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Measuring primary healthcare expenditure in low-income and lower middle-income countries
  1. Nathalie Vande Maele1,
  2. Ke Xu1,
  3. Agnes Soucat1,
  4. Lisa Fleisher2,
  5. Maria Aranguren1,
  6. Hong Wang3
  1. 1 Health Systems Governance and Financing, Organisation mondiale de la Sante, Geneve, Switzerland
  2. 2 Freelance consultant, Washington, District of Columbia, USA
  3. 3 Global Development Division, The Bill and Melinda Gates Foundation, Seattle, Washington, USA
  1. Correspondence to Nathalie Vande Maele; vandemaelen{at}


Primary healthcare (PHC) is considered as the pathway to Universal Health Coverage (UHC) and to achieving sustainable development goals. Measuring PHC expenditure is a critical first step to understanding why some countries improve access to health services, provide financial risk protection and achieve UHC. In this paper, we tested and examined different measurement options using the System of Health Accounts (SHA) 2011 for systematic monitoring of PHC expenditure. We used the ‘first-contact’ approach to PHC and applied it to the healthcare function or healthcare provider classifications of SHA 2011. Data comes from 36 recent low-income and middle-income countries health accounts 2011–2016. Country spending on PHC varies largely, across countries and across definition options. For example, PHC expenditure ranges from US$15 to US$60 per capita. The sensitivity analysis highlighted the weight of including or excluding medical goods. The correlation analysis comparing countries ranking is strong between options. The study identified the major challenges in developing standard monitoring of PHC expenditure. One, there is a lack of clear operational definition for PHC, suggesting that a global standard definition would not replace the need for country context specific definition. Two, there is insufficient data granularity both because the standard framework does not offer it and because quality data breakdown is unavailable.

  • health systems evaluation
  • health economics
  • public health

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  • Handling editor Seye Abimbola

  • Contributors NVM, KX and AS led the overall design and the development of the methodology. MA conducted the data analysis and figures/tables production. LF contributed to the literature review and preparing and analysing the data. All co-authors contributed to writing and interpreting the results.

  • Funding Financial support were received from the Bill and Melinda Gates Foundation, Gavi, The Global Fund, USAID, DFID, European Commission and the governments of Japan, France, Luxembourg for Global Health Expenditure Tracking program which made the data available for this study.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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