The World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Operational Framework for Primary Health Care is the translation of the vision of the Declaration of Astana into actions. It suggests 14 levers, which are organised into “operational” and “core strategic” levers.
Building on this operational framework and the FIP Development Goals (DGs), FIP is committed to the delivery of the vision of the Declaration of Astana on primary health care (PHC) by pharmacists to accelerate progress in strengthening PHC. Each of the 14 levers in the framework is linked to the FIP DGs to demonstrate pharmacists’ contribution to PHC and the variety of roles and services they deliver.
Commitment and leadership within the health sector is important, but truly transformational change requires commitment and leadership beyond the health sector: the involvement of heads of state and governments, other political leaders (for example, parliamentarians), civil society and influential community, religious and business figures is important for mobilising large-scale improvements in PHC.
These leaders must ensure that PHC is treated as a priority by formalising commitments to it (for example, through declarations), by highlighting it in key documents (such as national development plans, and plans to achieve universal health coverage (UHC) and the UN Sustainable Development Goals), by regularly communicating its importance, by providing adequate financing and, ultimately, by focusing on the implementation of efforts to improve PHC. Commitment and leadership are particularly important because of the ambitious vision of PHC, in particular, the complexities associated with its three inter-related components: integrated health services, multisectoral policy and action, and empowered people and communities.
Political commitment and leadership that places PHC at the heart of efforts to achieve UHC and recognise the broad contribution of PHC to the SDGs is linked to two FIP DGs: DG 6 (Leadership development) and DG 13 (Policy development).
Governance refers to ensuring strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system design and accountability. Historically, in most low- and middle-income countries, governments have focused on delivering public sector services themselves rather than embracing a broader vision of governance that integrates the public and private sectors in a mixed health system. This arrangement is becoming increasingly outmoded, given both the growing range of actors involved in the health sector and the recognition that health ministries cannot act as a service provider for all health services. The broader vision of governance requires governments to oversee and guide the whole health system, not just the public system, to protect the public interest.
These shifts in governance should be supported by policy frameworks that reflect the broad definition of PHC. In particular, the concept of PHC as having three inter-related components — integrated health services, multisectoral policy and action, and empowered people and communities — should be embedded in key policy frameworks that govern the health sector.
Governance structure, policy frameworks and regulations in support of PHC that build partnerships within and across sectors are linked to two FIP DGs: DG 3 (Quality assurance) and DG 13 (Policy development).
In general, efforts to raise resources for PHC and use them most effectively should be embedded in a broad health financing strategy that encompasses the entire health sector. Developing or updating a health financing strategy should be undertaken in collaboration with a range of stakeholders, both within the health sector and outside it (such as finance ministries).
Such a strategy should also address key issues related to the allocation of resources within the health sector. Within the scope of PHC, funds should be rationally allocated among primary care, public health interventions, and initiatives that promote community engagement and multisectoral coordination.
Adequate funding for PHC that is mobilised and allocated to promote equity in access, to provide a platform and incentive environment is linked to two FIP DGs: DG 13 (Policy development) and DG 21 (Sustainability in pharmacy).
Building collaborative relationships that enable stakeholders to jointly define health needs, identify solutions and prioritise actions through contextually appropriate and effective mechanisms is central to PHC.
Communities comprise a diversity of actors, including individual users of health services and their families, lay public members, and private sector constituencies (both for-profit and not-for-profit), including civil society organisations (for example, consumer groups, community-based, faith-based and non-governmental organisations, and affiliate groups). People and communities, and their capacities, desires and mechanisms to engage are constantly evolving, in part owing to changing social dimensions, which have a profound impact on the process of engagement as well as on overall health and well-being.
Community and population engagement in health can be considered at three interlinked levels: in the governance of health systems, in planning and priority setting, and in the implementation and delivery of health services. Communities and stakeholders also have an important, two-pronged role in accountability, including: holding health systems accountable to their populations’ needs; and contributing to accountability in the governance, planning, delivery and evaluation of health care. Engagement of communities and other stakeholders from all sectors to define problems and solutions and prioritise actions through policy dialogue is linked to three FIP DGs: DG 6 (Leadership development), DG 8 (Working with others) and DG 13 (Policy development).
A model of care is a conceptualisation of how services should be delivered, including the processes of care, organisation of providers and management of services, supported by the identification of roles and responsibilities of different platforms and providers along the pathways of care. Successful models of care evolve in response to continuous performance monitoring, changing populations, health needs and contexts with the aim of ensuring that all people receive the right care, at the right time, by the right team and in the right place.
Models of care must be tailored to local contexts because what is required and feasible will inevitably differ between what works best in a fragile, conflict-affected setting and a stable upper-middle income country or between an urban and rural community. However, there are some principles that are common across all settings. First, models of care should promote integrated health services, strategically prioritising primary care and public health functions and ensuring adequate coordination between them. Secondly, at the level of individual health care services, health systems need to be reoriented to facilitate access to services closer to where people live, taking into consideration context, people’s preferences and cost-effectiveness. Thirdly, models of care should promote continuous, comprehensive, coordinated and person- and people-centred care, rather than focus on specific diseases. Finally, models of care should recognise the crucial role of PHC in addressing both existing and emerging health problems.
Models of care that promote high-quality, people-centred primary care and essential public health functions are linked to six FIP DGs: DG 7 (Advancing integrated services), DG 14 (Medicine expertise), DG 15 (People-centred care), DG 16 (Communicable diseases), DG 17 (Antimicrobial stewardship) and DG 19 (Patient safety).
The PHC workforce includes all occupations engaged in the continuum of promotion, prevention, treatment, rehabilitation and palliative care, including the public health workforce and those engaged in addressing the social determinants of health. Beyond service provision, health workers also include management and administrative staff who are crucial for the functioning of the health system across different care settings. An adequate, well-distributed, motivated, enabled and supported health workforce is required for strengthening PHC and progressing towards UHC.
Improving the availability and distribution of PHC workers where there are shortages is essential, but it is also important to improve the productivity and performance of the existing workforce. Adopting a diverse, sustainable skills mix geared to PHC, including proper links through all service delivery platforms to the social services workforce, ensures a more effective and efficient use of resources that is better aligned to community needs.
Delivering PHC through well-functioning, multidisciplinary teams requires optimising health workers’ skill mix. There is no ideal model for these teams as each country organises its health and social workforce on the basis of its own context, resource availability and investment capacity. The ideal composition of a multidisciplinary team should enable the delivery of continuous, comprehensive, coordinated and people-centred care.
Primary health care workforce lever is linked to 10 FIP DGs: DG 1 (Academic capacity), DG 2 (Early career training strategy), DG 4 (Advanced and specialist development), DG 5 (Competency development), DG 6 (Leadership development), DG 8 (Working with others), DG 9 (Continuing professional development strategies), DG 10 (Equity & equality), DG 12 (Pharmacy intelligence) and DG 13 (Policy development).
The physical infrastructure of health facilities has an important impact on both the ability of health care providers to do their jobs and patient satisfaction, which in turn tends to affect the use of health services. Infrastructure needs and maintenance are often overlooked or neglected, however, particularly in primary care settings such as clinics and health centres. Key elements of physical facility infrastructure include having reliable water supply, sanitation and waste disposal/recycling facilities, telecommunications connectivity and power supply.
Effective infection prevention and control measures and water, sanitation and hygiene (WASH) services in health care facilities are at the foundation of quality care. Facilities should have WASH services available for all users, including patients’ family members. They should meet national standards and be regularly maintained with enough skilled staff to keep them functioning and clean.
Telecommunications connectivity is becoming an increasingly indispensable aspect of the physical infrastructure for health care. Many countries rely on electronic systems for data collection. Thus, workers at facilities without connectivity may not be able to report regularly or may have to rely on their own personal equipment.
Physical infrastructure that ensures secure and accessible health facilities to provide effective services is linked to two FIP DGs: DG 10 (Equity & equality) and DG 21 (Sustainability in pharmacy).
PHC relies on access to health products, including medicines, vaccines, medical devices, in vitro diagnostics, protective equipment and vector-control tools, and assistive devices. These must be of assured safety, efficacy, performance and quality. In addition, they must be appropriate, available and affordable. Ensuring that appropriate health products are available and affordable depends upon several policy decisions and integrated processes related to the assessment, selection, pricing, procurement, supply chain management, maintenance (in the case of medical devices), prescribing and dispensing (in the case of medicines) and safe and appropriate use of all health products.
Maintenance of health products is another critical issue, particularly for medical equipment. This often requires specialised skills that may not be readily available at health facilities and thus, the availability of adequate budget for maintenance, spare parts or consumables and eventual replacement of equipment is also significant.
The availability and affordability of appropriate, safe, effective, high-quality medicines and other health products is linked to three FIP DGs: DG 14 (Medicines expertise), DG 18 (Access to medicines & services) and DG 20 (Digital health).
In the health area, the private sector refers to all non-state actors involved in health: for-profit and not-for-profit, formal and informal, and domestic and international entities. Almost all countries have mixed health systems with goods and services provided by the public and private sectors and health consumers requesting these services from both sectors. The private sector’s involvement in health systems is significant in scale and scope and includes the provision of health-related services, medicines and other health products, health insurance, supply chain management, training for the health workforce, information technology, as well as infrastructure and support services. The term “private sector” covers a wide array of actors and services across the health system, and includes such roles as sources of financing, developers of new technologies and products, managers of supply chains, advocates and service providers.
Both public and private sectors share responsibility for provision of services, but governments must oversee and guide the whole health system in order to protect the public interest. To do this the role of health ministries as stewards for health must be reinforced. Several approaches and tools can be used to ensure successful stewardship. At the level of policy development, the private sector should be treated as a constituency that can bring relevant expertise and it is often valuable to invite private sector representatives to participate in designing relevant strategies and policies.
Sound partnership between public and private sectors for the delivery of integrated health services is linked to two FIP DGs: DG 8 (Working with others) and DG 13 (Policy Development).
When supported by adequate resource flows in support of PHC and driven by PHC-oriented models of care, purchasing and payment systems increase the accessibility of priority interventions to the entire population and the integration of services with primary care and public health at their core. Strategic purchasing — including benefits design, provider payment methods and contracting arrangements — can strengthen the PHC orientation of models of care and promote the integration of health services while advancing other health system objectives.
Benefits design should always involve the participation of people and communities, including providers and purchasers, and should aim to promote equity and leave no one behind. Health service packages, often the basis for benefit entitlements, should take into account the model of care and reflect a comprehensive spectrum of population-wide and individual-based services and interventions throughout the course of life. Through inclusion of promotive, protective, preventive, resuscitative, curative, rehabilitative and palliative care services, across service delivery platforms, service packages can guide delineation of roles and improve coordination across service delivery platforms, thus informing the effective and efficient allocation of resources and improving integration.
Purchasing and payment systems that foster a reorientation in models of care for the delivery of integrated health services with primary care and public health at the core are linked to two FIP DGs: DG 13 (Policy development) and DG 21 (Sustainability in pharmacy).
Digital technologies are creating new ways in which people can hold service providers to account, as well as enabling more effective and larger-scale advocacy and health promotion efforts.
The revolution in information and communications technologies has brought about important shifts in how individuals and communities manage their own health and access information about health conditions, treatment options and the availability (and sometimes quality) of service providers. These shifts can play an important role in advancing the core PHC aim of empowering people and communities by putting new power in the hands of people and shifting the nature of the relationship between medical provider and patient by reducing the asymmetry of information.
Digital technologies are also having profound effects on the provision of health services, particularly through the rapid expansion of digital health interventions, particularly mHealth (mobile health) and eHealth (electronic health) initiatives. Governments have rapidly responded to this changing landscape by developing national strategies. Today more than 120 countries have developed national policies or strategies for eHealth, telemedicine or digital health.
The use of digital technologies for health in ways that facilitate access to care and service delivery, improve effectiveness and efficiency, and promote accountability is linked to one FIP DG: DG 20 (Digital health).
The Lancet Global Health Commission on High Quality Health Systems in the SDG Era highlighted that more deaths in low- and middle-income countries are now occurring as a result of poor-quality care than a lack of access to care. Quality care is effective, safe and people-centred. It needs to be timely, efficient, equitable and integrated. It is essential for improving performance, maintaining trust, ensuring the sustainability of health systems and guaranteeing that all efforts and resources invested in facilitating access to and delivering care are translated into improving people’s health. Quality care requires careful planning that involves and engages key stakeholders, including care recipients.
Quality control through internal monitoring and continuous measurement, alongside quality assurance, ensures that processes are adhering to a set standard and are continuously improved through quality improvement interventions to enhance performance. Systems at the local, subnational and national levels should be equipped to continuously assess, assure, evaluate and improve the quality of primary care, as well as other health services, through tailored interventions selected from a wide range of evidence-based quality improvement interventions to best suit their needs.
Systems at the local, subnational and national levels to continuously assess and improve the quality of integrated health services are linked to two FIP DGs: DG 3 (Quality assurance) and DG 6 (Leadership development).
Health systems, policies, strategies and operational plans should be informed by the best available evidence of what works and how. Health systems research and implementation research on interventions that support all three components of PHC is key to providing this information. This operational lever links directly with all other levers in the operational framework as health systems and implementation research should comprehensively foster the creation, management, dissemination and use of knowledge around all levers to advance progress in PHC.
It is crucial to ensure research dissemination to inform policy- and decision-making. Means of dissemination are being rapidly transformed as new options are enabled by modern information and communications technologies, such as wikis and learning models that operate virtually. Sharing successful approaches and models is important, but sharing examples of failures is also important so that others can learn from these.
Political commitment to and leadership of PHC are enabling factors to ensure that newly generated knowledge and learning around PHC is not only disseminated, but reflected in governance, policies, strategies and plans. The implication is that funding for PHC overall must ensure adequate and sustainable allocation of funds for PHC-oriented research to inform and accelerate decision-making and action around the PHC levers. Both political commitment and allocation of funding demonstrate how PHC-oriented research is mutually enabling to and enabled by the other levers.
Research and knowledge management, including dissemination of lessons learned, as well as the use of knowledge to accelerate the scale-up of successful strategies to strengthen PHC-oriented systems is linked to two FIP DGs: DG 11 (Impact & outcomes) and DG 12 (Pharmacy intelligence).
Monitoring, evaluation and review of health progress and performance are essential to ensure that priority actions and decisions are implemented as planned against agreed objectives and targets. Within the context of PHC, this means that countries will need to be able to assess gaps, determine priorities, establish baselines and targets, and track progress and performance across all the operational framework’s strategic and operational levers in their efforts to strengthen the three components of PHC.
Countries will need to be able to track how their decisions, actions and investments in PHC are addressing and improving service coverage, financial risk protection, determinants of health and ultimately the health status of individuals and populations. This endeavour requires that countries establish a comprehensive, coherent and integrated approach to monitoring and evaluation based on a logical, results-based framework that encompasses equity dimensions and multisectoral components across its entirety. The framework should include indicators that align with the operational framework levers and other related monitoring efforts.
Monitoring and evaluation through well-functioning health information systems that generate reliable data and support the use of information are linked to two FIP DGs: DG 11 (Impact & outcomes) and DG 12 (Pharmacy intelligence).