Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland.
Lancet Glob Health. 2019 Nov;7(11):e1500-e1510. doi: 10.1016/S2214-109X(19)30416-4. Epub 2019 Sep 26.
Primary health care (PHC) is a driving force for advancing towards universal health coverage (UHC). PHC-oriented health systems bring enormous benefits but require substantial financial investments. Here, we aim to present measures for PHC investments and project the associated resource needs.
This modelling study analysed data from 67 low-income and middle-income countries (LMICs). Recognising the variation in PHC services among countries, we propose three measures for PHC, with different scope for included interventions and system strengthening. Measure 1 is centred on public health interventions and outpatient care; measure 2 adds general inpatient care; and measure 3 further adds cross-sectoral activities. Cost components included in each measure were based on the Declaration of Astana, informed by work delineating PHC within health accounts, and finalised through an expert and country validation meeting. We extracted the subset of PHC costs for each measure from WHO's Sustainable Development Goal (SDG) price tag for the 67 LMICs, and projected the associated health impact. Estimates of financial resource need, health workforce, and outpatient visits are presented as PHC investment guide posts for LMICs.
An estimated additional US$200-328 billion per year is required for the various measures of PHC from 2020 to 2030. For measure 1, an additional $32 is needed per capita across the countries. Needs are greatest in low-income countries where PHC spending per capita needs to increase from $25 to $65. Overall health workforces would need to increase from 5·6 workers per 1000 population to 6·7 per 1000 population, delivering an average of 5·9 outpatient visits per capita per year. Increasing coverage of PHC interventions would avert an estimated 60·1 million deaths and increase average life expectancy by 3·7 years. By 2030, these incremental PHC costs would be about 3·3% of projected gross domestic product (GDP; median 1·7%, range 0·1-20·2). In a business-as-usual financing scenario, 25 of 67 countries will have funding gaps in 2030. If funding for PHC was increased by 1-2% of GDP across all countries, as few as 16 countries would see a funding gap by 2030.
The resources required to strengthen PHC vary across countries, depending on demographic trends, disease burden, and health system capacity. The proposed PHC investment guide posts advance discussions around the budgetary implications of strengthening PHC, including relevant system investment needs and achievable health outcomes. Preliminary findings suggest that low-income and lower-middle-income countries would need to at least double current spending on PHC to strengthen their systems and universally provide essential PHC services. Investing in PHC will bring substantial health benefits and build human capital. At country level, PHC interventions need to be explicitly identified, and plans should be made for how to most appropriately reorient the health system towards PHC as a key lever towards achieving UHC and the health-related SDGs.
The Bill & Melinda Gates Foundation.
初级卫生保健（PHC）是推进全民健康覆盖（UHC）的推动力。以 PHC 为导向的卫生系统带来了巨大的效益，但需要大量的财政投资。在这里，我们旨在提出 PHC 投资措施，并预测相关资源需求。
本建模研究分析了来自 67 个低收入和中等收入国家（LMICs）的数据。鉴于各国 PHC 服务的差异，我们提出了三种 PHC 措施，其中包括不同范围的干预措施和系统强化措施。措施 1 以公共卫生干预措施和门诊护理为中心；措施 2 增加了一般住院护理；措施 3 进一步增加了跨部门活动。纳入每个措施的成本组成部分基于《阿斯塔纳宣言》，并通过明确界定卫生账户内的 PHC 以及通过专家和国家验证会议最终确定。我们从世卫组织的可持续发展目标（SDG）标签中提取了每个措施的 PHC 成本子集，并预测了相关的健康影响。对金融资源需求、卫生人力和门诊就诊的估计以 PHC 投资指南的形式呈现，供 LMIC 国家参考。
从 2020 年到 2030 年，各种 PHC 措施每年需要额外的 2000 亿至 3280 亿美元。对于措施 1，各国人均需要额外增加 32 美元。在低收入国家，人均 PHC 支出需要从 25 美元增加到 65 美元，需求最大。总体卫生人力需要从每 1000 人 5.6 名工人增加到每 1000 人 6.7 名工人，平均每年为每人提供 5.9 次门诊就诊。增加 PHC 干预措施的覆盖面将避免约 6010 万人死亡，并将平均预期寿命延长 3.7 年。到 2030 年，这些增量 PHC 成本将占预计国内生产总值（GDP）的 3.3%（中位数为 1.7%，范围为 0.1-20.2%）。在常规融资情况下，2030 年将有 67 个国家中的 25 个存在资金缺口。如果所有国家的 PHC 资金增加 1-2%的 GDP，到 2030 年，将只有 16 个国家出现资金缺口。
加强 PHC 所需的资源因国家而异，取决于人口趋势、疾病负担和卫生系统能力。拟议的 PHC 投资指南推动了关于加强 PHC 的预算影响的讨论，包括相关系统投资需求和可实现的健康成果。初步结果表明，低收入和中低收入国家至少需要将目前对 PHC 的支出增加一倍，以加强其系统并普遍提供基本的 PHC 服务。投资于 PHC 将带来巨大的健康效益并建立人力资本。在国家一级，需要明确确定 PHC 干预措施，并制定计划，以最适当的方式使卫生系统向 PHC 重新定位，作为实现 UHC 和与卫生相关的可持续发展目标的关键杠杆。
比尔及梅琳达·盖茨基金会。
