Free Primary Healthcare: A path to more meaningful social inclusion and sustainable development

It is election season once again, and as usual, there is an ongoing debate on promises made by politicians and which individuals, or political parties are most trustworthy or capable of delivering on the promises they make to us.

As a medical doctor and public health practitioner, I have been particularly interested in the promise by former President John Dramani Mahama of the NDC to provide free primary healthcare if elected president.

This promise, as captured on page 62 and repeated on pages 74 and 112 of the NDC manifesto is an audacious one, which if successfully and sustainably implemented will lead to multiple benefits such as a reduction in overall healthcare costs, increased growth and productivity in multiple sectors, and lessons for other countries in the global south on what is possible with strong will and audacity.

The concept of primary health care has been repeatedly reinterpreted and redefined, based on what periods we live in or where in the world we find ourselves. Some have referred to it as the provision of ambulatory or first-level of personal healthcare services. Others have understood it as a set of priority health interventions for low-income populations (also called selective primary health care).

Other actors have understood primary health care as an essential component of human development, focusing not only on health but on the economic, social and political aspects of people’s lives. Of all the definitions, I prefer the following: Primary health care (PHC) is essential health care made universally accessible to individuals and acceptable to them, through full participation and at a cost the community and country can afford.

The World Health Organization (WHO) expands on this definition with key three key components, applying not only to the health of a population but addressing multiple determinants and empowering all stakeholders with a high level of agency and ownership of processes that ultimately affect not only their healthcare but all aspects of their lives. The three components are as follows:

Meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services;

Systematically addressing the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviors) through evidence-informed public policies and actions across all sectors; and

Empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services, and as self-carers and care-givers to others. Based on these considerations, strengthening primary healthcare, and placing it at the center of efforts to improve health and wellbeing are critical for three reasons:

1. It is well-positioned to respond to rapid economic, technological and demographic changes, all of which impact health and wellbeing; It has been proven to be highly effective and an efficient way to address the main causes and risks of poor health and wellbeing

2. Primary health care has been proven to be a highly effective and efficient way to address the main causes and risks of poor health and well-being today, as well as handling the emerging challenges that threaten health and well-being tomorrow

3. Solid investments in primary healthcare provide benefits that go beyond health.

This expanded definition, with all its appeal, cannot be achieved without accessibility and affordability, which in my experience working as a doctor in both rural and urban parts of Ghana would be synonymous with free.

This is because of the existence of pervasive poverty and the inability of the National Health Insurance Scheme (NHIS) to fully respond to many of our healthcare needs.

This inability has been mainly because of exemptions in what services can be accessed, as well as the occasional lack of products in health facilities which are signed on to the NHIS.

This pushes back the burden of buying health products to patients, who often cannot afford them, sometimes leading to an exacerbation of their conditions and the eventual need for even more expensive specialist care.

Multiple analyses have found that approximately half of the gains in reducing child mortality from 1990 to 2010 were due to factors outside the health sector (such as water and sanitation, education, economic growth).

This approach draws in a wide range of stakeholders to examine and change policies to address the social, economic, environmental, and commercial determinants of health and well-being.

Furthermore, primary healthcare has been shown to be a good value investment, as there is evidence that quality primary health care reduces total healthcare costs and improves efficiency by reducing hospital admissions.

The WHO in a recent scoping review found that an investment in preventive services provided huge economic benefit for countries. For example, in low and middle-income countries, the return on investment from childhood immunization is estimated to be as high as $44 for every dollar spent.

Other reviews estimate the return on investment from community health workers to be $10 for every dollar.

In addition, it is known that compared with providers of specialist care, primary care physicians use fewer resources in terms of hospitalizations, prescriptions and common tests and procedures.

A well-run, accessible, and effective primary healthcare system will reduce the incidence of health conditions becoming complicated before they are attended to. This translates to an overall reduction in the time spent in hospital, leading to more time at school, in economic ventures or with family.

Addressing increasingly complex health needs requires a multisectoral approach that integrates health-promoting and preventive policies, solutions that are responsive to communities, and health services that are people-centred.

Primary health care also includes the key elements needed to improve health security and prevent health threats such as epidemics and antimicrobial resistance, through such measures as community engagement and education, rational prescribing, and a core set of essential public health functions, including surveillance.

Strengthening systems at the community and peripheral health facility level contributes to building resilience, which is critical for withstanding shocks to the health system.

Stronger primary healthcare is essential to achieving the health-related Sustainable Development Goals (SDGs) and universal health coverage. It will also contribute to the attainment of other goals beyond the health goal (SDG3), including those on poverty, hunger, education, gender equality, clean water and sanitation, work, and economic growth, reducing inequality and climate action.

Strengthening primary healthcare will require prioritization of health needs, with significant investments in health infrastructure, service delivery, human resources, access to essential medicines, among others. This process of strengthening primary healthcare and making it accessible can be envisaged in two possible ways:

1. Firstly, trying to provide the requisite quality and quantity of health infrastructure, training and employing enough health workers, securing funding and then implementing free primary healthcare after all the prerequisites are in place.

2. Boldly increasing access and affordability, learning whilst doing this whilst working with relevant stakeholders to strengthen the different components simultaneously.

In the Ghanaian context, the first approach will not work, as it will take us a few decades to train the needed number of health workers, develop the required infrastructure and ensure that all other pre-requisites are in place. Even then, we may not be ready as new innovations will already be in play in other countries.

This policy is very feasible, and if the annual cost of $1.4 billion from our oil and non-taxed revenue estimated by the NDC will be significantly less than the benefits we will accrue from Free Primary Healthcare.

The second option is therefore the only option we have, to make enhanced primary healthcare a possibility and reap all the stated benefits of such a system.

Given all its benefits, for all areas of our lives, I believe the promise and possibility of Free Primary Healthcare in Ghana is a potential game-changer and one that must be supported to become a certainty in our country. The author is a Ghanaian medical doctor and Public Health expert