Schwarz D, et al. Primary Care 2030: Creating an Enabling Ecosystem for Disruptive Primary
Care Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries.
Annals of Global Health. 2020; 86(1): 9, 1–5. DOI: https://doi.org/10.5334/aogh.2471
EXPERT CONSENSUS DOCUMENTS, RECOMMENDATIONS, AND WHITE PAPERS
Primary Care 2030: Creating an Enabling Ecosystem for
Disruptive Primary Care Models to Achieve Universal
Health Coverage in Low- and Middle-Income Countries
Dan Schwarz*,†, David Duong*, Chase Adam‡, J. K. Awoonor-Williams§, Darren Back‖,
Abhay Bang¶, Rani Bang¶, Madeleine Beebe**, Shreya Bhatt††, John Campbell‡‡, Magnus
Conteh§§, Dessislava Dimitrova‖‖, Donika Dimovska‡‡, Jean-Paul Dossou¶¶,***, Timothy
Evans†††, Mazin Gadir‡‡‡, Khaleda Islam§§§, Ronald Kasyaba‖‖‖, Priya Kumar‡, Catherine
Levy¶¶¶, Tran Mai Oanh****, Nahed Monsef††††, Juhwan Oh‡‡‡‡, Nathaniel Otoo‡‡,
Daniel Palazuelos§§§§,‖‖‖‖, Andy Poh¶¶¶¶, Sylvana Sinha*****, Catharine Smith†††††, Ben
Stewart‡‡‡‡‡, Cicely Thomas‡‡, Beth Tritter§§§§§, Peter Varnum‖‖‖‖‖, Taylor Weilnau†††††
and Andrew Ellner*
Background: Forty years after Alma Ata, there is renewed commitment to strengthen primary health care
as a foundation for achieving universal health coverage, but there is limited consensus on how to build
strong primary health care systems to achieve these goals.
Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create
an enabling ecosystem for disruptive primary care innovation. We focused our discussion on four themes:
workforce innovation and strengthening; impactful use of data and technology; private sector engagement; and innovative financing mechanisms.
Findings: Here, we present a summary of our convening’s proceedings, with specific recommendations for
strengthening primary health care systems within each of these four domains.
Conclusions: In the wake of the Astana Declaration, there is global consensus that high-quality primary
health care must be the foundation for universal health coverage. Significant disruptive innovation will be
required to realize this goal. We offer our recommendations to the global community to catalyze further
discourse and inform policy-making and program development on the path to Health for All by 2030.
Introduction
Forty years after Alma Ata, the global community has
made enormous strides in poverty reduction and population health. However, we are still far from achieving Health
for All [1, 2]. Low- and middle-income countries (LMICs)
continue to rely on health systems designed primarily for
acute, episodic care, which are poorly equipped to meet
the needs of communities across their lifetimes, including the growing burden of non-communicable diseases.
There are universal challenges of healthcare access,
quality, patient-centeredness and cost as well as persistent, unacceptable health inequities [2].
* Harvard Medical School, Program in Global Primary Care and
Social Change, Boston, US
‖‖
World Economic Forum, Geneva, CH
¶¶
entre de recherche en Reproduction Humaine et en
C
Démographie, Public Health, BJ
Ariadne Labs at Brigham and Women’s Hospital and Harvard
T.H. Chan School of Public Health, Boston, US
†
‡
Watsi, San Francisco, US
Ghana Health Services, Policy, Planning, Monitoring and
Evaluation, Accra, GH
§
Instituut voor Tropische Geneeskunde, Public Health,
Antwerpen, BE
***
The World Bank Group, Health, Nutrition and Population
Global Practice, Washington, DC, US
†††
‖
fizer Inc., Social Investments and Corporate Responsibility,
P
New York, US
‡‡‡
Dubai Health Authority, Executive Office for Organizational
Transformation, Dubai, AE
¶
Society for Education, Action and Research in Community
Health (SEARCH), Gadchiroli, Nagpur, IN
§§§
Health Services of Bangladesh, BD
Muso, Bamako, ML
Medic Mobile, Mumbai, IN
**
††
‡‡
§§
Results for Development, Washington, DC, US
Last Mile Health Inc., Community Health Academy, Boston, US
‖‖‖
Uganda Catholic Medical Bureau, Kampala, UG
¶¶¶
anofi SA, Global Health Programs for Non Communicable
S
Diseases, Paris, FR
Health Strategy and Policy Institute, Department of Public
Health, Hanoi, VN
****
Art. 9, page 2 of 5
Our communities’ renewed commitment to primary
health care (PHC) as the foundation for universal health
coverage (UHC), ratified by the Astana Declaration [1],
presents an imperative to reflect on past failings, current
challenges, and future opportunities. Macro-economic
strategies favoring privatization of public services along
with loss of vision and political commitment to Alma Ata
during the 1980s were associated with a retreat to selective primary health care and disease-specific vertical strategies as the core approach to improving health for LMICs.
Consequently, an implementation gap between ambitious
vision and operationalization widened in the ensuing decades [3]. There have been some promising exemplars during the time period from Alma Alta to Astana, including
Cuba’s community-oriented primary health care system [4,
5], Brazil’s family medicine programs [6], and large-scale
community health worker programs such as Pakistan’s
Lady Health Workers [7] and India’s Anganwadi workers
[8]. With that being said, while the last half-century has
seen immense growth in biomedical discovery for preventing, diagnosing and treating disease, there has been
comparatively little innovation in our systems of health
care delivery to spread these advances to improve access
and quality of care and more equitable health outcomes.
To catalyze new thinking and innovation at this critical
moment, the Harvard Medical School Program in Global
Primary Care and Social Change, in partnership with
Results for Development and the World Economic Forum,
convened a group of diverse stakeholders for a high-level
dialogue entitled Primary Care 2030. We aimed to identify
priorities and forge new alliances across diverse stakeholders in order to foster an enabling ecosystem for disruptive
innovations in primary care. Here, we summarize our convening, adding to the global discourse of how to achieve
UHC by 2030. Full proceedings are accessible at https://
primarycare.hms.harvard.edu/sites/g/files/mcu856/
files/assets/Proceedings.pdf.
An enabling ecosystem for primary care
innovation
In the natural sciences, an ecosystem is a network of
organisms with interdependent relationships between
each other and the environment. Extrapolated to health
care, a health ecosystem consists of a diverse group of
stakeholders, including governments, private sector entities, civil society, health professionals, patients, and community members, working together to improve health.
For our convening, we brought together a group of global
stakeholders to catalyze innovative thinking across these
interdependent relationships. We focused our discussion
Dubai Health Authority, Department of Health Affairs,
Dubai, AE
††††
Seoul National University College of Medicine, JW LEE
Center for Global Medicine, Seoul, KR
‡‡‡‡
Harvard Medical School, Department of Global Health and
Social Medicine, Boston, US
§§§§
‖‖‖‖
Partners In Health, Boston, US
¶¶¶¶
United Arab Emirates Prime Minister’s Office, Dubai, AE
Schwarz et al: Primary Care 2030
on four themes: workforce innovation and strengthening;
impactful use of data and technology; private sector
engagement; and innovative financing mechanisms.
Workforce innovation and strengthening
LMIC health workforces struggle with shortages, inappropriate design, and insufficient support to meet the
needs of the communities they serve [9]. Simply adding
more health workers will not suffice; the workforce, from
development to deployment, needs to be re-designed
and professionalized, supported by strong and effective
supervision, and appropriately compensated. As above,
some historical examples of compelling programs from
Cuba, Brazil, Pakistan, India, and other countries provide
insights for future improvement and innovation.
During our convening, we agreed that team-based
approaches, inclusive of cadres such as mid-level practitioners [10] and community health workers [2, 11] with patients
and their families actively engaged in healthcare delivery,
will play a central role in scaling quality, patient-centered
primary care services. Allied health professionals, such as
health coaches, social workers, and patient navigators are
also critical to the effectiveness of multidisciplinary teams
[12]. Workforce strategies dependent upon physicians, or
strategies that fail to create and enforce accountability, will
continue to struggle to address the myriad access and quality challenges, especially on the front lines of care delivery.
Data and technology for quality and scale
Despite present challenges, society’s digital transformation is a key opportunity for paradigmatic shifts in the
scalability, safety, and quality necessary for UHC by 2030.
Many LMICs still struggle with fundamental data capacity
such as civil registration and vital statistics, significantly
limiting their ability to provide quality primary care across
patients’ lifetimes [13]. Transitioning from analog, paper
registry systems to secure, interoperable digital records
will enable longitudinal access to patients’ data across
facility and community settings.
Coupling digital records with mobile applications used
by patients and providers can augment data availability in
real-time, enabling proactive care partnerships between
patients and provider teams [14]. The adoption of usercentric technologies, including automated algorithmic
clinical decision support and tools for real-time communication between patients and care teams, can help to scale
quality primary care delivery, even in areas struggling with
workforce shortages and other access barriers.
Several policy priorities emerged from our discussions of how to foster technology-enabled, team-based
*****
Praava Health, BD
†††††
Harvard Medical School, Center for Primary Care, Boston, US
‡‡‡‡‡
F Hoffmann-La Roche AG, Foundation Medicine, Basel, CH
Primary Health Care Performance Initiative, Washington, DC, US
§§§§§
World Economic Forum, Global Health and Healthcare,
Geneva, CH
‖‖‖‖‖
Corresponding author: Dan Schwarz, MD, MPH
(dkschwarz@ariadnelabs.org)
Schwarz et al: Primary Care 2030
approaches to primary care. Firstly, there is a critical need
for user-centered, open-source technology innovations
with defined standards for data structure, security, and
regulations that ensure interoperability, while simultaneously preserving patients’ rights to privacy and data
ownership. Secondly, stakeholders must align around universal metrics for measuring the performance of primary
care systems, such as those developed by the Primary
Healthcare Performance Initiative (https://improvingphc.
org/). Thirdly, we must standardize methods for evaluating innovations in primary care service delivery, ensuring
that such evaluations receive funding priority on par with
biomedical research. Finally, we must take advantage of
the opportunities that real-time data availability offers,
developing stronger data feedback loops and enabling
rapid learning and improvement at the frontlines of care.
This includes improvements in health workforce management, surveillance of disease burdens, and predictive
planning for supply chains, among other opportunities.
Meaningful engagement with private sector entities
Historically, much of the global discourse has championed public sector health service delivery in LMICs so as
to build equitable health systems that can reach the most
vulnerable. It is increasingly clear that UHC will require a
more strategic engagement with the private sector [15].
Our conversations focused on how to cultivate trusting,
impactful relationships between governments, non-government organizations, multilateral organizations, academia, and private businesses, to optimize equitable care
delivery for patients and communities.
We agreed that the private sector must have a role in
both innovation and direct service delivery. Governments
historically struggle to catalyze research and development,
while the private sector has bandwidth and resources to
test and identify innovative best practices, including new
service delivery processes, technologies, diagnostics, and
medications. Working together, governments can collaborate with private sector actors to co-create products
and services, accelerating their deployment and adoption
at scale. To achieve this, governments need to develop
national plans that provide consistent, predictable data
regarding country demand, such that private sector entities can plan investments and contributions accordingly.
As service providers, private entities deliver health care
services in areas throughout LMICs, including in remote,
rural areas, where public sector services are limited in
access and quality [16]. By working formally through public-private partnership models, governments and private
entities can harness the benefits of both private and
public sector service delivery. In doing so, governments
can maintain strategic focus on core competencies of
regulating and performance monitoring to ensure quality
and equitable access.
Innovative financing mechanisms for universal health
coverage
We were particularly concerned with the financing and
purchasing mechanisms of the public sector, which have
historically posed significant barriers to innovation and
Art. 9, page 3 of 5
quality service delivery, especially within the most impoverished and marginalized populations. We agreed that a
major shift in financing from fragmented disease-specific
mechanisms [3] to a more federated, equitable and efficient financing based on prepayment, pooling, and strategic purchasing, is a critical step for all countries on the
path to UHC [17]. Working closely with the private sector, purchasing mechanisms within countries should be
strengthened with strategic frameworks, using technology
for predictive analysis of supplies, minimizing stock-outs,
and maximizing access. Furthermore, transitioning toward
health financing schemes that ensure financial protection
and reward preventative care will be necessary to incentivize value-based integrated service delivery for all populations. This may require new capacities and legislation to
enable strategic and value-based purchasing.
Furthermore, it is important to recognize that many
governments have not historically had the autonomy or
agency to determine their own financing and purchasing
mechanisms, which have often been driven by the agendas of multilateral organizations, development banks, and
non-governmental organizations. Accordingly, our group
emphasized the importance of these international entities
aligning amongst themselves with greater clarity on how
development assistance for health can contribute more
effectively to greater mobilization and better use of domestic financing, meeting the needs of local populations [18].
Limitations
We brought together a diverse group of global stakeholders
for a high-level dialogue on how to create an enabling ecosystem for disruptive primary care innovation. However,
this was by no means representative of all stakeholders
as key groups including patient representative groups,
diversity in geographical distribution, and global south
academic institutions were not present. Additionally,
the “private sector” in our convening predominately represents multinational corporations (MNC), rather than
private sector service delivery providers, which exist in
many LMICs. Given the limited scope of the private sector
representation in our convening, we did not discuss the
“private sector-ization” of health care services; rather, we
focused on how public-private partnerships in the form of
how MNCs can meaningfully contribute to the national
or sub-national PHC agenda, aligning objectives, strategies and shared indicators for success. The summary from
our convening is not intended to be representative of all
global voices, but rather, offer a concise perspective from
some engaged voices.
Conclusion
Much has changed in global health since Alma Ata in 1978.
While we celebrate advances, we must acknowledge our
shortfalls and the challenges ahead as we strive for UHC
by 2030. Today, the global burden of disease is changing,
health inequities are glaring, and past strategies will be
insufficient for overcoming the significant barriers in our
path. What has not changed, however, is the clarion vision
of PHC as the basis for quality health service delivery, and
its critical role in achieving UHC.
Art. 9, page 4 of 5
In this historic moment, we have summarized the
insights of our convening, to catalyze further discourse.
We firmly believe that UHC by 2030 is achievable, and
that strong, technology-enabled, team-based PHC will be
the foundation. It is time for a new visionary strategy that
appropriately leverages past lessons, coupled with current
opportunities, to advance primary care and finally achieve
Health for All.
Acknowledgements
All authors of this manuscript would like to thank all of
the participants in the Primary Care 2030 Meeting for
their expertise and contribution to these findings. A special thanks to Jennifer S. Puccetti, Dr. Salmaan Keshavjee,
and Dr. Nasreen Adamjee of the Harvard Medical School
(HMS) Department of Global Health and Social Medicine
for their support and contributions. Finally, we would like
to thank the Harvard Medical School Center for Global
Health Delivery in Dubai and their team for hosting this
meeting.
Competing Interests
Darren Back declares a conflict of interest of being
employed by the pharmaceutical company Pfizer Inc. No
other authors have conflicts of interest to disclose.
Author Contributions
Dan Schwarz and David Duong are joint-first authors who
contributed equally. All authors had access to the data and
a role in writing the manuscript.
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Art. 9, page 5 of 5
How to cite this article: Schwarz D, Duong D, Adam C, Awoonor-Williams JK, Back D, Bang A, Bang R, Beebe M, Bhatt S,
Campbell J, Conteh M, Dimitrova D, Dimovska D, Dossou J-P, Evans T, Gadir M, Islam K, Kasyaba R, Kumar P, Levy C, Oanh TM,
Monsef N, Oh J, Otoo N, Palazuelos D, Poh A, Sinha S, Smith C, Stewart B, Thomas C, Tritter B, Varnum P, Weilnau T, Ellner A.
Primary Care 2030: Creating an Enabling Ecosystem for Disruptive Primary Care Models to Achieve Universal Health Coverage in
Low- and Middle-Income Countries. Annals of Global Health. 2020; 86(1): 9, 1–5. DOI: https://doi.org/10.5334/aogh.2471
Published: 03 February 2020
Copyright: © 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution
4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.
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