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The 5S-5M-5C schematic: transforming primary care inputs to outcomes in low-income and middle-income countries
  1. Asaf Bitton1,
  2. Jeremy H Veillard2,
  3. Lopa Basu3,
  4. Hannah L Ratcliffe1,
  5. Dan Schwarz1,
  6. Lisa R Hirschhorn4
  1. 1 Ariadne Labs, Brigham & Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  2. 2 Health, Nutrition and Population Global Practice, World Bank Group, Washington, District of Columbia, USA
  3. 3 Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  4. 4 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  1. Correspondence to Asaf Bitton; abitton{at}

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Summary box

  • High-quality primary healthcare (PHC) is critical to achieving universal health coverage (UHC).

  • Primary care (PC) clinical services make up an important part of the value that a PHC approach offers.

  • There is a dearth of understanding about how to transform system inputs into the desired PHC outcomes.

  • We propose a schematic detailing the mechanisms and system-level functions required to transform inputs into better outcomes in PC clinical systems.

  • This schematic has important implications for the global research and policy agendas needed to achieve UHC by 2030. Particular emphasis should be placed on better measurement of the mechanisms described here, stronger data systems to translate measurement into improvement and private sector engagement and innovation to scale improvements in PC service delivery.


High-quality primary healthcare (PHC) is the most effective way to deliver person-centred, promotive, preventive and curative services to meet the majority of a population’s health needs.1 PHC is critical to improving population health, making health systems more equitable and resilient and promoting global health security. Furthermore, PHC is instrumental to achieving quality universal health coverage (UHC) and meeting the Sustainable Development Goals. However, as the global community marks the 40th anniversary of the Alma Ata Declaration in 2018,2 a significant gap remains between the original Declaration’s aspirational vision and the current reality of PHC throughout the world. PHC remains a neglected area of investment in most low-income and middle-income countries (LMICs), with limited prioritisation in public sector spending, poor integration with other sectors and alarming deficiencies in the quality of primary care (PC) clinical services delivered.3 Visits in PC are short, diagnoses frequently incorrect and treatments often unnecessary or harmful.4 Community priorities around healthcare needs are often not elicited within PHC and feedback from patients and communities is rarely sought.

To support PHC strengthening and improvement …

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