The Essential Role of Primary Health Care for Health Security

The Health of the Population

Unprecedented declines in US life expectancy preceded the COVID-19 pandemic with widening gaps in many health outcomes based on socioeconomic status, education, race and ethnicity differences. In the US, these declines involve a complex interplay of factors driven initially by the opioid epidemic and increasing rates of chronic illness and accelerated by the COVID-19 pandemic. While peer countries saw life expectancy rebound after the arrival of COVID-19 vaccines, the US has not. After a century of increasing life expectancy, this notable shift has triggered alarms among US Policy makers and public health officials. It has led to calls for health policy interventions that address both underlying sources of the decline and health care system reforms capable of restoring population health and longevity. What lessons have we collectively learned about the importance of Primary Health Care in resilience and health security as a result of the COVID-19 pandemic? How can Primary Health Care stakeholders collaborate to support an expanded role for US federal leadership in this space?

The Role of Primary Care

In May 2021, the National Academies for Science, Engineering, and Medicine (NASEM) released a groundbreaking report, entitled, Implementing High Quality Primary Care: Rebuilding the Foundation of Health Care. This report had 3 central tasks: 1) examine the current state of primary care in the US, 2) develop an implementation plan, and 3) inform primary care systems around the world. The NASEM described in detail the current state of primary care in the US, and then set 5 implementation objectives to achieve high-quality primary care available (Fig. 1).

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Figure 1.

Five objectives from Implementing High Quality Primary Care, National Academies of Sciences, Engineering, and Medicine.

The NASEM primary care report has proven influential. Shortly after the report’s release, the Assistant Secretary for Health at US Department of Health and Human Services’ (HHS) launched the Initiative to Strengthen Primary Health Care, in collaboration with the Department of Veterans Affairs (VA) and the Department of Agriculture. The HHS initiative created a unique window of opportunity for fostering and uniting strategic coordination across federal agencies and fulfilling the NASEM committee’s third goal of Primary Health Care collaboration across the globe. Accordingly, a 2-day international conference was planned, featuring prominent Primary Health Care leaders from high-income and low- and middle-income countries, who shared their innovative approaches and challenges in implementing Primary Health Care since the 2018 Declaration of Astana. The aim of this conference was to catalyze action toward revitalizing primary care in the US, align efforts to advance primary health care worldwide, and improve health and health security for all.¹

The Primary Health Care Intervention Conference

Table 1 shows keynote speakers for the conference, and Table 2 reports high-level themes from the conference.

Given the NASEM report’s first objective focused on payment for primary care, the conference opening plenary featured leadership from the Center for Medicare and Medicaid Innovation (CMMI), highlighting its commitment to the HHS’ efforts by embracing Primary Health Care as a key strategy for improving health equity with new primary care payment demonstrations.³ Dr. Liz Fowler described CMMI’s vision for elevating primary care and health equity through 2 new payment models, the Making Care Primary and States Advancing All-Payer Health Equity Approaches and Development (AHEAD). These new payment models build on past success, move toward prospective population-based primary care payment, and specifically mentioned using the NASEM report as a blueprint.^4,5

The conference featured the HHS Roadmap for Behavioral Health Integration and the related behavioral health coordinating council that include the integration of behavioral health into primary care as a key priority – also recommended in the NASEM report, under objective 2, expanding access to care.⁶ The behavioral health roadmap and coordinating council are precisely the management and accountability mechanisms that NASEM had proposed for primary health care and remain the model for actualizing its recommendations.

The Assistant Secretary of Health (OASH), Admiral Rachel Levine, provided an inspiring conference keynote, emphasizing that PHC is a common good and serves a foundational role in addressing national health priorities, including mental health and substance use, the maternal health crisis, and health inequities, among others.⁷ OASH worked across HHS departments to create a primary care coordinating strategy and a newly established NASEM Steering Committee on Primary Care, an advisory body composed of national experts in PC delivery, policy, and research, was established to support it.⁸ The details of the Standing Committee and how it can support HHS’ efforts are described in the accompanying article by Marc Meisnere.⁹ Meisnere emphasizes both the critical role that a federal coordinating body can serve to improve primary care in the US, and the equally important need to enable external experts in primary care policy, research, and clinical care to provide input on urgent issues as primary care policy evolves.

Tedros Ghebreyesus, Director-General of the World Health Organization, provided a short keynote via video, with a message about the urgent need to focus policy maker attention on the importance of securing primary health care as part of health security. Despite impressive progress in strengthening primary health care in many countries, the global struggle to respond to the COVID-19 pandemic underscores the critical need to include primary health care in populations health strategies, to better partner with public health, to promote global health security, and to improve health equity. The COVID-19 pandemic was a stress test for the global health care delivery systems that revealed many critical weaknesses which, if left unresolved, will ultimately lead to catastrophic consequences.

Dr. Atul Gawande shared USAID’s vision for primary health care, describing the new Primary Impact Initiative that builds on USAID’s longstanding commitment to strengthen Primary Health Care in low- and middle-income countries.¹⁰ This effort builds more intentional linkages across USAID’s current global health programs and initiatives to renew and further strengthen USAID’s commitment to Primary Health Care in the 7 focus countries. To ensure progress toward meeting the anticipated goals, USAID and HHS are developing dashboards to track progress on key Primary Health Care functions and population health outcomes. The HHS dashboard is responsive to the recommendations of the NASEM report and builds on a national scorecard developed by the Milbank Memorial Fund.¹¹

The Pan American Health Organization (PAHO) Director, Dr. Jarbas Barbosa emphasized the importance of preparedness of PHC in addressing and recovering from pandemics, and the need to strengthen it. Dr. Tom Freiden, President and Chief Executive Officer at Resolve to Save Lives and former head of the Center for Disease Control and Prevention, spoke to the need for better collaboration between primary care and public health. Specifically, Dr. Frieden spoke to the United State’s continued lag in population health, falling behind countries like Costa Rica, and the need for “robust” primary health care to turn it around. Professor Michael Kidd, who led Australia’s exemplary response to the COVID-19 pandemic, emphasized that a Primary Health Care–led public health response is the reason that their experience was far less tragic than that of most developed countries. Dr. Howard Haft and colleagues’ conference article on Primary Care-Public Health Integration builds on this conference topic.¹² They identify the most critical areas for investment in health care delivery systems: the integration of primary care and public health. They show how failing to strengthen these critical supporting elements can and will lead to cascading failures throughout the health care delivery system.

The July Primary Health Care conference was unique in its expansive focus on primary health care (not limiting itself to primary care) and public health, as well as its emphasis on both US and global examples of progress and promise. The accompanying article by Dr. Asaf Bitton and Dr. Bruce Finke underscores the imperative to evolve from primary care to primary health care approaches, and offers an encouraging perspective on steady US progress to date in 6 related areas of Primary Health Care.¹³ Notably, the conference was rich with related examples and engagement about Primary Health Care solutions that improve health equity, mental health, pandemic response and preparedness, and public health.

This conference helped set the stage for increased collaboration across US agencies and global Primary Health Care stakeholders. The Initiative to Strengthen Primary Health Care, led by OASH, was important context for this conference. OASH brought together agency leads from HHS agencies to develop a Primary Care Action Plan that was anticipated to serve as a roadmap for the evolution from primary care to primary health care in the US The OASH work served as a backdrop for the conference, with hopes that ideas and collaborations from the conference could help inform HHS efforts.

To engender the political support necessary to shift from the current narrow view of primary care to a more expansive and inclusive vision, the US needs a roadmap like the one HHS published for behavioral health. HHS published an Issue Brief to highlight current progress made toward the NASEM recommendations, including the HHS Primary Health Care Dashboard, but it missed the opportunity to use the painful lessons of the US COVID-19 response as a rallying cry for action across a broad and diverse set of health stakeholders.^14,15 As the recent Change Health care cybersecurity crisis¹⁶ again demonstrates, the imperative for a clear plan and call to action to strengthen the disjointed health care delivery ecosystem is needed now more than ever. Beginning with a strong foundation of primary health care is arguably the best place to start.

We invite you to review a fuller reporting of the conference content on the website and hope that the conference articles published in this issue offer deeper insights about the opportunity address our nation’s most important health problems by strengthening the foundation of primary health care in the US.¹