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EVALUATING PRIMARYHEALTH CARE POLICIES: A
STEP TOWARDS IDENTIFYING HUMAN RESOURCE ISSUES
IN COMMUNE HEALTH STATIONS IN VIETNAM
John Rule, Duc Anh Ngo, Tran Thi Mai Oanh, Alison Short,
Augustine Asante, Graham Roberts & Richard Taylor
www.hrhhub.unsw.edu.au
An AusAID funded initiative
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ACKNOWLEDGEMENTS
This document was reviewed internally by HRH Hub staff and two external reviewers.
Thank you to Professor Nick Zwar, Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, UNSW and Dr Michael O’Rourke, Adjunct Senior Lecturer, Public Health, School of Public Health, University of Sydney for helpful review comments. Thank you also to Dr John Dewdney, Visiti ng Fellow, HRH Hub, for comments and directi on on initi al draft s of the document and Lisa Thompson, Project Offi cer, HRH Hub, for helpful editi ng comments.
Thank you to all research team members at Health Strategy and Policy Insti tute, Hanoi, Vietnam, for their feedback aft er presentati on of an early draft of the document at a workshop held in Hanoi in June 2012.
© Human Resources for Health Knowledge Hub 2013
Suggested citati on:Rule, J et al. 2013, Evaluati ng Primary Health Care Policies: A Step in Identi fying Human Resource Issues in Commune Health Stati ons in Vietnam, Human Resources for Health Knowledge Hub, Sydney, Australia.
Nati onal Library of Australia Cataloguing-in-Publicati on entry
Rule, John
Evaluati ng Primary Health Care Policies: A Step in Identi fying Human Resource Issues in Commune Health Stati ons in Vietnam / John Rule ... [et al.]
9780733432330 (pbk.)
Primary health care—Low and middle-income countriesPrimary health care—VietnamPrimary health care—Commune Health Stati ons
Rule, John.University of New South Wales, Human Resources for Health Knowledge Hub.
Duc Anh Ngo.University of South Australia
Tran Thi Mai Oanh.Health Strategy and Policy Insti tute Vietnam
Alison Short.University of New South Wales, Human Resources for Health Knowledge Hub.
Augusti ne Asante.University of New South Wales, Human Resources for Health Knowledge Hub.
Graham Roberts.University of New South Wales, Human Resources for Health Knowledge Hub.
Richard Taylor.University of New South Wales, Human Resources for Health Knowledge Hub.
362.1
The Human Resources for Health Knowledge Hub
This report has been produced by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
CONTENTS
2 Acronyms
3 Executi ve summary
4 Background
4 Why is evaluati on of primary health care important?
4 Defi ning primary health care in lower- and middle-income countries
5 Previous eff orts to evaluate primary health care in lower- and middle-income countries
6 Rati onale for this literature review
8 Literature review method
10 Findings
10 Overview of fi ndings
11 Studies focused directly on informing policy development
11 Studies concerned with questi ons of quality and equity
12 Studies which developed performance indicators
13 A study using a results-based logic model
13 Summary of fi ndings
16 Conclusion
17 References
20 Appendix
LIST OF TABLES
7 Table 1. Characteristi cs of PHC from Alma Ata declarati on
9 Table 2. Data base search terms
9 Table 3. Exclusion parameters
10 Table 4. Example studies of PHC initi ati ves and diff erent evaluati on methodologies
14 Table 5. Summary of health performance indicators
15 Table 6. Examples of core CHS performance indicators from China CHS Logic Model
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
ACRONYMS
ART Anti retroviral therapy
CHS Commune Health Stati on or Community Health Service
HIV Human immunodefi ciency virus
HRH Human resources for health
HRH Hub Human Resources for Health Knowledge Hub
HSPI Health Strategy and Policy Insti tute (Vietnam)
PHC Primary health care
LMICs Low- and middle-income countries
MDG Millennium Development Goal
NGO Non government organisati on
TB Tuberculosis
WHO World Health Organizati on
A note about the use of acronyms in this publicati on
Acronyms are used in both the singular and the plural, e.g. NGO (singular) and NGOs (plural).
Acronyms are also used throughout the references and citati ons to shorten some organisati ons with long names.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
EXECUTIVE SUMMARY
This literature review is part of a collaborative project between the Health Strategy and Policy Institute (HSPI), based in Hanoi, Vietnam and the Human Resources for Health Knowledge Hub (HRH Hub), University of New South Wales. There is interest in finding a realistic, policy-relevant methodology and approach that can be used to evaluate the performance and effectiveness of the primary health care (PHC) system in Vietnam.
This review documents the ways in which PHC has been evaluated in low- and middle income countries (LMICs), with a focus given to countries that have undergone health sector reforms similar to Vietnam. It will inform a PHC policy analysis currently being conducted by HSPI and assist in conducting operational research to evaluate the effectiveness of Commune Health Stations (the basic unit of the PHC network) in the changing health system of Vietnam.
The review has been a step in the response to the situation in Vietnam where health system reform has had a significant impact on primary health care delivery and the area of human resources for health (HRH). Vietnam’s health system faces many challenges in HRH development within the primary health care network, for example, ensuring and maintaining the quality of HRH in rural areas. Other inputs in the primary health care network such as leadership and governance, health financing, health service delivery and health information systems will be of interest but the focus of the collaboration between HSPI and the Human Resources for Health Knowledge Hub, UNSW is specifically on human resources in primary health care.
Studies from LMICs using an explicit methodology or framework for measuring PHC effectiveness were collated. Databases of published articles were searched and a review of grey literature undertaken to identify relevant reports. Relevant studies were then classified according to study design, methods of data collection and evaluation of outcomes. PHC is a complex social intervention and the realist review approach was used with the aim of directing attention to the contexts in which the interventions were applied.
The review found that there is no consistent approach for assessing the effectiveness of PHC interventions in LMICs. Some presented a case study of PHC policy
implementation; others were disease specific or related to a specific health response context.
Some studies focused on PHC services using descriptive case studies or cross sectional data to assess user satisfaction with services and patient health outcomes. Other studies used documentary analysis, policy review or quantitative surveys in an attempt to assess effectiveness of PHC programs at the district or sub-national level.
Notably, one study in China, aiming to assess the impact of significant investment in PHC renewal programs, used a results-based logic model with input from local stakeholders, to develop a set of core community health facility indicators. This is a promising approach and could be potentially applicable in other LMIC contexts, including Vietnam.
It would be useful to develop an evidence-based approach which is applicable to LMICs for assessing the effectiveness of PHC programs and interventions; but there is no agreed approach which can be identified in the literature.
This review contributes to the development of an approach by identifying a possible role for operational and implementation research studies, which evaluate policy outcomes and consider important matters such as quality and user views of PHC effectiveness.
This document is focused on the diff erent approaches to evaluati ng PHC eff ecti veness that may be of use in Vietnam, the collaborati ve project between HRH Hub and HSPI anti cipates the completi on of a further report which will summarise policy development and challenges in the primary health care network at a grassroots level in Vietnam. In relati on to human resources for health at the primary health care level further informati on will be gathered on: the number of health workers; the distributi on of doctors, pharmacists and nurses; health care workforce structure at a commune level; and recruitment and retenti on policies.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
A major diffi culty has been that there are no control programs with which to compare PHC interventi ons to other possible interventi ons in LMICs.
BACKGROUND
Why is evaluation of primary health care
important?
There have been calls for large scale evaluati ons of PHC and a community focused operati onal research agenda may best meet this need [Gillam 2008]. Evaluati on and research needs to be context specifi c and rely on the commitment of local actors [Gillam 2008; Kruk et al. 2010].
In the context of progress toward the MDGs,
More detailed analysis and evaluati on within and across countries would be invaluable in guiding investments for primary health care. [Rohde et al. 2008, p.950]
Despite PHC being the main subject of the World Health Report [2008] and the topic of a special themed issue of the Lancet in 2008, where contributors argued that PHC is important in tackling health inequality in every country, there is no literature suggesti ng the best methods for evaluati on of PHC.
A major diffi culty has been that there are no control programs with which to compare PHC interventi ons to other possible interventi ons in LMICs. Consequently, few systemati c reviews of the impact of PHC in developing countries have been undertaken [Rohde et al. 2008; Macinko et al. 2009; Kruk et al. 2010]. Some assessment of primary care initi ati ves, and the ways in which they contribute to meeti ng health system goals in LMICs, needs to be developed; despite the fact that formal meta-analysis and comprehensive assessment of PHC interventi ons may not be possible [Kruk et al 2010].
Defi ning primary health care in lower- and
middle-income countries
Prior to the Alma-Ata Declarati on of 1978 (Table 1, page 7), PHC had been used as a strategy for expanding health services in LMICs and, with the declarati on, it became a central concept in global health [Kruk et al. 2010; Negin et al. 2010]. The World Health Organizati on (WHO) Report [2000], assessed work in the previous two decades, noti ng that PHC programs in developing countries could be considered as ‘parti al failures’. The core of this criti cism was that programs had failed to deliver access to health for all. This may have been because health service
delivery had not been able to respond to many problems encountered in developing countries; such problems included lack of access to essenti al drugs and lack of health care workers. Having no traditi on of PHC programs, insuffi cient structural support across government for implementati on and the limited experience of ministries of health were also signifi cant factors limiti ng PHC implementati on [Chabot 1984; Chen 1986; Diallo et al. 1993; Shonubi et al. 2005].
Another interpretati on of the WHO Report [2000] fi ndings is that in the two decades following the declarati on of Alma-Ata, changes in economic philosophy, promoted strongly by the World Bank and based on market forces and competi ti on, led to the replacement of PHC by ‘Health Sector Reform’.
As a result, a sharp decline in the use of the PHC followed in many countries. People in resource poor setti ngs sti ll had no access to basic services and gaps conti nued to widen [Hall & Taylor 2003]. MacDonald [2007] has argued that the global inequity in the availability of PHC is because the WHO principles of PHC have been undermined and sidelined.
The WHO Report [2008] was less criti cal of PHC than the 2000 report, and stated that PHC sti ll did have the potenti al to deliver progress towards the MDGs. The report stated that features of PHC could improve health outcomes in resource constrained setti ngs.
These features included: person-centredness; comprehensive and integrated care; conti nuity of care; and parti cipati on of pati ents, families and communiti es in the provision of health care. The 2008 document also referred to PHC as a set of values and principles and characterised PHC as a ‘movement’, which needed to respond to the pressures of globalisati on.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
The positi oning of PHC in strategy documents, such as the WHO Western Pacifi c Regional Strategy for Health Systems [2010], suggests that the promise of PHC values can sti ll be realised. In additi on, the Western Pacifi c Regional Strategy document says that there is a ‘consensus’ that countries which have developed PHC programs achieve bett er health outcomes, and,
... do bett er at achieving the four goals of health systems: improved health and health equity, universal coverage with fi nancial risk protecti on, responsiveness to the populati on’s desire for health services, and effi cient use of resources. [WHO, 2010, p.3]
PHC has been variously defi ned as: a strategy which must deal with ‘social, economic and politi cal causes and consequences of poor health’ [MacDonald 2007, p. 9]; a set of values or principles, a policy reform focus or a movement, and, a level of service provision [Rohde et al. 2008; WHO 2010]. PHC is necessarily adapted for changing circumstances and is more broadly viewed than it was 30 years ago [Chan 2008].
Notwithstanding diffi culti es experienced in implementi ng PHC, including competi ti on with an increasing number of verti cal and disease specifi c initi ati ves, PHC is an approach which has the potenti al to contribute towards the achievement of the MDGs in LMICs [Walley et al. 2008; Rohde et al. 2008; Kruk et al. 2010].
Previous eff orts to evaluate primary
health care in lower- and middle-income
countries
PHC interventi ons are by their nature complex and deal simultaneously with several health programs making it diffi cult to determine the specifi c contributi on of a PHC interventi on [Hill et al. 2000; Walley et al. 2008; Baum 2008]. In terms of PHC provision in LMICs, the trend for private sector engagement in service delivery and support of health systems is becoming more evident, parti cularly in countries that have undergone health system reforms characterised by the shift from state-owned to market-driven health systems [Palmer et al. 2003; Banatvala & Amery 2006]. There is also variability of progress in implementi ng PHC within countries, and variability in determining what is the cause and eff ect
of the verti cal programs and other interventi ons [Walley et al. 2008].
Kruk and colleagues [2010] found in their review that primary care programs were assisted by other program interventi ons such as community demand building. These are not specifi c health sector inputs and this complicates the evaluati on of PHC interventi ons since program inputs may originate in other sectors. Reforms which might be occurring, for example within the social services area, may substanti ally impact on health outcomes or health access and equity [Macinko 2009 et al.].
It is diffi cult to measure and assess the level of parti cipati on in decisions about health rights and access in countries where the majority of the populati on may not be engaged in decision making about health resource allocati ons [Beaglehole & Bonita 1997, p. 222]. It has also been argued that the best method for determining user views and community opinion about the value of PHC is a research area that requires more rigorous data collecti on, interpretati on and development [Schneider & Palmer 2002].
Not only are there complex factors in evaluati ng the implementati on and impact of PHC programs and initi ati ves, as described above, but there is a further issue of considering how knowledge developed from evaluati on is taken up in a policy context.
Some authors have argued that the uti lisati on of new knowledge does not always occur in an orderly and logical sequence [Stone 2002; Ogden et al. 2003; Ogilvie et al. 2005]. They suggest that evaluati on methods that are iterati ve and process-oriented may in fact be more likely to be infl uenti al and bring about change.
PHC interventi ons are by their nature complex and deal simultaneously with several health programs making it diffi cult to determine the specifi c contributi on of a PHC interventi on.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
There have been only a small number of relati vely well-designed observati onal studies, and a lack of rigorous experimental or quasi-experimental studies evaluati ng the impact of PHC on health outcomes in LMIC [Macinko et al. 2009].
Kruk and colleagues [2010] reviewed 76 papers discussing primary care programs in LMICs but noted that there were many shortcomings in the available evaluati on research. They identi fi ed that nearly two-thirds of the studies employed a pre-experimental or observati onal design, almost one-third employed a quasi-experimental design and only four studies employed an experimental design. Their conclusion was that it appeared that primary care initi ati ves are contributi ng to increased access to services and equity of access; but because there is no control program with which to compare PHC, it is impossible to rule out alternati ve explanati ons for changes that may be observed.
Labonte and Sanders [2010] conducted a synthesis of grey literature and studies which set out to evaluate Comprehensive Primary Health Care in selected countries of Asia. Several key points from their review, which considered 77 studies in 12 countries, are worth noti ng and apply equally to this current literature review:
• Some of the literature reports use of mix of methods and analysis which is processed in fi eld conditi ons - hence much of the literature may not follow rigorous scienti fi c, quanti tati ve evidence collecti on methods.
• There are possibly many PHC initi ati ves that have not been subject to any formal evaluati on that would lead to the publicati on of informati on on their success or not, but nevertheless will have valuable lessons to inform the ways in which primary care initi ati ves take shape in LMICs.
• The diversity of PHC initi ati ves across and within countries makes it diffi cult to develop indicators that can be applied in all contexts.
Rationale for this literature review
PHC interventi ons in LMICs have gone through several stages of implementati on including those occurring in parallel with major restructures of the health system. PHC initi ati ves are currently seen as a
way to ensure the realisati on of MDGs and there have been calls to “get back to the basics” of PHC programs [Chan 2012]. Thus, in order to determine how best to assess the performance and eff ecti veness of PHC, the important fi rst step is to understand how PHC has been evaluated and what performance indicators have been used.
There have been att empts, as described earlier, to review the literature on PHC evaluati on. However, the complexity of systemati cally reviewing the health eff ects of any social interventi on [Ogilvie et al. 2005] have made the task diffi cult. The realist review methodology has been developed to address some of the diffi culti es in synthesising complex interventi ons, but a realist review sti ll att empts to provide substanti al detail and address questi ons of context [Pawson et al 2005; Sheppard et al. 2009]. The realist review has therefore been selected as the best method for this literature review.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
TABLE 1: CHARACTERISTICS OF PHC FROM ALMA ATA DECLARATIONAdapted from Gillam [2008]
• Evolves from the economic conditi ons and socio-cultural and politi cal characteristi cs of a country and its communiti es.
• Is based on the applicati on of social, biomedical, and health services research and public health experience.
• Tackles the main health problems in the community through preventi ve, curati ve, and rehabilitati ve services as appropriate.
• Includes educati on on prevailing health problems; promoti on of food supply and proper nutriti on; an adequate supply of safe water and basic sanitati on; maternal and child health care, including family planning; immunisati on against the main infecti ous diseases; preventi on and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essenti al drugs.
• Involves all related sectors and aspects of nati onal and community development.
• Requires maximum community and individual self-reliance and parti cipati on in the planning, organisati on, operati on, and control of services.
• Develops the ability of communiti es to parti cipate through educati on.
• Should be sustained by integrated, functi onal, and mutually supporti ve referral systems, leading to bett er comprehensive health care for all, giving priority to those most in need.
• Relies on health workers, including physicians, nurses, midwives, auxiliaries, and community workers as well as traditi onal practi ti oners, trained to work as a team and respond to community’s expressed health needs.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
LITERATURE REVIEW METHOD
The following databases were searched for arti cles writt en in English: MEDLINE, EMBASE, the Cumulati ve Index of Nursing and Allied Health Library, the WHO Library, and the Cochrane Library. Two searches by project staff were performed in October 2011 to ensure that all relevant data had been captured at that ti me. The search was limited to English language texts. Additi onal key arti cles, conference publicati ons, and texts were identi fi ed through discussion with colleagues and by scanning the reference lists of selected papers.
The review also included an examinati on of documents which might be considered ‘working papers’, referred to by experts who have had recent fi eld experience establishing evaluati ve frameworks for assessing PHC performance and interventi ons.
The realist review method used here, searches for evidence; appraises studies; synthesises evidence and aims to draw conclusions; acknowledging that there will always be limitati ons on the nature and quality of the informati on that can be retrieved [Pawson et al. 2005].
One possible approach to the review would have been to search the evaluati on literature and data bases for major health service evaluati on methods and then examine the extent to which these had been applied to evaluati on of PHC in LMICs. This may have assisted with establishing search terms around evaluati on methods. However the intenti on of the literature review was to fi nd evaluati on approaches which also addressed questi ons of context within health systems, not just at a health service delivery level. The data base search terms from Table 2 (page 9) and exclusion parameters as outlined in Table 3 (page 9) were decided upon and found to be suffi cient, as initi al searches did capture the range of evaluati on methods.
Initi al database searches using terms from Table 2 yielded 2,150 results. When congruence amongst the search terms was applied there were 422 arti cles found which met the criteria of providing informati on on approaches to evaluati ng PHC in LMICs. Abstracts from the 422 arti cles were retrieved and were read by a review team in the light of exclusion parameters.
Many of the retrieved abstracts showed that arti cles concentrated on a specifi c disease or single health care interventi ons in the context of PHC programs.
These studies were therefore excluded, according to this literature review focus. Studies from developed country contexts were excluded due to the substanti ally diff erent needs and prioriti es in LMICs.
Some studies were found which argued for the rapid and ongoing implementati on of PHC projects [Chabot 1984; Chen 1986; Ramasoota 1997; Van Balen 2004], however these studies did not have an explicit evaluati on methodology and were therefore not included. Some studies functi oned as ‘opinion pieces’ about the potenti al of PHC or limitati on of PHC interventi ons, with no evidence provided that a systemati c evaluati on of PHC eff ecti veness or outcomes had been undertaken. Again these studies were excluded according to the exclusion parameters as outlined in Table 3.
From the 422 abstracts 15 arti cles were selected for further reading and analysis. These selected arti cles:
• Showed changes over ti me in evaluati on approaches.
• Dealt with diff erent levels of interventi on.
• Covered a range of methodologies.
• Were relevant to situati ons where major reforms had occurred or were underway within country health systems.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
TABLE 2: DATA BASE SEARCH TERMS
• Primary health care • Developing countries • Evaluati on • Access
• Primary care • Underdeveloped countries • Assessment • Accessibility
• Grass-roots health care • Low- and middle-income countries • Quality of care
• Commune health centre • Transiti onal countries and/or transiti onal economies
TABLE 3: EXCLUSION PARAMETERS
• Studies were excluded if they did not contain an explicit methodology or criteria for evaluati on and assessment of PHC service delivery or interventi ons.
• Studies were excluded if they had a specifi c disease focus or focused only on health outcomes in one parti cular health service area.
9
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
FINDINGS
Overview of fi ndings
There were very few quanti tati ve studies, experimental and quasi experimental studies identi fi ed; a point which had been noted by Kruk and colleagues [2010]. Table 4 (below) summarises the level of interventi on, methodologies used and the country, or region, of the 15 selected studies. A realist review does not aim to be exhausti ve or enti rely comprehensive, directs att enti on towards the diff erent approaches which have been applied in the fi eld and describes the context in which those approaches were applied.
Of the 15 selected arti cles over half were mixed method studies. The authors argued that the strength of these mixed method studies was that they captured contextual informati on and data through qualitati ve methods and combined this with quanti tati ve indicators developed to assess program outcomes, and health impacts. Detailed informati on
about the studies – aims, study design and outcomes can be found in the Appendix.
The selected studies were reviewed again and four diff erent types of studies were identi fi ed:
A. Studies focused on directly informing policy development, oft en providing a narrati ve account of the development of PHC at a country and policy level.
B. Studies concerned with the questi on of ‘quality’ and ‘equity’ and monitoring implementati on in relati on to service uti lisati on and community sati sfacti on.
C. Studies which att empted to develop a set of health performance indicators to measure eff ecti veness of PHC interventi ons.
D. A study using a results-based logic model, reported in detail and incorporati ng many of the tools from 1 – 3.
TABLE 4: EXAMPLE STUDIES OF PHC INITIATIVES AND DIFFERENT
EVALUATION METHODOLOGIES
LEVEL OF INTERVENTIONS METHODOLOGIES USED
Nitayrumphong [1990] • • Thailand
Birt [1990] • • Vietnam
Diallo et al. [1993] • • Senegal
Bloom [1998] • • China/Vietnam
Hill et al. [2000] • • Gambia
Moore et al. [2003] • • Lati n America
Duong et al. [2004] • • Vietnam
Shonubi et al. [2005] • • Lesotho
Perks et al. [2006] • • Lao
Fritzen [2007] • • Vietnam
Hansen et al. [2008] • • Afghanistan
Pongpirul et al. [2009] • • Thailand
Ditt on & Lehane [2009] • • Thailand
Wong et al. [2010] • • China
Negin et al. [2010] • Fiji
Count
ries
or R
egio
n
Sub-
nati o
nal
Mixe
dM
etho
d
Distric
t or
Loca
l
Nati on
al
Quanti
tati v
e
Qualit
ati ve
10
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
The next secti ons provide details of studies under the groupings (A) – (D)
(A) Studies focused on directly informing
policy development
The review found studies which provided an account of the economic and politi cal contexts and policies in which the PHC programs are delivered. For example, studies by Fritzen [2007], Pongpiril and colleagues [2009] and Negin and colleagues [2010] appeared useful for their potenti al to inform policy development. The study by Negin and colleagues [2010] included a document review and semi-structured key informant interviews – which extracted informati on about the slow decline of the use of PHC faciliti es in Fiji and subsequently generated recommendati ons for a range of strategies for revitalising community health centre acti viti es.
The review found eight narrati ve or descripti ve studies of the ways which PHC initi ati ves have been implemented. Three studies att empted a comparison at district level and two studies took a case study approach assessing policy impacts and outcomes, such as service uti lisati on, at a local level.
All studies found that the goals of PHC initi ati ves should conti nue to be pursued and provided policy focused recommendati ons to overcome barriers to implementati on.
(B) Studies concerned with questions of
quality and equity
The Quality Assurance Project was initi ated to measure the eff ecti veness of PHC in developing countries uti lising a quality assessment approach [Brown et al. 1990]. Quality assurance methods were intended to help PHC program managers defi ne clinical guidelines and standard operati ng procedures. The authors suggested that as well as evaluati ng populati on coverage or the technological merits of health interventi ons, health providers might assess the quality of services compared with prescribed standards.
Walker [1983] noted that there were studies which described the outcomes of parti cular interventi ons, for example, the supply of nutriti on services, but very litt le work had been carried out in connecti on with questi ons of quality, access or equity.
The Quality Assurance Project promoted a method of direct observati on of pati ent/provider encounters as a way of ensuring that quality, as understood by clients, would be assessed, rather than quality as understood by the providers and managers of PHC programs. Some specifi c strategies were recommended by Brown and colleagues [1990] and these included:
• Reviewing a program’s clinical and managerial standards or norms.
• Assessing pati ent and community sati sfacti on with the services provided.
• Reviewing supervisory systems and management acti viti es to see if they are delivering outcomes as intended.
• Assessment of the adequacy of faciliti es, logisti cs and equipment for various programs.
During the 1990s, a number of studies in developing and less developed countries engaged with this quality assurance approach [Nicholas et al. 1991; Reerink & Saueborn 1996; Valadez et al. 1996].
Whitt aker [1999] reviewed the use of a quality framework using structure, process and outcome variables in developing countries and identi fi ed challenges in assessing and implementi ng quality improvement. Some of the challenges noted were: staff and managerial fati gue, professional health care providers’ concerns about intrusion by ‘less qualifi ed’ staff , and overcoming providers’ beliefs that quality improvement is impossible in contexts where there are seriously limited resources.
Some of the challenges noted were: staff and managerial fati gue, professional health care providers’ concerns about intrusion by ‘less qualifi ed’ staff , and overcoming providers’ beliefs that quality improvement is impossible in contexts where there are seriously limited resources.
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Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
In the literature, the quality assurance approach to PHC seems to disappear around the year 2000; this was concurrent with the criti cism being made of PHC at that ti me:
... that it [PHC] did not establish whether it was actually bringing about a quanti fi able change in the health of populati ons in the early 1990s. Its data, analysis and evaluati on systems were weak at a ti me when there was a demand for evidence-based demonstrati ons in health status. [Hall & Taylor 2003, p. 20]
Elements of the quality assurance approach conti nue to be included, for example, in the work of Labonte and Sanders [2010]. They propose that as well as measuring PHC eff ecti veness specifi cally in terms of health outcomes or health sector achievements; eff ecti veness can be assessed in terms of PHC processes and principles, including:
• The explicit value of health equity in services.
• The integrati on of rehabilitati ve, curati ve, preventi ve and health promoti on.
• The extent to which there is community involvement and citi zen parti cipati on.
• The extent to which there is collaborati on and involvement with other sectors.
• The extent to which there is acti on of non-medical determinants of health.
• Whether rights based approaches have been incorporated.
The problem with approaches to PHC research concentrati ng on quality, equity and parti cipati on is that there is no method for agreeing on measurement indicators. For example, how is equity in health services to be measured? Are there any standards by which to measure concepts such as community involvement and citi zen parti cipati on?
Braveman and Gruskin [2003] view equity as a principle that is diffi cult to measure in health care provision. Schneider and Palmer [2002] argue that measuring parti cipati on or sati sfacti on with services is a diffi cult exercise in establishing the truth about people’s opinions and should not be limited to snapshot assessments.
The emphasis on quality assessment in PHC is important but no metrics, or agreed upon measurements or tools, have emerged from the broad concepts; certainly no metrics that can be applied in all circumstances.
(C) Studies which developed performance
indicators
Two signifi cant review arti cles by Kruk and Freedman [2008] and Kruk and colleagues [2010] deal with the issue of assessing health system performance in developing countries and reviewing the contributi on of PHC initi ati ves in LMICs. They note that assessing the contributi on of PHC in developing countries is challenging; there are shortcomings in the available evaluati on research; and there are very few systemati c reviews of the impact of PHC on health in developing countries.
In att empti ng to develop a framework they identi fy three categories related to the performance dimension of eff ecti veness. A porti on of the summary table developed by Kruk and Freedman [2008] on the eff ecti veness dimension is shown on page 14 and those marked in bold were suggested by the authors as sample indicators for developing country contexts. However, even those indicators may not be especially sensiti ve, or relevant for all country situati ons.
While these indicators may be helpful to policy makers interested in assessing the eff ects of diff erent policies, they aim to construct a common framework that could be used across diff erent health systems. The problem with this approach is that health systems are not necessarily comparable across countries [Banatvala & Amery 2006; Walley et al. 2008] so, in fact, a method which allows the development of local context specifi c indicators would be more valuable.
The next secti on provides some informati on on a method used to develop indicators for community health service faciliti es in urban China. This has signifi cant advantages over the assessment criteria proposed by Labonte and Sanders [2010] and Kruk and colleagues [2010], because the method includes a way of developing relevant indicators informed by a comprehensive analysis of the components of PHC program eff ecti veness and effi ciency and guided by
12
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
the needs defi ned through extensive consultati on with relevant stakeholders.
(D) A study using a results-based logic
model
Recent work to develop a set of PHC performance indicators which can be used to identi fy Community Health Service (CHS) Facility prioriti es in urban China is reported by Wong and colleagues [2010]. The arti cle also contains details of the specifi c steps taken to develop a China CHS Logic Model (adapted from the Canadian PHC results-based logic model).
The authors describe the Logic Model as ‘heuristi c’; in the sense that it is being used as a possible method, requiring further investi gati on, in a situati on where it is known that populati on-based reporti ng on health outcomes is not perfect. In China there is no established nati onal reporti ng system for the CHS faciliti es, although some level of monitoring and reporti ng focused on examining structural components of the service, such as fi nancing and faciliti es management, does occur.
Examples of core performance indicators developed for the project are shown on page 15. Sources of data to measure indicators were to include health authority records, CHS facility data and pati ent surveys. In the China CHS Logic Model, 31 input categories were identi fi ed, 64 acti vity level indicators and 105 output indicators were developed.
When the Results-Based Logic Model and the performance indicators were applied the informati on compiled was used to eff ecti vely infl uence policy outcomes. In one district the incidence of measles was found to be higher due to immigrant children not being immunised because of lack of human resources and facility space. This informati on provided the evidence to commence discussions with CHS facility managers about strategies to change this situati on. In both districts where the model was piloted, the coordinati on between CHS and other services was identi fi ed as being poor and fi ndings provided evidence of the need for more formal and structured dialogue between faciliti es.
The methodology required the constructi on of a provisional China CHS Logic Model with performance framework and relevant indicators through policy analysis and literature review. Secondly, a
series of stakeholder consultati ons to review the framework and indicators was held. This included the development of partnerships with the two health districts that were to pilot the framework. Thirdly, a set of indicators to measure diff erent inputs, acti viti es, outputs and outcomes in the Logic Model was designed.
Components of the model included the social, cultural, policy, legislati ve/regulatory and physical contexts as well as populati on characteristi cs. Inputs including fi scal, material and humans resources for health featured in the model. PHC products and services including the volume, distributi on and type were noted, for example informati on on health promoti on, disease preventi on and rehabilitati ve services. The model also included eff ecti veness indicators for immediate, intermediate and fi nal outcomes.
This study provides a promising approach because indicators were developed based on intensive consultati on with relevant stakeholders, rather than based on the discreti on of evaluators, researchers or funding agencies with a set of pre-designed indicators.
Summary of fi ndings
This literature review has found that there are few studies systemati cally evaluati ng the implementati on of PHC programs in LMICs. From the studies examined, the authors of this literature review made a classifi cati on, not simply in terms of methodology or study design, but also in terms of the relati onship to policy impacts.
One group of studies, largely observati onal and qualitati ve in method, att empted to inform policy development by providing detailed informati on about the historical background of PHC interventi ons.
This literature review has found that there are few studies systemati cally evaluati ng the implementati on of PHC programs in LMICs.
13
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
Another group of studies att empted to address the questi ons of quality, access and equity of access to PHC services, but these studies did not develop any informati ve metrics.
Some studies developed a set of indicators which could be applied and assist in the measurement of performance; however, there may be limitati ons in terms of transferability from one country context to another.
The most promising approach has been used in China where a results-based logic framework has been
developed through consultati on and partnership, and a set of performance measurement indicators relevant to the local context were developed and applied. The strength of this approach led to policy acti on by health service, including recommendati ons in regard to human resource allocati on and coordinati on of services. The Logic Model needs iterati ve review, as argued by Wong and colleagues [2011], and the PHC indicators are being modifi ed on an ongoing basis.
TABLE 5: SUMMARY OF HEALTH PERFORMANCE INDICATORS
Adapted from [Kruk & Freedman, 2008]
PERFORMANCE DIMENSION CATEGORY SAMPLE INDICATORS
• Infant mortality*
• Maternal mortality
Health status • Neonatal mortality
• Incidence of low birth weight
Eff ecti veness (outcomes) • Survival rates for lung cancer
• Being treated with respect• Length of wait for care
Pati ent sati sfacti on • Administrati ve simplicity
• Percepti on of access to specialists
• Adequacy of ti me spent with physician
Availability
• Physicians, nurses, hospitals per 1000 populati on• Percentage of populati on within 10km of a clinic
Eff ecti veness (outputs) Access to care • Referral rates for women with obstetric complicati ons
Uti lisati on• TB case detecti on rates• ART treatment rates for people with advanced HIV
* Indicators marked in bold were suggested as sample indicators for developing country contexts.
14
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
TABLE 6: EXAMPLES OF CORE CHS PERFORMANCE INDICATORS
FROM CHINA CHS LOGIC MODEL
Excerpt from [Wong et al. 2010]
CATEGORY N EXAMPLES OF CORE INDICATORS
Health Human Resources • % of qualifi ed health care providers (physicians, nurses, nurse practi ti oners) in CHS
Inputs (n=31 with three examples shown here)
Material Resources • % of sub-districts who have at least one community health centre
Fiscal Resources • Amount of fi nancial investment for capital infrastructure
Policy and governance • % of CHS faciliti es that can be reimbursed through publicly funded health insurance
Acti viti es (n=64 with three examples shown here)
Health care management • % of PHC providers who completed a two-way referral of pati ents
Clinical level • % of CHS faciliti es who can off er Chinese traditi onal medicine
Type • % of PHC organisati ons who currently provide health educati on, illness preventi on
Volume • % of pati ents with hypertension who have health care coordinated by case manager
Outputs (n=105 with three examples shown here)
• % of pati ents who have a regular doctor
• % of pati ents who were referred to other doctors and have informati on back
Quality • % of pati ents who report that they were given enough ti me to discuss fears and concerns
• % of pati ents who rated the quality of CHS good or excellent
15
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
The aim of this literature review, as part of a collaborati ve initi ati ve between HSPI and the HRH Knowledge Hub, was to identi fy the diff erent approaches to evaluati ng PHC initi ati ves in LMICs. It is anti cipated that informati on from this review will serve as a methodological platf orm for future studies in Vietnam, through HSPI. The aim of future studies will be to determine how best to assess the performance and eff ecti veness of CHSs in Vietnam.
This is congruent with the argument put by Gillam [2008] that any study which att empts to evaluate PHC will need to be context specifi c and will rely on the commitment of local actors to best determine how it will be conducted. In the context of a renewed interest in the potenti al of PHC to deliver global health goals, in countries where major health sector reforms and challenges are conti nuing, the fi ndings of the review are relevant to calls for a more evidence based approach to the assessment of the benefi ts of PHC initi ati ves.
This review has found that there is no internati onally standardised methodology or approach to PHC research, but that over the last thirty years there has been a range of approaches used. These have been, mostly, observati onal and descripti ve accounts of the success and diffi culti es of implementi ng PHC programs. The review found that there had also been signifi cant interest in assessing the ‘quality’ of PHC services; questi ons of quality, access and equity of access remain important.
The review found only a few examples of studies where metrics and indicators were developed and tested. It is important to note that indicators developed in one country or context will not always be relevant in another context and it may
not be possible to develop a set of internati onally standardised evaluati on tools.
The background literature which described the changes over the last 30 years in implementati on of PHC (and indeed interest in implementi ng PHC initi ati ves) suggests that any approach used needs to be capable of adaptati on and change over ti me. The review found that the development of a results-based logic model combined with indicators for assessing local situati ons appeared to be an approach which had the potenti al for applicati on in LMICs. Such applicati ons need further investi gati on, since other examples may exist which have not yet been documented through research studies or be available in published literature.
The approach of coming to an agreement about quanti fi able indicators is relevant to the project in Vietnam, as HSPI is positi oned to begin that discussion with partners and stakeholders. Stakeholder consultati ons at a nati onal through to local Commune Health Stati on level will be important to establish what those indicators may be. HSPI is ideally placed to negoti ate the components of the broader results-based framework, defi ning the areas of PHC eff ecti veness and effi ciency as relevant in Vietnam.
... any study which att empts to evaluate PHC will need to be context specifi c and will rely on the commitment of local actors to best determine how it will be conducted.
CONCLUSION
16
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
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AP
PE
ND
IX
TITL
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F TH
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Y/R
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: wha
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orke
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g 19
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tabl
ishe
d by
the
Min
istr
y of
H
ealth
.
Prim
ary
heal
th c
are:
from
asp
irati o
n to
ach
ieve
men
t [D
iallo
et a
l. 19
93]
The
stud
y ai
med
to
revi
ew S
eneg
al’s
resp
onse
to
initi
ati v
es a
imed
at
stre
ngth
enin
g PH
C.
Des
cripti v
e st
udy
base
d on
som
e qu
anti t
ati v
e da
ta
from
an
oper
ati o
nal l
evel
ev
alua
ti on
of fi
ve d
istr
ict
heal
th c
entr
es.
The
stud
y id
enti fi
ed
barr
iers
whi
ch le
d to
the
PHC
stra
tegy
bei
ng d
iscr
edite
d in
the
eyes
of m
edic
al
staff
in
the
publ
ic s
ecto
r –
due
to d
rug
dist
ribu
ti on
and
supp
ly p
robl
ems,
dem
oral
izati
on
of p
erso
nnel
, de
velo
pmen
t of c
land
esti n
e pr
ivat
e pr
acti c
e.
The
auth
ors
note
d th
e diffi
culty
in s
electi n
g a
met
hodo
logy
.
Prim
ary
heal
th c
are
mee
ts th
e m
arke
t in
Chin
a an
d Vi
etna
m
[Blo
om 1
998]
The
pape
r ai
med
to o
utlin
e th
e ch
ange
s w
hich
had
take
n pl
ace
in th
e he
alth
sec
tors
of
Chi
na a
nd V
ietn
am d
urin
g th
e tr
ansiti o
n to
a m
arke
t ec
onom
y an
d de
scri
be h
ow
that
tran
siti o
n infl u
ence
d he
alth
sec
tor
perf
orm
ance
.
Nar
rati v
e ac
coun
t of
impa
ct o
n in
fras
truc
ture
de
velo
pmen
t, h
ealth
m
anag
emen
t sys
tem
, co
mm
unity
mob
ilisati o
n,
heal
th fi
nanc
e sy
stem
and
pl
anni
ng u
sing
pri
ncip
les
of
PHC.
In b
oth
coun
trie
s it
was
iden
ti fi e
d th
at c
hild
and
in
fant
mor
talit
y ha
d de
clin
ed a
nd li
fe e
xpec
tanc
y ha
d co
nti n
ued
to g
row
, no
evid
ence
was
ava
ilabl
e in
rega
rds
to s
ub-n
ati o
nal t
rend
s. P
riva
te h
ealth
se
rvic
es w
ere
prov
idin
g gr
eate
r ch
oice
for
som
e,
but l
imiti
ng a
cces
s fo
r th
ose
who
cou
ld n
ot aff o
rd
user
pay
s fe
es b
eing
intr
oduc
ed. F
acto
rs w
hich
co
ntri
bute
d to
hea
lth im
prov
emen
ts w
ere
not
clea
rly
isol
ated
in th
is re
port
.
20
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
TITL
E O
F TH
E ST
UD
Y/R
EPO
RT
KEY
QU
ESTI
ON
/OB
JECT
IVE
OF
THE
STU
DY
DES
IGN
COM
MEN
TS
Dec
line
of m
orta
lity
in c
hild
ren
in r
ural
Gam
bia:
the
infl u
ence
of
villa
ge-le
vel p
rim
ary
heal
th c
are
[Hill
et
al.
2000
]
The
stud
y ai
med
to a
sses
s th
e eff
ecti
ven
ess
of P
HC
prog
ram
s.
Long
itudi
nal c
ompa
rati v
e st
udy.
Dat
a on
infa
nt a
nd c
hild
mor
talit
y w
as c
olle
cted
ov
er a
15
year
per
iod
in 4
0 vi
llage
s an
d co
mpa
riso
ns
wer
e dr
awn
betw
een
thos
e w
ith a
nd w
ithou
t PH
C.
The
stud
y fo
und
that
sup
ervi
sion
of t
he P
HC
syst
em
wea
kene
d aft
er
1994
and
mor
talit
y ra
tes
rose
si
gnifi
cant
ly.
Det
erm
inan
ts o
f hea
lth s
tatu
s an
d th
e infl u
ence
of p
rim
ary
care
se
rvic
es in
Lati
n A
mer
ica
1990
-98
[Moo
re e
t al.
2003
]
The
stud
y ai
med
to e
xam
ine
the
fact
ors,
incl
udin
g th
e im
pact
of t
he p
rovi
sion
of
PHC
serv
ices
, whi
ch w
ere
asso
ciat
ed w
ith u
nder
-fi v
e m
orta
lity
rate
s in
22
coun
trie
s of
Lati
n A
mer
ica
and
the
Cari
bbea
n du
ring
the
1990
s.
Multi v
aria
te a
naly
sis
draw
ing
on a
ggre
gate
d da
ta fr
om
Wor
ld B
ank
and
the
Uni
ted
Nati
ons
Chi
ldre
ns F
und.
Mis
sing
dat
a po
ints
from
cou
ntri
es m
eant
that
man
y va
riab
les
had
drop
ped
from
the
anal
ysis
. Phy
sici
ans
per
1000
peo
ple
wer
e si
gnifi
cant
ly a
ssoc
iate
d w
ith
low
er u
nder
-fi ve
mor
talit
y ra
tes
but s
o w
ere
thre
e no
n-he
alth
car
e in
dica
tors
. Fem
ale
liter
acy
rate
s w
ere
foun
d to
be
high
ly c
orre
late
d, a
long
with
two
othe
r no
n-he
alth
fact
ors.
The
stu
dy d
esig
n co
uld
not s
how
th
at o
bser
ved
impr
ovem
ents
of u
nder
-fi ve
mor
talit
y ra
tes
wer
e du
e to
pri
mar
y he
alth
car
e in
terv
enti o
ns.
Uti l
izati
on
of d
eliv
ery
serv
ices
at t
he
prim
ary
heal
th c
are
leve
l in
rura
l Vi
etna
m [D
uong
et a
l. 20
04]
The
stud
y in
vesti
gat
ed fa
ctor
s infl u
enci
ng th
e uti
lisati o
n of
del
iver
y se
rvic
es a
t the
pr
imar
y he
alth
car
e le
vel.
Qua
nti t
ati v
e su
rvey
, foc
us
grou
p di
scus
sion
s an
d in
-de
pth
inte
rvie
ws.
The
stud
y id
enti fi
ed
that
cos
ts o
f ser
vice
s w
as a
n im
port
ant f
acto
r; b
ut in
som
e di
stri
cts
soci
al, c
ultu
ral
and
relig
ious
fact
ors
and
the
nati o
nal t
wo-
child
pol
icy
wer
e ba
rrie
rs to
ser
vice
uti l
isati
on.
The
met
hod
did
not s
pecifi c
ally
add
ress
eff e
c ti v
enes
s of
Com
mun
e H
ealth
Cen
tre
oper
ati o
ns.
“Hea
lth fo
r All”
in a
Lea
st-D
evel
oped
Co
untr
y [S
honu
bi e
t al.
2005
]Th
e arti c
le d
escr
ibes
and
pr
ovid
es a
n ev
alua
ti on
of th
e he
alth
car
e sy
stem
in L
esot
ho
base
d on
pri
mar
y he
alth
car
e pr
inci
ples
.
A n
arrati v
e de
scri
pti o
n of
th
e st
ruct
ure
of th
e he
alth
sy
stem
is p
rovi
ded.
Thi
s in
clud
ed a
sys
tem
of h
ealth
ce
ntre
s an
d cl
inic
s, e
ach
serv
ing
appr
ox 1
0,00
0 pe
ople
ac
cess
ible
to p
eopl
e w
ithin
1-
2 ho
urs
wal
k.
The
repo
rt c
oncl
uded
that
edu
cati o
n w
as th
e m
ost
eff e
cti v
e m
eans
of p
rovi
ding
a s
usta
inab
le s
oluti
on
to
heal
th p
robl
ems
in L
esot
ho a
nd p
erha
ps o
ther
low
- in
com
e co
untr
ies.
A v
ery
sim
ple
tool
cal
led
a vi
sual
an
alog
sca
le w
as u
sed
to a
sses
s th
e eff
ecti
ven
ess
of th
e sy
stem
dur
ing
visi
ts to
var
ious
hea
lth
insti
tuti
ons
by
the
auth
ors.
Fea
ture
s of
the
syst
em,
whi
ch in
clud
ed p
ati e
nt re
tain
ed m
edic
al re
cord
s an
d en
suri
ng e
asy
acce
ss to
faci
liti e
s re
gard
less
of
soci
oeco
nom
ic s
tatu
s, re
side
nce
or n
atur
e of
the
illne
ss, w
ere
high
ly ra
ted.
21
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
TITL
E O
F TH
E ST
UD
Y/R
EPO
RT
KEY
QU
ESTI
ON
/OB
JECT
IVE
OF
THE
STU
DY
DES
IGN
COM
MEN
TS
Dis
tric
t hea
lth p
rogr
amm
es a
nd
heal
th-s
ecto
r re
form
: cas
e st
udy
in th
e La
o Pe
ople
’s D
emoc
rati c
Re
publ
ic [P
erks
et a
l. 20
06]
The
stud
y so
ught
to e
valu
ate
the
relati o
nshi
p be
twee
n ce
ntra
lly m
anag
ed d
isea
se-
spec
ifi c
prog
ram
s an
d pr
imar
y he
alth
car
e de
liver
y in
one
parti c
ular
dis
tric
t.
Doc
umen
t rev
iew
, col
lati o
n of
impa
ct d
ata
and
eval
uati o
n w
orks
hops
.
Dat
a as
sess
ed in
clud
ed fa
cilit
y uti
lisati o
n, m
ater
nal
mor
talit
y an
d in
fant
and
chi
ld m
orta
lity
stati
sti c
s.
Lega
cies
of p
rim
ary
heal
th c
are
in a
n ag
e of
hea
lth s
ecto
r re
form
: Vi
etna
m’s
com
mun
e cl
inic
s in
tr
ansiti o
n [F
ritz
en 2
007]
The
pape
r ai
med
to e
valu
ate
the
stra
tegy
and
out
com
es
of th
e att
em
pt in
Vie
tnam
to
revi
talis
e th
e gr
assr
oots
in
fras
truc
ture
of P
HC
agai
nst
the
back
drop
of t
he c
ount
ry’s
ec
onom
ic tr
ansiti o
n.
A d
escr
ipti v
e ac
coun
t of
inte
rrel
ated
dev
elop
men
ts
of m
arketi s
ati o
n an
d de
cent
ralis
ati o
n w
as li
nked
to
dat
a fr
om th
e W
orld
Ba
nk a
nd M
inis
try
of H
ealth
. A
stu
dy o
f 88
clin
ics
– ev
alua
ti ng
proj
ect o
utpu
ts,
the
stre
ngth
of o
ther
PH
C co
mpo
nent
s an
d cl
inic
co
vera
ge –
was
con
duct
ed.
Hav
ing
som
e em
piri
cal d
ata
to in
form
the
anal
ysis
pr
ovid
ed fo
r a
repo
rt w
hich
exp
lore
d th
e th
eoreti c
al
cove
rage
of t
he r
ural
pop
ulati
on
acce
ss to
bas
ic
heal
th s
ervi
ce th
roug
h th
e ne
twor
k of
pub
lic c
linic
s an
d us
eful
ly id
enti fi
ed
disr
upti o
ns s
uff e
red
beca
use
of th
e tr
ansiti o
n to
a m
arke
t eco
nom
y. T
he s
tudy
al
so id
enti fi
ed
that
equ
itabl
e ac
cess
to b
asic
hea
lth
serv
ices
for
poor
est s
egm
ents
of t
he p
opul
ati o
n re
mai
ns p
robl
emati
c.
Det
erm
inan
ts o
f pri
mar
y ca
re
serv
ice
qual
ity in
Afg
hani
stan
[H
anse
n et
al.
2008
]
The
stud
y ai
med
to d
escr
ibe
the
leve
l of q
ualit
y of
ca
re p
rovi
ded
by a
genc
ies
impl
emen
ti ng
basi
c he
alth
pr
ogra
ms
and
iden
ti fy
fact
ors
asso
ciat
ed w
ith v
ariati o
ns in
qu
ality
.
Cros
s se
cti o
nal s
urve
y,
with
out c
ontr
ol, o
f a ra
ndom
sa
mpl
e of
25
heal
th fa
ciliti
es.
Th
e st
udy
incl
uded
hea
lth
wor
kers
, pati
ent
s an
d ca
reta
kers
inte
rvie
ws.
Dat
a w
as d
raw
n fr
om 1
553
heal
th w
orke
r in
terv
iew
s an
d 57
19 o
bser
vati o
ns. A
‘sca
le o
f qua
lity
care
’ was
de
velo
ped
usin
g m
easu
re fr
om c
linic
al c
onsu
ltati o
ns
e.g.
com
mun
icati
on
and ti m
e sp
ent w
ith p
ati e
nts.
Th
is d
emon
stra
ted
sign
ifi ca
nt v
ariati o
ns s
uch
as
high
per
form
ance
of N
GO
faci
liti e
s, s
ignifi c
ant
regi
onal
var
iati o
ns, a
nd th
e infl u
ence
of g
ood
clin
ical
su
perv
isio
n.
Polic
y ch
arac
teri
sti c
s fa
cilit
ati n
g pr
imar
y he
alth
car
e in
Tha
iland
: A
pilo
t stu
dy in
tran
siti o
nal c
ount
ry
[Pon
gpir
ul e
t al.
2009
]
The
pilo
t stu
dy a
imed
to
ass
ess
impo
rtan
t pr
imar
y he
alth
car
e po
licy
char
acte
risti
cs,
suc
h as
eq
uita
ble
dist
ribu
ti on
of
reso
urce
s ac
ross
pro
gram
s in
a c
onte
xt w
here
ther
e ar
e lim
ited
data
base
s.
Nar
rati v
e sy
nthe
sis
from
exp
ert i
nter
view
s an
d do
cum
ent r
evie
w.
Que
sti o
nnai
re s
urve
y of
5
seni
or p
olic
ymak
ers,
5
acad
emic
ians
and
77
prim
ary
care
pra
cti ti
oner
s.
The
stud
y pr
ovid
ed u
sefu
l inf
orm
ati o
n ab
out r
egio
nal
vari
ati o
ns in
PH
C de
liver
y an
d re
com
men
ded
a w
ider
st
udy
be im
plem
ente
d.
22
Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries
TITL
E O
F TH
E ST
UD
Y/R
EPO
RT
KEY
QU
ESTI
ON
/OB
JECT
IVE
OF
THE
STU
DY
DES
IGN
COM
MEN
TS
Tow
ards
real
isin
g pr
imar
y he
alth
ca
re fo
r th
e ru
ral p
oor
in T
haila
nd:
Hea
lth p
olic
y in
acti
on
[Ditt
on &
Le
hane
, 200
9]
The
aim
was
to e
valu
ate
a Pr
imar
y Ca
re U
nit i
n Th
aila
nd.
Case
stu
dy d
raw
ing
data
fr
om o
bser
vati o
n, re
view
of
pati
ent
list
s an
d re
cord
s,
docu
men
t rev
iew
and
key
pe
rson
nel i
nter
view
s.
Use
d St
arfi e
ld’s
con
cept
ual f
ram
ewor
k of
eva
luati
ng;
fi r
st c
onta
ct c
are,
long
itudi
nalit
y, c
ompr
ehen
sive
ness
an
d co
ordi
nati o
n. P
olic
y an
d pr
acti c
e im
plic
ati o
ns
wer
e dr
awn
from
the
stud
y. R
esul
ts c
ould
not
be
gene
ralis
ed a
nd s
tudy
lack
ed e
xter
nal v
alid
ity.
The
evol
uti o
n of
pri
mar
y he
alth
ca
re in
Fiji
: Pas
t, p
rese
nt a
nd fu
ture
[N
egin
et a
l. 20
10]
The
stud
y ai
med
to
unde
rsta
nd th
e ev
oluti
on
of P
HC
in F
iji; h
ow p
olic
ies
had
chan
ged
over
ti m
e an
d th
e ro
le o
f var
ious
ac
tors
in infl u
enci
ng p
olic
y de
velo
pmen
t.
The
stud
y us
ed d
ocum
ent
revi
ew, s
emi-s
truc
ture
d ke
y in
form
ant i
nter
view
s an
d W
alt a
nd G
ilson
’s h
ealth
po
licy
tria
ngle
to a
naly
se a
nd
colla
te in
form
ati o
n.
Empi
rica
l dat
a ga
ther
ed th
roug
h hi
stor
ical
do
cum
ents
and
lite
ratu
re s
earc
h, a
s w
ell a
s 14
in
terv
iew
s, p
rovi
ded
data
on
the
slow
dec
line
of P
HC
and
use
of P
HC
faci
liti e
s. A
rang
e of
fact
ors
from
th
e en
d of
WH
O fu
ndin
g, d
omesti c
inst
abili
ty a
nd
cultu
ral c
hang
es in
Fiji
an v
illag
es w
ere
iden
ti fi e
d as
im
pacti
ng
on P
HC
prov
isio
n. A
rang
e of
str
ateg
ies
for
revi
talis
ing
com
mun
ity h
ealth
cen
tre
acti v
iti es
in a
w
ay th
at fo
cuse
d on
‘qua
lity’
of h
ealth
ser
vice
s w
ere
reco
mm
ende
d.
Dev
elop
ing
a pe
rfor
man
ce
mea
sure
men
t fra
mew
ork
and
indi
cato
rs fo
r co
mm
unity
hea
lth
serv
ice
faci
liti e
s in
urb
an C
hina
[W
ong
et a
l. 20
10]
The
stud
y ai
med
to d
evel
op
a Ch
ina
resu
lts b
ased
Log
ic
Mod
el a
nd a
set
of r
elev
ant
PHC
indi
cato
rs to
mea
sure
Co
mm
unity
Hea
lth S
tati o
n pr
ioriti e
s.
A fr
amew
ork
and
indi
cato
rs
wer
e de
velo
ped
with
con
tent
va
lidati
on
ensu
red
thro
ugh
polic
y an
alys
is, c
riti c
al re
view
of
lite
ratu
re, a
nd s
take
hold
er
cons
ultati o
n.
The
fram
ewor
k an
d in
dica
tors
to m
easu
re in
puts
, acti v
iti es
, out
puts
and
out
com
es w
ere
appl
ied
in
two
dist
rict
s to
gen
erat
e da
ta a
bout
ope
rati o
ns. D
ata
was
then
sha
red
with
Com
mun
ity H
ealth
Stati o
n m
anag
ers
for
cons
ider
ati o
n of
cha
nges
in p
olic
y an
d pr
acti c
e.
23
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AND MANAGEMENT REVIEW SERIES
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• HIV and human resources challenges in Papua New Guinea: An overview
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The Human Resources for HealthKnowledge Hub is one of four hubsestablished by AusAID in 2008 as part of the Australian Government’s commitment to meeti ng the Millennium Development Goals and improving health in the Asia and Pacifi c regions.
All four Hubs share the common goal of expanding the experti se and knowledge base in order to help inform and guide health policy.
Human Resource for Health Knowledge HubUniversity of New South Wales
Some of the key themati c areas for this Hub include governance, leadership and management; maternal, newborn and child health workforce; public health emergencies; and migrati on.
www.hrhhub.unsw.edu.au
Health Informati on Systems Knowledge HubUniversity of Queensland
Aims to facilitate the development and integrati on of health informati on systems in the broader health system strengthening agenda as well as increase local capacity to ensure that cost-eff ecti ve, ti mely, reliable and relevant informati on is available, and used, to bett er inform health development policies.
www.uq.edu.au/hishub
Health Finance and Health Policy Knowledge HubThe Nossal Insti tute for Global Health (University of Melbourne)
Aims to support regional, nati onal and internati onal partners to develop eff ecti ve evidence-informed nati onal policy-making, parti cularly in the fi eld of health fi nance and health systems. Key themati c areas for this Hub include comparati ve analysis of health fi nance interventi ons and health system outcomes; the role of non-state providers of health care; and health policy development in the Pacifi c.
www.ni.unimelb.edu.au
Compass: Women’s and Children’s HealthKnowledge HubCompass is a partnership between the Centre for Internati onal Child Health, University of Melbourne, Menzies School of Health Research and Burnet Insti tute’s Centre for Internati onal Health.
Aims to enhance the quality and eff ecti veness of WCH interventi ons and focuses on supporti ng the Millennium Development Goals 4 and 5 – improved maternal and child health and universal access to reproducti ve health. Key themati c areas for this Hub include regional strategies for child survival; strengthening health systems for maternal and newborn health; adolescent reproducti ve health; and nutriti on.
www.wchknowledgehub.com.au
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