. Geneva: World Health Organization; 2018. https://www.who.int/docs/default-source/primary-health-care-conference/operational-framework.pdf?sfvrsn=6e73ae2a_2
  6. Quality Management Program Guide. Ministry of Health and Child Care, Zimbabwe; 2015. (Accessed 20 June, 2019). https://depts.washington.edu/edgh/zimbabwe-hit/web/project-resources/national_QI_program_guide.pdf
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  29. Primary health care systems (PRIMASYS): case study from Peru, abridged version. Geneva: World Health Organization; 2017. https://www.who.int/alliance-hpsr/projects/alliancehpsr_peruabridgedprimasys.pdf?ua=1
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  33. Health Policy Plus. 2017. Review of Adolescent Family Planning Policies in Malawi. Washington, DC: Palladium, Health Policy Project. http://www.healthpolicyplus.com/ns/pubs/7159-7279_MalawiAdolescentFPPolicyBrief.pdf
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