THE TRANSFORMATIVE ROLE

OF HOSPITALS IN THE FUTURE

OF PRIMARY HEALTH CARE
© World Bank/Curt Carnemark
THE TRANSFORMATIVE ROLE
OF HOSPITALS IN THE FUTURE
OF PRIMARY HEALTH CARE
WHO/HIS/SDS/2018.45

© World Health Organization 2018. Some rights reserved. This work is available under CC BY-NC-SA 3.0 IGO licence.

Acknowledgements

This document was produced as part of the Technical series on primary health care on the occasion of
the Global Conference on Primary Health Care under the overall direction of the Global Conference
Coordination Team, led by Ed Kelley (WHO headquarters), Hans Kluge (WHO Regional Office for Europe)
and Vidhya Ganesh (UNICEF). Overall technical management for the Series was provided by Shannon
Barkley (Department of Service Delivery and Safety, WHO headquarters) in collaboration with Pavlos
Theodorakis (Department of Health Systems and Public Health, WHO Regional Office for Europe).

This document was produced under the technical direction of Ann-Lise Guisset and was built on ‘People-
centred hospitals towards universal health coverage: a WHO position paper’(in press) and ‘A global
vision for person- and Community centered hospitals in a PHC-based health system’ (in press) that were
developed through the inter-regional taskforce on hospitals. We acknowledge the principal writing team of
these foundational documents: Anjana Bhushan (WHO Regional Office for the Western Pacific), Nino Dal
Dayanghirang (WHO Regional Office for Africa), Eric de Roodenbeke (International Hospital Federation),
Nigel Edwards (Nuffield Trust, WHO consultant), Tarcisse Lokombe Elongo (WHO Regional Office for
Africa), Ricardo Fabrega (WHO Regional Office for the Americas), Ann-Lise Guisset (WHO headquarters),
Indrajit Hazarika (WHO Regional Office for the Western Pacific), Jerry La Forgia (Aceso Global, WHO
consultant), Vivian Lin (WHO Regional Office for the Western Pacific), Hernan Montenegro (WHO
headquarters), Hamid Ravaghi (WHO Regional Office for the Eastern Mediterranean) and Juan Tello (WHO
Regional Office for Europe).

Valuable comments and suggestions to the first draft were made by WHO collaborating partners and
regional and country office staff, in particular, Shannon Barkley (WHO), Ghazanfar Khan (Consultant, WHO
headquarters).

The views expressed in this document do not necessarily represent the opinions of the individuals
mentioned here or their affiliated institutions.
The 1978 Declaration of Alma-Ata represented a turning
point in the history of global health, when primary
health care was adopted in pursuit of health and well-
being for all. In 1981, a long-serving Director‑General of
WHO, Halfdan Mahler, commented, “A health system
based on primary care cannot be realized without
support from a network of hospitals.”

Dr Mahler’s words still ring true: primary health care

remains the path to universal health coverage. But
with far-reaching social, economic and clinical changes
over the past four decades, health systems, including
hospitals, are working in a vastly different context.
Hospitals can play a powerful role in supporting and
amplifying the benefits of primary health care. This
requires building on hospitals’ unique strengths
while dissolving the walls that separate them from
the rest of health systems – and from the people
they exist to serve.

This brief builds on the work by the informal WHO

Inter-regional Taskforce for hospital planning and
management to review the literature, gather country
experiences and build a consensus for a renewed
vision for hospitals and identification of key policy
levers and interventions at the organizational level to
drive hospitals transformation. Those are presented in
more details in WHO position paper “People-centred
hospitals towards universal health coverage” and its
accompanying advocacy brochure “Promise and legacy:
The vital role of hospitals in achieving universal health
coverage”. Promising practices presented in boxes
throughout the brief illustrate only few of the extremely
rich interventions implemented globally in a wide variety
of contexts.

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 Ending an outmoded
dichotomy
Hospitals are powerful institutions: while they have the political,
economic and social weight to block change, they are also
uniquely positioned make change happen. The 2008 World
Health Report Primary Health Care: Now More than Ever1 noted
that “health systems do not spontaneously gravitate towards
PHC values, in part because of a disproportionate focus on
specialist, tertiary care, often referred to as ‘hospital-centrism’”.
However, with strong leadership and a clear policy direction,
hospitals can transform themselves into key contributors to
primary health care development.

The key step in transformation is a conceptual one: to end

the dichotomy which imposes increasingly counter-productive
barriers between hospitals (tertiary or referral care) and primary
care (first level care). The time for disciplinary medical specialty
“silos”, strict hierarchies and rigid categorization by level of
care must be addressed for at least the following four essential
reasons.

Primary health care approach applies to all providers in the

health care ecosystem. For hospitals, it means a paradigm shift
from being dominant, technocratic, and relatively isolated
institutions to becoming community and person-centred.

From the people’s perspective, their experience with health

and social care providers cuts across a variety of settings. Care
coordination and integration across health pathways is critical
especially for the rapidly growing number of frail people
suffering from multiple chronic diseases.

When properly integrated, both hospital-based referral care

and primary care services benefit from the success of the
other. For example, effective primary care reduces unnecessary
admissions and service congestion in hospitals. Equally,
integrated hospitals allow primary care services to offer patients
truly comprehensive care, ensuring continuity of services before
and after hospitalization. The result is that people benefit from
more humane, effective and efficient health services.

Hospitals often are an essential setting for healthcare workers’

education. This is where generations of doctors, nurses and
allied professionals receive a substantial component of their
pre-certification training. Hence, hospitals shape the future of
health professions, including those who will be work in primary
care settings.
1
T he World Health Report 2008: Primary Health Care (Now More Than Ever) [Internet].
World Health Organization; 2008. Available from: http://www.who.int/whr/2008/en/

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The vision
Guided by PHC precepts, the vision for people-centred hospitals
features transformation occurring in three ways. First, hospitals will
move away from their traditional definition as physical buildings
(bounded by walls and beds) and instead see themselves as flexible
organizations that pull together scarce resources and function as a
public good. Second, they will leave behind their isolating status as
institutions uniquely responsible for individual patients requiring highly
specialized acute care, and instead embrace joint responsibility with
other care providers for population health. Third, they will broaden
their focus from immediate, acute episodes to a wider and ultimately
more effective focus on integrated care pathways.

In this transformative vision, hospitals are fully embedded in the

communities they serve, working closely with other health care and
social providers, and responding to users’ needs and preferences.
Applying a primary health care approach to everything they do, they
not only treat specific medical conditions but continuously strive at
improving the overall health of the people they serve – including the
aged, the chronically ill, and population groups that are currently
under-served. They consider patients and relatives as partners,
engaging and empowering them in their health and health care
decisions. Placing people’s comprehensive needs and preferences at the
centre, they provide comprehensive social, psychological and spiritual
support and identify opportunities to integrate traditional medicine
where relevant to the local context. They don’t miss on opportunities
for promotion and prevention; incorporating health education and
sensitization messages for patients and their carers as they go through
recovery and rehabilitation. Hospitals also contribute to public health
services such as for instance disease surveillance activities.

Certainly, in this vision, caring for patients requiring high-intensity,

multi-specialty care services, and complex technologies continues to be
among the core activities of hospitals, and this is where their unique
value-added lies. However, they regularly re-assess what services they
deliver to better respond to local needs and capacities. Rather than
directly delivering every possible service themselves, they specialize in
some areas while re-orienting other services towards more out-patient,
home- and community-based care. Taking full advantage of portable
and mobile technologies and thinking “outside the box” to embrace
innovations such as rotating staff with other providers, hospitals can
take on a broad spectrum of roles to support service provision formerly
thought to be in the strict realm of public health and primary care.

Finally, in this vision, hospitals also lead by example in sustainable

development by embracing social responsibility principles, leading
on improved working conditions, and reducing their impact on the
environment. They are striving to ‘leave no one behind’, going beyond
their walls to reach the most vulnerable in need of referral services, for
instance, designing innovative ways of delivery, such as mobile clinics
and medical trains. They are full partners in reducing the vulnerability
of individuals and families to catastrophic health costs, for instance by
providing free lifesaving surgeries and other services.

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 Sharing responsibility:
the networked hospital
This means hospitals will need to transform how they
are run and what services they deliver. In some cases,
they will directly deliver certain primary care services;
in others, they will assist other providers – clinics, care
homes, community centres – to take on services that
were once assumed to be strictly the preserve of the
tertiary level. Much will depend on their determination
–and the enabling factors in the policy environment
and system architecture– to work with other parts of
local health systems.

In some fields, hospitals have an opportunity to

contribute to integrated people-centred services, even
if these are not under hospitals’ direct responsibility.
Examples include supporting the management of frail
older people in residential and nursing home care, and
contributing to palliative and end of life care. Whatever
the field, hospitals will help to mainstream prevention
and health promotion as “everybody’s business”.

Rapid scientific change in how long-term conditions

are managed means that primary care doctors, nurses
and other clinicians need support in their work and
in keeping up to date. This creates opportunities
for hospital specialists in endocrinology, respiratory
medicine, nephrology, mental health, and many other
fields. Rather than being the last link in the clinical
chain, they will be transformed into key players
in networks that manage chronic conditions such
as diabetes, heart failure and asthma, oversee the
administration of complex treatments, and help with
quality improvement. This will require a different
approach to consultation, and a change in the
relationship between hospitals, primary care providers
and patients.

Promising practices: networked

hospital
In South Africa, a partnership between the
pharmacy of RK Khan Hospital and local
organizations permits facilities such community
halls, temples and churches to be used for
issuing medicine to patients with chronic
conditions.

In Netherlands, hospital-based specialists

support the ParkinsonNet network which
enables patient self-management and
minimizes need for hospital care. Patients with
Parkinson’s disease can use an online tool to
manage their care and exchange information
with each other and with professionals.

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Pathways to
transformation
The success of this vision depends not only
hospitals themselves, but on health system
decision-makers at the national level,
in provinces and states, and municipal
governments. They are responsible for
creating a legislative and regulatory
environment to translate the vision for
concrete transformation from hospitals
operating in isolation to hospitals fully
embedded in their communities and their
local service delivery “ecology”.

Two intertwined
approached to
dissolving external
and internal walls
In broadest terms, transforming hospitals
will require work from two directions.
Externally, hospitals’ roles and functions
will be re-defined within a networked,
partnership model that embraces
both health and social care. Internally,
hospitals will be re-organized in ways that
strengthen their clinical and administrative
performance, deliver patient-centred care,
and open their doors both to pre- and
post-hospitalization partners.

The two approaches are closely

intertwined: a hospital’s internal
organization and ability to work across
institutional boundaries are constrained by
its position within the system. Conversely,
a hospital that is poorly governed, does
not collect performance data, focuses on
volume and profits, or provides low-quality
care, and cannot take on new roles that
benefit society as a whole.

While governments can align incentives

and create an enabling environment, it
is the managers’ and clinicians’ role to
improve performance at the individual
hospital level. Similarly, governments
can set regulatory standards but
implementation depends on how hospitals
operate.

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 What health authorities
can do at the system level
Decision-makers at the national and subnational levels
can create the conditions to drive, enable and sustain a
paradigm. To do so, they must think of themselves as
system architects as well as supervisors. Only they will
ensure that health policy allows the voices of patients’,
including the most vulnerable, and patient organizations
to be heard, and that private sector health services serve
(or do not oppose) public health goals and standards.
Above all, they must ensure that policies and incentives
that govern hospitals are coherent and aligned with
primary health care principles, and that they support the
health-related Sustainable Development Goals 2030.

Implementing the national vision of the role of

hospitals and their contribution to primary health care
(both as level of care and as an approach) requires
simultaneously strengthening system design and
institutions; putting in place feedback mechanisms,
regulations and provider payment systems (performance
drivers); and ensuring adequate infrastructure,
technologies, human resources and information systems
(performance enablers).

First and foremost, measures to ensure functionality

of hospitals are needed, including safe and adequate
environmental conditions, availability of standard
precaution items, and proper maintenance of existing
facilities. In health systems with severe shortages of
human resources, deployment of health professionals
between health care settings (for example, referral
hospital in the capital versus provincial hospitals, or
between primary care and specialized care) requires
difficult allocation decisions, which need to be informed
by solid evidence in order to optimize the current
capacity.

Local health systems

matter
Local health systems are the very heart and soul of any
integrated and people-centred strategy. There will be
no well-functioning local health systems without well-
functioning hospitals, and vice versa. An initiatory local
approach has been adopted in a number of very diverse
contexts, such as China and the United Kingdom.

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 For more detailed information
WHO’s upcoming position paper “People-centred-hospitals towards universal health
coverage” details a variety of measures to assist health systems to achieve the
transformation. It focuses on on four main action areas: (i) clarifying countries’ vision
of hospitals’ contribution to service delivery objectives; (ii) strengthening system design
and institutions;(iii) introducing new performance drivers such as feedback mechanisms,
regulations and provider payment mechanisms; and (iv) guaranteeing performance enablers
including adequate infrastructures, technologies, human resources and information systems.

WHO Regional Offices are producing their own supportive technical guidance on hospital
planning and management, and it is hoped that stakeholders (from Ministries of Health to
local health authorities) will obtain and share these documents as widely as possible.

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