Primary Health Care

Partners: Ariadne Labs, Brigham and Women’s Hospital, Harvard University, Muhimbili University of Health and Allied Sciences, College of Medicine and Health Sciences, University of Rwanda

Study Results: BMJ Open, “Better evidence: prospective cohort study assessing the utility of an evidence-based clinical resource at the University of Rwanda,” August 2019

In American medical schools, a historical focus on memorization is giving way to knowing how to find information, synthesize it and apply it clinically. Evidence-based clinical resources (EBCRs) have the potential to help clinicians improve diagnostic and therapeutic accuracy. However, many EBCRs are subscription based, and their cost is prohibitive for most clinicians and trainees in low-income and middle-income countries. In the first study to link usage of online educational resources to performance in medical school examinations in Africa, medical students and faculty at the University of Rwanda were offered free access to UpToDate, a leading evidence-based clinical resource. The impact was assessed through two student surveys and their grades.

What did we learn?

• Over 92 percent of Rwandan medical students have an internet-ready device, capable of accessing UpToDate, but the $299 price tag of a subscription is very costly in a country that spent $52 per capita on healthcare in 2014.
• In 2014, the paper authors were able to form an agreement with Wolters Kluwer, the UpToDate parent company, to provide free subscriptions to medical students in Sub-Saharan Africa. Fifty-six percent of the 980 medical students and 29 percent of the faculty invited to enroll did so. About 88 percent of eligible final year students enrolled.
• Researchers were also able to precisely track online usage of UpToDate; enrolled final year students viewed on average 1.24 cases per day and continued to use UpToDate after graduating.
• After UpToDate access was granted, average grades of exams of the Rwandan graduating medical students – in internal medicine, pediatrics, obstetrics and gynecology and surgery – rose from 68 to 75 and students reported decreased use of Wikipedia.

Conclusions
Overall, the findings suggest that removing the subscription cost barrier can generate an uptake of EBCR use among East African medical students and, subsequently, better exam grades. The researchers caution, however, that while UpToDate may have helped students prepare for their exams more efficiently and increase their knowledge base, it is also possible that the exams in 2016 and 2017 were easier than those of years past or that the students were independently academically superior to the previous classes. Future research might explore other EBCRs and features that impact uptake and utility.

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.

Partners: Harvard T.H. Chan School of Public Health, Harvard Medical School, Harvard University, US Agency for International Development, World Bank, American University of Beirut, John Snow Inc., Mission of Japan to the European Union, the World Health Organization, London School of Hygiene and Tropical Medicine, the Rockefeller Foundation, UNICEF, Institute for Healthcare Improvement, Indonesian Ministry of Health, German Ministry of Economic Cooperation and Development

Study Results: BMJ, Building resilient health systems: a proposal for a resilience index, May 2017

Health system resilience is the capacity of health providers, administrators, institutions and the populations they serve to effectively prepare for and respond to crises. It includes the ability to maintain core functions when a crisis occurs and is informed by lessons learned during a crisis. Resilience is important for every country’s health system to be able to respond to sudden events like an earthquake or chronic stresses like supply shortages or provider turnover.

Health system resilience begins with measurement of critical capacities ahead of a crisis, but a standard framework or index has not existed.. In this study, researchers propose an approach to measuring health system resilience.

What did we learn?

• Resiliency translates into health systems that are:
  • Aware: The health system understands its capacity, population and risks.
  • Integrated: The health system coordinates with non-health sectors (e.g., education, transportation), engages citizens and communities to build trust, ties health care to public health and coordinates primary and referral care.
  • Diverse: They respond to a range of health needs and are adequately financed.
  • Self regulating: The system is able to isolate threats, retain core functions and leverage external capacity.
  • Adaptive: It is able move resources to meet needs, promote local decision-making and use evaluation to make improvements.
• Past experiences make a strong argument for improving health system resilience. Three recent crisis events led to improved health system resilience in each of the countries: chronic health system dysfunction aggravated by a rapid increase of refugees in Lebanon, the sudden and severe Ebola outbreak in Liberia, and repeated natural disasters in Indonesia. In each case, initial health system failure to respond to the effects of the crisis led to improvements in the core characteristics.
• An index is needed to promote health system resilience measurements. A health system’s resilience capacity should be measured prior to a crisis. Building on the core characteristics, the study team identified a set of preliminary measures of national health system resilience. They include drivers that take longer to affect, such as district health staff with public health training, and those that are quicker, such as the ability to reallocate funds during an emergency.
• National benchmarking should be done by each country. The index does not prescribe national benchmarks. Given the complexity and nuances of health systems and national contexts, benchmarks for resilience indicators should be set within countries to reflect the local context.

Conclusions:

National health systems are the first line of defense against health crises, but today they are rigid and slow to adapt. In order to effectively respond to crises and maintain core services, they must become more resilient. Resilience requires planning and investment in variables that are both relatively slow (e.g., health workers, managers, information systems) and fast (e.g., isolation wards, protective equipment, surveillance) to develop. Resilience also needs collaboration and trust with communities ahead of crises. The resilience index is designed to help countries determine whether their health systems can withstand future crisis events and should be tested in countries at high risk for these events.

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.