Use of public primary care facilities, economic development, and the health service transition

Many low- and middle-income countries (LMICs) have large networks of public primary care facilities (PCF) to provide affordable and quality health services close to communities. Public PCFs are expected to serve as the principal source of primary care. This study documents the extent to which public PCFs are used for illnesses treatable at the primary care level, and investigates the association between public PCF use, economic development, and UHC achievement.

A cross-section of Demographic and Health Surveys conducted after 2014 in 46 LMICs were analysed. The sources of medical advice for children seeking care outside their home for the following illnesses were identified - acute respiratory infections (ARI), diarrhoea, and fever.

There is considerable between-country variation in utilisation of public PCFs; in most countries public PCFs received less than half the patients seeking medical advice for conditions treatable at the primary care level. Second, economic development is associated with a 'health service transition' characterised by two related trends - decline in the share of patients seeking medical advice at public providers overall and at public PCFs, and a proportionate increase in the share of patients seeking medical advice at private providers; use of public PCFs declined by around 24 percentage points between the average low-income and middle-income country. However, most of the between-country variation in public PCF use was due to factors other than income. Third, cross-country regression analysis indicated that public PCF use was not associated with UHC achievement because a similar range of services are offered by private providers. Public PCF use was associated with lower catastrophic health expenditures.

The changes in care-seeking patterns and use of public PCFs brought about by economic development makes it critical to re-think primary health care service delivery models and financial protection mechanisms in transition countries.