WHO South-East Asia Journal of Public Health

: 2021  |  Volume : 10  |  Issue : 3  |  Page : 3--5

The significance of primary health care for building back better: lessons from COVID-19

Alaka Singh1, Stephanie M Topp2,  
1 Primary Health Care Unit, Department of Health Systems Development, WHO Regional Office for South-East Asia, New Delhi, India
2 College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia

Correspondence Address:
Dr Alaka Singh
Primary Health Care Unit, Department of Health Systems Development, WHO Regional Office for South-East Asia, New Delhi

How to cite this article:
Singh A, Topp SM. The significance of primary health care for building back better: lessons from COVID-19.WHO South-East Asia J Public Health 2021;10:3-5

How to cite this URL:
Singh A, Topp SM. The significance of primary health care for building back better: lessons from COVID-19. WHO South-East Asia J Public Health [serial online] 2021 [cited 2021 Apr 18 ];10:3-5
Available from: http://www.who-seajph.org/text.asp?2021/10/3/3/309866

Full Text

The coronavirus disease 2019 (COVID-19) pandemic, with its overlapping public health and economic emergencies, is a global reminder of the importance of addressing social and environmental determinants of health and inequality, and investing in health systems oriented towards primary care, all of which are components of a primary health care (PHC) approach.

PHC – the importance of which was famously articulated in the Declaration of Alma-Ata in 1978 and reaffirmed at the 2018 Astana Conference – is recognized as one of the best ways of promoting population health and well-being.[1],[2],[3] PHC is “a whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and preferences (as individuals, families, and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment”.[4] It promotes a focus on health systems oriented towards primary care, which have been shown to strengthen appropriateness, access, quality and efficiency of care, through their defining focus on people and the delivery of integrated preventive, curative and public health services.[5] However, the efficacy and impact of such primary care is understood to be intrinsically linked to, and embedded within, a broader context that is inclusive of participatory and responsive financing and governance structures, and policies and actions in non-health sectors.[6]

In 2020, with the aim of supporting countries to operationalize PHC, the World Health Organization (WHO) launched its Operational framework for primary health care: transforming vision into action.[7] Showcasing evidence-based strategic and operational levers, the framework highlights the need for a whole-of-society approach. Of note, the framework’s emphasis – on more and better multisectoral action, empowerment of people and communities, and the urgency of strengthening primary care as the “service front”[6] and programmatic engine of universal health coverage[2] – overlaps considerably with issues highlighted by the COVID-19 pandemic.

In the WHO South-East Asia Region, Member States have articulated a high-level commitment to the vision of PHC as one means by which to improve health and well- being. Even before the COVID-19 pandemic, an estimated 60 million people annually in the region experienced poverty because of out-of-pocket spending on health care. Regionally, various initiatives are seeking to both build primary care capacity and implement policies and strategies that reflect a multisectoral approach. As observed in the WHO Regional Director’s message accompanying this special issue, since 2014, achieving universal health coverage has been one of the flagship priorities across the South-East Asia Region, with service coverage improving from an average of 47% a decade ago to more than 61% in 2020. However, many challenges remain; the COVID-19 pandemic has provided opportunities for innovation and adaptation but has also presented new problems or compounded problems in relation to Member States’ efforts to operationalize PHC.

In this supplement, South-East Asia Region authors and others reflect on the challenges and lessons learned regarding PHC during the first 12 months of the COVID-19 pandemic, highlighting among other things examples of the rapid review and extension of health workforce capability; the expedited introduction of technological solutions to maintain and strengthen health care access; and newly decentralized governance arrangements designed to enable the integration of public health functions into front-line services.[8],[9]

Addressing the critical issue of access to essential services, for example, Reddy et al.[10] present findings from the analysis of routine facility data in India’s Telangana state, which show a positive association between a highly decentralized model of hypertension care that brings follow-up services and medicines closer to communities and indicators of service uptake and hypertension outcomes. Although identifying some decreases in service access during the pandemic-induced lockdown, the same study suggests a potentially protective effect on access to and use of hypertension follow-up services in populations covered by decentralized services compared with those covered by non-decentralized services. Zangmo et al.[11] similarly describe various adaptations to traditional models of antenatal care employed to ensure continuity of this vital service in country settings experiencing widespread social and economic lockdowns.

Bezbaruah et al.[12] and Zakoji and Sundararaman[13] observe the critical importance of integrating emergency response capabilities and functions with routine community engagement and health workforce functions in support of effective and sustained emergency response measures that can be led by local stakeholders and are trusted by local populations. Bahl[14] et al. describe how, despite the reduction in immunization services and surveillance for vaccine-preventable diseases across the South-East Asia Region early in the pandemic, rapid adaptation of guidelines and action plans meant that, in most countries, immunization coverage recovered during July–September 2020 to levels seen during the corresponding months in 2019. In fact, this was observed in Bangladesh, as reported by Wangmo et al.,[15] where the rate of fully immunized children fell by 46% between January and April 2020 but recovered to 100% by June 2020.

The benefits of long-term community engagement (a key pillar of comprehensive PHC), including through investment in community health workers, is evident in several contributions (Bezbaruah et al.,[12] Zakoji and Sundararaman,[13] Reddy et al.[10]). These contributions provide further evidence of the critical role of primary care services not only in ensuring access to essential health care during public health emergencies but also in providing a platform for long-term and sustained efforts to strengthen national and subnational health systems through community engagement.[3]

Even with examples of innovation and adaptation, multiple challenges to progressing PHC in the South-East Asia Region remain, particularly in the new context of the COVID-19 crisis. Zapata et al.[16] and Tangcharoensathien[17] note that, despite several decades of investment by Member States in human resources for health, huge health workforce challenges remain, with only two countries currently meeting the revised WHO threshold of 44.5 health workers per 10 000 population. The pandemic has highlighted the need to prioritize locally appropriate actions in the delivery of primary care, yet health budgets are overstretched and, as Kwon[18] points out, health governance and financing systems are too often unresponsive in the face of shifting health needs. Tandon et al.[19] observe that, in many South-East Asia Region countries, low levels of public spending on health and tied donor funding inhibit investment in primary care or the types of multisectoral action needed to realize PHC. Alongside the political economy of pharmaceutical research, development and sales, such budget constraints can influence the availability of medicines, which, despite the remarkable efforts behind the COVAX initiative, will affect the ability of different countries to access and roll out COVID-19 vaccines.

Reflecting on a long-standing challenge, Khan et al.[20] observe how, despite mixed health systems being the norm in the region, attention to, and investment in, effective regulatory mechanisms to ensure the quality and affordability of nongovernment (private for-profit and not-for-profit) services remain weak. Reflecting on issues of health governance, Tangcharoensathien[17] and Guisset et al.[21] observe how, often, decisions about health service type and availability are driven by siloed governance and financing systems that are distant, if not disconnected, from the realities of both patients and frontline providers. Looking at the intersection of such governance and regulatory issues, Rajbhandary et al.[22] describe the need for urgent investment to strengthen health information systems in the South-East Asia Region, noting the growing capacity for the collection and collation of health information within regional Member States but also the still underdeveloped capacity for analysing and utilizing these data at subnational and particularly facility levels, where it is arguably most needed. Walcott and Akinola[23] reflect on the power of digital technologies, including data capture from rapidly expanding telemedicine applications, to inform on better targeted interventions and advance the universal health care agenda. Wangmo et al. present data illustrating the positive role that health information systems, and especially the collection and use of routine data, have played in Bangladesh, to help identify and inform the government response, down to the health facility level, on early reductions in coverage of essential services during the first months of the COVID-19 pandemic.

Providing an important synthesis of many of these issues, Peiris et al.[24] review the literature to highlight how, even when accounting for some welcome pandemic-related health service adaptations, country-level attention to strategic functions that would strengthen underlying health systems in support of PHC remains generally weak. Challenges include many of the strategic areas identified in WHO’s operational framework, such as leadership, governance and policy, funding and allocation of resources, and engagement of communities and other stakeholders.[7]

Around the globe, the COVID-19 pandemic has laid bare the devastating impact of both structural inequities and suboptimally designed health systems. The pandemic has highlighted the pressing need to move away from brittle, uncoordinated and disease-specific responses and to reorient health systems towards a PHC approach. “Building back better” in the South-East Asia Region and beyond means taking stock of current weaknesses in often fragmented health systems and service functions and making changes to improve responsiveness, resilience and the capability to deliver better and more equitable health outcomes. This collection speaks to emerging insights and opportunities created by the willingness to adapt in the context of the COVID-19 pandemic but also to an urgent need to pay more attention to and invest more in PHC, before the health and economic impacts of the pandemic slow or reverse the progress made in recent decades. We hope that this collection serves to reinforce the need for enacted commitment to the vision of health for all, through investment in well-aligned governance, financing and structural reforms.


1Review of 40 years of primary health care implementation at country level. Geneva: World Health Organization Evaluation Office; 2019 (https://www.who.int/docs/default-source/documents/about-us/ evaluation/phc-final-report.pdf?sfvrsn=109b2731_4, accessed 2 February 2021).
2Primary health care on the road to universal health coverage: 2019 monitoring report. Geneva: World Health Organization; 2019 (https:// www.who.int/healthinfo/universal_health_coverage/report/2019/en/, accessed 2 February 2021).
3Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. The contribution of primary care to health and health systems in low- and middle-income countries: a critical review of major primary care initiatives. Soc Sci Med. 2010;70(6):904–11. https://doi.org/10.1016/j.socscimed.2009.11.025 PMID:20089341
4A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization and United Nations Children’s Fund (UNICEF); 2018 (https://www.who.int/docs/default-source/primary-health/vision.pdf, accessed 2 February 2021).
5Stigler FL, Macinko J, Pettigrew LM, Kumar R, van Weel C. No universal health coverage without primary health care. Lancet. 2016;387(10030):1811. https://doi.org/10.1016/S0140- 6736(16)30315-4 PMID:27203497
6Hone T, Macinko J, Millett C. Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals? Lancet. 2018;392(10156):1461–72. https://doi.org/10.1016/S0140- 6736(18)31829-4 PMID:30343860
7Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and United Nations Children’s Fund (UNICEF); 2020 (https://apps.who.int/iris/ handle/10665/337641, accessed 2 February 2021).
8Ariadne Labs, Brigham Health and Harvard TH Chan School of Public Health. Resource: supporting strong primary health care during the pandemic; 2020 (https://covid19.ariadnelabs.org/resources-supporting-strong-primary-health-care-during-the-pandemic/, accessed 3 February 2020).
9Dunlop C, Howe A, Li D, Allen LN. The coronavirus outbreak: the central role of primary care in emergency preparedness and response. BJGP Open. 2020;4(1):bjgpopen20X101041. https://doi. org/10.3399/bjgpopen20X101041 PMID:31992543
10Reddy TSK, Kunwar A, Durgad K, Tullu FT, Sreedhar C, Wassey A et al. Decentralization of India Hypertension Control Initiative services to maintain continuum of care for hypertensive patients during COVID-19 pandemic in Telangana. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S49–S58. doi:10.4103/2224-3151.309873.
11Zangmo R, Kumari A, Garg D, Sharma KA. Redesigning routine antenatal care in low-resource settings during the COVID-19 pandemic. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S36–S40. doi:10.4103/2224-3151.309871.
12Bezbaruah S, Wallace P, Zakoji M, Padmini Perera WLS, Kato M. Roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S41–S48. doi:10.4103/2224-3151.309872.
13Zakoji M, Sundararaman T. Emerging good practices and lessons learnt to maintain essential health services during the COVID-19 pandemic. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S26–S29. doi:10.4103/2224-3151.309868.
14Bahl S, Khanal S, Sharifuzzaman M, Liyanage J. Impact of the COVID-19 pandemic on immunization and surveillance of vaccine- preventable diseases in the WHO South-East Asia Region. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S33–S35. doi:10.4103/2224-3151.309870.
15Wangmo S, Sarkar S, Islam T, Rahman MH, Landry M. Maintaining essential health services during the pandemic in Bangladesh: the role of primary health care supported by routine health information system. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S93–S99. doi:10.4103/2224-3151.309884.
16Zapata T, Zakoji M, Kanda M, Travis P, Tangcharoensathien V, Buchan J, Jhalani M. Implementing a decade of strengthening the health workforce in the WHO South-East Asia Region: achievements and way forward for primary health care. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S76–S86. doi:10.4103/2224-3151.309881.
17Tangcharoensathien V. Deep impacts of COVID-19: overcoming challenges in strengthening primary health care by targeting the health workforce. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S73–S75. doi:10.4103/2224-3151.309880.
18Kwon S. Financing health in the new normal: issues and opportunities. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S61–S62. doi:10.4103/2224-3151.309875.
19Tandon A, Oliveira Cruz V, Bhatnagar A, Wang H, Haque T, Jhalani M. Financing health care in the WHO South-East Asia Region: time for a reset. WHO South-East Asia J Public Health. 2021;10(Suppl. 1): S63–S72. doi:10.4103/2224-3151.309879.
20Khan MS, Rahman-Shepherd A, van der Mark N, Dar O, Hasan R. Pandemic preparedness requires better regulation and stewardship of private providers that dominate provision of primary health care. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S59–S60. doi:10.4103/2224-3151.309874.
21Guisset A-L, Travis P, Nejad SB, Ved R, Rouleau K. Unpacking the service delivery function: COVID-19 provides an opportunity for some reverse thinking. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S30–32. doi:10.4103/2224-3151.309869.
22Rajbhandary R, Negandhi P, Sharma A, Zodpey S. Using the SCORE for Health Data Technical Package to strengthen primary health care. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S87–S90. doi:10.4103/2224-3151.309882.
23Walcott D, Akinola S. Shift to digital during the pandemic could enable universal health coverage. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S91–S92. doi:10.4103/2224-3151.309883.
24Peiris D, Sharma M, Praveen D, Bitton A, Bresick G, Coffman M et al. Strengthening primary health care in the COVID-19 era: a review of best practices to inform health system responses in low- and middle-income countries. WHO South-East Asia J Public Health. 2021;10(Suppl. 1):S6–S25. doi:10.4103/2224-3151.309867.