Each Exemplar country’s primary health care (PHC) system is unique, and each one evolved from its own set of political, economic, cultural, and geographic circumstances. The PHC reforms each country implemented are likewise specific to its context.
However, in their efforts to build strong, comprehensive PHC systems, Exemplar countries implemented reforms that can be sorted into three shared categories, or “pathways.”
- Pathway 1: Spending enough, and spending well, on PHC
- Pathway 2: Implementing systems for performance management, accountability, and community engagement
- Pathway 3: Improving access to care and facility readiness, boosting utilization rates
Building strong PHC systems with limited resources is a long-term, multicomponent project. However, the reforms countries implemented in each pathway overlapped and reinforced one another. Together, they improved health system efficiency, equity, and quality more comprehensively than interventions in each pathway might have done on its own.
The following recommendations are based on lessons from each pathway across the countries we studied. Other LMICs can learn from and apply these recommendations to their own health systems.
Recommendation 1: Spend enough, and spend well, on PHC
- Allocate adequate, consistent funding to PHC.
Exemplar countries spent more of their total health expenditure on PHC than their peers. Their governments also prioritized and protected this spending—in part because they recognized that investing in PHC (and particularly on expanding health system infrastructure and on enhancing financial protection for users) was politically popular.
- Implement strong national processes for strategic planning.
Exemplar countries took steps to align government agencies and sectors behind national PHC priorities. For instance, some countries integrated vertical disease programs to more efficiently coordinate resources toward national strategic priorities for PHC. Others developed and implemented district action plans to ladder up to five-year national health strategic plans to ensure that long-term health system and PHC goals are integrated into the day-to-day work of health service delivery.
For example, Peru’s coordination of existing poverty-reduction programs across various agencies reinforced health objectives across sectors and social programs.
- Align donor funding and programming with national priorities.
Exemplar countries implemented mechanisms for coordinating resources from across government and development partners to strengthen primary health care systems. These mechanisms—including sector-wide approaches (SWAps)—empower governments to make decisions about health sector plans and budgets while maintaining financing and other critical inputs for health system functionality and service delivery.
For example, Bangladesh and Rwanda used SWAps to collaborate with development partners on budget development, planning, and oversight of health programs, boosting internal capacity for management, monitoring, and evaluation and enabling government ownership of health system priorities.
- Improve decision-making capacity at subnational levels of the health system.
Exemplar countries improved their health systems’ responses to local needs and priorities by implementing reforms that aimed to increase local (district and facility) autonomy within health systems while maintaining authority and oversight of key functions at the central level. At the same time, they introduced capacity-strengthening and accountability mechanisms to maximize efficiency and to ensure the appropriate use of funds.
Exemplar countries thoughtfully calibrated the balance of functions between the central and subnational levels of their health systems. Health authorities at the national level were responsible for allocating resources for health services, establishing essential service packages, and managing human resources. Officials at the subnational level were responsible for bottom-up planning processes such as district and facility action plans. They also helped shape budget and procurement requests. These reforms enabled innovation, efficiency, and responsiveness to local needs.
- Allocate resources where they are most needed.
Exemplar countries prioritized equity in resource allocation. They engaged vulnerable communities in service-delivery planning and implementation, offered incentives to encourage providers to work in hard-to-reach areas, and expanded benefits packages and subsidies to vulnerable groups to decrease financial barriers to access.
For example, Zambia applied a resource allocation formula to rank districts based on deprivation. This formula enabled officials to disburse financial resources to the highest-need communities and facilities.
Recommendation 2: Implement systems for performance management, accountability, and community engagement
- Tie financing to performance.
Exemplar countries incentivized high performance at all levels of their health systems by establishing mechanisms to monitor and evaluate the effects of the PHC reforms they implemented. These mechanisms included results-based financing and performance-based contracting schemes that rewarded high-quality care and service delivery.
For example, Peru ties financial allocations to performance for administrators at various levels of the health system and ensures these performance indicators are available to the public.
- Build mechanisms for transparency and accountability.
Exemplar countries implemented tools such as independent public audits, performance-based contracts, online publication of programmatic targets and results, and community health scorecards. These mechanisms buoyed public trust in the health system and enabled community feedback and accountability.
For instance, Peru and Rwanda published health system scorecards online for the public to see.
- Invest in research institutions and data systems.
In Exemplar countries, government sponsorship helped align research priorities with national health agendas. More important, Exemplar countries enabled evidence-based policymaking by investing in systems that allow officials to track key health system data and incorporate them into program design and implementation, monitor progress, and make decisions faster and with more certainty.
For example, in Ghana, officials used the data they collected on the country’s community-centered PHC delivery strategy to improve it over time.
- Enable community engagement.
Exemplar countries engaged local communities to ensure their systems for health service delivery suited local needs and respected local values. (For example, they often employed staff fluent in local languages and knowledgeable about traditional medical practices.) Some established official partnerships with committees led by community members to organize and oversee PHC service delivery and to monitor the performance of districts, health facilities, and staff.
For example, in Ghana, Zambia, and Rwanda, communities were involved in setting priorities and developing plans at the district and health facility levels.
- Empower civil society groups.
In Exemplar countries, grassroots organizations and advocates for PHC often helped establish and guarantee equitable access to key health services, even during times of social and economic instability. Support for—and later formalization of—these groups was instrumental to ensuring community acceptability of services.
In Bangladesh and Peru, the government adopted and expanded care delivery practices pioneered by civil society groups focused on nutrition and reproductive health counseling.
Recommendation 3: Improve access to care and facility readiness to boost utilization rates
- Establish financial protection mechanisms to reduce out-of-pocket payments.
Exemplar countries aimed to reduce financial barriers to care, especially for the most vulnerable groups. They prioritized establishing financial protection mechanisms to reduce out-of-pocket expenses and increase access to critical services.
Ghana, Rwanda, and Peru invested in national health insurance schemes that covered many key health services and essential medicines. Ghana exempted pregnant women, children, and older people from premium payments, and Rwanda offered subsidies to those living below the poverty line.
- Promote demand for PHC services.
Exemplar countries implemented systems for the community to directly engage in the planning and delivery of PHC services to promote care-seeking. These systems established mechanisms both for feeding funding and programmatic information to the communities and for integrating feedback into the planning and management of services. Together, this resulted in services that better responded to local needs and priorities.
To help increase community involvement in and demand for service-delivery, planning and budgeting processes in Zambia included Neighborhood Health Committees.
- Improve health worker motivation and retention.
Exemplar countries experimented with a variety of tools aimed at minimizing staff shortages, balancing clinical skills across health facilities, and ensuring uninterrupted care delivery even in rural or hard-to-reach areas. Often, these tools included workforce formalization policies, financial and nonfinancial incentives, and adequate training and supervision.
In Peru, national policy requires health service providers to work in underserved, rural communities to qualify for further training or future employment in the public sector.
- Formalize the skilled community health worker (CHW) workforce in close-to-community service delivery.
In every Exemplar country, CHWs supported PHC service delivery and outreach—especially in hard-to-reach, underserved regions. They also served as essential liaisons between the community and the health system. Some Exemplar countries formalized their work status and provided support such as commensurate compensation and adequate training where fiscal space allowed.
For example, Rwanda tied part of CHWs’ compensation to their performance, which integrated them into systemwide priorities and incentivized achievement of key health targets.
- Build health facilities to meet people where they are.
Exemplar countries minimized geographic barriers to care by building community clinics, health posts, and compounds in rural and hard-to-reach places, reducing users’ travel time and distance. The countries also sought community input on where to construct health facilities to ensure they could conveniently serve as many people as possible. Four of the Exemplar countries also improved facility readiness by investing in human resources and equipment.
As Rwanda built more local health facilities, more people sought outpatient care at those facilities instead of hospitals. This encouraged earlier, more frequent visits and reduced costs.