OPM’s health consultant Odd Hanssen discusses a ground-breaking new report on defining and measuring primary healthcare expenditure
Primary healthcare is often cited as the key way to reach the health Sustainable Development Goal (SDG 3), as well as being an essential strategy of achieving universal health coverage (UHC). Often, donors and partners emphasise primary healthcare (PHC) as the type of health investments they want to support and scale up. However, despite all this, no precise definition of what counts as PHC has been put down.
A new paper, focusing on measuring primary health care expenditure in low- and middle-income countries, tries to bridge this gap by proposing a few definitions of what PHC entails, and, by applying these definitions to reports of national health accounts, enables cross country comparisons. While some contentious points still remain, such as how to adequately capture capital and private health expenditure, this report is a step forward in creating a standard definition for PHC across the world, and how to measure it.
- Defining primary healthcare: for many, a discussion about PHC evokes ideas of services that are delivered at particular types of facility, or the entire facility itself. However, many services that are clearly of a primary care nature, such as vaccinations, are often delivered through different channels, such as through campaigns. This paper proposes a new way to define PHC by identifying spending by healthcare function, which allows the capture of all services that can be considered as of a PHC nature.
- Enabling cross-country comparisons, or monitoring progress on primary healthcare spending: a key part of having a set definition on what constitutes as PHC is to be able to compare across countries how much is being spent on it, and to see how a country has changed its spending in this area over time. This means a country can consider whether it is spending enough, relative to other countries, or demonstrate it has made progress, relative to its position in the past.
- Helping countries contextualise their visions of primary healthcare: this new report proposes several definitions of what PHC includes, allowing countries a closer alignment between the type of healthcare model and framework envisioned for PHC at a local level and the concept at the global level. While a wide range of things can be considered within a broader scope of PHC, identifying which definition a country is most aligned with, such as including or excluding types of outpatient care, other services linked to main care (e.g. ancillary care), or inter-sectoral services and activities, allows for a fair comparison of progress and a clearer discussion of what is meant as PHC in each country.
Exploring remaining limitations
- Relying on national health expenditure data: while there is a clear demand for a comparable measure of what spending on PHC entails, the largest limitation remains – high quality recollection of health expenditure data. While the system of health accounts framework proposes different categories for how to disaggregate health expenditure data, few countries do this in practice. National records often struggle to capture these due to gaps in capacity. To more accurately reflect a country’s prioritisation of PHC, through its share of spending in this area, countries continue to need assistance in producing national health accounts reports and studies.
- Reporting private purchases of medical goods: while it is difficult to imagine a correct estimate of PHC spending without including all relevant medical goods, how to include all of these remains an issue. Due to the nature of expenditure tracking, the reporting of private purchases of medical goods outside of health facilities, such as those obtained in pharmacies, cannot be tracked to the service or function they relate to. While realising that it would represent a clear overestimation health spending in this area, an alternative proxy measure, such as equivalent proportion from public sector goods being applied to private sector goods, could be included to substitute the incomplete option of complete exclusion of all privately purchased medical products.
- Excluding capital investment: due to the nature of the national health accounting framework, the definition of PHC used in the report excludes capital investment. However, the need to build additional health facilities, particularly health posts and health centres, which lead the way in delivering these services, should not be overlooked, and a definition of PHC and its related expenditures should attempt to incorporate such spending in the future.