Between 2000 and 2018, the PHC Exemplar countries—Zambia, Ghana, Bangladesh, Rwanda, and Peru—implemented a range of interventions aimed at improving the efficiency, equity, and quality of their PHC systems. Together, these interventions fall into three key categories, or pathways:
- Spending enough, and spending well, on PHC
- Implementing systems for performance management, accountability, and community engagement
- Improving access to care and facility readiness, boosting utilization rates
Components within each pathway often overlapped with and reinforced one another. So did the pathways themselves. Together, these interactive pathways to PHC performance improved health system efficiency, equity, and quality more comprehensively than individual interventions might have done on their own.
PHC Exemplars taxonomy
Pathway 1: Spending enough, and spending well, on PHC
Drivers and interventions within Pathway 1 aimed to improve the level, flow, and allocation of funds to and within the PHC system.
All five Exemplar countries consistently allocated a substantial percentage of their total health expenditure to PHC. In some cases, this was because of a clear statement of goals for PHC in a government’s political commitments. The countries also worked to ensure a stable and sufficient flow of funds to the lower levels of the health system where PHC is typically delivered. High budget execution rates suggest that Exemplar countries managed and used the resources they allocated to PHC effectively and efficiently.
Pathway 2: Implementing systems for performance management, accountability, and community engagement
Drivers and interventions within Pathway 2 aimed to connect system managers, providers, and communities with the information they needed to manage and hold the system accountable for strong PHC system performance.
All five Exemplar countries aligned their PHC systems with local needs and priorities by fostering data and information availability and other mechanisms to facilitate community input and participation. Exemplar countries also built formal mechanisms for performance management and accountability to manage and make transparent core functions of PHC delivery.
Pathway 3: Improving access to care and facility readiness, boosting utilization rates
Drivers and interventions within Pathway 3 aimed to improve PHC utilization rates by making health services more affordable and available to users in or close to their communities.
All five Exemplar countries increased use of PHC services by reducing financial and physical barriers to access. Exemplar countries also improved the readiness of PHC facilities to respond to increased demands for health services, such as by ensuring the availability of essential medicines and supplies. All five PHC Exemplar countries grew and improved training and retention schemes for their health workforces, particularly community health workers and nurses.
Exemplar countries interactive pathways
Drivers
Between 2000 and 2018, the PHC Exemplar countries—Zambia, Ghana, Bangladesh, Rwanda, and Peru—implemented a range of interventions aimed at improving the efficiency, equity, and quality of their PHC systems. Together, these interventions fall into three thematically related pathways composed of 18 interconnected drivers, or groups of interventions that worked together within and across pathways to influence outcomes.
Pathway 1: Spending enough, and spending well, on PHC
In PHC Exemplar countries, governments were explicitly committed to improving PHC coverage and outcomes.
Strong political support for PHC unlocked the resources that health systems needed to implement interventions across all three pathways. It also enabled countries to establish mechanisms for preserving and protecting consistent PHC funding into the future.
Key interventions:
- Exemplar countries consistently allocated a larger share of their total health spending to PHC than their peers (see Figure 9).
- Exemplar countries introduced and expanded national health insurance or community-based health insurance benefits.
Rwanda and Peru implemented health insurance schemes that included a defined essential service package aimed at expanding access to critical PHC services.1
- Exemplar countries built community clinics and health posts to increase geographic access to health services.
Ghana has established more community health planning and services compounds in rural areas than any other type of health facility.
- Exemplar countries established donor pooled or district basket funds to align partner resources with national health priorities.
Zambia pooled and earmarked donor funds for district-level PHC, enabling those funds to reach frontline health facilities.
- Exemplar countries established national systems for performance-based contracting to improve system and provider performance.
Peru implements a yearly Demographic Health Survey to gather data on health system performance, which informs national strategic planning and budgeting processes.
Figure 9: PHC Exemplars allocations to PHC
Source: Institute for Health Metrics and Evaluation; GHED (2018), Rwanda HRTT (2014-15)
In PHC Exemplar countries, the timely movement of funds for PHC services was in line with budgetary needs.
Reorganizing governance processes and empowering subnational structures with some fiscal autonomy enabled funding allocated to PHC to flow through the system consistently and efficiently. It also ensured that districts and health facilities could use allocated funding to meet local needs.
Key interventions:
- Exemplar countries established and strengthened structures for administrative and fiscal decentralization, enabling funding to reach frontline health facilities.
Peru transferred meaningful administrative and budgetary autonomy to regional governments, including the ability to maintain bank accounts and disburse funds.
- Exemplar countries built systems for results-based financing (RBF) to reward improved health system performance.
Zambia piloted an RBF system with the World Bank that increased the use of maternal, newborn, and child health services as well as the predictable flow of funds to health facilities.
- Exemplar countries on average executed their health budgets at a higher rate (>90%) than other low- and middle-income countries (85%–90%), indicating more effective and efficient resource management.2,3
Figure 10: National budget execution rate (% spent relative to allocated)
PHC Exemplar countries used research and data analysis to make decisions, encourage innovation, and shape and inform the goals, strategies, and implementation of PHC services and interventions.
Investments in research and data analysis resulted in more evidence-based, cost-effective policies, particularly about health financing and priority interventions.
Key interventions:
- Exemplar countries invested in research institutions and centers of excellence.
Bangladesh’s investments in research yielded PHC interventions that were cost-effective, high-impact, and preventive.4
- Exemplar countries implemented evidence-based programs in combination with results-based budgeting to promote and incentivize performance of proven strategies.
Peru launched Plan Esperanza, a population-based cancer prevention program in combination with cancer prevention and control results-based budgeting to promote healthy lifestyles, early detection, and comprehensive cancer care.
- Exemplar countries established national health research agendas that aligned academic and scientific research with national health priorities.
Every five years, Rwanda produces a National Health Research Agenda to coordinate research priorities about the most pressing issues in the health sector.5
PHC Exemplar countries established processes for joint strategic planning, financing, oversight, and implementation of PHC.
Coordinating resources across sectors, government agencies, and development partners improved the efficiency and effectiveness of PHC delivery, boosted national health priorities, and reduced redundancy.
Key interventions:
- Exemplar countries developed sector-wide approaches (SWAps) to coordinate partner assistance and steer it toward shared health system goals, improving efficiency and management capacity at all levels of the system.
Ghana’s first sector-wide approach pooled government and donor resources into a single fund, which became a major source of funding to districts and increased the autonomy and capacity of district managers.
- Exemplar countries established donor pooled or district basket funds to align partner resources with national health priorities.
Zambia pooled and earmarked donor funds for district-level PHC, enabling those funds to reach frontline health facilities.
- Exemplar countries implemented conditional cash transfer programs that targeted the poorest households.
Ghana’s conditional cash transfer program, Livelihood Empowerment Against Poverty, provided monthly payments to people in the country’s poorest households and enrolled them in the National Health Insurance Scheme.
- Exemplar countries coordinated cross-sectoral programming to align government action in other sectors with national health priorities.
Peru used cross-sectoral programming to address chronic childhood malnutrition through the establishment of the National Strategy for Combating Poverty and Chronic Child Malnutrition, known as CRECER, that coordinated programs under different government agencies that helped halve the rate of chronic malnutrition among poor children between 2005 and 2016.
- Exemplar countries established public-private partnerships to consolidate resources and to implement PHC system improvements.
Bangladesh used a public-private partnership to build health clinics managed by neighborhood committees and staffed by community health care providers. Communities—acting as private actors—donated the land, and the government funded construction, service providers, medicines, and other supplies.6
- Exemplar countries introduced mechanisms for district (joint) action planning that reduced duplication of key health system functions and improved the quality of health services.
In Zambia, District Health Management Teams overseen by District Health Boards consulted with stakeholder groups to coordinate planning and connect communities to health facilities.
PHC Exemplar countries established and implemented strategic action plans aligned with their long-term PHC goals and priorities.
Strategic planning across sectors and within the health sector itself helped develop national priorities for PHC and anchor them in action across stakeholder groups, including civil society organizations. Supportive mechanisms and programs coordinated planning and budgeting processes and ensured that those processes were responsive to local needs.
Key interventions
- Exemplar countries anchored long-term health sector and PHC goals in five-year strategic plans.
Bangladesh produced coordinated strategic plans aimed at increasing access to and use of maternal and child health and family planning services.7
- Exemplar countries coordinated cross-sectoral programming to align government action in other sectors with national health priorities.
Peru used cross-sectoral programming to address chronic childhood malnutrition through the establishment of the National Strategy for Combating Poverty and Chronic Child Malnutrition, known as CRECER, that coordinated programs under different government agencies and helped halve the rate of chronic malnutrition among poor children between 2005 and 2016.
- Exemplar countries introduced mechanisms for district (joint) action planning that reduced duplication of key health system functions and improved the quality of health services.
In Zambia, District Health Management Teams overseen by District Health Boards consulted with stakeholder groups to coordinate planning and connect communities to health facilities.
PHC Exemplar countries allocated pooled funds to providers for the delivery of PHC services in a way that accounted for health system priorities and local needs—spending better, not more.
Financing and payment systems that enabled the delivery of key services to vulnerable populations in alignment with national policy objectives helped countries spend efficiently and improve health outcomes. These mechanisms maximized PHC coverage to all populations, reduced the total cost of care, and rewarded high-quality care delivery.
Key interventions:
- Exemplar countries introduced and expanded national health insurance (NHI) or community-based health insurance benefits to incentivize the provision of priority services. NHI empanelment included both public- and private-sector providers to enable active purchasing from a range of providers.
Ghana’s National Health Insurance Scheme benefits package covered all preventive and secondary care in empaneled health facilities, improving access to essential health services, making those services more affordable, and boosting service utilization.
- Exemplar countries established systems for performance-based contracting to improve system and provider performance.
Zambia implemented a performance-based contracting scheme to make population-based allocations contingent on satisfactory performance audits and financial reports at lower levels of the health system.
- Exemplar countries built systems for results-based financing (RBF) to reward improved health system performance.
Zambia piloted an RBF system with the World Bank that increased the use of maternal, newborn, and child health services as well as the predictable flow of funds to health facilities.
- Exemplar countries implemented processes for facility accreditation as part of health insurance design that guaranteed a baseline level of service quality.
In Rwanda, public facilities must have received accreditation before they could access performance-based financing schemes.8
- Exemplar countries developed systems for mixed-methods provider payments that incentivized both increased service delivery and improved quality of care.
In Peru, health insurance reform established agreements with regional governments using a mixed method provider payment mechanism with fixed payments per patient and variable payments based on defined performance indicators. This incentivized improved service delivery, increased staff motivation, and overall service quality and coverage.
PHC Exemplar countries granted autonomy to subnational units to manage and finance PHC service delivery.
Shifting some decision-making power to subnational levels helped improve overall health system efficiency, responsiveness, and health outcomes. Decentralizing authority for some planning, spending, and implementation ensured that resources were allocated according to local needs and priorities.
Key interventions:
- Exemplar countries adopted reforms that increased decentralization, expanding district-level autonomy especially while maintaining top-down authority and oversight of key functions.
In Ghana, Rwanda, and Peru, districts had substantial autonomy over human resources, and districts in Zambia had managerial autonomy with an emphasis on planning and budgeting.9
Figure 11: PHC Exemplar countries’ decision-making autonomy across health system functions
Pathway 2: Implementing systems for performance management, accountability, and community engagement
PHC Exemplar countries enhanced officials’ commitment to PHC goals and their capacity to implement key strategies and actions.
Increasing autonomy encouraged strong leadership and management and enabled operational efficiencies at subnational levels of the health system, helping countries meet objectives while minimizing disruptions.
Key interventions:
- Exemplar countries implemented national stakeholder dialogues that promote unified and cross-sectoral interventions to promote health.
Peru established a Roundtable Against Poverty that convenes leadership figures from various sectors to advocate for poverty-reduction policies at the national and subnational levels.
- Exemplar countries introduced financial incentives for managers.
Peru established the SERVIR program in 2001 to improve human resources management, in part by implementing performance bonuses to attract and retain senior staff.
- Exemplar countries established systems for performance-based contracting to improve system and provider performance.
In Rwanda, public officials’ contracts aimed to promote results-oriented performance. Regular public evaluations ensured health targets were met.10
PHC Exemplar countries routinely collected high-quality data and used them to inform the planning and implementation of PHC services and interventions.
Investing in health information systems with reliable, routine data inputs increased systemwide efficiency.
Key interventions:
- Exemplar countries performed annual demographic health surveys.
Ghana used data from the national District Health Information System to track health service operations, monitor potential disease outbreaks, identify gaps in care, and inform decision-making.
- Exemplar countries introduced digital national ID cards.
In 2013, Peru introduced an electronic version of its national identity card, which linked demographic and social information with health data and helped ensure equitable distribution and targeting of services according to need.
- Exemplar countries implemented health management information systems (HMIS).
Rwanda collected key health data via an HMIS, a national AIDS informatics system, and community health systems.11
- Exemplar countries built systems for results-based financing to reward improved health system performance.
Rwanda and Zambia allowed facilities to use part of their performance-based financing for staff bonuses, rewarding high-quality service delivery.12
Figure 12: PHC Exemplar country information systems
PHC Exemplar countries developed tools to ensure public transparency and accountability and to enable government agencies to track and improve health system performance.
Developing structures for oversight and transparency and tying funding to health outcomes enabled public accountability for health system performance. As health systems matured, these structures grew more formal.
Key interventions:
- Exemplar countries established health auditing bodies that ensured the provision of high-quality health services.
Peru’s Superintendencia Nacional de Salud (SUSALUD), an independent public auditor, monitored public and private providers’ compliance with health regulations, published information on all providers, and hosted a public database of provider evaluations.
- Exemplar countries built systems for results-based financing (RBF) to link funding to specific, pre-agreed results to ensure funds are used as intended.
In Zambia, the RBF scheme was leveraged to encourage maternal, newborn, and child health services and improved the quality of care in districts where it was implemented.
- Exemplar countries held national stakeholder dialogues and established systems for performance-based contracting that were publicly reported to improve transparency and ensure system and provider performance.
In Rwanda, public officials’ contracts aimed to promote results-oriented performance. Regular public evaluations ensured health targets were met.13
PHC Exemplar countries benefited from civil society groups that advocated for PHC, provided oversight, and delivered services at the grassroots level.
Partnering with civil society advocacy groups gave citizens a voice in their own care and governments a source of new ideas and proven programs to expand and extend PHC systems.
Key interventions:
- Exemplar countries fostered grassroots self-help groups that advocated for access to health services and developed innovative pilots that were later institutionalized into formal PHC systems.
In Peru, grassroots activists in the 1950s created community-based health and nutrition programs that evolved into donor-funded communal kitchens for low-income Peruvians in the 1980s and 1990s and were later adopted as part of the government’s official social strategy.
- Exemplar countries enabled NGOs to provide PHC services to communities.
In Bangladesh, the government began to partner with NGOs in the 1990s to support locally driven programs in family planning and primary health care. Although the government deploys community health workers, NGOs deploy far more.14
PHC Exemplar countries designed and delivered PHC services in accordance with local or traditional practices and values.
Aligning health policy with local traditions stimulated demand for health care and maximized the accessibility and relevance of care across diverse communities.
Key interventions:
- Exemplar countries created local health committees to give users more input into PHC systems and PHC systems more precise insights into people’s needs.
In Zambia, Neighborhood Health Committees operate a level below health clinics and are the health system’s closest point of contact to communities. Their members often belong to, and therefore understand, the communities they serve.
- Exemplar countries integrated community traditions in reforms aimed at PHC system accountability.
In Rwanda, performance-based contracting—called Imihigo after the Rwandan tradition—required leaders at all levels to set public performance targets in priority areas.15
- Exemplar countries designed health services that prioritized sensitivity to local cultures.
Peru’s Enfoque “cultural adjustment” reform mandated that PHC facilities seeking accreditation must employ staff who speak local languages and adopt locally accepted practices such as the use of herbal remedies or traditional birthing facilities.
PHC Exemplar countries engaged communities in the design and delivery of PHC services.
Bringing communities into the planning and management of PHC services established trust and made services more responsive to local needs.
Key interventions:
- PHC Exemplar countries created local health committees to give users more input into PHC systems and PHC systems more insights into community needs.
Zambia’s Neighborhood Health Committees operate a level below health clinics and are the health system’s closest point of contact to communities. Their members often belong to the communities they serve.
- Exemplar countries relied on community input to plan and manage local health clinics.
Ghana built and operated community health and planning services compounds with community participation, including advice about site selection and routine feedback from community health management meetings.
Figure 13: PHC Exemplar country community engagement mechanisms
Note: Subantional primary data collection selected four additional districts for deeper study. This visual depicts the variation of engagement mechanisms at the sub-national level.
Pathway 3: Improving access to care and facility readiness, boosting utilization rates
PHC Exemplar countries delivered essential health services in or near people’s homes and communities.
Delivering services using community-based models increased the use of those services irrespective of users’ age, gender, location, or economic status.
Key interventions:
- Community health clinical and technical staff cadres are trained health professionals strategically deployed closer to communities to promote locally accepted health services.
In Ghana, Community Health Officers and Community Health Volunteers drive outreach and PHC coverage services in rural communities.
- Exemplar countries designed community health worker programs to ensure a more equitable distribution of health workers, especially to regions with poorer and more vulnerable populations.
In Bangladesh, a mix of community health workers deployed by the government and NGOs, government-deployed family welfare assistants responsible for family planning, community skilled birth attendants funded by an NGO, and USAID-supported community volunteers charged with reducing maternal mortality provide PHC services to more than 100 million rural residents.16
- Exemplar countries implemented community care networks that defined health needs for specific populations and designs outreach services to address them.
In Peru, a comprehensive family- and community-based approach to health care includes programs specifically designed to strengthen and deliver PHC—including for mental health and cancer care.
PHC Exemplar countries focused on making PHC services affordable at the point of use.
Reducing health care costs removed a substantial barrier to care-seeking and ensured that using PHC did not push people into poverty.
Key interventions:
- Exemplar countries introduced and expanded national health insurance or community-based health insurance benefits.
Zambia, Rwanda and Peru implemented health insurance schemes that included a defined essential service package aimed at expanding access to critical PHC services.17
- Exemplar countries eliminated fees for users of the PHC system.
Zambia eliminated user fees, aiming to improve financial protection by reducing medical expenditure and encouraging patients to use health facilities.
- Exemplar countries used deprivation-based allocation formulas to expand access to PHC services.
In Zambia, the Ministry of Health developed a “deprivation matrix” to rank districts according to measures of need, to inform allocation of resources to highest-need communities and facilities.
- Exemplar countries introduced targeted exemptions and subsidies for users of the PHC system.
In Ghana, the Free Maternal Health Care Policy automatically registered pregnant women with the National Health Insurance Scheme and ensures they receive free comprehensive maternal care.
- Exemplar countries implemented conditional cash transfer programs that targeted the poorest households.
Peru’s conditional cash transfer program, known as JUNTOS, targeted households in extreme poverty and encouraged participants to use public health services by automatically enrolling them in the country’s health insurance program.
PHC Exemplar countries constructed an adequate number of health facilities—even in hard-to-reach areas—and made sure they were ready to provide high-quality PHC services.
Ensuring there were enough fully equipped health facilities available in both rural and urban settings was essential to ensuring PHC services reached all population groups.
Key interventions:
- Exemplar countries constructed community-based health facilities.
Ghana has established more community health planning and services compounds in rural areas than any other type of health facility.
- Exemplar countries established public-private partnerships.
Bangladesh used a public-private partnership to build health clinics managed by neighborhood committees and staffed by community health care providers. Communities donated the land, and the government funded construction, staff, equipment, and supplies.18
PHC Exemplar countries recruited, trained, and retained a skilled PHC workforce.
Offering incentives to increase the number and improve the geographic distribution of staff helped boost demand for services and buoy staff morale and motivation.
Key interventions:
- Exemplar countries used community health workers to bring services closer to the community.
Bangladesh employed a diverse and pluralistic community health worker workforce, including salaried government employees and an NGO-supported workforce.19
- Exemplar countries employed different incentives to persuade workers to deploy to rural areas.
Zambia started the Health Workers Retention Scheme in 2003 to encourage skilled clinicians to work in hard-to-reach and underserved areas. The program offered a wide range of financial and nonfinancial incentives.
- Exemplar countries built systems for results-based financing to reward improved health system performance.
Peru and Rwanda deployed provider payment models that included fixed components and variable incentives for different types of health workers. Rwanda and Zambia allowed a portion of facility performance-based financing schemes to be used for staff bonuses.20
Figure 15: PHC Exemplar country changes in service coverage given densities of nursing and midwifery personnel
PHC Exemplar countries procured drugs and supplies at appropriate prices and minimized waste.
Ensuring the consistent availability of essential medicines contributed to better service delivery and quality of care.
Key interventions:
- Exemplar countries built local drug manufacturing capacity to help reduce procurement prices and stockouts.
Bangladesh’s Essential Drugs Company Limited is a government-owned entity that manufactures and supplies medicines to all government health care outlets nationwide.21
- Exemplar countries introduced digital procurement systems, enabling officials at all levels of the health system to track and order supplies more precisely.
Peru uses a national electronic procurement and stock management system, Sistema Integrado de Suministro de Medicamentos e Insumos Médico-quirúrgicos, to help prevent stockouts.
- Exemplar countries exercised some degree of procurement autonomy, a key enabler of shorter lead times and reduced stockouts.
In 1994, Peru established PACFARM, a system for the provision of 63 essential medicines at all public health facilities that is self-supported by a revolving fund. The reform, which granted regional autonomy for procurement, improved supply management efficiency and removed financial barriers to access to essential medicines.
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1
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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2
Global Financing Facility. Global Health Expenditure Database. https://data.gffportal.org/
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3
Chronic under-execution rate of health budgets is considered below 85%.
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4
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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5
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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6
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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10
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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11
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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12
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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13
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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14
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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15
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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16
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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17
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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18
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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19
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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20
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)
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21
PHC cross-country synthesis workshop 2023. (Interim source prior to publishing country narrative.)