Primary Health Care Financing Must Put People Before Profits

The Cure That Never Arrives

In 1978, the world’s health leaders gathered in Alma-Ata, Kazakhstan, and made a promise so bold it still echoes: every person on earth would have access to primary health care. It was a vision of medicine as a right, not a privilege. Forty-four years later, in 2022, a team led by Kara Hanson at the London School of Hygiene and Tropical Medicine published a brutal audit in The Lancet Global Health. The promise had not been kept. In most low-income and middle-income countries, primary health care (PHC) was not just failing. It was trapped in a cycle that made failure self-perpetuating.

Here is the paradox the authors found: the very thing that should fix health systems is being starved by the way we pay for them. And the people who suffer most are the ones the system was meant to serve.

The Vicious Cycle Nobody Designed

Hanson and her colleagues did not just review the literature. They built a commission. They analyzed data from 67 low-income and middle-income countries (LMICs), interviewed policymakers, and mapped out the financial flows that determine who gets care and who does not. What they found was not a simple story of too little money. It was a story of money flowing in the wrong direction.

The abstract puts it starkly: “Public funding for PHC is insufficient, access to PHC services remains inequitable, and patients often have to pay out of pocket to use them.” That sentence is a diagnosis. But the mechanism is more interesting.

Here is how the cycle works. Underfunded PHC facilities cannot afford enough staff, medicines, or equipment. So the care they provide is unreliable and often poor quality. Patients notice. They start skipping the local clinic and going straight to a hospital or a specialist. That costs them more time and money, but they figure it is worth it for care that might actually work. Meanwhile, the PHC facility loses the funding that follows patients. With even less money, quality drops further. More patients leave. The cycle tightens.

“A vicious cycle has undermined PHC,” the authors write. “Underfunded services are unreliable, of poor quality, and not accountable to users. Therefore, many people bypass primary healthcare facilities to seek out higher level specialist care. This action deprives PHC of funding, and the lack of resources further exacerbates the problems that have driven patients elsewhere” (Hanson et al., 2022).

The tragedy is that this is not inevitable. It is a choice. A choice made by budgets, by payment models, by political priorities. And it is a choice that can be unmade.

Why Primary Care Is the Best Bet We Have

Before we get into the fixes, it is worth understanding what is at stake. Primary health care is not just a nice idea. It is the most efficient platform for delivering the interventions that actually save lives.

The commission points out that PHC handles the vast majority of basic health needs: vaccinations, maternal care, management of chronic diseases like diabetes and hypertension, and essential public health functions like disease surveillance. When PHC works well, it catches problems early, prevents complications, and keeps people out of expensive hospitals. It is the difference between a $5 checkup and a $5,000 emergency room visit.

The COVID-19 pandemic made this brutally clear. Countries with strong PHC systems were better able to maintain routine vaccinations, manage chronic conditions, and coordinate public health responses. Countries with weak PHC systems saw their hospitals overwhelmed and their health workers burned out. Hanson et al. note that the pandemic “brought the need for well functioning primary healthcare into sharp focus.”

But here is the uncomfortable truth: the world has known this since 1978. The Alma-Ata Declaration was not a secret. The 2018 Astana Declaration reaffirmed the commitment. And yet, as the commission’s data shows, most LMICs still spend a tiny fraction of their health budgets on PHC. The gap between rhetoric and reality is a canyon.

The Money Problem: More Is Not Enough

The obvious answer is: just spend more on PHC. But the commission’s analysis suggests that is too simple. The problem is not just how much money flows into PHC. It is how that money flows.

In many countries, PHC funding comes from a mix of sources: government budgets, donor funding, and out of pocket payments from patients. The mix matters. When patients pay at the point of care, they use less care, especially preventive care. When governments fund PHC through fixed budgets, facilities have no incentive to attract patients or improve quality. When donors fund vertical programs for specific diseases like HIV or malaria, the money bypasses the general PHC system and leaves it weaker.

The commission found that in many LMICs, out of pocket payments account for a large share of PHC financing. That is a regressive tax on the sick. It means a poor family with a child who has a fever might skip the clinic entirely, waiting until the child is severely ill and needs hospitalization. By then, the cost is higher and the outcome worse.

Hanson and her colleagues argue that the goal should be to move toward “public financing that is pooled and prepaid.” In plain language: governments should collect taxes or insurance premiums and use that money to fund PHC directly, so patients do not have to pay when they get sick. This is how most high-income countries do it. It works.

The People at the Center

The commission’s title includes the phrase “putting people at the centre.” That is not just a slogan. It is a design principle.

The authors argue that PHC financing should be organized around the needs of two groups: the people who use services and the people who provide them. Right now, neither group is well served.

For users, the problem is that PHC is often not where they want to go. It is inconvenient, understocked, and sometimes disrespectful. A woman with a sick child might have to walk two hours to a clinic that has no medicine, wait all day, and then be told to come back next week. She will not come back. She will go to a hospital or a traditional healer or nothing at all.

For providers, the problem is that they are often paid in ways that discourage good care. A doctor in a rural PHC clinic might be on a fixed salary, regardless of how many patients she sees or how well she treats them. Or she might be paid per visit, which incentivizes her to see as many patients as possible in as little time as possible. Neither model rewards quality, continuity, or prevention.

The commission calls for payment models that align incentives with outcomes. Capitation payments that give facilities a fixed amount per person enrolled, with bonuses for quality metrics. Performance based financing that rewards facilities for meeting targets like vaccination rates or hypertension control. And most importantly, patient centered design that makes facilities accountable to the communities they serve.

What the Research Does Not Prove

The commission’s analysis is comprehensive, but it leaves important questions open. For instance, the authors do not prove that any single financing model works everywhere. Context matters. A capitation system that succeeds in rural Rwanda might fail in urban India. The devil is in the implementation details.

The commission also does not fully resolve the tension between vertical and horizontal funding. Vertical programs for HIV, tuberculosis, and malaria have saved millions of lives, but they have also fragmented health systems. The authors acknowledge this trade off but do not offer a clean solution. They suggest that vertical programs should be designed to strengthen PHC systems, not bypass them. But that is easier said than done.

And there is a harder question the commission does not fully answer: what happens when governments simply do not have the money? In the poorest countries, domestic resources for health are tiny. Donor funding is volatile and often tied to specific priorities. The commission calls for more domestic financing, but it does not pretend that is easy.

These are not failures of the research. They are honest acknowledgments that the problem is hard. Anyone who claims a simple fix is selling something.

The Accountability Gap

One of the most striking findings in the commission is about accountability. In many LMICs, PHC facilities are not accountable to the people they serve. They answer to the Ministry of Health, which is far away and rarely visits. Patients have no way to complain or demand better service. So they vote with their feet, which means they leave.

The authors argue that accountability must be built into the financing system. If a facility is paid based on enrollment, it has an incentive to attract and retain patients. If it is paid based on quality metrics, it has an incentive to improve. If community health committees have a role in overseeing budgets, patients have a voice.

This is not just about efficiency. It is about dignity. A health system that treats people as passive recipients of charity is a health system that fails. A health system that treats people as customers with choices and rights is a health system that might work.

The Political Economy of Reform

If the solution is so clear, why has it not happened? The commission does not shy away from this question. The answer, they suggest, is political.

Reforming PHC financing means taking money away from powerful interests. Hospitals and specialists have more political clout than rural clinics and community health workers. Pharmaceutical companies profit from fragmented, disease specific funding. Bureaucrats resist change. And donors have their own agendas.

Hanson and her colleagues call for “political leadership and sustained commitment.” That sounds like a platitude, but it is not. They mean that reforming PHC financing requires building coalitions, managing opposition, and staying the course over years. It is not a technocratic fix. It is a political struggle.

The good news is that there are examples of success. Countries like Thailand, Ethiopia, and Costa Rica have built strong PHC systems with relatively low spending. They did it by making deliberate choices: pooling funds, paying providers differently, and holding facilities accountable. The commission draws on these examples to show what is possible.

What This Actually Means

The Lancet commission is not an academic exercise. It is a blueprint. Here is what it means for the people who make decisions about health spending.

• ▸Stop funding PHC through patient payments. Out of pocket payments at the point of care are a barrier to access and a driver of poverty. Move toward prepaid, pooled financing through taxes or insurance. This is the single most important change.

• ▸Pay providers for outcomes, not just visits. A fixed salary or a per visit fee does not reward quality. Use capitation payments with quality bonuses. Give facilities an incentive to keep people healthy, not just to see them when they are sick.

• ▸Make facilities accountable to communities. Give patients a voice in how PHC is run. Establish community health committees with real authority over budgets and priorities. If a facility is failing, patients should be able to demand change.

• ▸Design vertical programs to strengthen systems, not bypass them. When donors fund disease specific programs, they should invest in the PHC infrastructure that delivers those services. Do not build parallel systems that leave the rest of care behind.

• ▸Invest in the PHC workforce. Facilities cannot function without trained, motivated, fairly paid health workers. That means better salaries, better training, and better working conditions. It also means respecting the people who do this work.

The promise of Alma-Ata was not naive. It was ambitious. And it is still achievable. But it requires a shift in how we think about health financing. Not as a technical problem to be optimized, but as a moral choice about who matters.

Putting people before profits is not a slogan. It is the only way to make primary health care work. And if the last pandemic taught us anything, it is that we cannot afford to keep failing.