Achieving Universal Primary Health Care Through Health Systems Strengthening: Lesotho’s National Primary Health Care Reform

Abstract

This doctoral thesis examines how different aspects of health systems strengthening (HSS), such as human resources, supply chain, service delivery, and governance, can contribute to achieving universal health coverage (UHC). The doctoral thesis contains two key sections: the Analytical Platform, which examines key aspects of the existing literature on this topic, and the Results Summary, which presents a case study from Lesotho. The Analytical Platform consists of one narrative chapter focused on the role that values can play in setting health system priorities, and two systematic reviews which examine whether different HSS interventions - namely 1) task shifting and 2) improvements to health product procurement and supply chain - can improve health system efficiency in low- and middle-income countries (LMICs). The first review finds that substantial evidence exists for task shifting as a means to generate cost savings for care related to tuberculosis, HIV/AIDS, and various other diseases at the primary health care (PHC) and community levels. The second review finds that substantial evidence exists for pooled procurement as a means to achieve cost savings, and that a wide range of supply chain interventions can increase drug availability in different contexts. The Results Summary synthesizes Lesotho’s experience with a National PHC Reform, which sought to strengthen health systems to create universal access to comprehensive PHC and which can in turn serve as the foundation for broader UHC in the country. The Reform consisted of interventions at multiple levels, including a Village Health Worker (VHW) program, expanded services at clinics, decentralized management of the district health system, and central oversight of the Reform. Documentation of the Reform noted several key insights. First, in this model, VHWs do not simply have discrete clinical tasks, but rather have cross-cutting activities that aim to increase patient utilization of services across multiple disease areas. Second, by taking a comprehensive approach to improve population health, the Reform model specifically aims to build state capability in strengthening health systems. The findings from the Analytical Platform and Lesotho’s experiences documented in the Results Summary are relevant for policymakers, practitioners, and researchers working to achieve UHC through HSS in LMICs, especially in a post-2015 agenda.