Integrative Review on Primary Health Care Financing in National Health Systems: Ensuring Access and Equity ()
1. Introduction
Primary health care financing has been, over the years, a widely debated subject in the scientific community. The debate on the subject is broad, diverse and continuous, especially considering that National Health Systems, which have Primary Care as their gateway, and need an adequate financing model to ensure access and equity. For example, Brazil, which has a universal Unified Health System (SUS), had its financing model changed after 21 years. Such model was replaced by the federal government through Ordinance 2.979, of November 12, 2019 (Brasil, 2019).
Among the considerations made by the Ministry of Health (MS) to justify the change in the current financing model, the following can be highlighted: “...the need to expand the population’s access to Primary Health Care services in order to ensure the universality of SUS” (Brasil, 2019). In addition, the following justification is also indicated by the MS: “...the need to equitably review the federal costing funding way related to Primary Health Care” (Brasil, 2019).
However, the justifications of the MH can be widely criticized. Among several opposing arguments, it can be noted that the modification of the Primary Health Care financing breaks with the Fixed Primary Care Baseline, implemented since 1998, which ensured a total per capita value transferred to the municipality, so that it could plan and execute health actions and services at this level of care as a whole, respecting the constitutional principles of the SUS (Mendes & Carnut, 2020). Moreover, it is known that from the equity point of view, the new model does not follow the determinations provided by the Brazilian Law n. 141/2012, article 17 (Brasil, 2012b), in which the guiding criterion for the transfer of federal resources to municipalities refers to health needs (Mendes & Carnut, 2020).
The discussion on the topic of financing primary care essentially passes through the definition proposed by Kleczkowski et al. (1984) who point out that the care model is the guide for the financing process and, therefore, in the case of Primary Health Care (PHC), must be in line with its expanded conceptual basis, which will be discussed below.
For the purposes of our discussion, we will take as the main reference of Primary Health Care the definition proposed by the Brazilian Ministry of Health:
“Primary Health Care (PHC) is the first level of health care and is characterized by a set of health actions, at the individual and collective level, which covers the promotion and protection of health, the prevention of diseases, diagnosis, treatment, rehabilitation, harm reduction and health maintenance with the aim of developing comprehensive care that impacts the health situation and autonomy of people and the health determinants and conditions of communities” (Brasil, 2012a: p. 19).
By principle and definition, this should be the first care that the SUS’s user must receive, that is, the gateway for him to have access to health. For this reason, in a universal health system, it is necessary to expand access to health until there are guarantees that the entire population can access the system through this care model.
Regarding the definition of the term access, there is a wide discussion from a health perspective. As Travassos & Martins (2004) state, “access” is a complex concept that varies among authors and according to the time and context used. According to them, “authors such as Donabedian, use the noun accessibility—character or quality of being easy to approach—while others prefer the noun access—act of entering, entry—or both terms to indicate how easily people obtain health care” (p. 2).
The scientific discussion on the term also goes through the “health needs” issue. That is, access has to do with the ability to produce actions and services that meet the health needs of a given population (Travassos & Martins, 2004). Providing access, therefore, represents not only the distribution of resources or health equipment, but also the equitable allocation of these resources and health equipment according to the health needs of users of the system.
In such a view, the guarantee of equity in the primary health care financing is necessary, given the different health needs that each population has, due to the geographic and socioeconomic conditions to which each one is subjected. The term equity, considered one of the guiding principles of the SUS, has some possible definitions that are worth highlighting. The first, formulated by West, worked on by Porto (2002), discriminates the principles between horizontal equity—where there is equal treatment for all—and vertical equity—which would be unequal treatment for unequals. Porto (2002) summarizes and reminds us that “behind the first concept (horizontal) is the principle of equality, while the second (vertical) presupposes positive discrimination, and, furthermore, that equal treatment may be not equal” (p. 129).
In addition to this, Porto (2002) brings the concept of equity worked on by Julian Le Grand, who distinguishes five types of equity linked to the distribution of public expenditure and Artells and Mooney, who summarize seven possible concepts of equity in health and who, in all of them, consider the distribution of public expenditure as a central point of concern. And despite the vast bibliography on the subject, for the purpose of our discussion, we will also consider the concept of equity by the Ministry of Health, which associates the direct relationship with the concept of equality and social justice, stating that equity means treating unequals unequally, investing more where the need is greater (Brasil, 2020).
This is one reason why there is equitable funding between different regions. Unequally financing unequal regions. However, there is little care, as the criteria for apportioning funding must be precise and consider the health needs of different populations, as recommended by Brazilian Law n. 141/2012 (Brasil, 2012b).
In this sense, it is essential to know the discussion in the scientific literature that deals with financing primary care in national health systems seeking to refer it to the aspects of expanding access and ensuring equity. Thus, it is possible to expand the frame of reference of this theme to reflect on the content necessary to think about the financing model of PHC in the SUS in Brazil.
2. Method
2.1. Objective
The objective of this research is to review the scientific literature on financing primary health care (PHC) in national health systems, in terms of expanding access and ensuring equity. To achieve this objective, an integrative systematic review of the literature was conducted.
2.2. Data Source and Search Strategy
The method chosen for this research was integrative review of national and international literature, with the objective of synthesizing the current knowledge, from different authors and published on the subject and presented as initial basis the following question: “What has the scientific literature made available on financing primary care in national health systems, in terms of expanding access and ensuring equity?”.
From then on, we chose to work in this Review with two repositories of scientific studies, two portals (which bring together different databases), the Virtual Health Library (VHL) and PubMed.
The main question gave rise to three key items, which were searched on the DeCS platform (Health Sciences Descriptors) for the specific Descriptors, according to the applicability of the definitions. In the PubMed database, a translation into English was used, available in Decs for the descriptors identified in Portuguese, and additionally, these same terms were searched in the National Center for Biotechnology Information (NCBI) database. Certain terms, when considering the literal translation, were not found, and therefore were replaced by synonyms in the Medical Subject Headings (MeSh Terms).
The final descriptors, derived from each key item and used for research in the VHL and PubMed, can be analyzed in Chart 1.
The search used a methodological technique for combining several descriptors with each other, through Boolean operators, in order to find the best syntax, in order to refine it. In order to improve the search strategy, it was decided to group “Access” and “Equity” in the same Key Item. Starting from the VHL portal, using the Boolean operator “OR”, the result is shown in Chart 2.
Chart 1. Definition of key items and descriptors in DeCS/BIREME and MeSH Terms PubMed.
Source: author’s elaboration.
Chart 2. Search Results by groups of descriptors in the VHL/Bireme.
Source: author’s elaboration.
Regarding the PUBMED Portal, the key items were also worked on with MeSH Terms. Or the construction, the same syntax construction methodology was used and the Boolean operator “OR” was also used. The results are presented in Chart 3.
Chart 3. Search results by MeSH terms groups.
Source: author’s elaboration.
Given the large number of results found, it was decided to continue the search strategy using the Boolean operator “AND”, in order to narrow down the search through the connection between the descriptors and the MeshTerms and the different keywords. However, in order to direct the search to the object of study, from the perspective of the basic guarantees that the financing of the National Health System should offer, the keywords “Accesso”/“Access” and “Equidade”/“Equity” were used in the “title, abstract and subject” of the articles, as additional mandatory criteria for inclusion of the article in the final syntax, resulting in the final syntaxes shown below:
VHL/BIREME Portal:
mh:(mh:((mh:(mh:(“Financiamento da assistencia a Saude” OR “Recursos em saude” OR “financiamento governamental” OR “gastos em saude” OR “financiamento de capital” OR “financiamento dos sistemas de saúde” OR “Atenção Primaria à Saude”) AND mh:(“Sistemas Nacionais de Saude” OR “Sistema Unico de Saude” OR “Sistemas de Saude” OR “Políticas de Saude” OR “Serviços de Saude”) AND mh:(“Acesso aos serviços de Saude” OR “Acesso Universal aos Serviços de Saude” OR “Acesso Efetivo aos Serviços de Saude” OR “Equidade” OR “Equidade em Saude” OR “Equidade no Acesso aos Servicos de Saude” OR “Equidade na Alocacao de Recursos”))) AND (tw:(“Acesso”)) AND (tw:(“Equidade”))))
PubMed Portal:
(((((“Healthcare Financing” [MeSH Terms]) OR (“Health Resources” [MeSH Terms])) OR (“Financing, Government” [MeSH Terms])) OR (“Health Expenditures” [MeSH Terms])) OR (“Primary Health Care” [MeSH Terms])) AND ((((((“Health Policy” [MeSH Terms])) OR (“Health Services” [MeSH Terms])) OR (“Delivery of Health Care, Integrated” [MeSH Terms])) OR (“Delivery of Health Care” [MeSH Terms])) OR (“Patient Acceptance of Health Care” [MeSH Terms])) AND ((((“Health Services Accessibility” [MeSH Terms]) OR (“Universal Health Care” [MeSH Terms])) OR (“Health Equity”[MeSH Terms])) OR (“Health Care Rationing” [MeSH Terms])) AND (“Access” [Title])) AND (“Equity” [Title])
The result of the addition of these terms in the search, carried out on July 20, 2020, was the reduction to 51 publications in the VHL/BIREME portal and 47 publications in the PubMed portal, totaling 98 publications.
Of the 98 publications, 6 were excluded for being repeated. After that, publications that did not refer to scientific articles were excluded. Thus, 24 publications were excluded for being monographs, theses, internet resources, complete editorials, book chapters, dissertations, and publications that addressed very specific case studies and/or were not related to the theme of financing primary health care in national health systems, leaving 69 scientific articles. After this stage, 28 articles were excluded when the titles and abstracts were read, and 41 remained. Then, the articles were also excluded because they were not available to be read in full. Finally, of the 24 remaining articles, those that were not related to the research question were also excluded (3). Thus, 21 included articles were considered for this review. The description of each step of this process can be seen in Figure 1.
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Figure 1. PRISMA flowchart on the selection process of articles included in the review, 2021. Source: author’s elaboration.
2.3. Data Analysis
The data analysis process of the included articles followed the integrative review method, including the steps of extracting, visualizing, comparing, and synthesizing the data conclusions. Data extraction was completed by 2 reviewers (D.G.S. and A.M). The data extraction form was prepared based on the research question that guided this review. The articles that generated doubts were consensual among the researchers who jointly arbitrated on their permanence or exclusion.
The following data were extracted from the included articles: author (year of publication), country, objectives, main results, financing of national health systems and Primary Health Care (PHC), access and equity. Data integration was operationalized by the thematic analysis method. This method was chosen because the typology of the articles allowed a more refined integration of the data.
3. Results
Twenty-one publications were analyzed, presented in Chart 4, which detail the health system of 16 different countries, with at least one representing each continent, not including Africa, that was mentioned only in one study (McPake et al., 2011) found, but that was excluded from the analysis after full reading for being directed only in a case study on hospital care in Maputo, Mozambique. Two publications present data from regions and contain more than one country analyzed, but mention individual aspects of each country, being them: Araújo et al. (2011) address aspects of Latin American countries (Argentina, Brazil, Colombia and Mexico) and Mcmichael and Healy (2017) who analyze the health systems of the Greater Mekong Subregion (Cambodia, Laos, Muanmar, Thailand and Vietnam).
There was a predominance of countries in Asia, with 8 publications and Latin America, with 7 publications. The countries, object of this study, mentioned in one or more articles with the highest number of publications were: Australia (4), Brazil (4) and Cambodia (4), followed by Argentina (2), Colombia (2) and Laos (2), while Canada, Chile, India, Malaysia, Mexico, Myanmar, New Zealand, United Kingdom, Thailand and Vietnam were in only one (1) publication each. The analyzed publications (21) were published predominantly in English (16), followed by Portuguese (3) and Spanish (2). The results are presented in Chart 4.
The presented results show that the publications address not only the issue of PHC financing, but also more broadly the financing of the national health system as a whole, detailing driving aspects, impacts and results in access and equity of policies implemented over the years, especially in developing countries (Chart 5). The guarantee of access and equity in national health systems is presented through the perspective of different countries that have different and complementary health financing mechanisms, such as public and private, but
Chart 4. Summary table of the articles included: author, year, country, method, objectives and main results.
Source: author’s elaboration.
Chart 5. Summary table of the articles included: author, year, country, financing of national health systems and Primary Health Care (PHC), access and equity.
Source: author’s elaboration.
which are much more complex than this common simplistic classification, evidencing the importance of a national health system being public, financed and directed according to the health needs and social determinants of its population, having primary health care as its main strategy and guiding model, fully integrated to different levels of care.
Despite extensive dialogue, analysis and historical basis on the importance of ensuring access and equity, the scientific conceptualization of terms for the reader is set aside (Chart 5).
According to the information mentioned in Chart 5, it is possible to obtain the following synthesis presented in Table 1 below.
Even so, it is possible to affirm that 100% of the publications explored, in detail, through the literature or a specific case study, initiatives and policies that sought, through different forms of financing, to offer access and increase equity, according to the concepts presented here (Chart 5).
The authors analyzed here describe a series of financing models, historical analysis and incentives for primary health care in national health systems. In turn, as diverse as the models presented, is the adoption of the concepts of access and equity addressed.
4. Discussion
The authors analyzed here describe a series of financing models, historical analysis and incentives for primary health care in national health systems. In turn, as diverse as the models presented, is the adoption of the concepts of access and equity addressed.
4.1. Primary Health Care Financing in National Health Systems
The financing models presented vary among the countries analyzed. Fajuri (2012), in his study, faces a challenge similar to this one and makes use of the financing concepts proposed by Beveridge and Bismarck to group the analyzed countries. The first model proposes that national health systems be financed by taxes, as is the case in the United Kingdom, Ireland, Spain, Greece and Portugal and the second, by Bismarck, would be a model financed by social health insurance, as this is the case of countries like Austria, Germany, Belgium, France and Switzerland, for example. By analyzing the publications presented here, we can classify, within this logic, countries such as Brazil and Colombia (Araújo et al.,
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Table 1. Summary table of Chart 5 including publications analyzed.
Source: author’s elaboration.
2011), Chile (Fajuri, 2012), and Australia (Corscadden et al., 2016; Thomas et al., 2015) that are closer to the Beveridge model. And the countries of the Greater Mekong Subregion (Cambodia, Laos, Myanmar, Thailand and Vietnam) (McMichael & Healy, 2017) are closer to the Bismarck model. However, this classification presented here has been subject to controversy, and it is also important to emphasize that in practice, none of these models applied today prevents coexistence with other financing models.
In Brazil, for example, Araújo et al. (2011) report the existence of a public health system, universal, regulated, managed and financed by the Government, available to all Brazilians, without exception, and a private system that offers additional coverage, with different services, to those who adhere to private health insurance (which are also regulated by the Government). Serapioni & Tesser (2019) when analyzing the Brazilian health system against the international typology, conclude that the Brazilian system is mixed/segmented, as it has many Beveridgean aspects, few Bismarckians and adds a new model called Smithians, based on the theory of Adam Smith, and inserted here due to the presence of voluntary private insurance in the Brazilian system.
Following this line of reasoning, Argentina (Araújo et al., 2011), would also fit as a mixed model. The country has a tripartite health system (public, social insurance and private), and the public one, despite being financed by taxes, can charge a minimum amount at the moment of use. Social insurance, on the other hand, is financed by compulsory contributions made by workers and employers, and finally, private insurance, which is organized through prepaid health plans. India (Singh & Chokshi, 2014), on the other hand, constitutionally follows the logic of the health guarantor state, where the government should, as mandated by the constitution, make financial provisions for the promotion of the population’s well-being, increased nutritional levels and standard of living. But the government spends only 1.2% of the Gross Domestic Product (GDP) on health, which is very little, leading to increased individual family spending on items such as medication, which could be subsidized, for example.
Ensor et al. (2017) present a detailed analysis of the historical evolution of Cambodia’s health care system and financing and additionally bring light to a mode of financing that is considered complementary, explaining that Cambodia’s national health system is composed of three forms different types of financing, the first being the government itself through a public health service, but where there is still a disbursement by the patients who use it. The second way concerns the private health system, where the population can access the service by paying directly or through health insurance. And the third way, to meet a demand that the former do not cover, the Health Equity Funds (HEF) were created, which are health investment funds, managed by non-governmental organizations that finance the specific health care of the population that is demonstrably poor. Other publications (Ensor et al., 2017; Bigdeli & Annear, 2009; Ir et al., 2010) detail and analyze the mechanism and its benefit regarding access and equity for the population.
Generally, most publications analyzed reinforce the importance of PHC as an effective strategy to provide access to health, but do not detail specific financing models for PHC. However, it is possible to highlight some articles that describe PHC financing initiatives more accurately: 1) the case of HEFs, in Cambodia, where authors (Ensor et al., 2017; Ir et al., 2019; Bigdeli & Annear, 2009; Ir et al., 2010) detail the Vouchers mechanism, which enables effective access to PHC care by specific groups; 2) McMichael and Healy (2017) who compile in a table the different efforts and actions carried out by the countries of the Greater Mekong Subregion, specifically to offer PHC services to immigrants; 3) Juni (1996) reports that in Malaysia, basic health care is provided to the population through a defined base of eight PHC services that are offered free of charge to the population that cannot pay.
Furthermore, different initiatives, strategies and programs focusing on PHC are presented, such as the Family Health Strategy in Brazil (Andrade et al., 2005; Sisson, 2007) and the Community Health Workers program in Australia (Javanparast et al., 2018)—also existing in Brazil—which are programs that work closer to the population through community professionals. Díaz (2013) analyzes PHC as a strategy that should not only have a healing commitment, but also a preventive and social one, acting on the fragmentation between the different levels of care, as well as offering coordinated care continuity among them, especially between the PHC and specialized care. For this reason, he believes that PHC should be the main way to enter the Argentine health system. However, he considers that this objective is still far from being achieved, and it is important to generate joint and coordinated actions with an efficient allocation of expenses.
4.2. Guarantee of Access
With different levels of exploration of these concepts, few authors (9) do so, and, as Araújo et al. (2011) explain, access to health has variables that depend on the perspective from which it is assessed.
Singh and Chokshi (2014), and other authors (Fajuri, 2012; McMichael & Healy, 2017; Araújo et al., 2011; Juni, 1996) describe health as a right, guaranteed and assured by article 25 of the universal declaration of human rights and, by the constitution of some countries, such as Brazil and Mexico (Araújo et al., 2011), Chile (McMichael & Healy, 2017) and India (Singh & Chokshi, 2014), for example. And they point out that recognizing health as a right “is a primary requirement for designing, developing and executing relevant health policies, effective programs, quality products and efficient services available to all, thus leading to the realization of the principle of universality” (Singh & Chokshi, 2014: p. 24).
In this perspective, access, conceptualized by Fajuri (2012), approaches the point of view of universal access, as something that exists when “all inhabitants of the State, regardless of social class, race or gender, have access to a set of essential health products and services” (p. 222), considering that the State must necessarily assume the costs to guarantee a universal health system.
Richard et al. (2016) consider that, “in general, access can be defined as the opportunity or ease with which consumers and communities can use health services in an appropriate way and proportionate to their health needs”(p. 2), a definition that is supported by other authors (Corscadden et al., 2016; Thomas et al., 2015; Araújo et al., 2011; Whitehead et al., 2019), such as Corscadden et al. (2016) who consider that “the access begins when patients or consumers identify the needs and only ends when they receive a treatment that contributes positively to their health and well-being” (p. 223).
It is worth highlighting two definitions of access that stand out from the others presented. The first is the one that Corscadden et al. (2016) and Richard et al. (2016) use. Both use the concept presented in 2013 by Levesque et al. (2013), which is the result of a synthesis of the published literature on the concept of access to health care and which he concluded by synthesizing a classification of accessibility in five dimensions from the point of view of the service, and five corresponding skills on the population side. They detail that barriers to access can occur given the attributes of the service or skills of the population (Corscadden et al., 2016). The definition by Levesque et al. (2013) refers to the service attributes: accessibility, acceptability, availability and accommodation, ability to be paid and suitability. And the skills that are the result of a synthesis of the published literature on the concept of access to health care, of the population, corresponding: ability to perceive, search/seek, reach, pay and engage/involve.
Whitehead et al. (2019) adopts the concept of Penchansky and Thomas (1981) which is similar to the model by Levesque et al. (2013), and which is even worked on in Levesque’s review. The definition of Penchansky and Thomas (1981) considers as non-spatial, essential dimensions of access: affordability, accommodation and acceptability of services, availability and accessibility of the service. It adds that it is important to consider not only the attributes of the service, but also the abilities of individuals to access and interact with the system (Whitehead et al., 2019).
Other definitions were identified, such as Bigdeli and Annear (2009) who define access from the point of view of equitable access, based on Hardeman et al., classifying four major restrictions for equitable access. They are financial, geographic, information and intra-household restrictions. And they substantiate with other authors that the scarcity of information and the lack of community engagement are the biggest barriers to equitable access (Bigdeli & Annear, 2009). Richard et al. (2016) and Thomas et al. (2015) also mention access associated with the term equity.
Whitehead et al. (2019), however, shed light on a problem also identified in this review. There is complexity in choosing indicators to measure access. Whitehead et al. (2019) point out that there is a major flaw in most accessibility measures, as they tend to be location-based rather than people-based and therefore fail to consider spatial, temporal and social components of access, and suggest that researchers carefully consider the importance of spatial and non-spatial domains in equitable access and incorporate these components into more holistic measures of access.
4.3. About Equity
Regarding equity, the term is conceptually presented by few authors (8), however, as Sisson (2007) begins his text: “Equity is above all a principle of social justice” (p. 86). And it is in this perspective that Fajuri (2012) explains that, although health systems have their particularities, there is a predominant social consensus among the countries, which see health as a social good, since most services generate a collective benefit and not only an individual benefit to those who receive them. Araújo et al. (2011) characterize equity as “the ability to impartially recognize the right of each person, with a sense of justice and impartiality as its guiding principles” (p. S8).
Other authors (Díaz, 2013; McMichael and Healy, 2017; Javanparast et al., 2018), despite not conceptually defining equity in health, appropriate the term while discussing health inequities. McMichael and Healy (2017) classify it as “unfair and avoidable differences that result from some form of discrimination or lack of access to certain resources” (p. 1), similar to Javanparast et al. (2018) who consider them as disparities between population groups and that are avoidable and unfair. Díaz (2013), for example, suggests 6 key points to solve health inequities, being 1) ensuring that all inhabitants have formal coverage 2) Primary Care as essential health care 3) PHC as a provider model 4) guaranteeing social participation 5) Empower PHC 6) Ensure financing and investment in PHC, paying attention to the distribution of resources and amounts charged so that they are accessible and fair.
Other authors (Díaz, 2013; Corscadden et al., 2016; Lima et al., 2015) despite not presenting a conceptual definition of the term equity, use the concept in different approaches. Whether considering the term as a basic principle of Universal Health Coverage (UHC) (Singh & Chokshi, 2014), or considering it as intrinsically associated with access to health services (Lima et al., 2015) and the improvement of health outcomes (Corscadden et al., 2016), or that must consider social determinants when being financed or evaluated (Díaz, 2013; Javanparast et al., 2018; Richard et al., 2016).
It is important to highlight that just as there was little consensus on the concept of access or equity, there is also a notable difference between the indices used to measure access or equity. Sisson (2007) states that, although European countries agree with the importance of the principle of equity, there is no consensus on what this means. Becoming, therefore, next to access, one of the great difficulties of comparing the achievement or not of these objectives through measurement.
It can be noticed that the authors (Gómez et al., 2013; Ensor et al., 2017; Collins & Klein, 1980) use the term “access to the health system” and its measurement from the perspective of use. Collins and Klein (1980), for example, when faced with the need to identify PHC users in the United Kingdom health system (NHS), classify the data of health service users through a question in the survey questionnaire carried out. The question indicates people who have spoken to or visited a doctor in the last two weeks, but who did not visit a hospital, making them, according to Collins and Klein (1980), PHC users and then using this data to explain the main objective of the work, which is to analyze equitable access to health services by the different socio-demographic and economic groups that make up the population. Meanwhile, Whitehead et al. (2019) defined spatial (Geographic) equity as a key component in the equitable delivery of health services, as it is possible to measure the equitable distribution of health care, using geographic metrics of access to the service.
It is worth noting, within the financing models presented, the cases of Colombia (Gómez et al., 2013), Brazil (Andrade et al., 2005) and Australia (Javanparast et al., 2018) which, according to the authors, proved to be successful or minimally capable of improving the indices used to measure guaranteed access and/or equity.
Gómez et al. (2013) present data that prove a significant change regarding equity of access to the health system, after a reform carried out by the Colombian government, which, among other initiatives, expanded social health insurance (by contribution and subsidized), leading to 5, 6 times greater coverage of the population in later years. They also indicate improvements in access to the Colombian health system, from the point of view of equity, for all social classes, but especially for classes with lower incomes. They also show the positive impact that adequate government financing can have in guaranteeing access and equity in health services.
Javanparast et al. (2018), for example, detail the strategy of utilizing Community Health Workers (CHWs) as part of a coordinated and strategic action to provide an opportunity to increase the performance and efficiency of Australia’s healthcare system and improve equity and health outcomes for the population, including in countries that are not considered low-income, such as Brazil. In that country, Andrade et al. (2005) historically describe the Family Health Program, an initiative of a primary care model that showed a great increase in the Brazilian population’s access to health actions at the primary care level, simultaneously with the process of adaptation of the program financing.
However, it is important to note that not all strategies are successful. Nagpal et al. (2019) describe the Lao Government’s initiative to provide free care to pregnant women. It was able to guarantee access, but not equitable, highlighting “an important problem of this health policy, since free care at the place of delivery alone does is not equivalent to universal health coverage and that health system issues require due consideration” (p. i23). This aspect is related to the thinking of Thomas et al. (2015) who consider that the issues of disparity and inequity in access to health care need a systematic and national response to the topic.
4.4. Limitations of This Review
Throughout this review, by means of the research question, there was a search for descriptors that dialogued with this proposed issue. Given the large number of results found, it was decided to continue the search strategy using the Boolean operator “AND”, with the objective of delimiting the search through the connection between the descriptors (VHL) and the MeshTerms (PubMed) and the different key items. However, very high numbers of publications were obtained, being for the VHL, 1.516 and for PubMed, 19.988. With the aim of directing the search to the object of study, in the view of the basic guarantees that the National Health System financing should offer, the keywords “Access” and “Equity” were used in the “title, abstract and subject” of the articles, as an additional mandatory criterion for inclusion of the article in the final syntax. The result of the addition of these terms in the search, although limited to “titles, abstract and subject”, was the sudden reduction to 51 publications in the VHL and 47 publications in the PubMed portal. However, this measure adopted is not what the method of a review advocate, which always suggests using descriptors primarily. But this became necessary to direct the results of the identified studies, in a more precise way, with the research question.
A limiting factor of the review refers to the choice of only two portals (VHL and PubMed). Although these portals have many indexed databases, the search was not carried out exhaustively, as there are other databases that were not used in the research, in addition to other forms of study retrieval that can complement the use of databases such as: ancestral literature, manual search in related journals, the network of researchers, research records, and gray literature (Christmal & Gross, 2017).
The health systems addressed in the results of this study are quite different, which implies different financing schemes. On the one hand, health systems that are closer to the Beveridge model were treated—with a predominance of tax-based financing—such as, for example, Brazil, Colombia, Chile, Australia, etc. On the other hand, there are, for example, the countries of the Greater Mekong Subregion (Cambodia, Laos, Myanmar, Thailand and Vietnam) that are closer to the Bismarck model—financing schemes based on employee/employer contributions. And yet, many of them have mixed health systems—Beveridgian and Bismarckian. There is no doubt that the comparative analysis of the results is limited, as the systems are so antagonistic. Also, it is possible to say that even in universal health systems, such as Australia and Brazil, the financing conditions are very different and difficult to compare. Mainly, in relation to Brazil, it is worth mentioning that in addition to the health system having a historical underfunding and a recent process of unfunding, from the institutional coup of 2016, with the introduction of Constitutional Amendment n. 95, which froze public spending in 20 years, this universality of health is in an intense process of deconstruction (Mendes & Carnut, 2020), bringing more limitations to possible comparisons.
4.5. Implications for Public Policy
This review also presents restricted data on primary health care financing in national health systems, and it is important to produce new studies on this level of health care, with the intention of producing more specific evidence in the area, which, at the moment, after this research, is incipient.
It is important to recognize the limitations that the capture and analysis of the object present. The use of an integrative review, despite demonstrating an approximate overview of how an object has been studied, financing primary health care in national health systems, has the limit of not focusing essentially on the object per se. This demonstrates how some articles included in the review do not directly present financing schemes for primary care and are much more directed to the general financing of health systems, that is, they only “surround” the object, bringing subsidiary elements to think about the allocation of resources for primary health care, without often demonstrating a finished method and its dimensions/indicators. This implies that, in further studies, broadening the scope (through other databases) and using other review methods of greater precision in the apprehension (systematic reviews, for example) may be the way to advance the discussion.
It is noteworthy to recognize that the methodological strategy used for this object (primary health care financing in national health systems) is a challenging research topic, and, precisely because of this, few studies in the literature available in these two revised databases/portals were found. This reveals the importance of adapting the best type of review according to the researched object and its presentation in the scientific literature. Thus, it is understood that, even under the limitations of the method used, this is still the best way to capture this object at this stage of development of scientific research.
Despite these limitations of the present review, the effects on public policies of national health systems are relevant, enabling data on the knowledge of different financing schemes, in terms of access and equity, and their likely adoption by some countries. However, it is understood that more powerful studies are needed to ensure the analyses developed here.
4.6. Advances of This Study and the Research Agenda
After pondering the limitations of this study, it is essential to point out that its possibilities are undeniable in the debate on primary health care financing in national health systems, especially in times of long-lasting economic crisis (Roberts, 2016). As much as it has already been ratified in the scientific literature that the central problem of the macroeconomic health issue in the world, especially in this context of reinforced crisis of the Covid-19 and economic crisis, is the lack of financing of its public sector, allocating resources for primary health care admits a solution, even if palliative. Thus, knowing financing possibilities that guarantee greater access and equitably allocate resources for primary health care, as a guiding model for national health systems, means, in addition to enabling a fairer distribution of weak resources in the context of crisis, it is ultimately instance, allow attempts to provide health systems that better respond to the health needs of the population.
This study is presented as a baseline study, given the lack of synthesized and organized evidence on the primary health care financing in national health systems (levels 4 and 5), as Souza et al. (2010) comment in relation to the hierarchy of evidence, according to the research design. Thus, this review proposes to present itself as an initial study for new researchers, demonstrating the path of financing articles for primary health care in national health systems, being, therefore, a guide for new research.
To sum up, it is important to highlight the main contribution of this research according to the following aspects: 1) to enable the extensive debate regarding the financing of primary health care in national health systems; 2) to learn about experiences in different countries on ensuring the allocation of resources to primary health care as mechanisms for solutions in a context of economic crisis that has been impacting health systems; 3) to know possibilities for allocating resources for primary health care in national health systems that expand the population’s access and ensure greater equity, with a fairer distribution of resources; d) to have information on health systems that, through their financing scheme, have been responding better to the health needs of the population in a scenario of an economic crisis.
5. Final Considerations
This review shows, firstly, that Primary Health Care (PHC) is a fundamental mechanism in national health systems. These can be financed in different and creative ways, having PHC as a guiding strategy, as regulated in the Unified Health System (SUS) in Brazil. However, it is also evident that PHC will only be effective and guarantee the universal right to health once it is adequately financed, offering equitable access to the population, according to the health needs presented.
As Porto (2002) points out, there is no consensus on a single concept of equity or access. In this sense, it is necessary to promote theoretical and conceptual basis of the terms when using them, offering depth and common understanding to the reader.
The countries that indicated improvement in health outcomes when comparing access and equity measurement indices were countries that had extensive government financing, such as Colombia (Gómez et al., 2013) by expanding cost-free access to health insurance by poorer population, or from Malaysia (Juni, 1996) that directed resources effectively and, even investing relatively less than neighboring countries, obtained an improvement in the analyzed indexes. However, the indiscriminate availability of the resource alone will not solve the problem of avoidable and unfair disparities between different population groups. It is as indicated by Araújo et al. (2011) who claim that it is necessary to reverse the distributive logic of resources that is directed towards programs that do not address the real needs of the population.
For sure the solution is not simple. Providing health care facilities that are close to where people live can be a common measure to ensure equity. However, not paying attention to items such as opening hours, customs, cultures, languages, and ethnicities can result in barriers to access. And, despite being geographically close, the service becomes unfeasible, as for the residents of New Zealand, analyzed by Whitehead et al. (2019), who showed no preference for seeking care in the location closest to home, showing that the approach to access, in light of the availability of health care facilities closer to home, has important limitations.
Brazil stands out, along with other national health systems, with its regulated and established financing. Despite different PHC financing mechanisms, throughout the history of the SUS, it is essential to consider the provision of resources according to health needs, as recommended by law n.141/2012 (Brasil, 2012b). The importance is to ensure not only adequate financing, but also to establish distributive indices that reflect the reality of the population’s health needs. In this sense, guaranteeing equity and access means guaranteeing unequal funding for unequal needs and, therefore, any mechanism that does not take this into account cannot be classified as equitable, as it would violate one of the guiding principles of the SUS.
Thus, it is essential to maintain positive and continuous financing of primary health care as the guiding model of national health systems, having as a principle the distribution of resources according to health needs, ensuring access and equity. However, listening to the population and understanding their customs, cultures, and ethnicities has proven to be fundamental to address avoidable barriers. However, executing a plan and not adequately measuring the achievements can lead to serious mistakes. That is why it is necessary to promote the measurement of advances in access and equity through reliable indexes shared between different realities, unifying knowledge on the subject.