Subscribe to our weekly International update on Health Policies

Strengthening Primary Healthcare is vital to Achieve the Agendas of the 3 UN High-Level Meetings on Health

Strengthening Primary Healthcare is vital to Achieve the Agendas of the 3 UN High-Level Meetings on Health

The United Nations High Level Meetings (UN HLMs) are convened by the UN General Assembly, the main decision-making body of the UN that represents the interests of all member states. Importantly, UN HLMs are seen as the most conducive platform to raise political priorities that are plaguing the world. As the three UN HLMs on health in the New York-based headquarters draw near, key stakeholders need to be ready to argue a strong case for Universal Health Coverage (UHC), Tuberculosis (TB) and Pandemic Prevention, Preparedness and Response (PPPR).

The current state of the three agendas

Three UN High Level agendas are of key interest to the public health community this year. The first two (UHC and TB) have taken a massive hit in recent years while the third one (PPPR) seems already to be losing momentum as the pandemic is becoming a distant memory, at least for most citizens (PPPR only entered the UN’s radar after the emergence of SARS-CoV-2 in 2019; global health security has of course been a concern for much longer).

The waning interest and plummeting investment in UHC have put SDG 3.8 further out of reach. A number of reasons could have led to progress on UHC goals backsliding, including in many countries a reprioritisation of efforts towards addressing climate change and military defence due to the invasion of Ukraine and the unstable situation in the South China sea, among other regionally volatile regional and global issues. Debt crises, looming austerity, and limited fiscal space in many LMICs have also contributed to governments’ reluctance to further invest in UHC at this juncture.

On the global level, support for UHC has also faltered due to the increasing perception that UHC is first and foremost a national agenda and should be financed domestically. Donors have preferred to support vertical programs rather than UHC or other horizontal health systems strengthening programs. This has left LMICs behind in their bid to achieve universal health coverage against the stark reality of poverty in their countries. There is a need for global leadership to step up and address UHC inequities. The global tax justice agenda could be one channel to expand domestic fiscal space for LMICs to invest in UHC.

Unfortunately, the TB agenda presents an even grimmer reality as the progress achieved by national TB programs in certain states was upended during the pandemic. While the annual mortality from TB has been declining from 2005 to 2019, this trend was reversed in 2020 and 2021, overwhelmingly due to SARS CoV-2.

In the realm of PPPR, the Pandemic Fund — a dedicated stream of financial resources to fortify PPPR in low- and middle-income countries (LMICs) — is falling unacceptably short of its fiscal needs, having only raised 13% of the target quantum. This is despite commitments by most world leaders to keep PPPR well-funded as “no one is safe until everyone is safe”, and their rhetoric that no novel contagion will blindside us again. There remains a long (bureaucratic & political) journey ahead till IHR amendments and certainly a pandemic accord will see the light. In the meantime, the UN HLM declaration on PPPR is certainly not as ambitious as it could have been.

Acknowledging the synergy and interlinks between the agendas

Come September 2023 in New York, the world needs to mobilise high-level political support to drive the aforementioned three agendas. Recognition that the agendas directly and indirectly impact each other is critical for global health and humanity. For instance, during the recent pandemic, the lack of PPPR was aggravated by the absence of UHC in many countries. UHC is critical in ensuring that our populations, especially the vulnerable, are protected by providing access to both essential healthcare services and pandemic-related services. A study of 29 countries illuminated the power of UHC in reducing excess mortality and accelerating recovery rates during the COVID-19 pandemic. More upstream, UHC can be a path to make health a global public good and in turn nurture healthier populations which serve as a first line of defence to novel contagions.

Using TB as another example, the prevalence of TB has skyrocketed during the past three years as fiscal and human resources originally dedicated to TB programmes and other essential health services shifted significantly towards managing the pandemic. Tragically, 10.6 million people developed TB in 2021 — an increase of 4.5% from 2020 — with 1.6 million dying from the disease. Moreover, the prevalence of drug-resistant TB increased by 3% from 2020 to 2021, including 450,000 new cases of rifampicin-resistant TB (RR-TB). The reported number of people started on treatment for RR-TB in 2021 was 161,746, only about one in three of those in need. The lack of UHC in many countries resulted in a lack of access to essential TB services such as critical antibiotics, diagnostic tests and directly observed therapy, as supply chain disruptions and reallocation of healthcare personnel brought about by the pandemic further strained the health system.

This has sounded a clarion call for a global resolution to advance these three agendas through the unifying platform of UHC. The decision on the agendas to be discussed is decided through a UN resolution and by vote, after securing the consensuses of national stakeholders. International resolve will be vital.

Strengthening primary health care  to help reach the three agendas

Critically, strong people-centred primary health care (PHC) is essential for all three agendas. We have seen countries that leaned on PHC to reduce morbidity and mortality during the COVID-19 pandemic by offering detection, vaccination, treatment, and health educational services. Resilient and sufficiently resourced PHC is also in a better position to provide universal basic healthcare services, especially to those most in need, reducing catastrophic costs to vulnerable populations. Unfortunately, the window of opportunity for change might be squandered if immediate actions are not taken to boost PHC systems, such as expanding fiscal space for PHC, retaining healthcare workers in PHC settings and learning from the lessons of the past three years.

The UHC 2030 messages consistently emphasise the need to position PHC as a bastion of global health security and equity in both peacetime and emergencies. Fundamentally, PHC is the critical foundation upon which UHC can deliver on its promises. A strong PHC system underpins effective health service delivery, essential public health functions and emergency risk management, while empowering civil society and communities, and promoting gender equality. If implemented properly, a health system that maximises its PHC sector will be equipped to provide 90% of all essential UHC interventions

Successfully bolstering PHC, however, hinges on political and fiscal commitments. Indeed, the (1978) Alma-Ata and (2018) Astana declarations may seem like platitudes when PHC in many parts of the world remains severely and chronically underfunded. Three-quarters of the people in the world, including at least 85% of people residing in LMICs, still do not receive accessible, affordable and quality PHC. These declarations must be resurrected into action to strengthen PHC and realise the three UN HLM agendas in the coming years.

We can move one step closer to achieving the UN HLM agendas if we double down on PHC as a central strategy to meet most of an individual’s health needs through basic preventive, promotive, curative and rehabilitative care provided by trained healthcare and community health workers, well-resourced infrastructure and person-centred care. To achieve this, action is needed in four strategic areas:

First, countries need to commit (sufficient) fiscal resources in a transparent and accountable manner to strengthen their PHC landscape. To do this, there is a need to appreciate the benefits of investing in PHC rather than make PHC budgets the first to go as part of cost-cutting measures in the face of competing national priorities and for some countries, debt servicing.

Second, more needs to be done to attract and retain healthcare workers in the public PHC sector. This can be achieved by offering salaries commensurate to the wages of health staff practising in tertiary hospitals or in urban settings, as well as providing professional development opportunities, reducing bureaucracy, and increasing task-shifting to reduce clinical burden where appropriate. We also advocate for stronger community health worker support and better integration of multi-disciplinary medical teams into PHC. Community health workers are not a means to save costs but are a crucial node in the PHC ecosystem.

Third, policies to strengthen PHC need to be co-created not just with donors and policymakers but also with the community, civil society and PHC providers. Co-engineering will ensure that policies and programmes are patient-centred, inclusive and not duplicative. This aspiration can only be attained when all parties involved are seated at the same decision-making table with equal decision-making power.

Fourth, for structural changes in PHC to take shape, countries will need political and technical leadership to spearhead these PHC reforms. Political commitment must not waver in times of crisis or changing political cycles. On the technical front, reforms should ensure that PHC systems are resilient to shocks and optimally equipped to continue providing health services that go beyond the three agendas, encompassing the non-communicable disease burden, antimicrobial resistance, climate emergencies, emergence of other infectious diseases and poverty among many others. To that end, a shift towards horizontally integrated programmes that deliver coherent services is preferred over vertically siloed ones.

In the new multipolar and geopolitically volatile world, reaching global agreement is even more difficult than it already was before. However, governments, advocates, bilateral and multilateral agencies should seize this – rapidly narrowing – window of opportunity in a post-COVID world to reform PHC before it closes. In the upcoming UN HLMs on health, we call on world leaders to commit to building solid PHC foundations to ensure that everyone everywhere can attain the highest possible standard of health.  PHC might not be sufficient  in the face of the numerous climate and health challenges of the 21st century but it will surely remain essential.

the first author of this article, in a primary care setting in Indonesia, offering essential health services

About Chuan De Foo

Chuan De Foo is a public health professional based at the Leadership Institute for Global Health Transformation (LIGHT) in Singapore and an IHP correspondent. His areas of expertise lie in primary healthcare, health financing for universal health, integrative health delivery models, health equity and pandemic preparedness. Twitter handle: @chuande99.

About Chia Hui Xiang

Chia Hui Xiang is a researcher at the Leadership Institute for Global Health Transformation, Saw Swee Hock School of Public Health and a Master in Public Policy candidate at the Lee Kuan Yew School of Public Policy, both at the National University of Singapore.

About Madhumitha Ayyappan

Madhumitha Ayyappan is a first-year medical student at Duke-NUS Medical School in Singapore. She holds a BA(Honours) in Anthropology from Yale-NUS College and is researching surgical systems strengthening in Southeast Asia.
add a comment

Your email address will not be published. Required fields are marked *