Universal health coverage policies may fail to ensure the provision of primary care for all without a stronger commitment to community health

By Andres Garchitorena (Institut de Recherche pour le Developpement and NGO PIVOT), Felana A. Ihantamalala (Harvard Medical School and NGO PIVOT), and Matthew H. Bonds (Harvard Medical School and NGO PIVOT).


Nearly half of the world’s population lacks access to essential health services. To address this, most countries have committed to Universal Health Coverage (UHC), with the goal of ensuring the provision of primary health services that are “high quality, safe, comprehensive, integrated, accessible, available, and affordable for everyone everywhere”. Accordingly, UHC policies focus on reducing user fees at health facilities via fee exemptions or national health insurances, and on improving the quality of primary care through health systems strengthening. In practice, ensuring that health systems are capable of reaching everyone is both a design and a data problem. Health systems, after all, lack information on those who do not already access them, and a key determinant of that access is geography: many populations in rural areas of low- and middle-income countries need to walk several hours to consult at a health facility when they need care.

So we ask, how can health policies such as UHC be better designed to achieve universal access to primary health care? How can these information gaps be filled so that health systems are optimized to meet population needs?

To address these issues, the nongovernmental health organization, Pivot, recently partnered with the government of Madagascar to create a model of Universal of Health Coverage in the remote district of Ifanadiana.  This program includes many of the elements encouraged for national UHC policies, such as removal of user fees at health facilities, and improvements to healthcare quality via support to health system readiness and to clinical programs. It also strengthened the local community health program. These programs, which have evolved over time, have been integrated from the beginning with a unique dataset of geocoded patient records encompassing all health center visits in the district over the first four years (nearly 300,000 consultations), along with a vast geographic information system that maps over 20,000km of footpath, 100,000 houses, and every health facility. The result of the analysis of these data are published in our recent study “Geographic barriers to achieving universal health coverage: evidence from rural Madagascar”, which examined the contribution and limitations of policies for UHC and community health towards the realization of universal access to primary health care.

What did we find?

We found that the geographic reach of facility-based primary care is quite limited, even after fees are removed at the point of service and quality of services are improved. Half of all consultations in strengthened facilities were from patients who lived within 2 km. Those that lived within 5 km of a strengthened facility experienced substantial increases in utilization – exceeding 1 visit per person-year. But those who lived more than 5km from a strengthened facility accessed care less frequently than those who live near facilities which were never strengthened at all. Importantly for rural Madagascar and many other similar settings, most of the population (75%) lives more than 5km from a health facility. Using results from our statistical models, we predict that scaling up facility-based interventions alone (removing user fees, improving health system readiness), would only achieve modest increases in geographic coverage, with three quarters of the population consulting at facilities less than once per person-year.

However, there are solutions: strengthening community-health can have substantial impacts on the geographic reach of the health system. Community health workers (CHWs) are trained to provide a small subset of clinical services within their community, such as diagnose and treat common illnesses in children under five years. In Madagascar, there are two CHWs for each fokontany (a village or small group of villages), so even remote populations live in close proximity to a CHW. The effect of geography on primary care access in Ifanadiana was greatly reduced when accounting for community health consultations, reaching over 2 consultations per child-year regardless of distance to a health facility. CHWs were the main source of health care delivery for children in remote populations, representing 90% of primary care visits for those living further than 15 km from a health facility. Yet, less than 20% of the district population are part of the target age of CHWs (children under five years), leaving the vast majority of the population in remote areas with virtually no access to care. Further, community health programs are still under-resourced in many countries, where CHWs are considered local volunteers, are poorly compensated, and lack dedicated supervision and adequate training.

What does this mean?

These analyses show how powerful insights arise when comprehensive health reform occurs alongside data systems that are built to shed light on the complexity and heterogeneity of many global health challenges, and are tied to specific policy goals that are actionable. For Madagascar and similar low-income countries, wider support to community health is necessary to achieve universal access to primary care. In response to this evidence, Pivot has piloted a new program with the government of Madagascar to further strengthen the role of community health. In this new program, CHWs proactively visit every household at least once per month, receive biweekly direct supervision and training, and are paid the national minimum wage. This is in line with the recently updated World Health Organization guidelines on community health worker programs, which advise that CHWs should be professionalized – i.e., paid, trained and directly supervised. Yet most countries have not yet adopted policies based on these new guidelines. Our results provide the best evidence to date of the substantial gaps in care that will persist until public health systems adequately integrate professional community health programs. Though there remains debate on how to optimize community health, a greater ability for populations everywhere to access the formal health system is clearly fundamental to any hopes of achieving UHC. And we need the right data to identify who is missing. Professionalized CHWs can contribute to both the clinical and data gaps if they could further expand the scope of primary care services across a greater range of clinical cases and demographic groups.

N.B. Some authors are current or former employees of institutions discussed in this article, including the NGO PIVOT.

Image credit: NGO Pivot