The Investment Case for Strengthening Primary Healthcare and Community Health Worker Programs in Low- and Lower-Middle-Income Countries

Abstract

Universal health coverage is within reach of even the poorest countries if these countries are helped to expand their systems of primary healthcare (PHC). The overriding theme is that PHC (with a strong community outreach component) is the best bargain on the planet—alongside spending on primary and secondary education. Investing in PHC, both from domestic revenues and international grants and loans as necessary, can save millions of lives per year at a remarkably low cost. Many low- and middle-income countries (LMICs) direct too many resources to tertiary care rather than PHC. Community outreach programs, notably those that include community health workers, are chronically underfunded, even disproportionately relative to overall funding government for healthcare. In many or most LMICs, the political pressure on national policymakers is, strangely enough, to expand investments in higher level health facilities and specialized care—especially for hospitals. As a result, the underfunding of PHC leads to a vicious cycle. Because PHC services are underfunded, the quality of these services is weak, and patients bypass these facilities to obtain urgent PHC services they need at hospitals. Underutilization of PHC services at PHC facilities and provision of PHC services at hospitals leads to increased funding for hospitals, at leading to progressively lower levels of funding for PHC facilities and for strong community outreach. There is an immediate need to recognize community-level health programs as a permanent feature of effective health systems (even in high-income countries). Additional funding is needed to enable the concerted strengthening and expansion of PHC services in low- and lower-middle-income countries. This would enable, among other things, community health workers to reach their full potential and provide a broad range of life-saving and life-improving services by allocating the skills, supplies, supervision, salaries, and career opportunities that are needed.