Primary Health Care

Partners: Ariadne Labs; Brigham and Women’s Hospital; T.H. Chan School of Public Health, Harvard University; University of Science and Technology, Kumasi, Ghana; Ghana Health Service; Feinberg School of Medicine, Northwestern University. 

Study Results: Preliminary validation of the PRImary care facility Management Evaluation tool (PRIME-Tool), a national facility management survey implemented in Ghana, BMC Health Services Research

Research indicates better management of primary health care facilities   improves facility performance and patient outcomes in low- and middle-income countries. However, there is a distinct lack of valid, reliable, and scalable tools to measure PHC facility management in developing countries. To address this gap, Ariadne Labs and partners have developed the PRImary health care facility Management Evaluation tool (PRIME-Tool). Two versions of the PRIME-Tool were evaluated in initial trials in Ghana in 2016 and 2017. 

What did we learn? The PRIME-Tool was designed to assess performance in five core management domains: target setting, operations, human resources, monitoring, and community engagement. Researchers surveyed 142 primary health care facilities in Ghana in 2016 using a 27-item PRIME-Tool. In 2017, 148 facilities were surveyed, using an expanded 34-item tool. Analyzed items included: 

• Formal goals and priorities for service delivery
• Hand washing areas 
• Staff training to improve skills
• User fees displayed 
• Mechanisms report new disease outbreaks 
• Client opinions gathered 

Researchers found that PRIME-Tool results tended to skew toward better management scores. Ceiling effects (that is, scores clustering toward the best possible results) were found in 17 of the 27 items in both versions and both years of the survey. 

Based on preliminary validation, researchers modified the initial five core domains to better adapt to primary health care facilities in low- and middle-income settings. The revised domains include supportive supervision and target setting, active monitoring and review, community engagement, client feedback for improvement, and operations and financing. The revised tool will be tested in additional settings and further refined.

Conclusion: The PRIME-Tool can collect meaningful data on PHC facilities management in limited-resource settings. Its use underscores the importance of measuring the often unseen and undervalued processes that improve health outcomes. Researchers recommend the spread of the PRIME-Tool with the caveat that results may exhibit ceiling effects. 

Partners: Ariadne Labs; Brigham & Women’s Hospital; Harvard T.H. Chan School of Public Health; Comagine Health, Seattle
; Ghana Health Service Headquarters; 
 Christian Health Association of Ghana; Ministry of Health, Malaysia; Mongolian National University of Medical Sciences; National Health Insurance Service, South Korea; 
Society of Private Medical and Dental Practitioners, Ghana; Ministry of Health, Mongolia
; Seoul National University College of Medicine; Health Department of Arkhangai Province, Mongolia; 
 Feinberg School of Medicine, Northwestern University.  

Study Results: Empanelment: A foundational component of primary health care, Gates Open Research

Empanelment, also known as “rostering,” is a foundational strategy that enables health systems to improve patient experience and health outcomes and reduce costs. .However, there is little international guidance for defining empanelment or for how to implement empanelment systems in low- and middle-income countries. A multi-country collaborative within the Joint Learning Network for Universal Health Coverage and a technical facilitation team from Ariadne Labs and Comagine Health convened to produce a definition of empanelment. The group also produced a 16-page document that explained standard empanelment concepts and described why and how empanelment is used. 

What did we learn?

The group established the following definition for empanelment: Empanelment is a continuous, iterative set of processes that identify and assign populations to facilities, care teams, or providers who have a responsibility to know their assigned population and to proactively deliver coordinated primary health care toward achieving universal health coverage. 

The group stipulated that empanelment should be people-centered – not provider- centered – and based on individual needs. Empanelment should ensure that patients feel as though they are treated as a whole person, not as a set of diseases or conditions. 

Steps for empanelment were identified, including: 

• Identify the target population for which the health care facility, team, or provider will be responsible. 
• Develop or adapt a method to create a list of identifying characteristics (such as name, gender, and date of birth) for that population. 
• Assign individuals to a care team or provider. 
• Ensure providers are aware of their responsibilities. 

Conclusion:

Effective empanelment requires the assumption of responsibility for the health and well-being of a target population, including providing proactive primary health services based on each individual’s health status.

Partners: Ariadne Labs; Brigham and Women’s Hospital; Harvard T.H. Chan School of Public Health; Northwestern University Feinberg School of Medicine; Ministerio de Salud y Desarrollo Social, Buenos Aires, Argentina; Ministry of Health and Social Action, Dakar, Senegal; Ministry of Health, Kigali, Rwanda; Bill & Melinda Gates Foundation; Results for Development, Washington, D.C.; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Ghana Health Service; UNICEF Tanzania; Global Health Issues and Solutions, Rwanda; Health, Nutrition and Population Global Practice, World Bank Group. 

Study Results: PHC Progression Model: a novel mixed-methods tool for measuring primary health care system capacity, BMJ Global Health 

Good primary health care is essential for achieving universal health coverage. However, primary health care is weak in many low- and middle-income countries, often hampered by a lack of relevant data needed to drive improvement. The Primary Health Care Performance Initiative (PHCPI) was formed in 2015 to accelerate primary health care improvements through better measurement and knowledge sharing. The initiative developed the Primary Health Care Progression Model, a rubric-based, mixed-methods assessment tool that allows countries to evaluate and track progress in primary health care. In 2018, PHCPI partnered with five countries – Argentina, Ghana, Rwanda, Senegal, and the United Republic of Tanzania – to pilot the model and assess its effectiveness. 

What did we learn?

• High-level buy-in at the ministerial level should be obtained before the assessment model is employed.
• Messaging must carefully present assessment as an improvement effort, not a punitive or audit tool.
• Some countries centralized data collection within one or two individuals; others distributed responsibility to multiple members of the assessment team. Thus, multiple implementation approaches can be successful.
• The assessment tool can bring together diverse stakeholders, each of whom may have insight into a different aspect of primary health care. 

Conclusion:

The model was found to yield novel and actionable information on primary health care strengths and weaknesses. It was feasible to implement and deemed both highly acceptable and useful by stakeholders. In April 2019, PHCPI released an updated version. PHCPI has initiated partnerships with ten additional countries to support expansion of the undated model.

Partners: Ariadne Labs, Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health; Harvard Medical School; Kwame Nkrumah University of Science and Technology, Ghana; and Feinberg School of Medicine, Northwestern University

Study Results**Summary: Facility management associated with improved primary health care outcomes in Ghana, PLoS One  

Far too many countries have poor primary health care, a barrier to achieving universal health coverage. Better facility management is thought to be associated with better primary health care; however, this association has not been established in low- and middle-income countries. 

In the first study to quantify management performance in primary health care facilities in in Sub-Saharan Africa, researchers evaluated management at 142 primary health care facilities in Ghana and assessed the experiences of nearly 900 women who sought care there. Researchers quantified facility management and correlated the results with five “process outcomes,” such as drug access and family planning availability, and eight “experiential outcomes,” such as prompt attention, basic amenities, ease of understanding, and trust in health providers.

What did we learn?

• On a scale of 0 to 1, the average overall management score in Ghana was 0.76. 
• Management performance varied significantly by facility type; generally hospitals performed better overall than community health centers. 
• Higher management scores were associated with higher scores for some, but not all, process and experiential outcomes. For example, women at facilities deemed to be in the 90th percentile of management reported 8% higher ratings of trust in providers. However, women in that same category rated their waiting times as worse.
• Twenty-two percent of the women had to borrow money or sell something to afford the costs of the visit. 

Conclusion:

Higher management scores were generally associated with better outcomes, but the large variations in management performance indicate the need to strengthen practices to impact primary health care. Further work is needed to examine how existing policies, governance systems, and infrastructure may affect facility management, and how this management impacts health outcomes over time.

Partners: Ariadne Labs; the Division of General Medicine and Division of Global Health Equity, Brigham & Women’s Hospital; Bill & Melinda Gates Foundation; World Bank Group; University of Toronto Dalla Lana School of Public Health; Northwestern University Feinberg School of Medicine

Study Summary: “Primary health care system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017,” BMJ Global Health  

Strengthening primary health care is known to be a key to improving general population wellness. But evidence about how to do so is lacking or fragmented, despite a plethora of published research on different facets of global primary health care. Yet there is a pressing need to understand how to ensure delivery of primary health care core service functions in low- to middle-income countries. To address this issue, researchers conducted a scoping review of recent literature on primary health care utilizing the conceptual framework of the Primary Health Care Performance Initiative. A search of PubMed publications from January 1, 2010, to May, 31, 2017, retrieved 5,219 articles, 207 of which met final inclusion criteria. Researchers focused on 14 countries found to have improving primary health care systems.

What did we learn?

• Community-based primary health care systems with supportive governmental policies and financing structures (both public and private) consistently promoted better outcomes and equity.
• More public spending on primary health care appears to be associated with more equitable outcomes.
• Fees for service payment systems do not appear to be associated with better outcomes.
• Motivating providers through both extrinsic (financial) and intrinsic mechanisms lessens provider burn-out and possibly contributes to better outcomes.
• When clinical staff is lacking, tasks shifted to community health workers can provide increased patient access to care and effective interventions. 
• Financial limitations are not the only barrier to health care access; gaps in medication and other supplies impede care delivery and decrease access as patients bypass facilities reported to be lacking resources.

Researchers also found major gaps in understanding how social accountability and innovation systems impact primary health care. Little information was available for how systems can reliably innovate.

Conclusion:

 The 14 countries with improving systems in 2010 showed continued progress. While sharing lessons remains a worthwhile endeavor, it is far more important to publish rigorous data that allows for useful conclusions about successful (and unsuccessful) strategies. There remains a glaring lack of evidence about the best ways to adapt, implement, and sustain effective public health care strategies across multiple, varying contexts.

Partners: The World Bank, WHO, Chinese Ministry of Finance, the National Health and Family Planning Commission and Ministry of Human Resources and Social Security

Study Results: World Bank report, Healthy China: Deepening Health Reform in China, 2019

The Primary Health Care research team at Ariadne Labs has developed an eight-tenet model that characterizes effective primary health systems in middle and high-income countries. The eight tenets grew from our work with the World Bank on the China Health Study. As part of that study, Ariadne Labs was commissioned to develop 19 case studies to analyze 22 performance initiatives to strengthen person-centered, integrated primary health care in 10 counties in China and 12 other countries. As we analyzed the initiatives, certain themes emerged and are distilled in the eight-tenet framework:

• First: Primary health care is the first point of first contact
• Second: Functioning multidisciplinary teams
• Third: Vertical integration between primary, secondary and tertiary health care services
• Fourth: Horizontal integration among multiple types of health care services
• Fifth: Advanced information and communication technology (e-health)
• Sixth: Integrated clinical pathways and functional dual referral systems
• Seventh: Measurement standards and feedback
• Eighth: Accountability Certification

Conclusion: The eight tenets offer middle and high-income countries a framework for understanding and implementing the characteristics of a successful primary health care system.

Partners: The World Bank; Department of Medicine, Johns Hopkins School of Medicine; Northwestern University Feinberg School of Medicine

Study Results: BMJ Global Health, “The 5S-5M-5C schematic: transforming primary care inputs to outcomes in low-income and middle-income countries,” October 2018

High-quality primary health care is key to meeting a population’s health needs and is an essential building block for universal health care coverage. Yet in most low-income and middle-income countries (LMICs), primary health care remains a neglected area of investment, resulting in alarming deficiencies. This study cites evidence indicating that most primary care visits in LMICs are brief, with diagnoses frequently incorrect and treatments often unnecessary or harmful. To catalyze improvements, the Primary Health Care Performance Initiative (PHCPI) has developed a conceptual framework that builds on, expands, and links together previous frameworks with a novel focus on service delivery.

This paper presents the “5S-5M-5C” schematic–a simplified form of the PHCPI framework. The schematic describes and builds on the 4C’s defined in 1994: first-contact accessibility, continuity, comprehensiveness, and coordination. These are meant to ensure accessibility of affordable services when and where needed, fostering long-term patient-provider relationships, and effective transmission of health information across systems. The schematic also expands on the 4S’s – space, systems, staff, and stuff – defined nearly 20 years later and aim to ensure appropriately trained health care providers are available, sufficiently financed, and equipped with medication and supplies.

The “5S-5M-5C” schematic expands these frameworks. It incorporates a fifth C that references “person-centered,” meaning that patients should be regarded as a whole person, and that their needs and preferences respected. A fifth S – surveillance – is meant to encourage health practitioners to identify emerging threats and continually assess and respond to community needs. To these functions, the 5S-5M-5C schematic adds five processes – the five M’s  – aimed at transforming resources into high-quality primary health care. These processes, identified as multidisciplinary teams, motivation, management, measurement, and monitoring, must work together to be effective. Multidisciplinary health teams need sufficient motivation through both compensation and supportive supervision, and teams must continually measure data to drive improvement. Without active and regular monitoring of data, however, measurement is futile. Finally, management systems must coordinate effective care at the facility and community level.  

The 5S-5M-5C schematic provides insights for developing primary care systems capable of equitably meeting the needs of populations, communities, and individuals globally. It also lays out an agenda for prioritizing investment and research into primary care systems, both public and private while building a global dialogue appropriate for both LMIC’s and high-income settings.

What did we learn?

• Strong primary care requires well-trained, experienced managers and effective management systems. Otherwise, care delivery will be insufficiently resourced.
• While the public sector provides most primary care in LMICs, the private sector has a large role to play. Without incorporating primary health care innovations into primary care delivery by private sector partners, the goal of universal health care is likely to be impossible.

Conclusions
Research and policy agendas should be structured to better measure and strengthen the 5M processing to help LMICs build evidence-informed, data-based primary care programs. The effectiveness of the 5S-5M-5C model should help propel the emphasis on strong, high-quality primary care, which, in turn, will support overall health goals.

Partners:  The Primary Health Care Performance Initiative Partners, including the World Bank Group, Results for Development, the World Health Organization and the Bill & Melinda Gates Foundation

Study Results: The Millbank Quarterly, Better Measurement for Performance Improvement in Low- and Middle-Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection, December 2017

The Primary Health Care Performance Initiative (PHCPI) is a collaboration between the Bill & Melinda Gates Foundation, The World Bank, and the World Health Organization, in partnership with Ariadne Labs and Results for Development. Launched in 2015, PHCPI aims to catalyze improvements in primary health care (PHC) systems in 135 low- and middle-income countries in order to accelerate progress toward universal health coverage. This article describes the extensive, participatory process the Initiative has undertaken to develop a Conceptual Framework and identity and validate two sets of performance indicators, as well as ongoing work of the Initiative to improve data availability and operationalize the Initiative’s measurement agenda to drive performance improvement.

What did we learn?

• A common PHC language. The PHCPI conceptual framework establishes a common language for understanding primary health care system performance. It was developed through literature reviews and consultations with an advisory committee of international experts. The framework builds on the current understanding of system performance, and includes an expanded emphasis on the role of service delivery.
• PHC performance indicators. To measure performance across the conceptual framework, PHCPI generated two sets of performance indicators through a literature review of relevant indicators. This was cross-referenced against indicators available from international sources and evaluated through online surveys and in-person facilitated discussions. The first set of performance indicators, 36 Vital Signs, facilitates comparisons across countries and over time. The second set, 56 Diagnostic Indicators, elucidates underlying drivers of performance.
• Peer learning. Through more comprehensive and actionable measurement of quality primary care, PHCPI stimulates peer learning among countries and informs decision makers to guide primary care investments and reforms. Additional instruments for performance assessment and improvement are in development.

Conclusions:

The Primary Health Care Performance Initiative has developed a package of tools to support better measurement of primary health care system performance in low- and middle-income countries and use this measurement to drive performance improvement. The availability of high-quality data and reliable and validated indicators has been one of the Initiative’s main challenges. Moving forward, PHCPI will continue to develop and test additional performance assessment instruments, including composite indices and national performance dashboards. Through country engagement, the PHCPI will further refine its instruments and engage with governments to better design and finance primary health care reforms.

Case Study

Full case study can be viewed and downloaded here.

This case study traces the path Costa Rica took to achieving a high-performing health system and unpacks the country’s successful primary health care model. It is one of the first English-language publications to describe in detail the successful primary health care system in Costa Rica and the process by which this system was actualized. In this research, we examined seven aspects of how Costa Rica established its primary care system:

• the historical and cultural context to elucidate how the country came to the pre-conditions that supported the establishment of a robust primary health care system,
• the primary health care reform process in the 1990s, which marked a crucial turning point in the organization and delivery of primary health care in Costa Rica,
• the strategies and plans established in the 1990s, and the challenges and achievements of this process,
• the role that measurement and monitoring played in enabling the successful implementation of the reforms,
• the impact of the 1990s reforms on health outcomes in Costa Rica,
• the challenges facing Costa Rica’s primary health care system today,
• lessons learned from the Costa Rican experience which may be generalizable to other contexts.  

What did we learn?

As the world turns its attention toward the achievement of the Sustainable Development Goals and Universal Health Coverage, the Costa Rican experience detailed in this case study offers valuable lessons for the global community. PHC is a low cost option that can provide high quality care to all citizens. Costa Rica spends less than the world average on its health-care system overall while also producing strong health outcomes.

Conclusions:

Costa Rica demonstrates that it is possible for countries to use primary health care development as a main strategy for achieving Universal Health Care. As countries around the world pursue high-quality universal health coverage, Costa Rica’s experiences provide valuable lessons about the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.

Study Results: Health Affairs, 2017

Costa Rica’s universal primary care system produces strong outcomes with low overall spending and is considered an example for other countries around the world. Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied. This case study provides a detailed description of Costa Rica’s innovative implementation of four critical service delivery reforms:

• Integration of public health services and primary care delivery
• Multidisciplinary teams
• Geographic empanelment
• Measurement and reliable data feedback loops

To conduct this case study, the Ariadne Labs team performed an in-depth review of the English- and Spanish-language literature, supplemented by a series of interviews with key informants. The team searched relevant electronic databases for all articles containing the phrase Costa Rica and interviewed corresponding authors. The team also interviewed health care providers and administrators at five Costa Rican clinics in two health regions, Pacifico Central and Central Sur.

What did we learn?

• Integration of public health services and primary care delivery ensures health priorities are managed effectively and in a balanced way.
• Integrated health-care teams provide comprehensive care that covers the vast majority of health needs.
• Geographic empanelment – the process by which patients are assigned to primary care providers or care teams – allows reliable first-contact access.
• Health-care teams provide more continuous care and build a long-term, trusting relationship with each patient.
• Data collection and feedback loops are integral to the success of the primary care model.

Conclusion: The service delivery reforms highlighted here are not unique to Costa Rica, but in most low- and middle-income countries, these strategies have not been well-implemented or successfully scaled up nationally, reducing their potential impact. What is novel about the Costa Rican case are the four service delivery strategies that were effectively, efficiently and reliably executed on a national scale. The implementation of these reforms has provided four of the five key functions of strong primary health care: first-contact access, comprehensiveness, continuity and coordination. As countries around the world pursue high-quality universal health coverage, Costa Rica’s experiences provide valuable lessons about the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.

Study Results: WHO Bulletin, 2017

In recent years, Haiti has begun efforts to build a stronger primary health care system to address poor population health outcomes. Despite significant obstacles – natural disasters, poverty and underinvestment in health – Haiti has made notable health improvements in recent decades, including a steady decline in mortality among children younger than five years. With a shift in global health policy focus towards universal health coverage and the Sustainable Development Goals, this was an opportune time to test a methodology for assessing coverage of comprehensive, high-quality primary care in Haiti.

The goal of this study was to develop a composite measure of primary care quality and apply it to Haiti’s primary care system. The team then quantified access and effective access to primary care as the proportion of the population within 5 km of any primary care facility and a good facility, respectively.

What did we learn?

• Most Haitians do not live close to a high quality primary care facility. The study found that while 91% of the population lived within 5 km of a primary care facility, only 23% lived within 5 km of a facility with service delivery of good quality.
• The quality of services at the average primary care facility is only fair. This indicates that there are many gaps in the provision of high quality primary care.
• Patients reported receiving better quality of care. The quality indicators based on clients’ responses tended to be more positive than those that had been more objectively assessed, suggesting that that patients may have had low expectations when seeking care.
• There was not a geographical difference as to where high and low quality facilities were located. Although service quality was generally poor in rural areas, there was great variation between facilities within both rural and urban areas.

Conclusions: The results indicate significant gaps in the provision and receipt of primary care of good quality. In Haiti, as elsewhere, robust quality measurement is a crucial input to the ongoing efforts to improve the quality of primary care. The results have several implications for primary health care in Haiti. Funders, planners, policymakers and practitioners can use this data to compare performance within administrative areas and to identify the best- and worst-performing facilities within each area, allowing improvement interventions to be better targeted at particular facilities and identified gaps. Some facilities have achieved good quality of services despite Haiti’s challenging topography, suggesting that good quality can be more widely achieved throughout the country. Most primary care facilities of poor quality in Haiti are close to, and could learn from, a facility of good quality. This method of quality assessment of primary health care facilities has shown to provide useful results and is now being adapted to other countries as part of the Primary Health Care Performance Initiative, which Ariadne Labs helps lead.

Partners: The World Bank, The Bill & Melinda Gates Foundation, the World Health Organization, Results for Development

Study Results: Journal of General Internal Medicine, 2017

Primary health care is increasingly recognized as a core component of effective health systems and essential for achieving universal health coverage. However, there remains a large gap between what individuals and communities need and the quality and effectiveness of care delivered. This is especially true in low- and middle-income countries, where primary health care capacity is weak and health outcomes remain poor. To address this gap, the World Health Organization, the World Bank Group, and the Bill & Melinda Gates Foundation, in partnership with Ariadne Labs and Results for Development, launched the Primary Health Care Performance Initiative (PHCPI) in 2015. The goal of this consortium is to catalyze improvements in primary health care in low- and middle-income countries through better measurement and sharing of effective models and practices.

This paper outlines PHCPI’s conceptual framework to describe the components necessary for building strong primary health care systems, inform better assessment and identify gaps in performance. It also provides a set of 25 key performance indicators, or ”Vital Signs,” to assess primary health care system performance and allow countries to compare themselves to others.

What did we learn?

The core functions of primary health care are universal across the world: services that are accessible at the point of first contact, continuous, coordinated, comprehensive and people-centered. However, much work is needed to strengthen PHC measurement in low- and middle-income countries.

Conclusions: To make meaningful progress, there must be sustained leadership focus and investment in measuring the key primary health care domains. Furthermore, this data must be made transparent and relevant to health-care providers, particularly those at the front lines of service delivery. Countries must move beyond antiquated notions of “levels” of care, simplified packages of services or broad, poorly-defined concepts of primary health care, and move toward comprehensive, coordinated care that is truly centered around people and their needs.