Gatome-Munyua Agnes, Sparkes Susan, Mtei Gemini, Sabignoso Martin, Soewondo Prastuti, Yameogo Pierre, Hanson Kara, Cashin Cheryl
Results for Development Institute, Nairobi, Kenya
World Health Organization, Geneva, Switzerland.
BMJ Glob Health. 2025 Jan 14;10(1):e015088. doi: 10.1136/bmjgh-2024-015088.
Despite primary healthcare (PHC) being recognised in global declarations-Alma Ata in 1978 and Astana in 2018-and prioritised in national health strategies, chronic under-resourcing of PHC persists in most low-income and middle-income countries. More public spending is needed for PHC, but macrofiscal and political constraints often limit the ability of governments to allocate more public resources to PHC. Under-resourcing has been compounded by fragmented and rigid funding flows, which are inefficient and may erode equity, quality of care and public trust in PHC.This article explores the drivers of fragmentation in PHC financing-low public spending, which results in over-reliance on external sources to fund critical health interventions, and the proliferation of new financing schemes that do not take a system-wide view or adhere to the principles of universality. It then highlights some of the possible consequences of this fragmentation for the efficiency, equity and effectiveness of service delivery.Four countries-Argentina, Burkina Faso, Indonesia and Tanzania-are used to illustrate practical steps that may be taken to minimise the consequences of fragmentation in PHC financing: (1) consolidating multiple coverage schemes, (2) avoiding further fragmentation, (3) harmonising health purchasing functions and (4) streamlining funding flows to the provider level.The country examples reveal lessons for policy-makers grappling with the consequences of fragmented PHC financing. The paper concludes with a research agenda to generate additional evidence on what works to address fragmentation.
尽管初级卫生保健在1978年的《阿拉木图宣言》和2018年的《阿斯塔纳宣言》等全球宣言中得到认可，并在各国卫生战略中被列为优先事项，但在大多数低收入和中等收入国家，初级卫生保健长期资金不足的问题依然存在。初级卫生保健需要更多公共支出，但宏观财政和政治限制往往制约了政府向初级卫生保健分配更多公共资源的能力。资金流动分散且僵化，使资金不足问题更加严重，这种情况效率低下，可能会损害公平性、医疗服务质量以及公众对初级卫生保健的信任。本文探讨了初级卫生保健融资碎片化的驱动因素——公共支出低导致过度依赖外部资金来资助关键卫生干预措施，以及新融资计划的激增，这些计划没有从系统层面考虑，也未遵循普遍性原则。接着，本文强调了这种碎片化可能给服务提供的效率、公平性和有效性带来的一些后果。以阿根廷、布基纳法索、印度尼西亚和坦桑尼亚四个国家为例，阐述了为尽量减少初级卫生保健融资碎片化后果可采取的实际步骤：（1）整合多种覆盖计划；（2）避免进一步碎片化；（3）协调卫生采购职能；（4）简化流向医疗机构层面的资金流动。这些国家案例为应对初级卫生保健融资碎片化后果的政策制定者提供了经验教训。本文最后提出了一项研究议程，以获取更多关于如何解决碎片化问题的有效方法的证据。
