1. Federica Secci, senior health specialist1,
  2. Shams Syed, head, policy and partnerships2
  1. 1World Bank, Washington, DC, USA
  2. 2Special Programme on Primary Health Care, World Health Organization, Geneva, Switzerland
  1. Correspondence to: F Secci fsecciatworldbank.org

Quality of care must be a central focus of efforts to strengthen primary healthcare in the drive for universal health coverage, write Federica Secci and Shams Syed

It is easy to assume universal health coverage means reaching more people with healthcare services, but simply extending access to services is not enough. Universal health coverage also requires ensuring that the right people receive the appropriate services at the right time and that they are of adequate quality. To deliver on the promise of universal coverage, regain losses in service coverage resulting from covid-19, and accelerate progress towards health for all we need to strengthen primary healthcare worldwide.12 Primary healthcare, an inclusive whole-of-society approach that brings services for health and wellbeing closer to communities, provides a foundation for universal coverage, but lapses in quality can jeopardise trust and deter people from accessing primary care services. As countries continue to strive for universal coverage, we need to focus on quality when designing and delivering primary care.3

Despite the hard work of primary care providers globally, too often it is not an effective first point of contact with the health system. For example, if patient volume is too high, understaffed facilities may be overwhelmed, resulting in provider burnout; conversely, if patient volume is too low, providers may not be able to maintain the clinical skills required to deliver high quality care. A lack of meaningful engagement with and empowerment of individuals, families, and communities means people seeking care may not be treated with compassion or understand the implications of their health condition. When governments do not prioritise investments in primary healthcare, out-of-pocket payments for healthcare contribute to increasing inequalities.

Creating quality care

Yet primary healthcare can provide the much needed platform for integrating healthcare services and public health functions to improve population level outcomes. Embedding quality into primary healthcare ensures people’s first contact with health services is valued and trusted.4 A focus on quality implies that care is effective (those seeking care get an accurate diagnosis and appropriate treatment), does not cause harm, is tailored to people’s needs, and is available to everyone when needed. It is also requires different healthcare professionals and facilities to work together to improve care and ensure that available resources are targeted to improve health and avoid waste.5

Interventions for enhancing quality in primary healthcare cluster around four themes: system level considerations, improving clinical care, reducing harm, and engaging and empowering patients, families, and communities.6 For example, a participatory process has been at the centre of Malaysia’s strategic plan for quality since its launch in the 1980s. The process has led to an institutionalised commitment to quality improvement from policy makers, regulatory agencies, local authorities, and providers.78 Costa Rica has similarly embarked on a long process to promote high quality primary healthcare across its health system, supported by strong measurement and management systems that have been continuously adapted and refined to align with country values and norms.9

By building capacity in a multiprofessional health workforce prepared to collaborate, Malawi has improved quality by improving clinical care.10 Tailored infection prevention and control approaches recently formulated for health facilities across the world11 show how quality can be improved by reducing harm in primary healthcare. Finally, people and communities should be empowered to contribute to the generation and preservation of health. In Guatemala, citizen-led initiatives have held authorities to account for community identified lapses in health service delivery or quality for marginalised and indigenous populations, such as medicine shortages or lack of emergency transport.12

Embedding quality in primary healthcare is a complex process requiring action from multiple groups. Clinicians, managers, civil society, patients, and policy makers need to increase their efforts to create a culture of quality around evidence based primary care interventions that improve quality.79 Global and national platforms for peer-to-peer learning, such as the Joint Learning Network,13 can facilitate the exchange of practical knowledge—including measures of success—as well as which interventions have worked in which contexts.

Finally, primary healthcare requires adequate funding distributed in a reliable, equitable, and transparent way, with payments that encourage quality and team based care, not patient volume. When Estonia reformed its primary healthcare system, for example, bonuses to providers were progressively adjusted to increase the focus on quality of care and on management and prevention of non-communicable disease. This resulted in improved monitoring of almost all programme indicators and a slow but encouraging reduction in avoidable hospital admissions.14 Importantly, finance ministries must be engaged in constant dialogue to understand that quality primary healthcare is not a “nice to have” but a cost effective, essential platform for achieving strong health outcomes.2 Efforts to embed quality in primary healthcare require context specific adaptation as well as constant learning within and between systems and are essential in the pursuit of high quality health for all.


  • Competing interests: We have read and understood the BMJ policy on declaration of interests and have the no interests to declare. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is part of a collection proposed by the World Health Organization and the World Bank and commissioned by The BMJ. The BMJ peer reviewed, edited, and made the decision to publish these articles. Article handling fees are funded by the Bill & Melinda Gates Foundation. Jennifer Rasanathan, Juan Franco, and Emma Veitch edited this collection for The BMJ. Regina Kamoga was the patient editor.


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