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Marziyat Sarbasheva et al. RT&A, Special Issue № 6 (81), Part-3, SUSTAINABLE DEVELOPMENT OF PRIMARY..._Volume 19, December 2024
SUSTAINABLE DEVELOPMENT OF PRIMARY HEALTH
CARE SYSTEMS
Marziyat Sarbasheva, Zukhra Makhieva, Aina Maltsagova, Laura Khadzhieva,
Magomed Dzhafarov
Medical Academy named after Kh.M. Berbekov, RUSSIA [email protected]
Abstract
Sustainable development of primary health care systems is the basis for ensuring universal access to health services and improving the health of the population. The most important aspects of a sustainable approach are equity, accessibility and focus on the needs of the local community, which includes both disease prevention and treatment. Key areas of development are strengthening the medical infrastructure, improving the skills of personnel and introducing digital technologies to improve the quality of services. Adopting a strategy aimed at eliminating the social determinants of health helps to increase the resilience of health systems and their readiness to respond to emergencies. Involving the population in decision-making processes helps to more accurately take into account local needs and improve health literacy. Sustainable primary health care systems can significantly reduce health care costs, improve quality of life and contribute to a healthier society.
Keywords: primary health care, sustainable development, universal health coverage, health systems strengthening, health equity, community engagement, health workforce, social determinants of health, health infrastructure, digital health technologies
I. Introduction
Primary health care (PHC) is the foundation of any sustainable health system, providing accessible, comprehensive and equitable health care. The need for PHC development has increased significantly in recent decades due to global health challenges, including demographic changes, the rise of chronic diseases, pandemics and climate change. Sustainable development of primary care systems aims to create flexible and resilient structures that can adapt to the changing needs of society and effectively respond to new challenges.
One of the key challenges is to achieve universal health coverage (WHO), which requires expanding access to quality PHC services for all segments of the population, including vulnerable and disadvantaged groups. Sustainable development of PHC also involves eliminating health inequalities, when socioeconomic factors such as income, education and living conditions affect access to health care and people's health. This requires the implementation of integrated approaches aimed at improving the social determinants of health and involving local communities in decision-making.
The integration of modern technologies and innovations in primary health care also plays a key role in sustainable development. Digital technologies, telemedicine and electronic record-keeping systems can significantly improve the efficiency of health care delivery, especially in remote and hard-to-reach areas. The introduction of such technologies improves coordination between different levels of health care, facilitates timely provision of care and reduces the burden on specialized institutions.
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r ^
Strong leadership and government in human rights (or health
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Creating asystems cycle of feedback
using data to inform health care
L. J
Primary Health Care
Prioritisation of cost-effective interventions
Supporting skilled
and equipped health workers at all levels of the health system A
Establishing an interactive and integrated culture of community engagement
Providing an integrated continuum of care at the community level a
Figure 1: Core principles & components for effective implementation of primary health care
However, despite significant achievements, many countries continue to face challenges related to insufficient funding, shortages of health workers and weak infrastructure. These problems are exacerbated by inequalities in access to quality health services, especially in low- and middle-income countries. Developing sustainable primary health care systems requires a comprehensive approach that includes health policy reform, improved workforce training and the creation of stable financial mechanisms to ensure sustainability.
Sustainable development of primary health care is therefore a prerequisite for achieving the Sustainable Development Goals (SDGs) related to health and well-being. This paper examines key strategies and approaches to strengthen PHC systems, including the introduction of technology solutions, policy reform, and community engagement in health governance and decision-making processes.
II. Methods
This study employed a comprehensive approach to analyze the contributions of primary health care to achieving health-related Sustainable Development Goals (SDGs). The methods utilized included:
1. Literature Review: An extensive review of existing literature on primary health care and its role in public health was conducted. This involved analyzing peer-reviewed articles, reports from international organizations, and relevant policy documents.
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2. Data Collection: Quantitative data was gathered from national health statistics and databases, focusing on indicators related to health outcomes, access to primary care services, and SDG progress. Qualitative data was also collected through interviews with healthcare professionals and stakeholders to gain insights into barriers and facilitators of primary health care implementation.
3. Stakeholder Analysis: Key stakeholders, including government agencies, nongovernmental organizations, and community representatives, were identified and engaged. Their perspectives on the effectiveness of primary health care services and their impact on health equity were sought.
4. Case Studies: Specific case studies were conducted in various regions to illustrate best practices and challenges in primary health care delivery. These case studies provided context-specific insights and highlighted successful interventions that align with SDG objectives.
5. Policy Recommendations: Based on the findings, policy recommendations were developed to enhance the effectiveness of primary health care services. These recommendations aimed to address identified barriers and promote multisectoral collaboration to achieve health-related SDGs.
The analysis emphasized a holistic view of primary health care, integrating both health service delivery and broader determinants of health to provide a comprehensive understanding of its role in advancing public health goals.
III. Results
The global significance of primary health care (PHC) has grown, proving to be an effective strategy for enhancing community access to health services. Multilateral organizations and national governments have reached a consensus on the fundamental principles of PHC; however, its implementation varies across countries due to the unique characteristics of local health systems. This article is motivated by an investigation into the PHC models and strategies applied in the Americas and an examination of health network configurations from a PHC perspective.
A systematic literature review was conducted utilizing keywords across at least nine databases. Exclusion criteria included languages other than English, Portuguese, and Spanish, and non-refereed articles, while regional gray literature was included. This process identified 1,146 articles, of which 142 were selected after three rounds of analysis. The selected articles were categorized into six thematic areas.
The evidence gathered on health reforms within the region highlights the necessity to strengthen care strategies backed by PHC and resilient care networks that can adapt to the changing needs of the population and respond to medium- and long-term epidemiological trends.
The Commission's deliberations explored ways to use health financing mechanisms to incentivize national health systems to deliver equitable, comprehensive, integrated and high-quality primary health care (PHC). These services should be delivered through platforms that are responsive to people's needs and fully aligned with the goals of universal health coverage (UHC). We argue that countries must invest more and better in PHC, and that the financing mechanisms that support PHC - from resource mobilization and pooling to budgeting, allocation and purchasing - must put people at the centre.
We detail the key characteristics of people-centred PHC financing. We recognize that the scope for reorienting health financing policies towards PHC depends on the economic, social and political context of a particular region, country or subnational level, and that there is no single path to achieving optimal PHC financing.
Thus, the approach to funding must take into account both local conditions and the need to ensure equity and social justice in the provision of primary care.
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PHC is based on the principle that health is a fundamental right, emphasizing disease prevention and health promotion while necessitating intersectoral coordination and community involvement. As the first point of contact between the population and the health system, it plays a vital role in health care delivery.
Primary health care (PHC) is regarded as a crucial strategy in the health sector, as it fosters social development, encourages community participation, and promotes overall well-being within societies.
Figure 2: Framework for people-centered financing of PHC
Towards the late 1980s, the WHO/PAHO underscored the need to organize health services into various levels of care and develop referral systems to facilitate regional health service planning. The importance of integrated and decentralized care levels was reaffirmed by PAHO Member States in 2005 through the Montevideo Declaration and the Health Agenda of the Americas 2008-2017. The document titled "Integrated Health Services Networks," part of the "Renewal of Primary Health Care in the Americas" series, serves as the foundation for health system reforms that, within the PHC framework, aim to reorient, strengthen, and deepen four primary areas: care models, network governance and strategy, resource organization and management, and economic incentives.
Countries in Latin America have historically faced significant inequalities, not just in health outcomes but also in income distribution, education, access to clean water, and sanitation. By the early 1990s, nearly all Latin American and Caribbean nations had initiated or were considering health sector reforms. Key policies included the separation of functions, decentralization, improvements to health insurance schemes through patient nominalization, and the establishment of explicit service packages. In some instances, these reforms encompassed broader changes to state structures, including national constitutions.
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Various studies indicate that health system reforms in Latin American countries have promoted inclusion, citizen empowerment, and health equity, leading in many cases to the establishment of legal rights associated with health and universal coverage, thereby reducing disparities in health indicators among different income groups. Motivated by social justice and equity, civil society has played a pivotal role in advocating for citizen rights and the right to health. An example of this is the work of the Latin American Social Medicine (LASM).
At the international level, several organizations, including PAHO, WHO, UNICEF, and the World Bank, have significantly influenced the region's health system performance and outcomes, promoting the adoption of PHC proposals. With the dawn of the new century, PHC gained even greater global importance as a mechanism for effectively addressing the needs of health systems. Various approaches to PHC implementation have emerged, including comprehensive (CPHC), selective (SPHC), and renewed (RPHC) models.
The comprehensive approach views PHC as part of an integrated health care system linked to the socio-economic development of society, emphasizing cooperation with other sectors. However, it has faced criticism for being overly idealistic and difficult to implement across different communities. The selective approach subsequently emerged, focusing on specific interventions for high-risk populations but lacking the social equity, intersectoral collaboration, and community participation integral to CPHC. Lastly, the renewed approach combines family and community perspectives to strengthen existing health systems, aiming for equity and sustainability in access and the delivery of health services to defined populations and territories, incorporating elements of citizenship, social participation, and empowerment.
IV. Discussion
While access and continuity of care are fundamental goals in any primary care strategy, the high level of unmet health needs among populations relying on both public and private sector coverage highlights that the care demands surpass the capacity of any single provider. Health outcomes —and outputs —are the result of collaborative efforts, requiring the coordination of multiple levels of care and interdisciplinary cooperation. Therefore, implementing effective healthcare networks and ensuring care provision in fragmented systems through a robust regulatory framework are critical elements of a comprehensive primary health care (PHC) strategy.
The complexity of coordinating healthcare networks, which often operate across multiple overlapping jurisdictions as a result of decentralized and/or segmented systems, poses additional challenges. Common obstacles to efficiency in networked healthcare systems include breakdowns in referral and counter-referral mechanisms, the absence of standardized patient information, poor performance of the bodies responsible for coordinating services, a lack of commitment or training among healthcare personnel, and the failure to incorporate perspectives on ethnic and cultural diversity. As a result, understanding why healthcare networks fail requires a comprehensive approach.
Key elements that contribute to the effective functioning of healthcare systems include financial incentives and mechanisms for integrating new technologies. Financial incentives, along with a wide array of policies aimed at strengthening healthcare careers, can encourage healthcare workers to adopt preventive practices, make sound diagnostic decisions, and provide informed treatment. Reputation-based incentives also play a role, particularly when performance data on healthcare professionals is made public. Technology integration has proven beneficial in facilitating learning, promoting cooperation, and improving monitoring procedures, especially in rural areas, complementing care at the primary level.
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Beyond this, the presence of multiple jurisdictions within a network raises important discussions about the vertical integration of services, not only in terms of ownership but also in governance, oversight, and coordination. When funding sources are not aligned, service integration must focus on establishing regulatory and procedural links to distribute tasks and responsibilities effectively, ensuring complementarity and requiring a shared monitoring framework.
Thus, network governance becomes a crucial aspect for managers and policymakers to consider when setting priorities in a PHC plan. Strong leadership is essential to bring together different interests and change entrenched practices, serving as the foundation of network governance. The institutional design of regional health systems, political and economic conflicts, and the values of the involved actors are all critical factors that shape the regulation of PHC. Consequently, disconnects between stakeholders and weak leadership within health systems influence the effectiveness of PHC strategies.
Since 1978, the concept of primary health care (PHC) has undergone various interpretations and definitions, causing confusion in the understanding of the term and its practical application. To ensure more coordinated action at the global, national and local levels, the following definition has been proposed:
"PHC is an integrated approach to health that covers the whole of society and aims to achieve equitable access by every member of society to the highest possible level of health and well-being. It addresses the needs of the population at the earliest stages, providing a wide range of services, from health promotion and disease prevention to treatment, rehabilitation and palliative care, as close as possible to people's daily lives." This definition has been developed by WHO and UNICEF within the framework of the PHC concept for the 21st century, with a focus on achieving universal health coverage (UHC) and the Sustainable Development Goals (SDGs).
The PHC system includes three interrelated components:
1. A comprehensive set of health services, with an emphasis on primary health care, public health and related functions.
2. Intersectoral policies and actions that address the key determinants of health.
3. Engaging and empowering individuals, families and communities to actively participate in managing their health and social lives.
The concept of PHC is based on the values of social justice, equity, solidarity and cooperation. It is based on the recognition that the enjoyment of the highest attainable standard of health is a fundamental human right, regardless of status or condition. Achieving true universal health coverage requires a shift from disease-focused systems to people-centred and participatory systems. This requires governments at different levels to recognise the importance of action beyond the health sector to implement a whole-of-government approach to health, with a particular focus on equity and the entire life course. The concept of PHC aims to address a wide range of determinants of health and pays attention to the integrated aspects of physical, mental and social health. This approach ensures high-quality and comprehensive care at all stages of a person's life, not just the treatment of individual diseases, with a focus on maximum proximity to the patient's place of residence.
While there have been notable achievements in building primary health care (PHC) systems and health networks in Latin America, as reflected in key health indicators, there are still critical issues that need to be addressed based on the evidence analyzed. First, while the concept of PHC is embedded in institutional discourse and sectoral debates across the region, it faces significant challenges from the organizational structures of health systems. Intense fragmentation, ineffective decentralization, and the accumulation of isolated programs along the care continuum have led to the consolidation of a care model that deviates from best practices.
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Profound income inequality acts as a segmentation mechanism, creating different levels of coverage based on individuals' ability to pay. In recent decades, most countries in the region have made efforts to promote coordinated care models, but results have been uneven, and monitoring and evaluation of the impact achieved have been scarce. The limited coordination between subsystems amplifies disparities, leading to the development of fragmented health networks that often operate informally and without standardized protocols. Collaboration between providers within different subsystems is minimal, and the private sector does not function as a space for coordination and complementarity with the public sector or, in some cases, social security systems. Instead, it often exacerbates care gaps.
The evidence gathered for this review has highlighted several key themes discussed throughout the document. Most notably, there is a pressing need to strengthen PHC models and care networks, as indicated by the documented results. Additionally, the review identified gaps in coverage of other critical topics, such as how health systems adapt to evolving population needs and the accumulation of epidemiological challenges, including mental health issues, addictions, and environmental impacts.
Furthermore, this review found a lack of literature on the impact of financial and non-financial incentives on health service provision, resource allocation efficiency, and quality improvements, opening avenues for future research. This gap suggests a need for deeper interaction between research and political action in the Latin American and Caribbean region to facilitate information exchange, strengthen the evaluation of interventions, and jointly design a research-action agenda that has a meaningful social impact.
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