Without action, strained healthcare systems in the Global South risk collapse, deepening inequalities. Primary healthcare (PHC) is an effective way to improve healthcare and prevent such a collapse. This post proposes the ‘Five I’s for Healthcare Resilience’ – integrated care, information and digitalisation, integrity, involvement and investment – to build a stronger healthcare system.

Universal healthcare coverage (UHC) is the ultimate goal, as it ensures equitable, affordable and accessible healthcare for all, regardless of socioeconomic status. Strong PHC systems and prevention measures are critical components of UHC.

• Overreliance on costly hospital-based care limits access: Hospital-based treatment is expensive, inefficient and inaccessible to many. Strengthening community-based and preventive healthcare is essential for sustainable healthcare systems.
  
• Prevention is a more cost-effective strategy: Investing in preventive healthcare improves long-term outcomes and saves costs. Preventing pandemics costs $10.3–$11.5 billion annually – far less than the $30.1 billion spent on outbreak management.
  
  • A whole-of-society approach enables prevention: A whole-of-society approach enables prevention by addressing the root causes of health problems beyond the healthcare sector. Health is shaped by social, economic and environmental factors. A whole-of-society approach engages multiple sectors (education, agriculture, urban planning, social welfare) to address the causes of health disparities. It empowers communities with health literacy, better sanitation and nutritional security, and leverages cross-sector policies to reduce disease burdens and enhance pandemic preparedness.
  • PHC, as backed by the UN, provides a whole-of-society approach, shifting the focus from hospitals and specialists to community-level outpatient care. About 75% of the projected health gains from the Sustainable Development Goals (SDGs) could be achieved through PHC to reduce the burden of communicable and non-communicable diseases (NCDs) and increase average life expectancy by 3.7 years by 2030, saving over 60 million lives. An estimated 90% of essential UHC interventions can be delivered through a PHC approach. Expanding PHC also cuts costs and improves outcomes. Examples of PHC approaches that can generate substantial returns in low and middle-income countries (LMICs) include interventions in traffic accidents, drug-use disorders, type 2 diabetes and newborn care.
    
• Integrated care will ensure patient-centred services through immunisation programmes, disease care and community-based outreach. Additional to normal prevention programmes, harm prevention and reduction can help prevent disease and ensure social equity. PHC extends beyond healthcare programmes to include practices that reduce health risks and prevent costly interventions, for example integrating risk- and harm-reduction policies and practices with evidence-based regulations to prevent costly health and environmental burdens. This minimises health, social and legal harms from products such as drugs, tobacco, alcohol and ultra-processed foods. Examples include community-oriented substance use programmes, early interventions in terms of recreational drug use and tobacco cessation programmes. In addition, it reduces disease burdens and ensures equitable access to preventive care, protecting marginalised groups. Ensuring food security will also reduce healthcare burdens. By 2030, nearly 600 million people will face chronic undernourishment, most of them in the Global South. As populations grow, food security will be crucial for public health resilience. Malnutrition and food insecurity will increase hospitalisation rates, slow recovery from illnesses and raise healthcare costs.
  
• Information and digitalisation will expand access and enhance decision-making through technology such as the Internet of Medical Things in hospitals and digital health data. Artificial intelligence (AI) will enable better access to healthcare. Applications may include clinical support, treatment planning and health chatbots. Partnerships with the private sector are crucial to access AI tools.
  
• Integrity will strengthen accountability and trust. Ways of building integrity include improving leadership training, strengthening public financial management and ensuring autonomy in terms of accountability.
  
• Involvement of communities emphasises the importance of partnership and shared responsibility between health services and the communities they serve to empower people to define their needs and participate in the solutions.
  
• Investment will secure long-term financial viability by expanding revenues and leveraging private equity through public–private partnerships (PPPs).

Governments should improve their efforts to raise domestic resources for health expenditures. The consumption of tobacco, alcohol and sugar is associated with a rapid (‘epidemiological’) rise in NCDs such as diabetes, chronic respiratory disease, cardiovascular disease and cancer, accounting for almost three-quarters of deaths globally. The poor are disproportionately affected by the rise in NCDs and the impact is severely regressive. While health taxes are also regressive if they are paid by the poor, they may be used to offset the effects of rising NCDs by inducing shifts in consumption and by earmarking health tax revenues for crucial health expenditure. Unpopular as earmarking is among tax policymakers due to the funding rigours it may impose, possibly leading to underfunding in critical areas, the South African experience indicates that it is in fact discretion itself that causes underfunding in key areas such as public health. Repurposing ‘sin taxes’ as evidence-based health taxes, prioritising public health in the design and dedicating these revenues to support this objective will constitute a shift towards the use of taxes as a force for good in society.

PPPs can provide additional funding and expertise, as examples from various LMICs show. In Brazil, a PPP expanded healthcare by building and remodelling primary care facilities. In Lesotho, a PPP replaced a PHC hospital, with the result that mortality dropped by 41% and paediatric pneumonia deaths fell by 65%. PPPs also drive innovation and expertise: the AU aims to produce 60% of Africa’s vaccines by 2040. This cannot be achieved without private sector involvement.

Conclusion

Weak healthcare systems and structural challenges, including financial constraints and shifting global priorities, are straining healthcare systems in the Global South. This slows progress on the SDGs and hurt economic growth.  It is important that the G20 support a healthcare resilience framework amid demographics shifts and aid reductions globally.