Table 3

Summary of evidence of approaches to improve PHC efficiency

What works?Where?Why? (enablers of success)
Service delivery model
 Community-based approaches, task-shifting
  • Goa, India (mental health)24

  • Thailand (diabetes and hypertension screening)28

  • Indonesia, North India (basic package of care)53 112

  • Pakistan (maternal and reproductive health)50

  • Proximity of health facility

  • Focus on cost-effective essential services (eg, maternal and child health)

  • Community-based practitioners operate within an integrated team, supported by health system

 Integration of vertical programmes
  • Maharashtra, India (HIV prevention)52

  • Orissa, India (leprosy)113

  • Pakistan (blindness prevention)60

  • Philippines (diabetes prevention and care)114

  • Vietnam (mental health)61

  • Sensitisation of staff

  • Improved co-ordination across programmes

  • Advocacy with key political and administrative stakeholders

  • Adequate resourcing: staff and programme funds

  • Use of treatment guidelines

Health promotion and patient management tools
 Population-based screening
  • Bhutan (diabetes and hypertension)55

  • Indonesia (diabetes and hypertension)56

  • Universal (Bhutan) or targeted (high-risk groups >40 years, Indonesia) more cost-effective than opportunistic screening

  • Follow-up treatment follows PEN guidelines

 Electronic decision-support tools
  • Telangana State, India (hypertension management; physicians)58

  • More cost-effective than chart-based support

  • Link with counselling on lifestyle modification improves impact

PHC financing
 Contracting service through non-state providers
  • Bangladesh (basic package of care)65

  • Various (systematic review, basic package of care)64

  • Pakistan (eye health)60

  • Punjab, India (PHC)63

  • ‘Competition’ between providers may motivate performance

  • Better organisation and management capacity, in part due to autonomy/independence

  • Better systems and capacity to absorb and use budget

  • Better infrastructure, equipment, medicines supply

  • More staff

  • Good community links

  • Govt capacity for effective contract management

  • Trust between contract managers and providers

  • Regular supervisory visits

  • Bonus system linked to coverage

  • Link to higher-level facilities (also NGO run)

  • Shenzhen, China62

  • Combined with insurance model (means patients bypassing PHC have substantially higher out-of-pocket costs)

  • Investment in PHC infrastructure (increases willingness to use)

  • CHW, community health worker; PHC, primary health care.