Universal health coverage (UHC) is the main target of sustainable development goal 3, to ensure healthy lives and promote well-being for all at all ages. Primary Health Care (PHC) is essential for access for all to affordable high-quality healthcare and is considered the path towards achieving UHC. Financing PHC is the key to the provision of equitable universal care.^1,2

The Mexican health system is fragmented, which is typical of Latin America countries, and is characterised by different health-care rights for the insured and uninsured. Launched in 2015 and still in the early stages of implementation, the government’s Comprehensive Health Care Model (MAIS) aims to define and monitor patients’ care pathways through the system to ensure timely delivery of quality services.

Mexico currently faces great challenges to guarantee comprehensive PHC (CPHC). Innovative models focused on prevention and control, with strong community participation are a potential way going forward.¹ For this, it is necessary to have growing financing, used efficiently, and sufficiently allocated towards solving PHC priority needs. Likewise, efforts are required to implement and evaluate alternative financing models (for example, incentives for health personnel performance).

In 2014, the total health expenditure in Mexico was US$ 124 410 million, equivalent to 5.78% of its GDP, while the public health expenditure represented 52.62% of this amount (US$ 65 465 million). For this year, the public health expenditure allocated to PHC in Mexico was US$ 36 465 million, or 29.4% of total health expenditure.¹ Per capita Primary Care Health Expenditure (PHCE) at the national level was US$ 233.  Nevertheless, states with the lowest marginality index had a higher investment than the national average. Conversely, the states with the highest marginality index had a per capita of PHCE 2 or 3 times lower than the national average.⁴

In subsequent years, a reduction in the public health expenditure allocated on PHC has been observed. In 2018, this represented only 24.4% of total health expenditure. Great heterogeneity was observed in PHCE by state, with only 4 of them (Mexico City, capital of the country, and 3 southern states) spending more than the recommended 30%.¹ Important differences were also observed between the population with and without social security. At the national level, 19% of PHCE is allocated to the population with social security, the same variability was observed by state, between 14 and 24%.⁵

Additionally, a large proportion of PHCE is dedicated to outpatient care. The major challenge is to increase expenditure on preventive care.⁴ Public spending in PHC was shown to promote more equitable outcomes than spending focused on secondary care. Health policies in Mexico should include improvement in public health financing as part of organized efforts to build a health system centred on the basic principles of primary health care: equity, access, and prevention.

References

1. Assefa Y, Hill PS, Gilks CF, Admassu M, Tesfaye D, Van Damme W. Primary health care contributions to universal health coverage, Ethiopia. Bull World Health Organ. 2020 Dec 1;98(12):894-905A. doi: 10.2471/BLT.19.248328. Epub 2020 Sep 28. PMID: 33293750; PMCID: PMC7716108.
2. Goodyear-Smith F, Bazemore A, Coffman M, et al. Primary care financing: a systematic assessment of research priorities in low- and middle-income countries. BMJ Glob Health 2019;4:e001483. doi:10.1136/bmjgh-2019-001483
3. Productivity Commission 2021, Innovations in Care for Chronic Health Conditions, Productivity Reform Case Study, Canberra. Available at: https://www.pc.gov.au/research/completed/chronic-care-innovations/chronic-care-innovations.pdf (Accessed: May 22 2021)
4. Primary health care systems (PRIMASYS): case study from Mexico. Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO.

India’s most recent health care reforms started in 2005 with the National Rural Health Mission, which specifically targeted to strengthen rural primary health care services in India. Next set of reforms through National Health Policy 2017, introduced the concept of CPHC addressing both communicable and non-communicable diseases through PHC centres with multi-disciplinary teams, and to strengthen the health system through increased government spending. In 2018, with a vision to achieve Universal Health Coverage, the Government of India introduced Ayushman Bharat Program (ABP), which covers prevention and promotion as well as primary, secondary and tertiary care. There are two components of ABP (1) Strengthening of existing Sub Health Centres (SCs) and PHCs to Health and Wellness Centres (HWCs)  which aim to deliver an expanded range of services close to the community, and (2) Pradhan Mantri Jan Arogya Yojana (PMJAY) which focuses on providing financial protection to people below the poverty line for secondary and tertiary level hospitalisation services.

Health system in India:

Sub Centres: As on 31st March 2020, there are a total of 157921 Sub Centres (SCs) functioning both in rural and urban areas of India. These consist of 155404 SCs in rural areas & 2517 SCs in urban areas.

Primary Health Centres: There are 30813 Primary Health Centres (PHCs) functioning in both rural and urban areas in India. These consists of 24918 PHCs in rural areas and 5895 PHCs in urban areas.

Community Health Centres: There are 5649 Community Health Centres (CHCs) functional in the country, consisting of 5183 rural and 466 urban CHCs.

Health and Wellness Centres (HWCs): These centers were established as a component of Ayushman Bharat to provide comprehensive primary healthcare to the population. The program aimed at transforming existing 150,000 Sub- Health Centres and Primary Health Centres into HWCs by December 2022. As of 31^st March 2020,  there is a total of 38595 HWCs functional in India. This includes 18610 SCs that have been converted into HWC-SCs, and 19985 PHCs have been converted into HWC-PHCs. Out of the total HWC-PHCs, 16635 PHCs has been converted into HWCs in rural areas and 3350 in urban areas

Below is a snapshot of HWC operationalisation in two diverse Indian States:

Measuring the comprehensiveness of primary care requires attention to services provided across the life-course, burden of disease and from health promotion to palliation. The Primary Health Care Performance Initiative (PHCPI) (https://improvingphc.org/explore-country-data) selected three indicators to try and measure comprehensiveness of primary care from routinely collected data at a national level. These included the availability of HIV and TB services, services for non-communicable disease and five reproductive-maternal-neonatal-child health (RMNCH) services. A number of countries in sub-Saharan Africa are collaborating with the PHCPI and the evaluation of their comprehensiveness is shown in the Table below. Overall it appears that services for RMNCH are most available, closely followed by services for infectious diseases. Services for non-communicable diseases are much less available and ranged from 6% of facilities in Ghana to 97% in South Africa.  It was also striking that several countries could not provide data for all three indicators. Amongst those countries with complete data, Burkino Faso had the highest overall measurement at 89% and Ghana had the lowest at 55%. 

Table 1: Measurement of comprehensiveness by the PHCPI in ‘trail-blazer’ countries of sub-Saharan Africa 

NA = not available 

The Primary Care Assessment Tool (PCAT) also measures comprehensiveness of primary care across a much broader range of services (Box 1) from the perspective of patients, managers and primary care providers. The PCAT measures comprehensiveness on a scale from 1 to 4, where a score of 3 or more suggests good comprehensiveness. PCAT has been used to measure comprehensiveness in a national survey in South Africa¹, three districts in Malawi² and a set of private sector primary care clinics in Kenya (personal communication Dr Gulnaz Mohamoud). The mean scores for comprehensiveness were 3.2 in South Africa, 2.3 in Malawi and 2.1 in Kenya (personal communication Dr Gulnaz Mahmoud). Interestingly the worst score in this series was for private sector primary care and this may reflect the dominance of hospital-based services, easy access to specialists through health insurance and lack of any gatekeeping function. In Malawi primary care provided in primary hospitals was more comprehensive than care provided in health centres. In South Africa the scores of the managers and providers were significantly higher than that of patients at 3.6 (p<0.001) suggesting that either patients were unaware of the services available or that staff are overly optimistic. Nevertheless, only South Africa appeared to have an acceptable comprehensiveness score, although even there 33% of patients scored comprehensiveness as inadequate. 

Comprehensiveness of primary care, therefore, is still a challenge in sub-Saharan Africa and needs to be addressed. One needs to interrogate whether the lack of comprehensiveness is embedded in policy and system design, related to key inputs such as composition of the primary health care teams, equipment and supplies, or to the capability and motivation of primary care providers. 

Box 1: Services included in assessment of comprehensiveness by PCAT 

Immunisations 

Help with social grants 

Dental care 

Family planning 

Counselling for alcohol, smoking, mental health, HIV, 

TB testing 

Suturing of lacerations 

Tests for hearing and eyesight 

Application of plaster cast 

Cervical cancer screening 

Anorectal examination for colon cancer 

Antenatal care 

Minor surgery for ingrowing toenail 

Services for elderly and frail 

1. Bresick G, Von Pressentin KB, Mash R. Evaluating the performance of South African primary care: a cross-sectional descriptive survey. South African Family Practice. 2019 May 4;61(3):109-16. 

2. Dullie L, Meland E, Hetlevik Ø, et al. Performance of primary care in different healthcare facilities: a cross-sectional study of patients’ experiences in Southern Malawi. BMJ Open 2019;9:e029579. doi:10.1136/ bmjopen-2019-029579