Key messages

Infrastructure includes buildings and non-medical equipment, utilities and supply systems. Infrastructure needs and maintenance are sometimes neglected in primary care settings but patients care about the quality of primary health care (PHC) facilities. These have a direct impact on patient–provider interactions and patient satisfaction. They also significantly impact staff well-being and effectiveness.

• Basic requirements including water, sanitation and hygiene (WASH), solid waste management and reliable electricity and internet connections, are a fundamental prerequisite for high-quality, primary care.
• High-quality infrastructure and good (evidence-based) design (EBD) support the PHC approach, encouraging collaboration, staff and patient mental health and well-being. They facilitate efficiency and teamwork, and contribute to staff satisfaction, recruitment and retention. Infrastructure can also engage communities and build trust – but although this enables high-quality care, it cannot guarantee it.
• Investing in primary care infrastructure is typically less costly than hospital investment but still represents a major cost and has significant long-term implications, shaping provision for decades.
• Infrastructure investment must consider more than initial capital costs if it is to be appropriate and needs-responsive, by taking into account:
  • the medical and non-medical needs of individuals and communities
  • the likely pattern of future demand and of technological innovation
  • the implications of room layout and design
  • possible system shocks and how infrastructure might be adapted in response
  • reliability and maintenance costs over the whole life-cycle, including aspects of environmental impact (a more “value-based” approach).

12.1. Introduction

The provision and maintenance of adequate physical infrastructure are crucial investments in the early stages of implementing the PHC approach. The availability, reliability and appropriateness of infrastructure have a direct impact on care provision, patient satisfaction and the well-being and effectiveness of staff, although the latter is often overlooked when resources are limited. Responsive facility infrastructure that caters to the medical and non-medical needs of individuals and populations plays a vital role in building trust and engaging communities (WHO & UNICEF, 2020). Ensuring hygienic physical spaces and providing materials and equipment that support infection prevention and control are essential requirements for delivering primary care (WHO, 2016; Tomczyk et al., 2022). While high-quality infrastructure enables and supports high-quality primary care, it is important to note that it does not guarantee it. Specifically, it facilitates teamwork and communication (Karp et al., 2019, Lim et al., 2020, 2021, 2022), and influences the recruitment and retention of health workers (see Chapter 8).

In this chapter, infrastructure is defined as the “physical structures, including […] supporting systems, needed to provide health care” (Papanicolas et al., 2022). This includes buildings and non-medical equipment; utilities and supply systems to make buildings and equipment functional, such as water and electricity; disposal systems for waste; and transport and logistics infrastructure (WHO & UNICEF, 2020b). Medical devices and health technology (including digital tools) are not included here and are dealt with in Chapters 11 and 13. However, the term “infrastructure” can also be applied more broadly, to include geographical features such as spatial distribution that can determine access.

As explained in Chapter 1, the PHC approach comprises three components – multisectoral policy and action, community engagement and empowerment, and primary care and public health as the core of integrated health services (WHO & UNICEF, 2018). This chapter focuses on the latter element, as that is where the need for physical infrastructure has been most explicitly examined, i.e., facilities and resources to support delivery of primary care and public health services. The multisectoral action and community engagement components are reflected in their application to planning, developing and assessing health system infrastructure in response to identified health needs to optimize its value – a concept referred to as “needs-responsive infrastructure”.

Appropriate, needs-responsive infrastructure is a foundational enabler for PHC, a necessary but not sufficient condition for optimal service delivery. This chapter aims to identify what infrastructure is required, and how it can best be distributed, used and adapted, to deliver a responsive PHC-oriented health system. The chapter examines evidence across five key infrastructure domains, although there is considerable interaction and overlap between them: 1) distribution and availability of primary care infrastructure; 2) change over time and adaptability of primary care infrastructure; 3) non-medical equipment requirements; 4) the role of utilities such as electricity, water and sanitation, and solid waste management; 5) and implications of EBD literature in primary care services. Many of the available studies are not specific to PHC nor to primary care so evidence has been extrapolated from hospital and tertiary care settings.

12.2. Evidence review: health infrastructure to strengthen the PHC approach

12.2.1. Distribution and availability of primary care infrastructure

Primary care infrastructure is not established based solely on need or demand but is ideally co-created with facilities for more specialized levels of care. The distribution of one type of facility is inherently connected to the distribution of others, and historical factors related to the development of a health system can add complexity to spatial planning. Strategic reviews have prompted attempts in various places to reconsider the distribution of facilities at the system level, taking into account population health needs. Examples include the use of instruments like the “carte sanitaire” used in northern African countries, as well as regional health master planning tools like the “schemas regionaux d’organisation des soins” in France (Ministère de la Santé, 2018; Jacquemot, 2020). These approaches help determine the optimal distribution of services based on population needs, evolving demographics and technical capacity to deliver care services. A similar mapping approach used in Northern Ireland is described in Box 12.1.

Box 12.1

The integrated service model in Northern Ireland.

The spatial distribution and availability of facilities play a vital role in ensuring equitable access to health care (Levesque, Harris & Russell, 2013). However, this can intersect with patient perceptions of quality and their choices regarding service use. For example, a study conducted in Sierra Leone revealed that women in urban areas would travel further for care (2.2km vs. 0.6km) owing to preferences for affordability and perceived quality (Fleming et al., 2016). Similarly, in Nepal, investing in the quality of health posts was deemed equally important, if not more important, than increasing their numbers (Acharya & Cleland, 2000). The presence of community-level outreach services also influenced utilization. These studies distinguish between the availability and acceptability of services, emphasizing that both factors can influence decisions about the use of primary care services.

In high-income countries (HICs) like the United States of America (USA), better metrics are needed to assess access in congested urban areas. The term “spatial accessibility” combines concepts of distance and supply and is ed to evaluate access in these settings (Guargliardo, 2004; Fortney et al., 2005). In rural areas, additional factors, such as extended operating hours for primary care, may need to be considered owing to the limited availability of specialized services. While there may be less infrastructure available, a higher density of infrastructure supportive of PHC relative to the population is necessary (Al Saffer et al., 2021). Evidence from Northern Ireland following reconfiguration shows that more general practices per person are located in rural areas owing to higher levels of need measured by age and deprivation (Graham, 2018).

Innovative approaches to accessing capital, such as revolving loan funds, have been used to strengthen rural primary care infrastructure. These approaches also aim to enhance economic viability by integrating with other community development initiatives (Stewart et al., 2002). England’s Local Improvement Funding Trust is an example of a successful capital injection programme that mobilized investment through government-endorsed partnerships for long-term joint ventures in primary care facilities (Ibrahim, Price & Dainty, 2008). Networks of primary care facilities, coordinated through regional structures and public-private partnerships, have been implemented in rural settings in countries like Lebanon and Madagascar to engage communities in needs-responsive service development, promote person-centred care and strengthen PHC (Cordier et al., 2020; Hemadeh et al., 2020). In Australia, an evidence and consensus-based list of primary care services that rural and remote communities can expect to access has been developed to assist policy-makers in service planning and resource allocation, although outcomes have not yet been reported (Thomas, Wakerman & Humphreys, 2014).

Certain populations or groups with specific needs require special consideration to ensure their access to health care services. Examples include ensuring availability of post-abortion care (Bell et al., 2021), providing adequate facilities and staff for Lesbian, Gay, Bisexual, Trans, Queer, etc. (LGBTQ+) services (Jia, Polin & Sarin, 2020), and addressing the unique challenges faced by individuals with disabilities, where availability, acceptability, geography and affordability interact to limit access (Dassah et al., 2018). Additionally, during the COVID-19 pandemic, the location of temporary clinics for socially vulnerable populations became a critical issue that could be systematically mapped to address their specific needs (Mohagheghi et al., 2023).

12.2.3. Equipment requirements

The provision of adequate and appropriate materials, consumable items and equipment, as well as their positioning in the clinical environment, are recognized as critical resourcing and ergonomic elements of health service delivery, which increase compliance with accepted clinical practice (WHO, 2016). Guidance documents offering recommendations and minimum requirements are available (Temple-Bird et al., 1995; Heimann & Issakov, 2001; Lenel et al., 2005; WHO, 2011), but there are relatively few peer-reviewed studies that overtly identify or evaluate equipment requirements. There is also little empirical evidence about how to ensure that the correct equipment is actually installed.

Attempts have been made to identify essential equipment lists, based on the services that facilities are expected to provide; examples include the World Health Organization (WHO) package of essential noncommunicable (WHO-PEN) disease interventions for primary care (WHO, 2020), and the Essential Healthcare Technology Package (WHO-EHTP) that identifies various resources needed to provide given interventions (Heimann & Issakov, 2001). Health facility assessment tools such as the WHO Service Availability and Readiness Assessment (SARA) also provide guidance on how to generate reliable information about basic equipment, amenities, and diagnostic and therapeutic capabilities (WHO, 2023b). The literature offers many applications of such tools, commonly in low- and middle-income countries (LMICs) (Fortney et al., 2005; Cadogan et al., 2016; Bedoya et al., 2017; Oyekale, 2017; Ssensamba et al., 2019; Hemadeh et al., 2020; Meiqari et al., 2020; Aghaji et al., 2021; Al Saffer et al., 2021; Bell et al., 2021; Bintabara & Shayo, 2021; Maruf et al., 2021; Mazigo et al., 2021; Ntoimo et al., 2021). As an example, the Nigerian standards for buildings and premises include details such as land area, colour of the building, clean water source and clear signposting within the facility (Ntoimo et al., 2021). However, the key factor in supporting actual implementation of these lists is the capacity to undertake preliminary and feasibility assessments, as well as planning, designing, building, commissioning, operating, maintaining and disinvesting across the infrastructure lifecycle.

Expanding primary care infrastructure and equipment, though cheap compared to hospitals, still imposes significant costs. In India, the cost of scaling up primary care to reach statutory levels of infrastructure, including human resources, was assessed at over US$10 billion if executed over the period 2019–2023. This was more than 10% of current public expenditure on health, and just over one third was for construction (Singh et al., 2021). Increasingly, however, the discussion extends beyond costs to an examination of value. Value-based procurement of medical equipment is a framework that guides review and decision-making when purchasing medical devices. Value-based procurement takes into account the health care value equation (outcomes and related costs), and offers potential benefits for patients (lower costs and/or better outcomes), providers (greater efficiency), payers (stronger cost controls and reduced risks), suppliers (alignment of prices with outcomes), and society (reduced health care spending and better overall health) (Rahmani et al., 2021).

Equipment reliability and maintenance are important components of on-going value, especially in scenarios where overinvestment and cost overruns during construction lead to under-investment in operations and maintenance. One recent survey in LMICs showed that 40–70% of medical devices and equipment were broken, unused or unfit for purpose (Diaconu et al., 2017). Such problems are often attributable to shortcomings in procurement methods that do not take into account the total cost of ownership, although recruiting and retaining suitably skilled technical and engineering staff may also be challenging. Cost-effective procurement is one important component to ensure the appropriate costing of equipment ownership (see Box 12.2).

Box 12.2

Cost-effective procurement as part of lifecycle costing of equipment.

12.2.4. The role of utilities

Utilities such as reliable energy supply, WASH and waste management services are crucial for the delivery of safe, effective primary care and public health services and efficient facility operations (WHO & World Bank, 2015; WHO & UNICEF, 2020).

Electricity supply

In addition to being a fundamental enabler of primary care and public health services, reliable electrical power in health and care facilities also enables community engagement. Communities benefit from increased access to reliable electricity and greater access to health services, and the quality and quantity of services provided improves. Provision of physical infrastructure can enhance trust in the health system and signal responsiveness to community needs (WHO & UNICEF, 2020). Trust, in turn, is a key concept in community social capital which reflects the density of cooperative networks within a community and has been positively associated with utilization of primary care services (Zhang et al., 2021).

A large study in Ghana and Uganda (Javadi et al., 2020) showed that reliable energy was important for increased service availability, appropriate storage of vaccines and medicines, and health workers’ self-assessed ability to carry out maternal and child health-related tasks; it also improved community satisfaction with available health services. At the same time, multilevel stakeholder engagement was required to ensure suitable installation of energy infrastructure, community buy-in and participation. In this study, improving access to energy in health facilities was necessary, but would support overall health system strengthening through mechanisms such as workforce retention, access to medicines, equipment viability and digitization (Javadi et al., 2020). Electrical power is therefore critical to attainment of the United Nations Sustainable Development Goal 3 (SDG3) and its targets, focused on healthy lives and well-being across the lifespan (WHO, 2023a).

A reliable internet connection is equally important to implement telehealth and other digital solutions for ensuring access to primary care (see Chapter 11). However, in many countries, and especially rural areas, there is no stable internet connection that allows people to use digital health applications to engage in and manage their own health or take advantage of connecting more easily with health providers (PAHO, 2021; Hui et al., 2022).

Despite the demonstrated benefits, health care premises in LICs are often chronically underserved; for example, in South Asia and sub-Saharan Africa over 10% of health facilities lack access to electricity (WHO et al., 2023). Lack of reliable electricity supply has been associated with supply-side and quality factors such as reduced service provision and adverse effects on access to safe primary care services for women at Indian primary care centres (Shastry & Rai, 2021; WHO, 2023a). According to the WHO, close to a billion people, mostly in LMICs, receive their health care in facilities which have either no electricity or unreliable electricity (see Fig. 12.2). Because problems with reliable power make it difficult to capture, process and store information, the absence of basic data on energy access and requirements for health care facilities in many countries remains a challenge (WHO, 2023a).

Fig. 12.2

Estimated population served by health care facilities with no electricity access or with unreliable electricity, disaggregated by region. Source: WHO, 2023a

The growing global climate crisis will require profound changes across all energy systems – including in health care – and particularly focused on electricity. There is a need to expand the electricity supply in PHC in sustainable ways. This will almost certainly include simple strengthening of centralized transmission and distribution grids, although there will also be a need for mini-grids, stand-alone solar capability, batteries and other forms of storage, and adapted tariffs and other mechanisms to spread the necessary high up-front investment over the life of the equipment (WHO, 2023a).

Water, sanitation and waste management

The availability of safe water and WASH facilities in primary care, as in other health care settings, is an essential requirement for adequate infection prevention control (IPC) (WHO, 2016). Component #8 of the WHO core components for effective IPC programmes (see Box 12.3) refers to the built environment, materials and equipment for IPC at the facility level, recommending that patient care activities be undertaken in a clean, hygienic environment that facilitates practices related to the prevention of health care-associated infection and antimicrobial resistance. This includes all elements of WASH infrastructure and services, and availability of appropriate IPC materials and equipment (WHO, 2016).

Box 12.3

Core component 8: Minimum WASH requirement for primary care.

A 2019 global survey of IPC in health care facilities revealed lower scores in primary care for core component 8 compared to other settings, though PC settings showed the greatest compliance (25.6%) with all minimum requirements (Tomczyk et al., 2022).

A success story from Ghana (WHO, 2022a) demonstrates that infrastructure investment increased compliance with WASH Facility Improvement Tool (WASHFIT) scores as well as IPC core components (WHO, 2022b). However, even when there is apparent compliance with WASH guidelines, significant problems can remain. A microbiological assessment of 50 government clinics in South Africa showed that one third to two thirds of taps had significant bacterial contamination and two thirds of clinics had no soap in washrooms (Potgieter et al., 2021). This highlights the importance of ongoing attention to processes for cleaning, management and maintenance. Poor WASH has also been a predictor of patient dissatisfaction, though not necessarily reduced utilization, in LMICs (Bouzid, Cumming & Hunter, 2018).

Solid waste management

Solid waste management is a somewhat neglected subject in the literature. Whether and how materials are disposed of correctly and safely impinges on the wider community as much as on primary care services, although broader issues around waste management processes after removal from PHC premises, such as cost and environmental impact of landfill or incineration methods, are beyond the scope of this chapter. Separation practices, to remove sharps and chemical, radiological and other biowastes from domestic wastes generated by primary care facilities, are a major concern. Separation, as part of waste management for hazardous materials, is often done badly (Mesdaghinia et al., 2009; Hangulu & Akintola, 2017), resulting in hazardous material entering standard waste streams or being dumped illegally in some countries (Hangulu & Akintola, 2017). At the same time, ordinary domestic waste often goes into hazardous waste streams, and is subsequently dealt with more expensively than needed (Alves et al., 2014). Home care and other community settings may be especially prone to poor waste segregation practices, particularly by lay-users as distinct from health care professionals (Alves et al., 2012). As more advanced technologies are transferred from hospitals into primary care settings, waste management practices may need careful consideration and expansion to accommodate novel hazards such as radioactive materials, for example related to the use of mobile PET and PET/CT (Chua et al., 2008).

12.3. Country illustrations: health infrastructure supporting the PHC approach

12.4. Conclusion

There is limited empirical evidence regarding the role and impact of infrastructure in supporting the PHC approach. Often, the evidence is inconclusive or insufficient to draw definitive lessons. In the literature, primary care infrastructure is both “everywhere and nowhere”: it is central to service delivery yet not specifically examined in the vast majority of analyses of PHC performance. No direct correlation between the standard of primary care facilities and the output of health services has been found – perhaps because these relationships are complex and multifactorial. Yet the field of EBD in health care has identified some intriguing relationships between clinician and patient behaviours, workforce outcomes and health care delivery, and many of these can be extrapolated to PHC.

That said, infrastructure is important in the PHC approach. If infrastructure is in the wrong place or inappropriate, the quality of primary care will be affected. Many norms and guidelines have been developed, based on long-standing local and international experience, expert consensus and empirical evidence. Adequate infrastructure is a crucial enabler of high-quality care; however, infrastructure on its own cannot ensure performance – it is a necessary but not sufficient condition for the delivery of optimal primary care services.

These approaches have financial implications. Enhanced flexibility in infrastructure will likely mean providing a capital stock greater than that which is immediately required, which will be difficult especially for resource-poor settings. In addition, the more capital stock in place, the greater the lifetime maintenance costs that will be incurred. The broad range of contexts and resources across countries makes it difficult to draw generic or universal conclusions about an ideal specification of infrastructure for PHC, and what should be considered “adequate”.

A specific gap in the literature concerns what is known about the infrastructure that enables the PHC workforce to do its job better. Eventually, facilities – no matter how good or bad – only make sense as somewhere for service delivery. This will be highly context-dependent, but implies that the development of facilities needs to be co-designed and co-delivered with patients and the workforce in mind, and looking forward over the full working lifetime of the facility.

Lessons learned include the importance of considering the distribution of primary care infrastructure relative to other levels of care. Distance alone is not a predictive factor for access or utilization, as patient-perceived quality also influences behaviour. Flexibility and adaptability over time are crucial features of primary care infrastructure, especially in the face of emerging risks like COVID-19 and climate change.

Appropriate and well-maintained equipment is critical for high-quality PHC services. However, better equipment does not necessarily mean better services. Reliable utilities such as power, water and sanitation are essential components. Renewable energy sources will become increasingly important, and may reduce long-term operational costs, but are likely to require substantial upfront capital investment.

Evidence-based design principles suggest that building design can influence care processes and outcomes. Design features of the built environment in primary care settings, including room and building layouts, may influence staff mental health and well-being, provider–patient interactions and staff collaboration and communication. While patients and others may inaccurately use perceptions of infrastructure quality as a proxy for health service quality, these perceptions can affect engagement and utilization.

Infrastructure offers a material sign of investment and resources, and a signal about what is important in a particular place. Primary care buildings and facilities are specifically localized in a way which is both closer to community and less obtrusive than other care settings. Both infrastructure and workforce become an integrated part of the wider community’s stock of health care resources. Overall, therefore, while the literature on primary care infrastructure may have limitations, there is a clear recognition of its importance in delivering high-quality primary care and supporting the well-being of patients and health care workers. Further research is required to strengthen the evidence base and inform effective infrastructure planning and implementation.

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