For many marginalised and vulnerable populations, access to quality healthcare remains out of reach, despite overall global health progress. “There are 400 million people worldwide who do not have access,” said Dr Daniel Poulter MP, Chair of the All-Party Parliamentary Group on Global Health. “In 2015, 5.9 million children died from illnesses that are preventable and treatable.”
Dr Poulter’s comments were made as host of a roundtable in the House of Commons last month, held to discuss Malaria Consortium’s recent report, Community-Based Primary Healthcare: The Key to Unlocking Health for All. The discussion was convened by Malaria Consortium and chaired by John McConnell, Editor-in-Chief of The Lancet Infectious Diseases, with high-level participants from the UK Department for International Development (DFID), World Health Organization (WHO), Comic Relief, GlaxoSmithKlein, University of Washington, CORE Group and Malaria Consortium.
The report outlines the role that community-based primary healthcare (CBPHC) can play in extending quality assured health services to remote, underserved communities. In doing so, CBPHC can contribute towards achieving the Sustainable Development Goals’ (SDGs) objective of achieving universal health coverage by 2030.
One of the key factors for the success of CBPHC programmes is their acceptance by the communities they are established to serve. Harriet Jameson, Comic Relief, remarked upon the importance of considering relationship building as a critical investment from the start. Programmes are often designed and implemented with limited or no involvement of the community and national government, she said, making it difficult to create programmes that are sustainable beyond the life of the project. Salim Sadruddin, WHO, agreed with this, and went on to stress the need for non-governmental organisations (NGOs) to be more actively engaged with Ministries of Health and Ministries of Finance within the countries that they operate, since it is they who have ultimate responsibility for the health of the population.
“We provide the evidence base of what works, but communities and governments have the knowledge of what method will work in their communities,” added Paul Freeman, University of Washington. Although it may be more costly at the start, by building trust, creating mutual commitments, discussing expectations and involving communities during the design stage of CBPHC activities, the acceptability of the services will be higher, and when services are accepted and utilised, they are more likely to show long-term positive impacts on health
Jonny Baxter, DFID, agreed that longer term sustainability does take time, and may actually require less cost-effective starts. In order to persuade Ministries of Health and Ministries of Finance to fund these programmes, data-driven evidence is needed to demonstrate the effectiveness of CBPHC, and the economic returns gained from investing in them.
How to ensure the sustainability of CBPHC after donor funding ends was an important issue for Salim Saddudin, WHO. “To continue the gains and sustainability of donor-funded initiatives, it is important that all programmes start with sustainability in mind, with a gradual transfer of responsibilities to the government during the life of the project. Ideally, the government should make a commitment to provide resources beyond the life of the programme.”
“The project may do a lot of good,” added Dr. Poulter, “but unless it’s actually linked with the broader national agenda, it could not necessarily have the legacy or the lasting impact that may be desired, or could be achieved, if there’s a good enough efficacy of the intervention.” He reiterated Jonny Baxter’s earlier comments on the need for evidence, and posed the question, “How do we make sure evidence is gathered and worthwhile partnerships are being fostered?”
Dr James Tibenderana, Malaria Consortium, stressed that it is only by ensuring the quality of CBPHC that national governments will view these programmes as extensions of the health system, and therefore worth investing in. “Quality is essential. We cannot achieve universal health coverage if we are only delivering access,” said Dr Tibenderana. “If you have quality at the heart of any programme, you will be forced to address issues of sustainability and transferring programmes to government funding.” We often focus on extending access to services, rather than ensuring that they are of sufficient quality, but both are integral and should not be considered separate. By emphasising the quality of health services, he explained, this will also improve the uptake of health services by communities.
The advent of new easy-to-use diagnostic tools and drugs, and the adoption of mobile technology approaches, have made it easier for community health workers to provide quality healthcare and increase the range of health services. However, while technology can support, strengthen and improve CBPHC programmes, a more harmonised approach to technology and digital strategies is required in order to realise its true potential.
“I think what has happened with mobile technology in African and Asian countries represents a great opportunity,” said Helen Counihan, Malaria Consortium. However, implementing digital strategies within CBPHC programmes cannot overcome the challenges of weak governance and poor implementation, she warned. “Introducing any type of digital strategy is really only as good as the health system you apply it to. These interventions can have a great impact, but they will not fix a broken health system.”
By tackling the leading causes of childhood and maternal illness, which have such a large impact on development within a community, CBPHC, when implemented with quality in mind, can positively impact over than half of the 17 Global Goals for Sustainable Development. Through a strengthened health system and quality CBPHC activities, lives are saved, but also by improving the level of quality health services that are available at the community level, and communities can be helped to thrive. “We need to concentrate on ‘Survive, Thrive and Transform’ within primary healthcare,” said Lisa Hilmi, CORE Group. “People are committed to ‘Survive’, but not so much to the ‘Thrive’ and ‘Transform’.”
The roundtable brought together partners and experts to begin the conversation on extending access to quality health services in low income countries, but it is important this is sustained in order to push the CBPHC agenda forward, as Dr Poulter emphasised in his closing remarks: “It’s about how we develop and build the evidence base, and link that in to making meaningful change at the governmental level. It is a very welcome report, and we want to make sure we continue to make a difference. I look forward to working with the group here, and with others, to continue these discussions.”
For more information about community-based primary healthcare, download our report.