Table 2

Synthesised key findings and gaps; red = low evidence (0 to 6 articles), yellow = moderate evidence (7 to 13 articles), green = high evidence (14+ articles)

Subdomain (mapped to PHCPI framework - figure 1)Synthesised findingsKnowledge gapsEvidence base
A1. Governance and leadershipWe found an extensive number of publications on successful primary healthcare policies in six themes: effective national programme policies, bundling services through integrated protocols, integration with the private sector, task shifting, decentralisation and comprehensive, rights-based, participatory approaches. Most evidence comes from a small number of countries that implemented successful interventions and focuses on policies linking financial coverage expansion to PHC community workforce training and deployment. One strong example of quality management infrastructure came from Costa Rica’s EBAIS teams that collect vital registry and clinical data from their empanelled population; these data are then sent through a data feedback loop and inform local action plans.24 We found little evidence on social accountability, but one review of 37 social accountability programmes found that provider receptivity to citizens’ demands for better healthcare is mediated by provider perceptions of legitimacy of citizen groups.54 A1.a Primary healthcare policies - Most evidence on PHC policies is concentrated on a few frequently documented country examples such as Brazil, Thailand and Iran; more evidence from more countries is needed.High - 47 articles
A1.b Quality management infrastructure - Comparatively little is published about the contours and constructs of effective quality management in PHC systems, in particular how to set up systems and train staff to generate data feedback loops.Low - 4 articles
A1.c Social accountability - It is unclear how to best use social accountability mechanisms for improvement where providers are not empowered nor interested in external input. Evidence is needed to quantify the impact of investing in social accountability.Low - 3 articles
A2. Health financingThere was a significant amount of evidence on health financing, and payment systems in particular. In particular, there was strong evidence that introducing or increasing user fees has a negative impact on primary health services utilisation, especially preventive services.29 Moderate certainty evidence suggests that pay for performance is associated with slight improvements in health professionals’ use of tests or treatments, particularly for chronic diseases, but little or no improvement in utilisation outcomes was found.55 Compared with FFS, capitation appears in a few studies to be associated with moderately better outcomes, but the effect on utilisation and total costs is still unclear. Public spending in primary healthcare was shown to promote more equitable outcomes than spending focused on secondary care.44 Lack of funds, poor quality of care and lack of trust were documented to be major reasons for low financial coverage in LMIC, and financial hardship was more common in poorer countries.28 56 A2.a Payment systems - Further comparative evidence is needed to understand the relative impact of FFS vs capitation and global budgets on utilisation and outcomes. Future works should also examine the benefit of hybridised models of financing as well as elements of strategic purchasing such as gatekeeping.High - 30 articles
A2.b Spending on primary healthcare - More recent, comparable and widely available country level and disaggregated data is needed on PHC spending levels as well as research on optimising resource allocation mechanisms to promote equity of outcomes.Moderate - 7 articles
A2.c Financial coverage - Higher coverage was shown to promote higher utilisation of beneficial PHC services. More research is needed on the best types of insurance for mixed private/public systems, as well as how to sequence financial coverage expansions with service delivery reforms.Moderate - 10 articles
A3. Adjustment to population health needsThe reviewed literature demonstrates that surveillance systems are an essential component of resilient health systems and necessary for responding to all types of shocks. They can be bolstered by functioning vital statistics resources, robust local communication networks, population trust in the health systems and platforms for community dialogue.57 National priority setting is found to be dependent on effective community engagement, both locally and nationally, but good evidence on how to effectively scale these approaches is largely absent.54 58 The evidence shows that community ownership and mobilisation as well as adjustment to social norms and values are facilitators of sustainable system innovation.46 Case studies of health system stresses in Lebanon and Indonesia found that successful resilience hinged on rapidly mobilised public and private sector actors and nodal coordination and surveillance efforts.57 A3.a Surveillance - More research is needed to understand which surveillance approaches are feasible and effective across PHC systems in LMIC, including how to integrate data feedback loops into surveillance systems. Further work is needed for better NCD surveillance in PHC.Moderate - 7 articles
A3.b Priority setting - Additional research is needed to understand how best to monitor and communicate the effectiveness of priority setting decisions for planning purposes and in response to emerging diseases/outbreaks.Moderate - 7 articles
A3.c Innovation and learning - There is a major gap in the knowledge of the individual competencies, organisational capacities and systems features needed to ensure that leaders can be flexible and adapt to changing health needs.Low - 5 articles
B1. Drugs & suppliesGaps in availability of specific drugs and supplies were well documented at the facility and community levels across many countries. These gaps are associated with lower readiness, lower quality and reduced ability to expand needed services.31–33 Evidence from Ethiopia, Malawi and Rwanda shows that multimodal interventions to improve supply chains can be effective but require integration of product flow, data flow and effective people into intervention design.59 Success was shown to be more likely when the workforce is able and motivated to use integrated data to continually monitor the supply system.59 More research is needed on how new technologies can best be integrated to strengthen supply chains, reduce stock-outs and wastage and ensure responsiveness to emerging needs as well as best practices for ensuring appropriate pricing and quality of medications across all sources of care (including public and private facilities and pharmacies).Moderate - 7 articles
B2. Facility infrastructureThe reviewed literature showed that ensuring adequate distribution of facilities requires a national policy and strategy and appropriate investments.60 A focus on facility infrastructure can increase geographical access, even in war-torn countries like Afghanistan or countries in perpetual political and environmental crisis such as Haiti, but must be accompanied with adequate drugs and service delivery.28 61 More research in facility infrastructure can better clarify the appropriate mix of facility types based on population, health needs, geography and burden of disease as well as effective mapping of private sector facilities and their integration into policies and strategies to determine needs for additional facilities.Low - 3 articles
B3. Information systemsA systematic review of systematic reviews of eHealth implementation found that the following strengthen outcomes: selecting technology based on ability to be adapted, including end-users during design, interoperability with other systems, incentives to reduce start-up costs, standards and policies to guide implementation and ensure data safety and inputs such as electricity and connectivity.62 An eight country study of primary care facilities found that most information systems are not designed to ensure continuity of patient information and that even fewer have an electronic medical record able to ensure continuity and coordination.31 Major areas related to PHC information systems could benefit from more research, including: approaches to ensure interoperability between data sources, scalable and affordable approaches for planning eHealth, innovations that can strengthen information systems without significant infrastructure changes and efficient and feasible approaches to build off existing eHealth technology to structure Health Management Information Systems (HMIS) to serve patients, providers and managers.Low −2 articles
B4. WorkforceWhile global standards exist on the number and type of healthcare workers per population, measures of national averages often miss inequity of distribution which require local solutions.31 The literature indicated that ensuring adequate human resources for PHC in rural areas and the public sector remains a challenge, and a number of interventions have been tried with varying impact.63–65 Additionally, multiple studies showed that task shifting can be effective to address shortages of providers but requires supportive supervision, adequate supplies and pre-service and in-service training that matches the scope of services.34 41 43 66 67 Finally, community-based health workers can be a valuable expansion of the workforce but require training, systems and work to intentionally integrate physically and culturally into facility-based care systems.68 Despite the significant number of articles related to workforce, additional research could focus on: the ideal mix and number of providers based on different contexts and population health needs; the optimal role, training and remuneration of community-based health workers; the appropriate role for informal providers and effective and feasible approaches to ensure equitable distribution of human resources.High - 29 articles
B5. Funds NoneOur searches returned no articles concerned with the availability of funds at the facility level. While it could be an artefact of the PHCPI conceptual framework, in which systems-level payment and financing and facility-level financial management are both represented as separate areas, it could also reflect a lack of research focus on the optimal distribution and optimisation of PHC facility-based finance systems, including fiscal management and authority at the facility level.Low - 0 articles
C1. Population health managementMost studies reference the success of community-based programme for managing population health across a limited number of LMIC, including Costa Rica, Brazil and Ghana.24 34 69 Countries that have expanded proactive PHC provision beyond the clinic have showed evidence of more effective local priority setting and improved continuity, comprehensiveness and coordination.24 34 35 The literature shows that community-based programmes must be well integrated into the care delivery and public health systems in order to be effective. Finally, while not extensively studied, evidence shows that empanelment has been a critical component of community-based health worker programme to define the group of patients for targeting outreach and service delivery.34 C1.a Local priority setting - Outside a few countries like Ghana, more research is needed to understand how local priority setting should be measured, what interventions will ensure effective data use for local priority setting and which data are most actionable at the local level.Moderate - 7 articles
C1.b Community engagement - Future research should explore effective ways to develop, support and sustain meaningful community engagement, including at the facility level.High - 16 articles
C1.c Empanelment - There is relatively little evidence on empanelment in LMIC. Future research can explore effective models of empanelment and the criteria needed to implement empanelment.Low - 5 articles
C1.d - Proactive population outreach - Gaps remain in understanding how to structure health worker training and other supports to incent more proactive (as opposed to reactive) care.Moderate −11 articles
C2. Facility organisation and managementAt the facility level, multidisciplinary teams have been critical components of PHC system reforms in Costa Rica, Brazil and Turkey. Although evidence is limited, where implemented, multidisciplinary teams have improved continuity of team membership and leadership, increased patient trust and improved patient self-management.24 34 36 70 71 A number of systematic reviews of supportive supervision have found that it is associated with modest improvements in clinical performance, such as knowledge level, adherence to clinical protocols and consistency in record keeping.72 E-health has been found to be associated with more efficient use of data in facilities, more effective patient feedback, and greater adherence to protocols using mobile-based algorithms, although significant staff training and support is needed to ensure effective transitions.65 There are a few examples of methods to ensure continuous, iterative performance measurement and management in facilities, including Costa Rica’s EBAIS teams that use data from home visits to assess performance against national and regional targets as well as a balanced scorecard approach that has been used in Afghanistan.24 73 C2.a Team-based care organisation - There is a general paucity of evidence on optimising team-based care beyond a few middle-income countries; more evidence is needed on how to train providers to become teams, ideal leadership structure and how best to finance teams.Moderate −13 articles
C2.b Facility management capability and leadership - There is a dearth of evidence on management competencies and training of facility managers.Moderate - 9 articles
C2.c Information systems use - There is little available literature on how best to implement and improve local use of information communication technology and eHealth to improve outcomes in PHC as well as what ideal, low-cost, simple eHealth documentation and data records look like in low resource settings.Low - 5 articles
C2.d Performance measurement and management - Although there is substantial evidence on theoretical frameworks for performance management, its adaptation to local contexts is rather limited, with some country-based exceptions. More evidence is needed on the effectiveness of supportive supervision in under-resourced environments.High - 15 articles
C3. AccessRemoval of financial fees, when combined with geographical access has been seen to increase use of services and reduce mortality in a number of countries, although degree of impact varied, and attention to contextual barriers is necessary.45 74 75 Literature indicates that community health workers can improve geographical access through proactive outreach, but only for a limited scope of services. Timely access to services has been shown to be a challenge across a number of settings, and system redesign such as integration and changes in patient flow can improve timeliness, but more evidence on patient outcomes is needed.75 76 C3.a Financial access - More evidence is needed on the sustainability of existing models as well as feasible and effective ways to measure the impact of insurance schemes on reducing financial access barriers across sub-populations.Moderate - 13 articles
C3.b Geographical access - More research is needed on how to decentralise while maintaining quality of inputs, availability, and competency at a national level.Moderate - 12 articles
C3.c Timeliness - We found little evidence on how to improve timeliness. Research is needed on: measuring timeliness, improvements of timeliness that also ensure experiential and technical quality and novel approaches to expand timely access to specialty care.Low - 2 articles
C4. Availability of effective PHCThe literature shows that a combination of strategies including training opportunities for providers in more rural areas, salary increases and supporting infrastructure can increase availability in underserved areas.77 A common approach to increasing provider availability is task shifting which has been shown to be effective in a number of settings but requires adequate training and support.42 66 77 There are significant gaps in competency described across countries, areas of care, processes of care (ie, diagnosis, treatment, exams), cadres and health sectors.51–53 Protocol-based approaches that focus on a range of common conditions (such as Integrated Management of Childhood Illness - IMCI) are associated with improvements in technical competency but not always outcomes.78 Burnout and low motivation is common in a number of countries, and myriad measurement tools exist. A number of studies reported that interventions such as performance-based financing combined with a balanced scorecard and other performance-tied incentives did not improve motivation.49 50 The studies that we identified related to patient-provider respect and trust found that service integration led to higher patient reports of respect, lack of respect is associated with lower satisfaction in maternity care services, and in Afghanistan, poor trust and disrespect in maternity services is associated with bypass or non-use of care.36 79 80 Finally, unsafe practices in diagnosis and treatment - including medication quality - is well documented.53 81 But other domains of safety are not well-studied. C4.a Provider availability - Gaps exist regarding contextual factors that drive availability in different settings, sustainability of effective interventions and the role of task shifting.Low - 6 articles
C4.b Provider competence - More research is needed to explain the variance in the quality of care delivery across countries, as well as the influence of contextual factors such as payment, continuing training and credentialing on provider competence.High - 32 articles
C4.c Provider motivation - There is a gap in knowledge regarding which interventions to increase intrinsic and extrinsic motivation are feasible and sustainable, as well as how best to measure the impact of motivation on care delivery, provider availability and retention.High - 22 articles
C4.d Patient-provider respect and trust - A better understanding of how to improve experiential quality, including trust, is needed. Additionally, a gap remains in the understanding of the relationship between technical quality and patient satisfaction and reported responsiveness.High - 14 articles
C4.e Safety - Evidence is needed on effective, feasible and scalable interventions to sustainably improve safety both in direct patient care and facility practices and environment. This needs to be across the range of PHC-delivery sources (community-based, facility, public and private).Low - 4 articles
C5. High-quality PHCA review of patient experience of care in South America found that more than half of respondents reported not having a regular primary care provider.75 A systematic review of interventions to improve access to care for children found that interventions that delivered services at or closer to home and text messages were associated with a significant improvement in outcomes.82 Related to continuity, a study in Brazil found that centres with more available services and better structure, equipment and supply availability and information systems were associated with better continuity.83 However, a study from Iran found that patients who visited the same family physician did not necessarily report greater patient-perceived relational continuity; patient and provider perceptions of continuity are influenced by different factors.75 84 Gaps in both coordination and person-centred care have been documented across six Latin American/Caribbean countries.75 There are myriad studies that have explored determinants of satisfaction with person-centred care including structural factors, process factors, perceptions of quality and outcomes.80 85 C5.a First contact accessibility - While there are myriad intervention types for improving access, more evidence is needed about which levers should be used in which contexts as well as the appropriate tools for measuring first contact access in LMIC.Moderate - 12 articles
C5.b Continuity - Most of the evidence on continuity is from Latin America and Iran; key questions remain on the impact of continuity to a provider vs continuity to a team or facility in improving outcomes and perceptions of care.Moderate - 11 articles
C5.c Comprehensiveness - More evidence is needed on the integration of curative and preventive care within PHC facilities as well as the best ways to train staff to become more comprehensive in capacity and approach to the care of each patient.High - 16 articles
C5.d Coordination - There is a dearth of evidence on the experience of care coordination within large, fragmented public/private systems in sub-Saharan Africa and South Asia as well as the best ways to improve coordination and information transfer about transitions of care and referrals in these systems.Moderate - 11 articles
C5.e - Person-centred - More exploration is needed on the apparent lack of relationship between observed quality and care seeking behaviour as well as perceived vs observed quality.High - 18 articles
  • EBAIS, Equipos Básicos de Atención Integral de Salud; FFS, fee for service; LMIC, low-income and middle-income countries; NCD, non-communicable disease; PHC, primary healthcare; PHCPI, Primary Healthcare Performance Initiative.