Primary Health Care Performance Initiative Research Articles

Good Management Practice Is Correlated With Good Performance of Community-Engaged Primary Health Care Facilities in Peru.

Increasing prioritization of quality primary health care (PHC) includes community engagement as a key element to improve PHC performance. We assessed the correlation of good regional management practices with PHC performance in Peru in community-comanaged PHC that is designed with multiple accountability mechanisms. We conducted a secondary analysis of a survey of Dirección Regional de Salud (regional health directorates, DIRESAs) regarding their management of public PHC services with collaborative community involvement by a Comunidad Local de Administración de Salud (Local Community for Health Administration, CLAS). CLAS-run facilities have previously shown evidence of superior performance over standard PHC services. We classified survey questions on 5 management functions of the Primary Health Care Performance Initiative: leadership, information system, financial control, transfer of management and leadership skills to health facilities, and supervision. An expert panel designated management practices as "good" or "less effective." The outcome, PHC service performance, was the percentage of CLAS comanaged facilities in each DIRESA achieving coverage and utilization goals. We correlated frequency of good management practices with PHC service performance. DIRESAs were divided into Group 1, "higher performance," and Group 2, "lower performance," to identify specific practices linked to better performance. We identified 32 good management practices among 52 response options to 17 questions. Correlation between good management practice and good service performance was significant (r=.7266; 12 df; P<.01). An average of 91.1% and 37.6% of CLAS facilities achieved service goals in Groups 1 and 2, respectively. Of all good management practices identified, an average of 40.6% and 24.0% were used by Groups 1 and 2, respectively. Group 1 used 11 specific good practices more frequently than Group 2. Regional management and community-comanaged PHC services designed with accountability mechanisms should be intentionally aligned, incorporating these into policies, budgets, processes, and capacities to strengthen PHC services.

A rapid mixed-methods assessment of Libya’s primary care system

BackgroundLibya has experienced decades of violent conflict that have severely disrupted health service delivery. The Government of National Unity is committed to rebuilding a resilient health system built on a platform of strong primary care.AimCommissioned by the government, we set out to perform a rapid assessment of the system as it stands and identify areas for improvement.Design and settingWe used a rapid applied policy explanatory-sequential mixed-methods design, working with Libyan data and Libyan policymakers, with supporting interview data from other primary care policymakers working across the Middle East and North Africa region.MethodWe used the Primary Health Care Performance Initiative framework to structure our assessment. Review of policy documents and secondary analysis of WHO and World Bank survey data informed a series of targeted policymaker interviews. We used deductive framework analysis to synthesise our findings.ResultsWe identified 11 key documents and six key policymakers to interview. Libya has strong policy commitments to providing good quality primary care, and a high number of health staff and facilities. Access to services and trust in providers is high. However, a third of facilities are non-operational; there is a marked skew towards axillary and administrative staff; and structural challenges with financing, logistics, and standards has led to highly variable provision of care.ConclusionIn reforming the primary care system, the government should consolidate leadership, clarify governance structures and systems, and focus on setting national standards for human resources for health, facilities, stocks, and clinical care.

Abstract P153: Disruptions to Diabetes and Hypertension Care During the COVID-19 Pandemic and Recovery Approaches in the Latin America and Caribbean Region

Background: The COVID-19 pandemic disrupted healthcare services in Latin America and the Caribbean (LAC). However, few studies provided comprehensive and quantitative data on the magnitude of this disruption. Objectives: To synthesize evidence on the extent of disruptions to diabetes and hypertension care in LAC during the COVID-19 pandemic and interventions to recover. Methods: We conducted a scoping review of published papers in English, Spanish, and Portuguese. We adopted the Primary Health Care Performance Initiative (PHCPI) Framework to identify healthcare services susceptible to disruptions during the COVID-19 pandemic, specific to diabetes and hypertension, including recovery approaches. We synthesized study findings narratively to represent the diversity of findings geographically and health system. Results: Our search yielded 33,510 abstracts after de-duplication; following title/abstract screening and full-text review, 330 articles (218 on disruptions; 112 on interventions) were included in the synthesis. Although there was high heterogeneity, similarities in landscape of disruptions to primary care services across LAC exist. Of the PHCPI Framework domains, disruptions to workforce, medications and supplies, and patient-related outcomes were most recurrent. Intervention studies focused telehealth using digital strategies for diverse care areas and counseling support for health behaviors and mental health. There were data gaps within LAC regarding health system readiness and digital health effectiveness, adoption, efficiency, reach, and sustainability ( Figure ). Conclusions: This scoping review identified priorities for action within LAC: 1) establish and fund high-quality research and surveillance systems for hypertension and diabetes; 2) Optimally integrate digital health into hypertension and diabetes care; 3) implement mental health promotion strategies among healthcare workers; 4) establish optimal governance, leadership, and financing of healthcare systems.

Family planning integration in Ethiopia’s primary health care system: a qualitative study on opportunities, challenges and best practices

BackgroundFamily planning (FP) service integration into primary health care (PHC) is an effective approach to realize reproductive autonomy, increase the use of contraceptives, and improve maternal and child health outcomes. The Ethiopian government promotes integration of FP services into primary health care (PHC). However, there is paucity of evidence on the status of FP service integration. The aim of this study is to explore the state of FP integration into PHC services and identify facilitators and barriers to integration.MethodsA qualitative study nested with a larger national study was conducted from July to October 2022. A total of 60 interviews were conducted with FP stakeholders including, government organizations, non-governmental organizations, donors, service providers, and clients. Interviews were audio recorded, transcribed, and coded using OpenCode 4.03. The coded data were analyzed using framework analysis approach, using the Primary Health Care Performance Initiative (PHCPI) framework. Direct quotes and results from the coding and categorization were used to develop the report.ResultsFamily planning is largely provided in designated units by dedicated staff within PHC facilities. The provision of integrated FP service within each service unit is in its early stage. Successful examples of integration include integration of FP with postnatal care, abortion care, and youth-friendly service centers. Facilitators of integration include commitment of the government and partners, the presence of policies and guidelines, and positive attitude of service providers and clients. However, integration of FP also faces challenges that are largely related to challenges of the FP program even before integration. These include resource shortage, health workers shortage, health workers’ capacity/skill gaps, misconceptions about FP, religious and socio-cultural norms, and lack of awareness.ConclusionsIntegration of FP with PHC services in the Ethiopian public health facilities is viable. Pre-existing challenges of the FP program continued to be barriers to integration. Expanding the experiences of good practices in the integration of FP with post abortion care, post-natal care, and youth-friendly service centers to other components of PHC warrants attention. Addressing both supply- and demand-side challenges of the FP program is needed to facilitate the integration of FP with other PHC services.

Primary health care capacity assessment in Qatar: the primary health care progression model as an assessment method

Background: The Primary Health Care Performance Initiative (PHCPI) was developed as a measurement of Primary Health Care (PHC) to evaluate the PHC systems, improve services, and maximize health outcomes. With the limitation of data sources and metrics of PHC capacity, PHCPI designed the PHC Progression Model, as a rubric-based mixed-methods assessment tool for capacity measurement through a participatory process. This paper uses the PHC progression model to assess the system capacity of primary health care in Qatar. Methods: The PHC Progression Model consists of a set of 33 quantitative and qualitative measures, each of which is assessed using a rubric that classifies the level of performance into 4 levels, ranging from Level 1 (low capacity) to Level 4 (high capacity). The assessment measured both quantitative and qualitative information. Results: The assessment showed that PHC in Qatar has a strong capacity with an overall score of the key measures of capacity governance (3.6), inputs (4.0), and population health management (4.0). Conclusion: The main strength of the system was in the key inputs such as facility, workforce, fund, information system, and drugs and supply. Also, the assessment showed strong population health and facility management including standardized team organization, measuring performance, community engagement, and use of the information system data. Keywords: Primary health care, progression model, health system evaluation, health care capacity, Qatar

Barriers to Community-Based Primary Health Care Delivery in Urban China: A Systematic Mapping Review.

Providing access to a range of basic health services, community-based primary health care (CB-PHC) plays a vital role in achieving the goal of health for all. Driven by a strong political commitment, China’s CB-PHC progress in the past decade has been swift and impressive. However, a well-functioning delivery system for care has yet to be established. This systematic mapping review synthesizes selected evidence on barriers to CB-PHC delivery in urban China and draws lessons for policy development. We performed searches on five electronic databases: CINAHL, MEDLINE, Scopus, Web of Science, and China National Knowledge Infrastructure, and included studies published between 2012 and 2021. The Downs and Black and Critical Appraisal Skills Program checklists were used to assess the quality of eligible papers. We conducted our searches and syntheses following the framework set out in the Primary Health Care Performance Initiative (PHCPI). We synthesized the results of the included studies using a thematic narrative approach and reported according to PRISMA guidelines. Six salient barriers arose from our syntheses of 67 papers: lack of comprehensive health insurance schemes, lack of public awareness, superficial care relationships, gaps in communication, staff shortages and poor training, and second-rate equipment. These barriers are grouped into three subdomains following the PHCPI framework: access, people-centered care, and organization and management. A host of negative impacts of these barriers on community-based health care were also identified. It was not possible to determine clear causes of these barriers from the contributing evidence because of the lack of conceptual frameworks and research methods constraints. Non-eastern regions of China and access-related barriers require further exploration. It follows that, at the national level, the problems are likely more severe than the research suggests.

Stakeholder perspectives to inform adaptation of a hypertension treatment program in primary healthcare centers in the Federal Capital Territory, Nigeria: a qualitative study

BackgroundImplementing an evidence-based hypertension program in primary healthcare centers (PHCs) in the Federal Capital Territory, Nigeria is an opportunity to improve hypertension diagnosis, treatment, and control and reduce deaths from cardiovascular diseases. This qualitative research study was conducted in Nigerian PHCs with patients, non-physician health workers, administrators and primary care physicians to inform contextual adaptations of Kaiser Permanente Northern California's hypertension model and the World Health Organization’s HEARTS technical package for the system-level, Hypertension Treatment in Nigeria (HTN) Program.MethodsPurposive sampling in 8 PHCs identified patients (n = 8), non-physician health workers (n = 12), administrators (n = 3), and primary care physicians (n = 6) for focus group discussions and interviews. The Primary Health Care Performance Initiative (PHCPI) conceptual framework and Consolidated Framework for Implementation Research (CFIR) domains were used to develop semi-structured interviews (Appendix 1, Supplemental Materials) and coding guides. Content analysis identified multilevel factors that would influence program implementation.ResultsParticipants perceived the need to strengthen four major health system inputs across CFIR domains for successful adaptation of the HTN Program components: (1) reliable drug supply and blood pressure measurement equipment, (2) enable and empower community healthcare workers to participate in team-based care through training and education, (3) information systems to track patients and medication supply chain, and (4) a primary healthcare system that could offer a broader package of health services to meet patient needs. Specific features of the PHCPI framework considered important included: accessible and person-centered care, provider availability and competence, coordination of care, and proactive community outreach. Participants also identified patient-level factors, such as knowledge and beliefs about hypertension, and financial and transportation barriers that could be addressed with better communication, home visits, and drug financing. Participants recommended using existing community structures, such as village health committees and popular opinion leaders, to improve knowledge and demand for the HTN Program.ConclusionsThese results provide information on specific primary care and community contextual factors that can support or hinder implementation and sustainability of an evidence-based, system-level hypertension program in the Federal Capital Territory, Nigeria, with the ultimate aim of scaling it to other parts of the country.

Providers' perspectives on the performance of primary healthcare centres in India: The missing link.

BackgroundPrimary healthcare centres (PHCs) form the foundation of the Indian public health system, and thus their effective functioning is paramount in ensuring the population's health. The World Health Organisation (WHO) has set six aspects of performance assessment for general health systems, which are hardly applicable to the PHC setup in a low‐ and middle‐income country. The Primary Health Care Performance Initiative (PHCPI) has prescribed a framework with five domains consisting of 36 indicators for primary healthcare performance assessment from a policy point of view. For the assessment to be realistic, it should include inputs from stakeholders involved in care delivery, so this study examines the perspectives of healthcare providers at PHCs in India.MethodologyThe authors used qualitative research methodology in the form of responsive evaluations of healthcare provider's interviews to understand the indicators of PHC performance.Results and ConclusionThe study results showed that healthcare providers considered efficient teamwork, opportunities for enhancing provider skills and knowledge, job satisfaction, effective PHC administration, and good community relationship as PHC performance assessment. These domains of performance could be considered the ‘missing link’ in PHC assessment, since they are deemed important by providers and did not coincide with the WHO aspects and the PHCPI performance assessment framework.

Primary health care contributions to universal health coverage, Ethiopia.

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017.

IntroductionThe 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed.MethodsGuided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised.ResultsWe retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period.ConclusionOur findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.

The Primary Health Care Performance Initiative (PHCPI): Issues and Challenges for Malaysia as a Trailblazer Country

A strong and robust Primary Health Care system is essential to achieving universal health coverage and to save lives. The Global Conference on Primary Health Care 2018: from Alma-Ata towards achieving Universal Health Coverage and the Sustainable Development Goals at Astana, Kazakhstan provided a platform for low‐ and middle‐ income countries to join the Primary Health Care Performance Initiative (PHCPI). At this Global Conference, Malaysia has declared to become a Trailblazer Country in the PHCPI and pledged to monitor her Vital Signs Profiles (VSP). However, the VSP project requires an honest and transparent data collection and monitoring of the Primary Health Care system, so as to identify gaps and guide policy in support of Primary Health Care reform. This is a huge commitment and can only be materialised if there is a collaborative partnership between Primary Care and Public Health providers. Fundamental to all of these, is the controversy concerning whether or not ‘Primary Care’ and ‘Primary Health Care’ represent the same entity. Confusion also occurs with regards to the role of ‘Primary Care’ and ‘Public Health’ providers in the Malaysian Primary Health Care system. This review aims to differentiate between Primary Care, Primary Health Care and Public Health, describe the relationships between the three entities and redefine the role of Primary Care and Public Health in the PHCPI-VSP in order to transform the Malaysian Primary Health Care system.

Effect of Integrated Supportive Supervision on the Quality of Health-Care Service Delivery in Katsina State, Northwest Nigeria.

Background:Katsina State Government in Northern Nigeria introduced integrated supportive supervision (ISS) in primary health centers. The study was guided by the Primary Health Care Performance Initiative Conceptual Framework. The goal of the study was to measure the impact of ISS on the quality of primary health-care delivery. The outcome variables measured include infrastructure, basic equipment, human resources for health, essential drugs, the number of pregnant women screened for HIV, and the number of children receiving immunization.Methods:The study was a cross-sectional survey of 34 health facilities. Kruskal-Wallis nonparametric test followed by Dunn post hoc test and analysis of variance followed by Tukey post hoc test were both employed to compare the mean values of various indicators obtained over 6 visits of the ISS program from July 2018 to December 2018.Findings:The study shows the positive effect of the ISS on infrastructure, human resources for health, essential drugs, and the number of pregnant women screened for HIV (P < .05). Human resources for health and the number of children receiving immunization were both not affected by ISS (P > .05).Conclusion:Integrated supportive supervision need to be embedded into the 3 levels (primary, secondary, and tertiary) of health-care service delivery.Implications:Integrated supportive supervision will strengthen the Katsina State health system, ensure efficient use of the health facility assets and resources utilization, and improve patient/client satisfaction.

High-quality health systems in the Sustainable Development Goals era: time for a revolution.

High-quality health systems in the Sustainable Development Goals era: time for a revolution.

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.

Policy Points: Strengthening accountability through better measurement and reporting is vital to ensure progress in improving quality primary health care (PHC) systems and achieving universal health coverage (UHC).The Primary Health Care Performance Initiative (PHCPI) provides national decision makers and global stakeholders with opportunities to benchmark and accelerate performance improvement through better performance measurement.Results from the initial PHC performance assessments in low‐ and middle‐income countries (LMICs) are helping guide PHC reforms and investments and improve the PHCPI's instruments and indicators. Findings from future assessment activities will further amplify cross‐country comparisons and peer learning to improve PHC.New indicators and sources of data are needed to better understand PHC system performance in LMICs. ContextThe Primary Health Care Performance Initiative (PHCPI), a collaboration between the Bill and Melinda Gates Foundation, The World Bank, and the World Health Organization, in partnership with Ariadne Labs and Results for Development, was launched in 2015 with the aim of catalyzing improvements in primary health care (PHC) systems in 135 low‐ and middle‐income countries (LMICs), in order to accelerate progress toward universal health coverage. Through more comprehensive and actionable measurement of quality PHC, the PHCPI stimulates peer learning among LMICs and informs decision makers to guide PHC investments and reforms. Instruments for performance assessment and improvement are in development; to date, a conceptual framework and 2 sets of performance indicators have been released.MethodsThe PHCPI team developed the conceptual framework through literature reviews and consultations with an advisory committee of international experts. We generated 2 sets of performance indicators selected from a literature review of relevant indicators, cross‐referenced against indicators available from international sources, and evaluated through 2 separate modified Delphi processes, consisting of online surveys and in‐person facilitated discussions with experts.FindingsThe PHCPI conceptual framework builds on the current understanding of PHC system performance through an expanded emphasis on the role of service delivery. 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. Key challenges include a lack of available data for several indicators and a lack of validated indicators for important dimensions of quality PHC.ConclusionsThe availability of data is critical to assessing PHC performance, particularly patient experience and quality of care. The 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.

Assessing the quality of primary care in Haiti.

ObjectiveTo develop a composite measure of primary care quality and apply it to Haiti’s primary care system.MethodsUsing the Primary Health Care Performance Initiative’s framework, we defined four domains of primary care service delivery: (i) accessible care; (ii) effective service delivery; (iii) management and organization; and (iv) primary care functions. We gave each primary care facility in Haiti a quality score for each domain and overall, with poor, fair and good quality indicated by scores of 0.00–0.49, 0.50–0.74 and 0.75–1.00, respectively. We quantified access and effective access to primary care as the proportions of the population within 5 km of any primary care facility and a good facility, respectively.FindingsOf the 786 primary care facilities in Haiti in 2013, only 332 (43%) facilities were classified as good for accessible care. Fewer facilities were classified as good in the domains of effective service delivery (30; 4%), management and organization (91; 12%) and primary care functions (43; 5%). Although about 91% of the population lived within 5 km of a primary care facility, only an estimated 23% of the entire population – including just 5% of the rural population – had access to primary care of good quality.ConclusionDespite an extensive network of health facilities, a minority of Haitians had access to a primary care facility of good quality. Such facilities were especially scarce in rural areas. Similar systematic analyses of the quality of primary care could inform national efforts to strengthen health systems.

Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries

Primary health care (PHC) has been recognized as a core component of effective health systems since the early part of the twentieth century. However, despite notable progress, there remains a large gap between what individuals and communities need, and the quality and effectiveness of care delivered. The Primary Health Care Performance Initiative (PHCPI) was established by an international consortium to catalyze improvements in PHC delivery and outcomes in low- and middle-income countries through better measurement and sharing of effective models and practices. PHCPI has developed a framework to illustrate the relationship between key financing, workforce, and supply inputs, and core primary health care functions of first-contact accessibility, comprehensiveness, coordination, continuity, and person-centeredness. The framework provides guidance for more effective assessment of current strengths and gaps in PHC delivery through a core set of 25 key indicators (“Vital Signs”). Emerging best practices that foster high-performing PHC system development are being codified and shared around low- and high-income countries. These measurement and improvement approaches provide countries and implementers with tools to assess the current state of their PHC delivery system and to identify where cross-country learning can accelerate improvements in PHC quality and effectiveness.