The research conducted by the Primary Health Care team at Ariadne Labs seeks to create a clear language around what primary health care is and develop an appropriate set of measurable outcomes that can be adapted globally. We have done this by leading and collaborating on studies ranging from how to define a common primary health care framework to a case study of Costa Rica’s strong foundation for primary health care service delivery.
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.
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, Deepening Health Reform in China, 2016
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.
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.