Transforming Primary Health Care: Showcasing Examples of Primary Care Networks
Authors: Mahlet Gizaw, Amanda Folsom, Luis Gabriel Bernal Pulido
Additional contributions to this blog were made by Alberta Adjebeng Biritwum-Nyarko, Linda A. Vanotoo, Martin Lutalo, and Marelize Gorgens.
As countries work to achieve universal health coverage by improving access to and utilization of essential health services for their populations, many are undertaking health system transformations to prioritize and strengthen primary health care (PHC). A growing number of countries are designing and implementing primary care networks (PCN) to strengthen PHC financing and delivery and ultimately improve access to and utilization of care, a process that can be supported through shared knowledge and peer-to-peer learning. PCNs are horizontal networks of collaborating primary care providers working together to provide quality primary care to patients in a coordinated approach. As part of its partnership with the Joint Learning Network for Universal Health Coverage (JLN) and facilitated by Results for Development (R4D), the Primary Health Care Performance Initiative (PHCPI) led a Learning Exchange focused on implementing and measuring the performance of primary care networks between March and November 2022. The learning exchange had three key objectives:
- Convene country teams and individual health care professionals from across disciplines in cross-country virtual learning to identify and adapt best and promising practices in the implementation and measurement of PCNs,
- Provide access to lessons and resources and apply timely, relevant experience and expertise for the implementation of PCNs, and
- Provide peer problem-solving support for PHC needs.
Implementation case teams from Colombia, Ghana, and Kenya participated along with over 80 peer learners from government and civil society organizations across 25 countries.
In response to country demand, the JLN’s Reimagining Primary Health Care Collaborative held a virtual session on June 7th, 2023, to share reflections on the 2022 PCNs Learning Exchange. Participants shared PCN implementation experiences from Colombia, Costa Rica, Ghana, and Kenya. Below are a few highlights from the discussion:
While financing PCNs is context-specific, countries face a common challenge of how to finance preventive and promotive care
Participant countries’ experiences using PCNs to improve PHC financing demonstrated that countries need to test and adapt approaches that will be practical for their context. Ghanaian stakeholders recognized the importance of designing and costing an Essential Health Service Package and aligning it to the National Health Insurance benefits package to know the gaps and plan to address them. Some financing initiatives are being considered on a pilot basis to cover integrated preventive promotive, rehabilitative, and to a lesser extent some curative care to learn what will work best. They discussed their initial considerations of group credentialing of Networks of Practice (as PCNs are called in Ghana) rather than the usual credentialing of individual facilities to facilitate the bonding and cost-sharing of joint activities when reimbursements from the National Health Insurance Authority are received. The challenge of financing population-based preventive and promotive services, which are not yet included in the essential care package remains. Kenyan stakeholders worked on developing costing reports to ensure that the PCNs were properly financed, ensuring adequate funding for PHC facilities and community health units. On the other hand, Colombian PHC providers, who organize their own PCNs, sign agreements with health insurers and receive payments from them to offer preventive care to a panel of users. They also receive financial support from local health authorities to support population-based health promotion activities.
There are diverse ways to design, establish, and operationalize PCNs
Despite the lack of robust evidence, countries are testing and adapting PCN models as they learn lessons in operationalizing the networks. PCNs are evolving in different and changing contexts. PCNs in LMICs are designed around the systems that already exist. For example, in Ghana, the ‘hub and spoke’ approach was used for PCN implementation including piloting PCNs in a few districts and scaling up nationwide as Networks of Practice: placing emphasis on the Health center as the Hub and also with the view to include all providers who buy-into the concept including private providers. On the contrary, Costa Rica used a long-term approach that aligned with national and subnational priorities as well as local community contexts. In communities with cultural practices for maternal and child health, PCNs worked with their communities to understand and respect the cultural practices to ensure that all mothers were willing to receive care at PCN facilities. Lessons from Kenya included a need for slow transition strategies to carefully scale up and operationalize the PCNs to ensure that funding effectively shifts from facilities to networks.
PCN accountability and governance are key for PCNs to achieve what they are established to deliver
It is essential to have an accountability framework and integrate it as a foundation at the national and sub-national levels during the conceptualization phase of PCNs. Key factors required for accountability include strong political will, community involvement, coalition building by different actors within and outside of the health sector, and advocacy for a solid accountability structure. It is also important to have a PCN governing body responsible for allocating and managing resources. The governance body can be shared, opening an accountability space between the government and the people, and further promoting transparency in decision-making and resource allocation.
Future cross-country and subnational learning is needed in financing PCNs and performance measurement
Participating countries have identified several areas for future cross-country learning including financing primary care through PCNs and measuring the effectiveness and performance of PCNs. Other emerging learning topics included using digital health and telemedicine for care coordination, data management and information technology practices, provider accreditation, and good practices in PCN management. Countries have also identified the need to systematize and invest in implementation-oriented learning across PCNs at subnational levels (districts, counties, regions).