Primary Health Care (PHC) is the foundation of a strong health care system. It aims to improve the overall health and well-being of people and communities across all stages of life, at a cost communities and countries can afford.
This Exemplars study will look at the efficiency and effectiveness of PHC systems – specifically, how some countries can achieve stronger levels of PHC performance relative to their level of total spending on health. In each PHC Exemplar country, we will outline the story of how efficiency improvements were achieved. These stories will include an understanding of country context and strategy, define the operations of the core components of the system that drove the change, and detail remaining challenges and the areas of focus for the country moving forward. These lessons can then inform progress in countries that are underperforming relative to their current level of spending on health.
What will we learn?
This project looks at five countries that have achieved stronger levels of PHC performance over the past two decades, relative to their level of total spending on health. It asks:
What are the specific drivers of PHC performance and efficiency in each Exemplar country ?
- Which aspects of each country’s PHC system (such as workforce productivity or supply chain efficiency) are especially exemplary?
- How does each country allocate resources to support the achievement of its PHC goals?
How did each Exemplar country reform its health system to improve and streamline PHC delivery over time?
- How did each country sequence investments and improvements in PHC over the past 20 years to achieve efficiency gains and boost coverage?
- How did they come to those decisions? What processes, tools, and information did each country use to shape changes in policy and practice?
How can other decision-makers, funding institutions, norm-setting bodies, and technical assistance providers apply these findings to their own contexts?
- What were the enabling factors in each Exemplar country, and how did decision-makers utilize them to improve and optimize PHC delivery?
- What were the constraints in each Exemplar country, and how did its decision-makers address those constraints?
These case studies will build on existing knowledge to generate concrete recommendations for other countries seeking to improve their own PHC systems.
Where are we working?
Research is underway in Zambia, Ghana, Bangladesh, Peru, and Rwanda.
Partners from the London School of Hygiene & Tropical Medicine and the KEMRI Wellcome Trust selected these countries based on several measures of PHC system performance. The final methodology and selection of countries was guided by a Technical Advisory Group (TAG) of global health experts and decision-makers.
In one proximate measure of system performance, these five PHC Exemplar countries achieved higher levels of effective coverage, relative to peers who spent the same amount on health. This indicates that their systems might be comparatively more efficient. In addition to overall efficiency, the PHC Exemplar countries demonstrated strong performance on key indicators of primary health care coverage, health outcomes and equitable delivery of high-quality health services.
The selected countries are also at different points on the path to PHC efficiency improvement and overall system maturity. Consequently, our research findings may be relevant to a range of countries.
UHC effective coverage related to total health expenditure per capita spending
Learning how and why these Exemplar countries have improved and/or maintained strong PHC system performance can help other countries do the same.
How are we conducting this research?
A multidisciplinary team of researchers uses a rigorous, innovative, mixed-methods approach to evaluate how these countries achieved efficiency in their PHC systems and explain what other countries can learn from them. Given its focus on operational drivers of efficiency, the Exemplars work focuses mainly on the primary care and public health components of PHC.
First, the team adapted the WHO Operational Framework for Primary Health to meet the needs of this research effort. This was followed by a review of the literature and secondary data to learn what interventions each country implemented and how the performance and efficiency of their PHC systems evolved over time.
- At the national level, researchers generate evidence from iterative reviews of the literature and key informant interviews on the sequence of investments that improved PHC performance. This is complemented by group model building to understand these investments’ pathways of action, and an analysis of the best available time series data on PHC systems’ performance over the past two decades.
- At the district level, researchers identify high-performing districts and carry out a group modelbuilding exercise with district-, facility-, and community-level stakeholders to show the interactions and interdependencies between local- and national-level structures of the PHC system. They combine the resulting causal loop diagram with qualitative and time series data to generate hypotheses around the most efficient allocation of resources within a PHC system. For select countries, the team explores and tests these hypotheses using a system dynamics modeling simulation.
For each PHC Exemplar country, we introduce the country’s context and strategy, define core operations components that drove system efficiency improvements; and detail remaining challenges and additional areas of focus.
Health officials in relatively underperforming countries can use these lessons to understand the actionable steps they can take to improve PHC system performance within their current levels of spending.
| The UHC Effective Coverage Index, developed by the Institute for Health Metrics and Evaluation, combines coverage and quality to measure whether health gains are realized from the delivery of essential health services. Notably, the index is highly correlated with key health outcomes, such as under-five mortality, neonatal mortality, and life expectancy. Read more here about the measure and limitations here and here. |
Who is involved?
Research team
Co-lead: London School of Hygiene & Tropical Medicine- Dr. Anna Vassall, Co-Principal Investigator
- Dr. Fiammetta Bozzani, Post-Doctorate Researcher
- Dr. Dina Balabanova, Senior Advisor
- Dr. Edwine Barasa, Co-principal Investigator
- Dr. Rose Muthuri, Post-Doctorate Researcher
- Dr. Beatrice Amboko, Post-Doctorate Researcher
Principal Investigators in Exemplar countries
- Prof. Felix Masiye, University of Zambia
- Dr. Luis Huicho, Universidad Peruana Cayetano Heredia
- Dr. Genevieve Aryeetey, University of Ghana
- Dr. James Humuza, University of Rwanda
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Dr. Fauzia Huda, icddr,b
Additional investigators with expertise in public health, health economics, public policy and business, and systems science are contributing to this research.
Technical Advisory Group (TAG)
Experts from a diverse range of organizations guide our Exemplars research in PHC.
- Dr. Tessa Edejer, Coordinator, Costs, Effectiveness, Expenditure and Priority Setting, Department of HGF, WHO
- Dr. Erin Ferenchick, The Global Fund to Fight AIDS, Tuberculosis and Malaria
- Dr. Diane Gashumba, Former Minister of Health, Rwanda; Principal, Health Concepts and Innovation Solutions, Ltd.
- Marelize Gorgens, Data Science and Digital Health Innovation Lead/Health Emergency Preparedness and Response, World Bank
- Dr. Piya Hanvoravongchai, Lecturer, Chulalongkorn University; Program Director, Equity Initiative
- Dr. Humphrey Cyprian Karamagi, Data Analytics and Knowledge Management, WHO AFRO
- Tracey McNeill, Director Health Systems, Bill & Melinda Gates Foundation
- Dr. Raj Panjabi, Senior Director for Global Health Security and Biodefense, U.S. National Security Council
- Dr. David Peters, Professor & Chair, Department of International Health, Johns Hopkins University Bloomberg School of Public Health
- Dr. Rajani Ved, Director, Health, India Country Office, Bill & Melinda Gates Foundation