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Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017
  1. Asaf Bitton1,2,
  2. Jocelyn Fifield1,
  3. Hannah Ratcliffe1,
  4. Ami Karlage1,
  5. Hong Wang3,
  6. Jeremy H Veillard4,5,
  7. Dan Schwarz1,6,
  8. Lisa R Hirschhorn1,7
  1. 1 Ariadne Labs, Boston, Massachusetts, USA
  2. 2 Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3 The Bill & Melinda Gates Foundation, Seattle, Washington, USA
  4. 4 World Bank Group, Washington, District of Columbia, USA
  5. 5 Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
  6. 6 Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  7. 7 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  1. Correspondence to Dr Asaf Bitton; abitton{at}


Introduction The 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed.

Methods Guided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised.

Results We retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period.

Conclusion Our findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.

  • health policy
  • health systems
  • review
  • public health

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  • Handling editor Stephanie M Topp

  • Contributors AB and LRH conceptualised the paper. AB, HLR, LRH, JF and DS wrote the initial version of this report for the priority setting meeting in 2017, and AB, JF and AK adapted it to a manuscript. HW and JV provided critical revisions. All authors contributed intellectual content, edited the manuscript and approved the final version for submission.

  • Funding Funding for this research was provided by the Bill & Melinda Gates Foundation.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

  • Data sharing statement No additional data are available.

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