Primary healthcare system performance in low-income and … · understand where future research is most needed. Methods Guided by the Primary Healthcare Performance Initiative (PHCPI)

1Bitton A, et al. BMJ Global Health 2019;4:e001551. doi:10.1136/bmjgh-2019-001551

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

Asaf Bitton, 1,2 Jocelyn Fifield, 1 Hannah Ratcliffe,1 Ami Karlage,1 Hong Wang,3 Jeremy H Veillard,4,5 Dan Schwarz, 1,6 Lisa R Hirschhorn 1,7

Research

To cite: Bitton A, Fifield J, Ratcliffe H, et al. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Global Health 2019;4:e001551. doi:10.1136/bmjgh-2019-001551

Handling editor Stephanie M Topp

► Additional material is published online only. To view please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjgh- 2019- 001551).

Received 7 March 2019Revised 25 April 2019Accepted 15 June 2019

For numbered affiliations see end of article.

Correspondence toDr Asaf Bitton; abitton@ bwh. harvard. edu

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

AbsTrACTIntroduction The 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.Methods Guided 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.results We 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.Conclusion Our 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.

InTroduCTIonIn recent years, primary healthcare (PHC) has re-emerged as an important strategy in both

improving population health and in making healthcare systems more effective, respon-sive and efficient. In 2016, 193 countries adopted the Sustainable Development Goals (SDGs), making the achievement of universal health coverage (UHC) a principal goal for the global health community through 2030.1 Multiple global, national and subnational

Key questions

What is already known? ► Improving primary healthcare (PHC) performance will be essential for achieving universal health cov-erage, but evidence about how to do so is lacking or fragmented, and there is a pressing need to prioritise research efforts, build the field of research around targeted questions and better understand how to ensure the core service delivery functions of PHC.

What are the new findings? ► Some areas of PHC system performance are well-re-searched, such as PHC policies, health financing and health workforce, but we lack a sufficient evidence base in a wide enough range of countries about how to adapt these strategies to new contexts.

► Major research gaps exist in understanding social accountability, effective information and quality management systems, fund flows and how to im-prove facility and district management.

► Our country-specific review of 14 countries with improving systems in 2010 generally found con-tinued progress over the last decade in the scope of services, quality of services, access for margin-alised populations and progressive health financing initiatives.

What do the new findings imply? ► As countries implement new PHC strategies, they should be designed with rigorous evaluation and measurement across a wider array of countries in order to share and grow knowledge and learning about translating PHC research to universal health coverage implementation.

on June 29, 2021 by guest. Protected by copyright.

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2 Bitton A, et al. BMJ Global Health 2019;4:e001551. doi:10.1136/bmjgh-2019-001551

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organisations recognise that strong PHC systems will be essential to achieving UHC.2–7 Additionally, the global health community has just celebrated the 40th anniver-sary of the Alma-Ata Declaration with the issuance of the 2018 Astana Declaration, which reconfirmed the central role of PHC to improving health and defined PHC as a triad of multisectoral policies to promote health, engaged communities to promote health and integrated clinical and public health services to deliver better primary care.8

Despite this increased focus on the centrality of PHC, the performance of PHC systems globally, and in partic-ular in low-income and middle-income countries (LMIC), is poor. Significant improvements in PHC systems and service delivery are needed in order to meet the SDGs and achieve UHC. Efforts to do so, however, are hampered by the state of PHC research in LMIC which is currently fragmented, underfunded and under-prioritised. While a plethora of research exists on different facets of PHC globally, there is a need to prioritise disparate research efforts, build the field of research around targeted ques-tions linked to the provision of equitable care and better understand how to ensure the core service delivery func-tions of PHC that are linked to desired outcomes.

Several notable publications over the last decade have attempted to describe the state of PHC knowledge, and, more specifically, to identify interventions that have successfully improved outcomes and identified emerging or remaining knowledge gaps. However, these reviews did not employ a systematic approach, described middle- and high-income countries rather than LMIC or focused narrowly on the functions of PHC.9 10 Thus, just as researchers, policymakers and other stakeholders in LMIC are re-focusing improvement efforts on PHC, there is an urgent need to better understand the state of recent research on PHC in LMIC, and to map remaining gaps in that research.

To meet this need, we conducted a scoping review of the recent literature to assess the state of global knowl-edge on PHC in LMIC and understand where further PHC systems research efforts are most needed. This scoping review was completed as the foundational docu-ment for a priority setting exercise conducted in July 2017 (described more fully elsewhere in this online supple-mentary files).11 The goal of that exercise was to identify specific content areas for which more in-depth research into measurement and improvement strategies is likely to lead to significant impact on PHC service delivery, outputs and outcomes. The results of the priority-setting exercise formed the basis for a new PHC research consor-tium in LMIC.11

MeTHodsWe conducted the scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidance.12 A scoping review was deemed to be appropriate given that the purpose of this review was to explore broadly

the evidence on primary healthcare research in LMIC, a topic that is diverse, wide-ranging and methodologically complex. A further justification for this approach was that PHC has a wide and heterogeneous evidence base, and a paucity of existing summative systematic reviews. Additionally, the review sought to assess the extent, range and nature of the evidence, elements that are well suited to exploration using a scoping review methodology.12

scoping the reviewWe anchored our review in the conceptual framework of the Primary Healthcare Performance Initiative (PHCPI) -- a collaboration between the World Health Organ-ization (WHO), the World Bank Group and the Bill & Melinda Gates Foundation, in partnership with Ariadne Labs and Results for Development Institute.7 13 14 PHCPI aims to catalyse improvement in PHC in LMIC through better measurement and evidence-based improvement strategies. The PHCPI conceptual framework (figure 1) describes the necessary components of a high-functioning PHC system.14 As defined by the WHO, PHC includes three components: primary care services and integrated health services, empowered people and communities and multisectoral policy and action.15 PHCPI focuses on PHC overall, with a particular focus on integrated health service delivery and people-centred care.13

PHCPI defines a PHC system as the totality of the system, inputs and service delivery components that contribute to high-quality primary care services and achieve the four functions of PHC described by Barbara Starfield - first contact accessibility, continuity, comprehensiveness and coordination - as well as person-centredness.14 16 This conception of PHC systems guided our search strategy.

For this review, we focused specifically on the 13 topics within the system, inputs and service delivery domains of the framework, recognising that by design, improvements in these areas should lead to improvements in outputs and outcomes and that the levers for PHC improvement are generally within these domains. Definitions for each of these specific topic areas are included elsewhere.17

Beginning with a search guided by the PHCPI concep-tual framework, we then conducted a country-specific review of 14 countries identified as high or rapidly improving performers in the last systematic summary of PHC literature, so as to more deeply examine the global literature in the context of these countries.2 We therefore limited our research on these countries to the past 7 years, since the 2010 summary was published, so as to provide updated summaries of these countries’ literature and gain insights into the current state of their PHC systems and trajectories since that publication (full results of this search are presented in online supplementary file 3).

Information sourcesOur scoping review process included four main compo-nents. The first was a search of the peer-reviewed litera-ture in PubMed. We limited the date range of included studies to 1 January, 2010 to 20 March, 2017. The former


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Bitton A, et al. BMJ Global Health 2019;4:e001551. doi:10.1136/bmjgh-2019-001551 3

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Figure 1 PHCPI conceptual framework. PHCPI, Primary Healthcare Performance Initiative.

date was selected such that our review could build off of the last review of PHC initiatives in LMIC, as discussed above.2 The latter date was selected to align with a priority setting meeting that occurred in July 2017, for which the extended results of this review (presented in online supplementary file 3) were a foundational resource.11

This first component of the systematic review included two separate searches. We started with a generic search for all review publications in PubMed that included the term ‘primary care’ OR ‘primary healthcare’ AND a set of search terms used to identify all articles from a low-in-come or middle-income country (online supplementary file 1). Next, to focus on the topics of interest from the PHCPI conceptual framework, we conducted a search of review articles using the terms ‘primary care’ OR ‘primary healthcare’, AND the search terms from above to specify articles about LMIC, AND a set of key terms from the targeted areas of the PHCPI conceptual frame-work. These latter terms are also included in the online online supplementary file 1.

The second main component of our scoping review was a search to explore primary healthcare performance in 14 countries profiled in Kruk et al 2010.2 As described above, this was the most recent review of the state of primary healthcare in LMIC. Among other data, Kruk et al described 14 countries that had implemented primary healthcare initiatives at a large scale or were fragile states that had made substantial progress in promoting primary healthcare as the first point of contact. These countries included: Costa Rica; Cuba; Brazil; Bolivia; Mexico; Niger; Ghana; The Gambia; Thailand; Sri Lanka; Kerala, India; Iran; Afghanistan and Liberia.2 Although this list is far from representative of all progress or innovation

in PHC in LMIC, it has considerable overlap with coun-tries profiled in the World Health Report 2008, Shi et al’s9 2012 examination of primary care functions as assessed using the primary care assessment tool, and countries profiled by PHCPI.18 19 This component of the review was conducted using search terms of ‘primary care’ or ‘primary healthcare’ in addition to each of the country names.

For the third main component of our search, we reviewed all articles labelled as ‘low- or middle-income countries’ in the PHC evidence portal, part of the McMaster University Health Systems Evidence portal for collecting and making a standardised rating of systematic reviews of health interventions.20 21

Finally, in the fourth component of our review, we conducted a search of all publications in PubMed from 1 January, 2010 to 31 May, 2017, by the 17 individuals who had confirmed participation at the Primary Healthcare Measurement and Implementation Research Consor-tium Priority Setting Meeting.11

selection of data sourcesTo select articles for inclusion from these searches, at least one author reviewed titles using the inclusion criteria that the article focused on the primary care setting in a low-income or middle-income country, addressed a topic relevant to the PHCPI framework, and that the publication was available in English. A subsequent full-text review was conducted by at least one author with the following criteria: (1) the article focused on primary healthcare, not on vertical, disease-specific issues; (2) the intervention or method of study was related to strength-ening primary healthcare systems or functions, even if


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Figure 2 Summary of search, selection and inclusion process.

disease-specific outcomes were assessed; (3) the article concerned a large population area, not a small-scale pilot; (4) the article connected to the PHCPI framework and/or one of the countries of focus; (5) the article was a research or review article that included qualitative or quantitative data or described a new methodology and (6) the article was available in English. For the articles from the PHC evidence portal, they needed to also meet the criteria that they included evidence from at least three LMICs to ensure that the focus was primarily on LMIC as opposed to high-income countries. During the full-text review, additional articles were included through a bibliographic search (figure 2).

data charting and analysisTo extract the content from the full set of identified articles, every article was tagged for its relevance to the

PHCPI conceptual framework (figure 1) using Mendeley V.1.19 (Elsevier, Amsterdam, Netherlands). Articles could include multiple tags, and for each tag, one author extracted and summarised the relevant information. Finally, authors reviewed all extractions for each topic and generated evidence highlights and gaps. The full list of included articles is presented in the online supple-mentary file 2, and full summaries are presented in the online supplementary file 3.

Patient and public involvementPatients were not involved in this study.

resulTsWe retrieved a total of 5219 articles using the search strategy, of which 481 were accessed in full text, and


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Table 1 Selected characteristics of reviewed publications

Identified studies

# %

Year published

Before 2010 1 0.5%

2010 6 2.9%

2011 18 8.7%

2012 17 8.2%

2013 20 9.7%

2014 30 14.5%

2015 38 18.4%

2016 57 27.5%

2017* 20 9.7%

Region

Africa 45 21.7%

USA 50 24.2%

South-East Asia 19 9.2%

Europe 2 1.0%

Eastern Mediterranean 26 12.6%

Western Pacific 9 4.3%

Multiple 38 18.4%

NA 18 8.7%

Article type

Systematic review 36 17.4%

Non-systematic review 17 8.2%

Primary research (all) 127 61.4%

Primary research - quantitative 85 41.1%

Primary research - qualitative 19 9.2%

Primary research - mixed methods 23 11.1%

Conceptual literature 27 13.0%

*the search concluded on 31 May, 2017.NA, not available.

207 met the inclusion criteria and were included in the scoping review (figure 1). The list of all included studies are included in the online supplementary file 2.

Publication descriptionsOf the included articles, 70% were published between 2014 to 2017, with more than one-quarter of the articles published in 2016 alone (table 1). Despite parts of our search strategy focusing specifically on review articles, the majority of identified articles were primary research (61.4%), and 66.9% of these analysed quantitative data. Systematic reviews comprised 17.4% of the total identi-fied articles.

FindingsTable 2 presents our synthesised findings from this scoping review. We found that a number of areas of PHC system performance are well-studied. The four topics

with the highest volume of research were workforce, payment systems, provider competence and PHC policies, together accounting for two-thirds of the total included studies (table 2). Effective, integrated and comprehen-sive PHC policy and governance systems appear to be associated with better long-term system performance.22–26 Good evidence exist that insurance programmes can increase access to PHC by decreasing financial barriers and preventing catastrophic losses; whereas, user fees act as an additional barrier to access.26–30 More public spending on PHC appears to be associated with more equitable outcomes. In addition, fee for service (FFS) payment systems alone do not appear to be associated with better outcomes. Capitation appears to be show modest improved outcomes, as does pay for performance on top of FFS (though the benefits are often transient).

Financial limitations are not the only access barriers to care access. We found evidence that gaps in medication and other supplies not only impede care delivery but also decrease access as patients may avoid or bypass facilities that lack necessary resources, and quality of care.31–33 However, even in areas with a high volume of evidence there are remaining research questions or little infor-mation on implementation, social accountability mecha-nisms for PHC, adjustment to population health needs or adaptation to other contexts.

The evidence for the core PHC functions (first-contact access, continuity, comprehensiveness, coordination and person-centredness) was moderate-to-strong in LMIC. Comprehensiveness, access and person-centredness in particular had strong evidence of linkages to important improved outcomes. Coordination and continuity were less-studied, but still associated with moderate improve-ments. Related domains in trust and provider compe-tence clearly showed both the association with improved outcomes when both are high, as well as even stronger relationships to poor outcomes when both are low.

There were a number of topics that had a moderate evidence base that was often concentrated on a few specific service delivery topics or geographical areas. For instance, there is evidence that empanelment and multidisciplinary teams serve as a useful base on which to build PHC strategies and to attend to population health concerns in limited countries.24 34–39 Management appears to play an important role in mediating or improving facility outcomes, but there is little information available on how to measure it systematically or improve it.40 Moti-vating providers through both explicit (ie, financial) and implicit ways appears to be important to maintaining and improving clinical outcomes. Additionally, in contexts lacking sufficient clinicians, the evidence shows that task shifting to community health workers or other health workers can provide increased patient access to care and increased coverage to effective interventions. Task shifting was shown to be most successful when supported by policies, training and proper integration of commu-nity health workers into the existing workforce.34 41–43 However, evidence is lacking on the best ways to use these


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Tab

le 2

S

ynth

esis

ed k

ey fi

ndin

gs a

nd g

aps;

red

= lo

w e

vid

ence

(0 t

o 6

artic

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, yel

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= m

oder

ate

evid

ence

(7 t

o 13

art

icle

s), g

reen

= h

igh

evid

ence

(14+

art

icle

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Sub

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e

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f pub

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six

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l pro

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tegr

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and

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t ev

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and

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the

se d

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are

then

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a fe

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and

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l act

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ns.2

4 W

e fo

und

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7 so

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rovi

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of l

egiti

mac

y of

citi

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ps.

54

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a P

rimar

y he

alth

care

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icie

s -

Mos

t ev

iden

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n P

HC

pol

icie

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con

cent

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d o

n a

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freq

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ly d

ocum

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d c

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ple

s su

ch a

s B

razi

l, Th

aila

nd a

nd Ir

an; m

ore

evid

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from

mor

e co

untr

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is n

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ed.

Hig

h -

47

artic

les

A1.

b Q

ualit

y m

anag

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t in

fras

truc

ture

- C

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arat

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y lit

tle is

p

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hed

ab

out

the

cont

ours

and

con

stru

cts

of e

ffect

ive

qua

lity

man

agem

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in P

HC

sys

tem

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par

ticul

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t up

sys

tem

s an

d t

rain

sta

ff to

gen

erat

e d

ata

feed

bac

k lo

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Low

- 4

art

icle

s

A1.

c S

ocia

l acc

ount

abili

ty -

It is

unc

lear

how

to

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t us

e so

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ac

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tab

ility

mec

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sms

for

imp

rove

men

t w

here

pro

vid

ers

are

not

emp

ower

ed n

or in

tere

sted

in e

xter

nal i

nput

. Evi

den

ce is

nee

ded

to

qua

ntify

the

imp

act

of in

vest

ing

in s

ocia

l acc

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abili

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Low

- 3

art

icle

s

A2.

Hea

lth fi

nanc

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Ther

e w

as a

sig

nific

ant

amou

nt o

f evi

den

ce o

n he

alth

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ncin

g, a

nd p

aym

ent

syst

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in

par

ticul

ar. I

n p

artic

ular

, the

re w

as s

tron

g ev

iden

ce t

hat

intr

oduc

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or in

crea

sing

use

r fe

es h

as a

ne

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pac

t on

prim

ary

heal

th s

ervi

ces

utili

satio

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spec

ially

pre

vent

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serv

ices

.29

Mod

erat

e ce

rtai

nty

evid

ence

sug

gest

s th

at p

ay fo

r p

erfo

rman

ce is

ass

ocia

ted

with

slig

ht im

pro

vem

ents

in

heal

th p

rofe

ssio

nals

’ use

of t

ests

or

trea

tmen

ts, p

artic

ular

ly fo

r ch

roni

c d

isea

ses,

but

litt

le o

r no

im

pro

vem

ent

in u

tilis

atio

n ou

tcom

es w

as fo

und

.55

Com

par

ed w

ith F

FS, c

apita

tion

app

ears

in a

few

st

udie

s to

be

asso

ciat

ed w

ith m

oder

atel

y b

ette

r ou

tcom

es, b

ut t

he e

ffect

on

utili

satio

n an

d t

otal

co

sts

is s

till u

ncle

ar. P

ublic

sp

end

ing

in p

rimar

y he

alth

care

was

sho

wn

to p

rom

ote

mor

e eq

uita

ble

ou

tcom

es t

han

spen

din

g fo

cuse

d o

n se

cond

ary

care

.44

Lack

of f

und

s, p

oor

qua

lity

of c

are

and

lack

of

tru

st w

ere

doc

umen

ted

to

be

maj

or r

easo

ns fo

r lo

w fi

nanc

ial c

over

age

in L

MIC

, and

fina

ncia

l ha

rdsh

ip w

as m

ore

com

mon

in p

oore

r co

untr

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28 5

6

A2.

a P

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syst

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- Fu

rthe

r co

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evid

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to u

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elat

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imp

act

of F

FS v

s ca

pita

tion

and

glo

bal

b

udge

ts o

n ut

ilisa

tion

and

out

com

es. F

utur

e w

orks

sho

uld

als

o ex

amin

e th

e b

enefi

t of

hyb

ridis

ed m

odel

s of

fina

ncin

g as

wel

l as

elem

ents

of s

trat

egic

pur

chas

ing

such

as

gate

keep

ing.

Hig

h -

30

artic

les

A2.

b S

pen

din

g on

prim

ary

heal

thca

re -

Mor

e re

cent

, com

par

able

an

d w

idel

y av

aila

ble

cou

ntry

leve

l and

dis

aggr

egat

ed d

ata

is n

eed

ed

on P

HC

sp

end

ing

leve

ls a

s w

ell a

s re

sear

ch o

n op

timis

ing

reso

urce

al

loca

tion

mec

hani

sms

to p

rom

ote

equi

ty o

f out

com

es.

Mod

erat

e -

7 ar

ticle

s

A2.

c Fi

nanc

ial c

over

age

- H

ighe

r co

vera

ge w

as s

how

n to

pro

mot

e hi

gher

util

isat

ion

of b

enefi

cial

PH

C s

ervi

ces.

Mor

e re

sear

ch is

ne

eded

on

the

bes

t ty

pes

of i

nsur

ance

for

mix

ed p

rivat

e/p

ublic

sy

stem

s, a

s w

ell a

s ho

w t

o se

que

nce

finan

cial

cov

erag

e ex

pan

sion

s w

ith s

ervi

ce d

eliv

ery

refo

rms.

Mod

erat

e -

10

artic

les

A3.

Ad

just

men

t to

pop

ulat

ion

heal

th n

eed

sTh

e re

view

ed li

tera

ture

dem

onst

rate

s th

at s

urve

illan

ce s

yste

ms

are

an e

ssen

tial c

omp

onen

t of

re

silie

nt h

ealth

sys

tem

s an

d n

eces

sary

for

resp

ond

ing

to a

ll ty

pes

of s

hock

s. T

hey

can

be

bol

ster

ed

by

func

tioni

ng v

ital s

tatis

tics

reso

urce

s, r

obus

t lo

cal c

omm

unic

atio

n ne

twor

ks, p

opul

atio

n tr

ust

in t

he h

ealth

sys

tem

s an

d p

latf

orm

s fo

r co

mm

unity

dia

logu

e.57

Nat

iona

l prio

rity

sett

ing

is fo

und

to

be

dep

end

ent

on e

ffect

ive

com

mun

ity e

ngag

emen

t, b

oth

loca

lly a

nd n

atio

nally

, but

goo

d

evid

ence

on

how

to

effe

ctiv

ely

scal

e th

ese

app

roac

hes

is la

rgel

y ab

sent

.54

58 T

he e

vid

ence

sho

ws

that

com

mun

ity o

wne

rshi

p a

nd m

obili

satio

n as

wel

l as

adju

stm

ent

to s

ocia

l nor

ms

and

val

ues

are

faci

litat

ors

of s

usta

inab

le s

yste

m in

nova

tion.

46 C

ase

stud

ies

of h

ealth

sys

tem

str

esse

s in

Leb

anon

an

d In

don

esia

foun

d t

hat

succ

essf

ul r

esili

ence

hin

ged

on

rap

idly

mob

ilise

d p

ublic

and

priv

ate

sect

or a

ctor

s an

d n

odal

coo

rdin

atio

n an

d s

urve

illan

ce e

ffort

s.57

A3.

a S

urve

illan

ce -

Mor

e re

sear

ch is

nee

ded

to

und

erst

and

whi

ch

surv

eilla

nce

app

roac

hes

are

feas

ible

and

effe

ctiv

e ac

ross

PH

C

syst

ems

in L

MIC

, inc

lud

ing

how

to

inte

grat

e d

ata

feed

bac

k lo

ops

into

sur

veill

ance

sys

tem

s. F

urth

er w

ork

is n

eed

ed fo

r b

ette

r N

CD

su

rvei

llanc

e in

PH

C.

Mod

erat

e -

7 ar

ticle

s

A3.

b P

riorit

y se

ttin

g -

Ad

diti

onal

res

earc

h is

nee

ded

to

und

erst

and

ho

w b

est

to m

onito

r an

d c

omm

unic

ate

the

effe

ctiv

enes

s of

p

riorit

y se

ttin

g d

ecis

ions

for

pla

nnin

g p

urp

oses

and

in r

esp

onse

to

emer

ging

dis

ease

s/ou

tbre

aks.

Mod

erat

e -

7 ar

ticle

s

A3.

c In

nova

tion

and

lear

ning

- T

here

is a

maj

or g

ap in

the

kn

owle

dge

of t

he in

div

idua

l com

pet

enci

es, o

rgan

isat

iona

l cap

aciti

es

and

sys

tem

s fe

atur

es n

eed

ed t

o en

sure

tha

t le

ader

s ca

n b

e fle

xib

le

and

ad

apt

to c

hang

ing

heal

th n

eed

s.

Low

- 5

art

icle

s

B1.

Dru

gs &

sup

plie

sG

aps

in a

vaila

bili

ty o

f sp

ecifi

c d

rugs

and

sup

plie

s w

ere

wel

l doc

umen

ted

at

the

faci

lity

and

co

mm

unity

leve

ls a

cros

s m

any

coun

trie

s. T

hese

gap

s ar

e as

soci

ated

with

low

er r

ead

ines

s, lo

wer

q

ualit

y an

d r

educ

ed a

bili

ty t

o ex

pan

d n

eed

ed s

ervi

ces.

31–3

3 E

vid

ence

from

Eth

iop

ia, M

alaw

i and

R

wan

da

show

s th

at m

ultim

odal

inte

rven

tions

to

imp

rove

sup

ply

cha

ins

can

be

effe

ctiv

e b

ut r

equi

re

inte

grat

ion

of p

rod

uct

flow

, dat

a flo

w a

nd e

ffect

ive

peo

ple

into

inte

rven

tion

des

ign.

59 S

ucce

ss

was

sho

wn

to b

e m

ore

likel

y w

hen

the

wor

kfor

ce is

ab

le a

nd m

otiv

ated

to

use

inte

grat

ed d

ata

to

cont

inua

lly m

onito

r th

e su

pp

ly s

yste

m.5

9

Mor

e re

sear

ch is

nee

ded

on

how

new

tec

hnol

ogie

s ca

n b

est

be

inte

grat

ed t

o st

reng

then

sup

ply

cha

ins,

red

uce

stoc

k-ou

ts a

nd

was

tage

and

ens

ure

resp

onsi

vene

ss t

o em

ergi

ng n

eed

s as

wel

l as

bes

t p

ract

ices

for

ensu

ring

app

rop

riate

pric

ing

and

qua

lity

of

med

icat

ions

acr

oss

all s

ourc

es o

f car

e (in

clud

ing

pub

lic a

nd p

rivat

e fa

cilit

ies

and

pha

rmac

ies)

.

Mod

erat

e -

7 ar

ticle

s

Con

tinue

d


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/B

MJ G


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BMJ Global Health

Sub

do

mai

n (m

app

ed t

o

PH

CP

I fra

mew

ork

- fi

gur

e 1)

Syn

thes

ised

find

ing

sK

now

led

ge

gap

sE

vid

ence

bas

e

B2.

Fac

ility

infr

astr

uctu

reTh

e re

view

ed li

tera

ture

sho

wed

tha

t en

surin

g ad

equa

te d

istr

ibut

ion

of fa

cilit

ies

req

uire

s a

natio

nal

pol

icy

and

str

ateg

y an

d a

pp

rop

riate

inve

stm

ents

.60

A fo

cus

on fa

cilit

y in

fras

truc

ture

can

incr

ease

ge

ogra

phi

cal a

cces

s, e

ven

in w

ar-t

orn

coun

trie

s lik

e A

fgha

nist

an o

r co

untr

ies

in p

erp

etua

l pol

itica

l an

d e

nviro

nmen

tal c

risis

suc

h as

Hai

ti, b

ut m

ust

be

acco

mp

anie

d w

ith a

deq

uate

dru

gs a

nd s

ervi

ce

del

iver

y.28

61

Mor

e re

sear

ch in

faci

lity

infr

astr

uctu

re c

an b

ette

r cl

arify

the

ap

pro

pria

te m

ix o

f fac

ility

typ

es b

ased

on

pop

ulat

ion,

hea

lth n

eed

s,

geog

rap

hy a

nd b

urd

en o

f dis

ease

as

wel

l as

effe

ctiv

e m

app

ing

of p

rivat

e se

ctor

faci

litie

s an

d t

heir

inte

grat

ion

into

pol

icie

s an

d

stra

tegi

es t

o d

eter

min

e ne

eds

for

add

ition

al fa

cilit

ies.

Low

- 3

art

icle

s

B3.

Info

rmat

ion

syst

ems

A s

yste

mat

ic r

evie

w o

f sys

tem

atic

rev

iew

s of

eH

ealth

imp

lem

enta

tion

foun

d t

hat

the

follo

win

g st

reng

then

out

com

es: s

elec

ting

tech

nolo

gy b

ased

on

abili

ty t

o b

e ad

apte

d, i

nclu

din

g en

d-u

sers

d

urin

g d

esig

n, in

tero

per

abili

ty w

ith o

ther

sys

tem

s, in

cent

ives

to

red

uce

star

t-up

cos

ts, s

tand

ard

s an

d p

olic

ies

to g

uid

e im

ple

men

tatio

n an

d e

nsur

e d

ata

safe

ty a

nd in

put

s su

ch a

s el

ectr

icity

and

co

nnec

tivity

.62

An

eigh

t co

untr

y st

udy

of p

rimar

y ca

re fa

cilit

ies

foun

d t

hat

mos

t in

form

atio

n sy

stem

s ar

e no

t d

esig

ned

to

ensu

re c

ontin

uity

of p

atie

nt in

form

atio

n an

d t

hat

even

few

er h

ave

an e

lect

roni

c m

edic

al r

ecor

d a

ble

to

ensu

re c

ontin

uity

and

coo

rdin

atio

n.31

Maj

or a

reas

rel

ated

to

PH

C in

form

atio

n sy

stem

s co

uld

ben

efit

from

m

ore

rese

arch

, inc

lud

ing:

ap

pro

ache

s to

ens

ure

inte

rop

erab

ility

b

etw

een

dat

a so

urce

s, s

cala

ble

and

affo

rdab

le a

pp

roac

hes

for

pla

nnin

g eH

ealth

, inn

ovat

ions

tha

t ca

n st

reng

then

info

rmat

ion

syst

ems

with

out

sign

ifica

nt in

fras

truc

ture

cha

nges

and

effi

cien

t an

d fe

asib

le a

pp

roac

hes

to b

uild

off

exis

ting

eHea

lth t

echn

olog

y to

st

ruct

ure

Hea

lth M

anag

emen

t In

form

atio

n S

yste

ms

(HM

IS) t

o se

rve

pat

ient

s, p

rovi

der

s an

d m

anag

ers.

Low

−2

artic

les

B4.

Wor

kfor

ceW

hile

glo

bal

sta

ndar

ds

exis

t on

the

num

ber

and

typ

e of

hea

lthca

re w

orke

rs p

er p

opul

atio

n,

mea

sure

s of

nat

iona

l ave

rage

s of

ten

mis

s in

equi

ty o

f dis

trib

utio

n w

hich

req

uire

loca

l sol

utio

ns.3

1 Th

e lit

erat

ure

ind

icat

ed t

hat

ensu

ring

adeq

uate

hum

an r

esou

rces

for

PH

C in

rur

al a

reas

and

the

p

ublic

sec

tor

rem

ains

a c

halle

nge,

and

a n

umb

er o

f int

erve

ntio

ns h

ave

bee

n tr

ied

with

var

ying

im

pac

t.63

–65

Ad

diti

onal

ly, m

ultip

le s

tud

ies

show

ed t

hat

task

shi

ftin

g ca

n b

e ef

fect

ive

to a

dd

ress

sh

orta

ges

of p

rovi

der

s b

ut r

equi

res

sup

por

tive

sup

ervi

sion

, ad

equa

te s

upp

lies

and

pre

-ser

vice

and

in

-ser

vice

tra

inin

g th

at m

atch

es t

he s

cop

e of

ser

vice

s.34

41

43 6

6 67

Fin

ally

, com

mun

ity-b

ased

hea

lth

wor

kers

can

be

a va

luab

le e

xpan

sion

of t

he w

orkf

orce

but

req

uire

tra

inin

g, s

yste

ms

and

wor

k to

in

tent

iona

lly in

tegr

ate

phy

sica

lly a

nd c

ultu

rally

into

faci

lity-

bas

ed c

are

syst

ems.

68

Des

pite

the

sig

nific

ant

num

ber

of a

rtic

les

rela

ted

to

wor

kfor

ce,

add

ition

al r

esea

rch

coul

d fo

cus

on: t

he id

eal m

ix a

nd n

umb

er o

f p

rovi

der

s b

ased

on

diff

eren

t co

ntex

ts a

nd p

opul

atio

n he

alth

nee

ds;

th

e op

timal

rol

e, t

rain

ing

and

rem

uner

atio

n of

com

mun

ity-b

ased

he

alth

wor

kers

; the

ap

pro

pria

te r

ole

for

info

rmal

pro

vid

ers

and

ef

fect

ive

and

feas

ible

ap

pro

ache

s to

ens

ure

equi

tab

le d

istr

ibut

ion

of

hum

an r

esou

rces

.

Hig

h -

29

artic

les

B5.

Fun

ds

N

one

Our

sea

rche

s re

turn

ed n

o ar

ticle

s co

ncer

ned

with

the

ava

ilab

ility

of

fund

s at

the

faci

lity

leve

l. W

hile

it c

ould

be

an a

rtef

act

of t

he

PH

CP

I con

cep

tual

fram

ewor

k, in

whi

ch s

yste

ms-

leve

l pay

men

t an

d fi

nanc

ing

and

faci

lity-

leve

l fina

ncia

l man

agem

ent

are

bot

h re

pre

sent

ed a

s se

par

ate

area

s, it

cou

ld a

lso

refle

ct a

lack

of

rese

arch

focu

s on

the

op

timal

dis

trib

utio

n an

d o

ptim

isat

ion

of P

HC

fa

cilit

y-b

ased

fina

nce

syst

ems,

incl

udin

g fis

cal m

anag

emen

t an

d

auth

ority

at

the

faci

lity

leve

l.

Low

- 0

art

icle

s

C1.

Pop

ulat

ion

heal

th

man

agem

ent

Mos

t st

udie

s re

fere

nce

the

succ

ess

of c

omm

unity

-bas

ed p

rogr

amm

e fo

r m

anag

ing

pop

ulat

ion

heal

th a

cros

s a

limite

d n

umb

er o

f LM

IC, i

nclu

din

g C

osta

Ric

a, B

razi

l and

Gha

na.2

4 34

69

Cou

ntrie

s th

at h

ave

exp

and

ed p

roac

tive

PH

C p

rovi

sion

bey

ond

the

clin

ic h

ave

show

ed e

vid

ence

of m

ore

effe

ctiv

e lo

cal p

riorit

y se

ttin

g an

d im

pro

ved

con

tinui

ty, c

omp

rehe

nsiv

enes

s an

d c

oord

inat

ion.

24 3

4

35 T

he li

tera

ture

sho

ws

that

com

mun

ity-b

ased

pro

gram

mes

mus

t b

e w

ell i

nteg

rate

d in

to t

he c

are

del

iver

y an

d p

ublic

hea

lth s

yste

ms

in o

rder

to

be

effe

ctiv

e. F

inal

ly, w

hile

not

ext

ensi

vely

stu

die

d,

evid

ence

sho

ws

that

em

pan

elm

ent

has

bee

n a

criti

cal c

omp

onen

t of

com

mun

ity-b

ased

hea

lth

wor

ker

pro

gram

me

to d

efine

the

gro

up o

f pat

ient

s fo

r ta

rget

ing

outr

each

and

ser

vice

del

iver

y.34

C1.

a Lo

cal p

riorit

y se

ttin

g -

Out

sid

e a

few

cou

ntrie

s lik

e G

hana

, m

ore

rese

arch

is n

eed

ed t

o un

der

stan

d h

ow lo

cal p

riorit

y se

ttin

g sh

ould

be

mea

sure

d, w

hat

inte

rven

tions

will

ens

ure

effe

ctiv

e d

ata

use

for

loca

l prio

rity

sett

ing

and

whi

ch d

ata

are

mos

t ac

tiona

ble

at

the

loca

l lev

el.

Mod

erat

e -

7 ar

ticle

s

C1.

b C

omm

unity

eng

agem

ent

- Fu

ture

res

earc

h sh

ould

exp

lore

ef

fect

ive

way

s to

dev

elop

, sup

por

t an

d s

usta

in m

eani

ngfu

l co

mm

unity

eng

agem

ent,

incl

udin

g at

the

faci

lity

leve

l.

Hig

h -

16

artic

les

C1.

c E

mp

anel

men

t -

Ther

e is

rel

ativ

ely

little

evi

den

ce o

n em

pan

elm

ent

in L

MIC

. Fut

ure

rese

arch

can

exp

lore

effe

ctiv

e m

odel

s of

em

pan

elm

ent

and

the

crit

eria

nee

ded

to

imp

lem

ent

emp

anel

men

t.

Low

- 5

art

icle

s

C1.

d -

Pro

activ

e p

opul

atio

n ou

trea

ch -

Gap

s re

mai

n in

un

der

stan

din

g ho

w t

o st

ruct

ure

heal

th w

orke

r tr

aini

ng a

nd o

ther

su

pp

orts

to

ince

nt m

ore

pro

activ

e (a

s op

pos

ed t

o re

activ

e) c

are.

Mod

erat

e −

11

artic

les

Tab

le 2

C

ontin

ued

Con

tinue

d


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MJ G


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BMJ Global Health

Sub

do

mai

n (m

app

ed t

o

PH

CP

I fra

mew

ork

- fi

gur

e 1)

Syn

thes

ised

find

ing

sK

now

led

ge

gap

sE

vid

ence

bas

e

C2.

Fac

ility

org

anis

atio

n an

d

man

agem

ent

At

the

faci

lity

leve

l, m

ultid

isci

plin

ary

team

s ha

ve b

een

criti

cal c

omp

onen

ts o

f PH

C s

yste

m r

efor

ms

in C

osta

Ric

a, B

razi

l and

Tur

key.

Alth

ough

evi

den

ce is

lim

ited

, whe

re im

ple

men

ted

, mul

tidis

cip

linar

y te

ams

have

imp

rove

d c

ontin

uity

of t

eam

mem

ber

ship

and

lead

ersh

ip, i

ncre

ased

pat

ient

tru

st

and

imp

rove

d p

atie

nt s

elf-

man

agem

ent.

24 3

4 36

70

71 A

num

ber

of s

yste

mat

ic r

evie

ws

of s

upp

ortiv

e su

per

visi

on h

ave

foun

d t

hat

it is

ass

ocia

ted

with

mod

est

imp

rove

men

ts in

clin

ical

per

form

ance

, su

ch a

s kn

owle

dge

leve

l, ad

here

nce

to c

linic

al p

roto

cols

and

con

sist

ency

in r

ecor

d k

eep

ing.

72

E-h

ealth

has

bee

n fo

und

to

be

asso

ciat

ed w

ith m

ore

effic

ient

use

of d

ata

in fa

cilit

ies,

mor

e ef

fect

ive

pat

ient

feed

bac

k, a

nd g

reat

er a

dhe

renc

e to

pro

toco

ls u

sing

mob

ile-b

ased

alg

orith

ms,

alth

ough

si

gnifi

cant

sta

ff tr

aini

ng a

nd s

upp

ort

is n

eed

ed t

o en

sure

effe

ctiv

e tr

ansi

tions

.65

Ther

e ar

e a

few

ex

amp

les

of m

etho

ds

to e

nsur

e co

ntin

uous

, ite

rativ

e p

erfo

rman

ce m

easu

rem

ent

and

man

agem

ent

in fa

cilit

ies,

incl

udin

g C

osta

Ric

a’s

EB

AIS

tea

ms

that

use

dat

a fr

om h

ome

visi

ts t

o as

sess

p

erfo

rman

ce a

gain

st n

atio

nal a

nd r

egio

nal t

arge

ts a

s w

ell a

s a

bal

ance

d s

core

card

ap

pro

ach

that

ha

s b

een

used

in A

fgha

nist

an.2

4 73

C2.

a Te

am-b

ased

car

e or

gani

satio

n -

Ther

e is

a g

ener

al p

auci

ty o

f ev

iden

ce o

n op

timis

ing

team

-bas

ed c

are

bey

ond

a fe

w m

idd

le-

inco

me

coun

trie

s; m

ore

evid

ence

is n

eed

ed o

n ho

w t

o tr

ain

pro

vid

ers

to b

ecom

e te

ams,

idea

l lea

der

ship

str

uctu

re a

nd h

ow b

est

to fi

nanc

e te

ams.

Mod

erat

e −

13

artic

les

C2.

b F

acili

ty m

anag

emen

t ca

pab

ility

and

lead

ersh

ip -

The

re is

a

dea

rth

of e

vid

ence

on

man

agem

ent

com

pet

enci

es a

nd t

rain

ing

of

faci

lity

man

ager

s.

Mod

erat

e -

9 ar

ticle

s

C2.

c In

form

atio

n sy

stem

s us

e -

Ther

e is

litt

le a

vaila

ble

lite

ratu

re

on h

ow b

est

to im

ple

men

t an

d im

pro

ve lo

cal u

se o

f inf

orm

atio

n co

mm

unic

atio

n te

chno

logy

and

eH

ealth

to

imp

rove

out

com

es in

P

HC

as

wel

l as

wha

t id

eal,

low

-cos

t, s

imp

le e

Hea

lth d

ocum

enta

tion

and

dat

a re

cord

s lo

ok li

ke in

low

res

ourc

e se

ttin

gs.

Low

- 5

art

icle

s

C2.

d P

erfo

rman

ce m

easu

rem

ent

and

man

agem

ent

- A

lthou

gh t

here

is

sub

stan

tial e

vid

ence

on

theo

retic

al fr

amew

orks

for

per

form

ance

m

anag

emen

t, it

s ad

apta

tion

to lo

cal c

onte

xts

is r

athe

r lim

ited

, w

ith s

ome

coun

try-

bas

ed e

xcep

tions

. Mor

e ev

iden

ce is

nee

ded

on

the

effe

ctiv

enes

s of

sup

por

tive

sup

ervi

sion

in u

nder

-res

ourc

ed

envi

ronm

ents

.

Hig

h -

15

artic

les

C3.

Acc

ess

Rem

oval

of fi

nanc

ial f

ees,

whe

n co

mb

ined

with

geo

grap

hica

l acc

ess

has

bee

n se

en t

o in

crea

se

use

of s

ervi

ces

and

red

uce

mor

talit

y in

a n

umb

er o

f cou

ntrie

s, a

lthou

gh d

egre

e of

imp

act

varie

d,

and

att

entio

n to

con

text

ual b

arrie

rs is

nec

essa

ry.4

5 74

75 L

itera

ture

ind

icat

es t

hat

com

mun

ity h

ealth

w

orke

rs c

an im

pro

ve g

eogr

aphi

cal a

cces

s th

roug

h p

roac

tive

outr

each

, but

onl

y fo

r a

limite

d

scop

e of

ser

vice

s. T

imel

y ac

cess

to

serv

ices

has

bee

n sh

own

to b

e a

chal

leng

e ac

ross

a n

umb

er

of s

ettin

gs, a

nd s

yste

m r

edes

ign

such

as

inte

grat

ion

and

cha

nges

in p

atie

nt fl

ow c

an im

pro

ve

timel

ines

s, b

ut m

ore

evid

ence

on

pat

ient

out

com

es is

nee

ded

.75

76

C3.

a Fi

nanc

ial a

cces

s -

Mor

e ev

iden

ce is

nee

ded

on

the

sust

aina

bili

ty o

f exi

stin

g m

odel

s as

wel

l as

feas

ible

and

effe

ctiv

e w

ays

to m

easu

re t

he im

pac

t of

insu

ranc

e sc

hem

es o

n re

duc

ing

finan

cial

acc

ess

bar

riers

acr

oss

sub

-pop

ulat

ions

.

Mod

erat

e -

13

artic

les

C3.

b G

eogr

aphi

cal a

cces

s -

Mor

e re

sear

ch is

nee

ded

on

how

to

dec

entr

alis

e w

hile

mai

ntai

ning

qua

lity

of in

put

s, a

vaila

bili

ty, a

nd

com

pet

ency

at

a na

tiona

l lev

el.

Mod

erat

e -

12

artic

les

C3.

c Ti

mel

ines

s -

We

foun

d li

ttle

evi

den

ce o

n ho

w t

o im

pro

ve

timel

ines

s. R

esea

rch

is n

eed

ed o

n: m

easu

ring

timel

ines

s,

imp

rove

men

ts o

f tim

elin

ess

that

als

o en

sure

exp

erie

ntia

l and

te

chni

cal q

ualit

y an

d n

ovel

ap

pro

ache

s to

exp

and

tim

ely

acce

ss t

o sp

ecia

lty c

are.

Low

- 2

art

icle

s

Tab

le 2

C

ontin

ued

Con

tinue

d


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/B

MJ G


jgh-2019-001551 on 16 August 2019. D

ownloaded from

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BMJ Global Health

Sub

do

mai

n (m

app

ed t

o

PH

CP

I fra

mew

ork

- fi

gur

e 1)

Syn

thes

ised

find

ing

sK

now

led

ge

gap

sE

vid

ence

bas

e

C4.

Ava

ilab

ility

of e

ffect

ive

PH

CTh

e lit

erat

ure

show

s th

at a

com

bin

atio

n of

str

ateg

ies

incl

udin

g tr

aini

ng o

pp

ortu

nitie

s fo

r p

rovi

der

s in

mor

e ru

ral a

reas

, sal

ary

incr

ease

s an

d s

upp

ortin

g in

fras

truc

ture

can

incr

ease

ava

ilab

ility

in

und

erse

rved

are

as.7

7 A

com

mon

ap

pro

ach

to in

crea

sing

pro

vid

er a

vaila

bili

ty is

tas

k sh

iftin

g w

hich

has

bee

n sh

own

to b

e ef

fect

ive

in a

num

ber

of s

ettin

gs b

ut r

equi

res

adeq

uate

tra

inin

g an

d

sup

por

t.42

66

77 T

here

are

sig

nific

ant

gap

s in

com

pet

ency

des

crib

ed a

cros

s co

untr

ies,

are

as o

f ca

re, p

roce

sses

of c

are

(ie, d

iagn

osis

, tre

atm

ent,

exa

ms)

, cad

res

and

hea

lth s

ecto

rs.5

1–53

Pro

toco

l-b

ased

ap

pro

ache

s th

at fo

cus

on a

ran

ge o

f com

mon

con

diti

ons

(suc

h as

Inte

grat

ed M

anag

emen

t of

Chi

ldho

od Il

lnes

s -

IMC

I) ar

e as

soci

ated

with

imp

rove

men

ts in

tec

hnic

al c

omp

eten

cy b

ut n

ot

alw

ays

outc

omes

.78

Bur

nout

and

low

mot

ivat

ion

is c

omm

on in

a n

umb

er o

f cou

ntrie

s, a

nd m

yria

d

mea

sure

men

t to

ols

exis

t. A

num

ber

of s

tud

ies

rep

orte

d t

hat

inte

rven

tions

suc

h as

per

form

ance

-b

ased

fina

ncin

g co

mb

ined

with

a b

alan

ced

sco

reca

rd a

nd o

ther

per

form

ance

-tie

d in

cent

ives

d

id n

ot im

pro

ve m

otiv

atio

n.49

50

The

stud

ies

that

we

iden

tified

rel

ated

to

pat

ient

-pro

vid

er r

esp

ect

and

tru

st fo

und

tha

t se

rvic

e in

tegr

atio

n le

d t

o hi

gher

pat

ient

rep

orts

of r

esp

ect,

lack

of r

esp

ect

is

asso

ciat

ed w

ith lo

wer

sat

isfa

ctio

n in

mat

erni

ty c

are

serv

ices

, and

in A

fgha

nist

an, p

oor

trus

t an

d

dis

resp

ect

in m

ater

nity

ser

vice

s is

ass

ocia

ted

with

byp

ass

or n

on-u

se o

f car

e.36

79

80 F

inal

ly, u

nsaf

e p

ract

ices

in d

iagn

osis

and

tre

atm

ent

- in

clud

ing

med

icat

ion

qua

lity

- is

wel

l doc

umen

ted

.53

81 B

ut

othe

r d

omai

ns o

f saf

ety

are

not

wel

l-st

udie

d.

C4.

a P

rovi

der

ava

ilab

ility

- G

aps

exis

t re

gard

ing

cont

extu

al fa

ctor

s th

at d

rive

avai

lab

ility

in d

iffer

ent

sett

ings

, sus

tain

abili

ty o

f effe

ctiv

e in

terv

entio

ns a

nd t

he r

ole

of t

ask

shift

ing.

Low

- 6

art

icle

s

C4.

b P

rovi

der

com

pet

ence

- M

ore

rese

arch

is n

eed

ed t

o ex

pla

in

the

varia

nce

in t

he q

ualit

y of

car

e d

eliv

ery

acro

ss c

ount

ries,

as

wel

l as

the

influ

ence

of c

onte

xtua

l fac

tors

suc

h as

pay

men

t, c

ontin

uing

tr

aini

ng a

nd c

red

entia

ling

on p

rovi

der

com

pet

ence

.

Hig

h -

32

artic

les

C4.

c P

rovi

der

mot

ivat

ion

- Th

ere

is a

gap

in k

now

led

ge r

egar

din

g w

hich

inte

rven

tions

to

incr

ease

intr

insi

c an

d e

xtrin

sic

mot

ivat

ion

are

feas

ible

and

sus

tain

able

, as

wel

l as

how

bes

t to

mea

sure

the

imp

act

of m

otiv

atio

n on

car

e d

eliv

ery,

pro

vid

er a

vaila

bili

ty a

nd r

eten

tion.

Hig

h -

22

artic

les

C4.

d P

atie

nt-p

rovi

der

res

pec

t an

d t

rust

- A

bet

ter

und

erst

and

ing

of h

ow t

o im

pro

ve e

xper

ient

ial q

ualit

y, in

clud

ing

trus

t, is

nee

ded

. A

dd

ition

ally

, a g

ap r

emai

ns in

the

und

erst

and

ing

of t

he r

elat

ions

hip

b

etw

een

tech

nica

l qua

lity

and

pat

ient

sat

isfa

ctio

n an

d r

epor

ted

re

spon

sive

ness

.

Hig

h -

14

artic

les

C4.

e S

afet

y -

Evi

den

ce is

nee

ded

on

effe

ctiv

e, fe

asib

le a

nd s

cala

ble

in

terv

entio

ns t

o su

stai

nab

ly im

pro

ve s

afet

y b

oth

in d

irect

pat

ient

ca

re a

nd fa

cilit

y p

ract

ices

and

env

ironm

ent.

Thi

s ne

eds

to b

e ac

ross

th

e ra

nge

of P

HC

-del

iver

y so

urce

s (c

omm

unity

-bas

ed, f

acili

ty,

pub

lic a

nd p

rivat

e).

Low

- 4

art

icle

s

C5.

Hig

h-q

ualit

y P

HC

A r

evie

w o

f pat

ient

exp

erie

nce

of c

are

in S

outh

Am

eric

a fo

und

tha

t m

ore

than

hal

f of r

esp

ond

ents

re

por

ted

not

hav

ing

a re

gula

r p

rimar

y ca

re p

rovi

der

.75

A s

yste

mat

ic r

evie

w o

f int

erve

ntio

ns t

o im

pro

ve a

cces

s to

car

e fo

r ch

ildre

n fo

und

tha

t in

terv

entio

ns t

hat

del

iver

ed s

ervi

ces

at o

r cl

oser

to

hom

e an

d t

ext

mes

sage

s w

ere

asso

ciat

ed w

ith a

sig

nific

ant

imp

rove

men

t in

out

com

es.8

2 R

elat

ed

to c

ontin

uity

, a s

tud

y in

Bra

zil f

ound

tha

t ce

ntre

s w

ith m

ore

avai

lab

le s

ervi

ces

and

bet

ter

stru

ctur

e,

equi

pm

ent

and

sup

ply

ava

ilab

ility

and

info

rmat

ion

syst

ems

wer

e as

soci

ated

with

bet

ter

cont

inui

ty.8

3 H

owev

er, a

stu

dy

from

Iran

foun

d t

hat

pat

ient

s w

ho v

isite

d t

he s

ame

fam

ily p

hysi

cian

did

not

ne

cess

arily

rep

ort

grea

ter

pat

ient

-per

ceiv

ed r

elat

iona

l con

tinui

ty; p

atie

nt a

nd p

rovi

der

per

cep

tions

of

con

tinui

ty a

re in

fluen

ced

by

diff

eren

t fa

ctor

s.75

84

Gap

s in

bot

h co

ord

inat

ion

and

per

son-

cent

red

ca

re h

ave

bee

n d

ocum

ente

d a

cros

s si

x La

tin A

mer

ican

/Car

ibb

ean

coun

trie

s.75

The

re a

re m

yria

d

stud

ies

that

hav

e ex

plo

red

det

erm

inan

ts o

f sat

isfa

ctio

n w

ith p

erso

n-ce

ntre

d c

are

incl

udin

g st

ruct

ural

fact

ors,

pro

cess

fact

ors,

per

cep

tions

of q

ualit

y an

d o

utco

mes

.80

85

C5.

a Fi

rst

cont

act

acce

ssib

ility

- W

hile

the

re a

re m

yria

d in

terv

entio

n ty

pes

for

imp

rovi

ng a

cces

s, m

ore

evid

ence

is n

eed

ed a

bou

t w

hich

le

vers

sho

uld

be

used

in w

hich

con

text

s as

wel

l as

the

app

rop

riate

to

ols

for

mea

surin

g fir

st c

onta

ct a

cces

s in

LM

IC.

Mod

erat

e -

12

artic

les

C5.

b C

ontin

uity

- M

ost

of t

he e

vid

ence

on

cont

inui

ty is

from

Lat

in

Am

eric

a an

d Ir

an; k

ey q

uest

ions

rem

ain

on t

he im

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C

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BMJ Global Health

Table 3 Summary of the quantity of evidence and the trajectory of 14 PHC systems (2010 to 2017); red = low evidence (0 to 6 articles), yellow = moderate evidence (7 to 13 articles), green = high evidence (14+ articles)

Country Evidence baseTrajectory of PHC system since 2010

Afghanistan Moderate – 12 Improving

Bolivia Low - 4 Indeterminate

Brazil High - 43 Improving

Costa Rica Low – 3 Stable to improving

Cuba Low – 1 Indeterminate

Gambia Low - 2 Indeterminate

Ghana High - 14 Improving

Iran Moderate - 11 Stable

Kerala Low - 2 Indeterminate

Liberia Low - 3 Stable to improving

Mexico Moderate - 10 Stable to improving

Niger Low - 3 Indeterminate

Sri Lanka Low - 5 Stable to improving

Thailand High - 15 Stable to improving

PHC, primary healthcare.

strategies in various LMIC contexts, and the extent to which task shifting can work for more complex condition or in people with multiple comorbidities.

We found the least volume of evidence on funds, infor-mation systems and timeliness. For funds in particular - a topic defined as the availability, control and management of funds at the facility level - our search returned no arti-cles.17 Very little information was available as well for how PHC systems can learn and innovate in a reliable manner, and better engage populations in their work. Much more research is also needed on patient safety in PHC settings in LMIC.

Country-specific findingsOur review of 14 countries in Kruk et al’s (2010) paper described progress in many of the reviewed countries (table 3). Of the nine countries with sufficient evidence, all had either stable or improving outcomes since 2010. Eight (57%) of the 14 countries reviewed were catego-rised as ‘Low’ for the quantity of the evidence, with six of those eight having three or fewer articles published during the period of review. Five of those six were ulti-mately categorised as an ‘Indeterminate’ trajectory given the dearth of evidence. Only three countries (21%) were qualified as ‘High’ quantity of evidence. It is notable that 33% of all country-specific articles focused on Brazil exclusively, which generates a disproportionately high amount of high-quality PHC evidence. No country previ-ously identified had clearly worsening outcomes. The full summaries of the country update are in online supple-mentary file 4.

dIsCussIonWe conducted a scoping review of the recent literature on PHC in LMIC (2010 to 2017), based on the struc-ture of the PHCPI conceptual framework. We profile 207 articles in this review, which reveal a heterogeneous focus of the recent literature. We found a few thoroughly researched components of PHC particularly in the areas of PHC policy, payment and workforce - including prov

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Primary healthcare system performance in low-income and … · understand where future research is most needed. Methods Guided by the Primary Healthcare Performance Initiative (PHCPI)