J Ambulatory Care ManageVol. 32, No. 2, pp. 150–171Copyright c© 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Impact of PrimaryHealthcare on PopulationHealth in Low- andMiddle-Income Countries

James Macinko, PhD; Barbara Starfield, MD, MPH;Temitope Erinosho, PhD

Abstract: This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC)on health outcomes in low- and middle-income countries. Studies were abstracted and assessedaccording to where they took place, the research design used, target population, primary caremeasures, and overall conclusions. Results indicate that the bulk of evidence for PHC effective-ness is focused on infant and child health, but there is also evidence of the positive role PHChas on population health over time. Although the peer-reviewed literature is lacking in rigorousexperimental studies, a small number of relatively well-designed observational studies and the con-sistency of findings generally support the contention that an integrated approach to primary carecan improve health. A few large-scale experiences also help identify elements of good practice. Thereview concludes with several recommendations for future studies, including a focus on better con-ceptualizing and measuring PHC, further investigation into the advantages of comprehensive overselective PHC, need for experimental or quasi-experimental research designs that allow testing ofthe independent effect of primary care on outcomes over time, and a more detailed conceptualframework guiding overall evaluation design that places limits on the parameters under consider-ation and describes relationships among different levels and types of data likely to be collected inthe evaluation process. Key words: developing country, evaluation, population health, primaryhealthcare

THE WORLD HEALTH ORGANIZATION(WHO) formalized its commitment to pri-

mary healthcare (PHC) in 1978, when it wasidentified as central to the achievement of thegoal of “Health for All”and as a key instrumentfor improving health throughout the world(WHO, 1978).

In the decades following Alma Ata, manylow- and middle-income countries have un-

Author Affiliations: Department of Nutrition, FoodStudies, and Public Health, New York University,New York (Drs Macinko and Erinosho); andDepartment of Health Policy and Management, TheJohns Hopkins Medical Institutions, Baltimore,Maryland (Dr Starfield). Dr Erinosho is now withHealth Promotion Research Branch, NationalCancer Institute, Rockville, Maryland.

Corresponding Author: James Macinko, PhD, Depart-ment of Nutrition, Food Studies, and Public Health, NewYork University, 35 W 4th St, 12th Floor, New York, NY10012 (james.macinko@nyu.edu).

dergone dramatic changes, including democ-ratization, economic liberalization in an in-creasingly globalized world, redefining therole of the state, and reforming their healthand social services systems. Health reforms, inparticular, have aimed at streamlining health-care financing and decentralizing authorityfor planning and implementation. There isincreasing evidence that not all of these re-forms have strengthened PHC, nor have theyuniformly contributed to improving healthor equity in its distribution (Infante & deMata, 2000; Mackintosh, 2000; Varatharajan &Thankappan, 2004).

In many high-income countries, various at-tributes of primary care have been shownto exert a positive influence on health costs,appropriateness of care, and outcomes formost of the major health indicators (Bindmanet al., 1996; Forrest & Starfield, 1996, 1998;Starfield, 1998; Starfield et al., 2005a, 2005b).

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Primary Healthcare in Low- and Middle-Income Countries 151

There is also evidence that countries charac-terized by a strong primary care orientationhave better and more equitable health out-comes than those systems that are orientedtoward specialty care (Macinko et al., 2003;Starfield, 1996; Starfield & Shi, 2002). Nev-ertheless, there is considerable debate abouthow effective PHC has been in improvingpopulation health in low- and middle-incomecountries (Filmer et al., 2000; Lewis et al.,2004).

The 30-year anniversary of the Alma Atameeting, the changing health challenges inthe developing world, and the widespreaddissatisfaction with the status quo have gen-erated interest in a renewed and reinvigo-rated approach to health systems develop-ment based on PHC (“Margaret Chan putsprimary health care,” 2008; Pan AmericanHealth Organization, 2005; WHO, 2008). Toaid in this process, the present review as-sesses the peer-reviewed literature for evi-dence of the effectiveness of previous PHCexperiences with the goal of identifyinglessons learned and providing suggestions forstrengthening the PHC evidence base.

METHODS

The literature review was conductedby searching the US National Library ofMedicine’s PubMed database, the CochraneDatabase of Systematic Reviews, and the In-ternet (via Google) for articles that containedthe phrases “primary care”or “primary healthcare” along with the terms “evaluation” or“impact” in either the title or the abstract.Several journals that publish on healthcarein the developing world were also handsearched. All articles were then culled toidentify additional references. This processrevealed more than 10 000 potential articlesas of July 2008.

From the large potential pool of articles,we excluded all commentaries and non–peer-reviewed works and all articles related to Eu-ropean or other Organization for EconomicCooperation and Development countries. Ab-stracts and study designs were then reviewedto identify articles that addressed the evalua-

tion of PHC programs, systems, and servicesand to exclude articles that (1) did not explic-itly define the scope of the PHC intervention;(2) evaluated only one component of selectiveprimary care services (eg, immunization, oralrehydration therapy); or (3) did not includedata on changes in health outcomes attributedto the PHC intervention. Overall, 36 key arti-cles were retrieved and abstracted.

The Appendix contains a synthesis of themain objectives, study designs, outcomes,PHC measures, and results of the reviewed ar-ticles. We adopt the term “selective”to charac-terize interventions directed at selected indi-vidual health conditions (such as control of di-arrheal diseases) and “integrated” to describeapproaches that are more directed at health ingeneral. In the presentation of results, we dis-tinguish between PHC tasks or services (ie, di-rected at a specific health problem) and PHCfunctions (ie, directed at assuming the mainrole of PHC within health systems, regardlessof the specific health problem).

RESULTS

Figure 1 shows the distribution of new ar-ticles by year on the topic of PHC, which hasincreased each year and, after a relatively sta-ble period from 1995 to 2003, now averagesabout 500 new articles per year.

Table 1 shows characteristics of the 36abstracted studies. Geographically, they arefairly evenly distributed: slightly more than athird are from Africa, about a third are fromLatin America and the Caribbean, a quarterfrom Asia, with the remaining representingmultiple regions. In terms of study design,most (45%) use a pre- and postinterventioncross-sectional design with controls or com-parison groups, about 14% use a case-controldesign, another 11% use multivariable longitu-dinal analyses of ecological data, 1 study usesan experimental design, and 1 uses a cohortapproach. All remaining studies employeda variety of observational designs withoutcontrols.

In terms of outcomes, more than three-quarters of the studies focused on infant orunder-5 mortality, with the remainder dealing

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Figure 1. The number of new articles published in PubMed with “primary health care” in the abstract ortitle, by year (1975–2007).

Table 1. Characteristics of studies reviewed(N = 36)

Number

Domain of studies

Geographic region

Latin America and the

Caribbean Sub-Saharan

12

Africa 16

Asia 8

Other (or multiple regions) 1

Study design

Experimental or

quasi-experimental

5

Prospective study with

control group

1

Repeated (pre/post)

cross-sectional design

with control

16

Case-control 5

Repeated (pre/post)

cross-sectional design

without control

5

Systematic literature review 1

Observation/qualitative

study/single cross-section

3

Main outcome studied

Infant or under-5 mortality 28

Other (child) 1

Other (adult) 7

with maternal mortality, life expectancy, all-cause mortality, and cause-specific mortalityin adults. All but 3 studies measured PHC ex-posure by residence in a geographic area inwhich PHC services were being delivered.The other 3 assessed individual use of spe-cific PHC services. Nearly all studies point to apositive impact of the PHC intervention stud-ied: only 5 articles show no improvement at-tributable to PHC.

The magnitude of impact also varied con-siderably. Reductions in infant and under-5mortality attributed to PHC averaged morethan 40% and varied from 0 to as high as71%, with interventions lasting from 2 yearsto more than 10 years.

Studies on specific PHC tasks

Several studies analyzed the association ofspecific primary care tasks with health out-comes. Moore et al. (2003) conducted a panelstudy of 22 Latin American countries overthe period from 1990 to 1998. The studyfound that the most important contributorto lower under-5 mortality was women’s lit-eracy, followed by vaccination coverage anduse of oral rehydration therapy. A similar anal-ysis conducted by using Demographic andHealth Surveys from 5 East African countriesestimated that nearly three-quarters of the

Primary Healthcare in Low- and Middle-Income Countries 153

attributable risks for mortality in childrenyounger than 1 year might be amenable topreventive services, including antenatal care,immunizations, fertility regulation, and use ofpotable water (Brockerhoff & Derose, 1996).In both studies, the extent to which these ser-vices were part of an integrated PHC systemor the result of an effort targeted only at majorcauses of infant and child mortality is unclear.

Dugbatey (1999) assessed the relationshipbetween a set of “Health for All” policies(health education, nutrition, water and san-itation, and maternal/child health services)and health outcomes at the national level in4 African countries in the 1990s. Througha comparative case study design, the authorshowed that PHC-sensitive conditions (suchas infant mortality) were improved in the2 countries with more comprehensive PHCpolicies (Botswana and Zimbabwe), as op-posed to those with a less coherent set of PHCpolicies (Ghana and Cote d’Ivoire), in spite ofthe latter having higher gross national productper capita (Dugbatey, 1999).

The Bellagio Child Survival Study Groupconcluded that nearly 10 million child deathsworldwide could be averted by tasks or ser-vices including combined use of oral rehy-dration therapy (Victora et al., 2000), immu-nization (England et al., 2001), micronutrientsupplementation, promotion of exclusivebreast-feeding (Arifeen et al., 2001), and oth-ers, all but one of which (neonatal intensivecare) would be expected to be delivered bya PHC system. This estimate is supported byanother study (Berman, 2000) that estimatedthat about 62% of all disability adjusted lifeyears (lost in the adult and child populationof developing countries) would be amenableto primary care services (termed “ambulatoryhealthcare” by Berman). Access to primarycare appears to be particularly important inAfrica; some authors suggest that up to 80%of child deaths occur at home, without thechild having any contact with the health sys-tem (Oluwole et al., 2000)

Integrated management of childhood ill-ness (IMCI) reflects a horizontal primary careapproach in the sense that it combines sev-eral specific interventions. An evaluation of

IMCI programs in Brazil, Peru, Uganda, Egypt,and Tanzania showed that although the ap-proach was in many cases more compre-hensive and effective than individual verticalinterventions, poor access, low levels of uti-lization, and structural weaknesses in healthsystems limit its impact on population health(Bryce et al., 2003; WHO, 2004) A recent re-view suggested that a more comprehensiveapproach to PHC and health systems devel-opment will be required for strategies such asthe IMCI program to flourish (Freedman et al.,2005).

Rohde et al. (2008) identify 13 coun-tries that have implemented comprehen-sive PHC (Thailand, Turkey, Vietnam, Brazil,Sri Lanka, El Salvador, Tunisia, DominicanRepublic, Iran, Kazakhstan, Turkmenistan,China, and Cuba). Their analysis suggests thatthese countries experienced important healthgains and that in comparison with coun-tries having more selective PHC approaches,health improvements—particularly for condi-tions that require sustained and coordinatedcare—seem to “depend on progression tocomprehensive primary health care with a re-liable referral system linking to functioning fa-cilities” (Rohde et al., 2008, p. 958).

Studies of specific primary

care programs

The Navrongo experiment in Ghana wasthe only experimental study identified. In it,villages received 1 of 4 different interven-tions: professional community nurses; vol-untary community health workers (CHWs);a combination of both; and nothing (con-trol). In the nurse-only intervention areas,under-5 mortality fell by 14% during 5 yearsof program implementation, compared withthat before the intervention period (Penceet al., 2007; Phillips et al., 2006). In thevolunteer-only villages, under-5 mortality in-creased by 14%. The professional nurse inter-vention added approximately $2 per capita tothe $6.80 per capita budgeted for PHC ser-vices. Note that the study used a “plausibil-ity” rather than a “probability” design, mean-ing that treatments were not truly randomlyassigned.

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In the Gambia, Hill et al. (2000) comparedPHC and non-PHC communities over a 15-year period. Primary care was assessed by thepresence of a community health nurse as asupervisor to village health workers (VHWs)and traditional birth attendants; presence ofan expanded program of immunization and abasic package of maternal and child health ser-vices; and community participation in health-care provision, priority setting, and fund rais-ing. The study found that although child mor-tality declined in intervention and controlvillages, the decline was generally steeperin PHC villages (Hill et al., 2000). As a typeof natural experiment, the authors reportthat once PHC services were stopped in thevillages (because of lack of funds), the trendreversed and infant mortality increased tolevels higher than those in control (non-PHC)villages.

Velema et al. (1991) studied access and lon-gitudinality of primary care services to a pop-ulation of about 13 000 in Benin. In a matchedcase-control study, 2 factors were partic-ularly influential in predicting death risk:measles vaccination before their first birthday(Odds ratio [OR] = 0.4) and regular con-tact with VHWs (OR = 0.36). The authorsconcluded that regular contact with VHWs,which is consistent with the person-focusedcare over time function of primary care, im-proves the likelihood of child survival.

In Haiti, the activities of an integrated lo-cal health system, based on a PHC model(the Hopital Albert Schweitzer or HAS), wereassociated with infant and under-5 mortalitythat are about half of those in other areaswith similar income levels (Perry et al., 2007).This was accomplished through a decades-long partnership with local communities. Interms of resources, HAS had fewer physiciansand fewer hospital beds per capita than didthe rest of Haiti but more nurses, CHWs, andother outreach and support staff. The HASsystem costs about $19 per capita, includ-ing community development initiatives (Perryet al., 2006).

Other studies of PHC programs using pre-and postintervention measures and control orcomparison groups include the following:

• A large NGO-delivered PHC program(focused on maternal and child healthservices) targeted about 340 000 poorhouseholds in Bangladesh. Services weredelivered through trained family healthvisitors and included regular householdvisits, illustrating the importance of a fam-ily focus in PHC. After 5 to 6 years,program areas experienced a 52% reduc-tion in infant mortality and a 49% re-duction in under-5 mortality, larger de-creases than those experienced in controlareas (Mercer et al., 2004). Another studyin Matlab, Bangladesh, showed the im-pact of a community-based PHC approachemploying supervised and trained VHWs(with referrals to health centers staffedby healthcare professionals) on loweringunder-5 mortality from acute lower respi-ratory tract infections by 32% in 2 years(Fauveau et al., 1992). Prior studies inMatlab had also documented reductionsin under-5 and maternal mortality due todifferent PHC interventions (Chen et al.,1983; Fauveau et al., 1991).

• In a cohort study conducted inPondicherry, India, provision of a broadrange of PHC services, including homevisits by PHC nurses in 12 villages (totalpopulation of about 16 000), decreasedinfant and child mortality by more than65% (Dutt & Srinivasa, 1997). Anothersmaller-scale Indian study assessed theeffects of VHW provision of primaryand maternity care and health educationto pregnant women and grandmothers,resulting in reductions in neonatal mor-tality by 62% and infant mortality by 71%,as compared with preintervention levels(Bang et al., 1999).

• In Liberia (Becker et al., 1993) and Zaire(Chahnazarian et al., 1993; Taylor et al.,1993), a more selective PHC approachwas attributed to reductions in under-5mortality by as much as 28% over a 5-yearperiod, an improvement that was signifi-cantly greater than that reported in com-parison areas.

• A study using 2 waves of nationally repre-sentative surveys in Indonesia found that,

Primary Healthcare in Low- and Middle-Income Countries 155

while holding other village- and maternal-level variables constant, the addition of amaternity clinic and a physician to a vil-lage was found to decrease the odds ofinfant death (relative to an infant born be-fore the clinic existed) by about 15% and1.7%, respectively (Frankenberg, 1995).

• In Bolivia, a comprehensive community-based PHC program (delivered by paidnurses and community volunteers withsome physician support) serving a pop-ulation of about 15 000 successfully re-duced under-5 mortality by more than52% over a 5- to 6-year period, as com-pared with control areas (Perry et al.,1998, 2003). Costs for the program wereestimated at about $10 per person.

• In Pakistan, a case-control study of chil-dren who had diarrhea or acute respira-tory tract infections showed that the useof a traditional healer (as opposed to atrained VHW) raised the odds of a child’sdeath by a factor of 14 (OR = 14.5; 95%confidence interval [CI] = 4.23–49.8),and frequent changing of providers (ie,lack of continuity with a PHC provider)raised the odds of death 8 times (OR = 8;95% CI = 2.22–28.8) (D’Souza & Bryant,1999).

Studies of countrywide PHC experiences

There have been only a few studies that di-rectly test the hypothesis that health systemsbased on a strong PHC orientation (basedon PHC principles) lead to better overallindicators.

By 1985, Costa Rica’s life expectancy hadreached 74 years, and infant mortality de-clined from 60 per 1000 in 1970 to 19 per1000, levels comparable with those in moredeveloped countries. Explanations for thisrapid progress include the development of auniversal social security system and a mul-tidimensional approach to health improve-ment, which included expanding PHC ser-vices, investing in education and sanitation,and improving access to secondary and ter-tiary healthcare services (Haines & Avery,1982; Klijzing & Taylor, 1982; Rosero-Bixby,

1986). PHC improvements beginning in the1970s were estimated to have reduced in-fant mortality by between 40% and 75%(Rosero-Bixby, 1991).

In the 1990s, additional Costa Ricanreforms sought to improve PHC coverageand efficiency. A quasi-experimental studycomparing 3 groups of districts on the basisof when they adopted PHC reforms foundthat, in addition to other improvements inliving standards, PHC reforms significantlyreduced mortality in both adults and children(Rosero-Bixby, 2004a). For every 5 additionalyears after PHC reforms, child mortalitydeclined by 13% and adult mortality by4%. The proportion of the population withinsufficient access to PHC services declinedby 15% in reformed districts compared withonly a 2% decline in districts that did notundergo reforms. The reforms additionally im-proved equity in access by targeting the leastprivileged population first (Rosero-Bixby,2004b).

Brazil’s family health program (FHP) is nowperhaps the largest community-based PHCsystem in the world. In 2007, the programencompassed more than 27 000 community-based teams responsible for providing careto about 85 million people (Brazilian Min-istry of Health, Department of Primary Care,2006). The FHP is based on an explicit strat-egy to provide all core primary care functions,including first-contact access for each newneed, long-term person-focused care, compre-hensive care for most health needs, coordi-nated care when it must be sought elsewhere,and a focus on the family and the community.These functions are achieved through theprogram’s decentralized organization, elimi-nation of copays for services, incentives to lo-cal government for increasing access to theprogram, and multidisciplinary teams com-posed of a physician and a nurse who deliverclinic-based care along with CHWs who makeregular home visits and perform community-based health-promotion activities (Ministry ofHealth of Brazil, 2003). Costs for the pro-gram (which includes access to pharmaceu-ticals) are estimated at between $25 and $35(Macinko et al., 2007). A panel data analysis

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of Brazilian states from 1990 to 2002 showedthat an increase in FHP coverage by 10% wasassociated with an average 4.6% decrease ininfant mortality, controlling for other healthdeterminants, including water supply, livingconditions, doctor and hospital supply, andwomen’s education (Macinko et al., 2006).A follow-up study conducted at the microre-gional level for 1999–2004 showed that the ef-fect of FHP coverage was especially strong forconditions that are known to be sensitive toprimary care (such as postneonatal mortalityand deaths from diarrheal diseases) (Macinkoet al., 2007). Several studies also demon-strated associations between CHWs and lowerinfant mortality in specific Brazilian states(Emond et al., 2002; Svitone et al., 2000).

A few other countrywide observations aresuggestive of the role of PHC in populationhealth improvements, although these studiesdo not explicitly quantify the contribution ofPHC to health improvements or explicitly testthe impact of specific PHC interventions.

Cuba’s universal PHC program uses familyhealth physicians and nurses, who provideuniversal, comprehensive, integrated, and in-tersectorial care to geographically defined ar-eas with a focus on families (Evans et al.,2008; Waitzkin, 1997). Changes in PHC ac-cess, organization, and delivery over the past40 years correspond to about a 40% declinein infant mortality over the same period, evenwhile other indicators such as gross nationalproduct per capita have not substantially in-creased (Riveron Corteguera, 2000). Invest-ments in prevention integrated into PHC mayalso have contributed to the control of car-diovascular diseases, resulting in lower-than-expected mortality and fewer avoidable hos-pitalizations for these and related conditions(Spiegel & Yassi, 2004). Lessons learned fromthe Cuban experience suggest the potentialbenefits of organizing an entire health sys-tem around the PHC approach (Franco et al.,2007).

In Mexico, child mortality declined from 64per 1000 live births in 1980 to 23 per 1000in 2006 (Sepulveda et al., 2006). These re-ductions were consequent to a strategy thatbegan with a number of disease-specific pro-

grams and expanded to a broader strategy thatcombined vertical programs with more com-prehensive PHC and human development ap-proaches, including legislation making accessto maternal and child health services a citi-zen’s right (Frenk et al., 2003). Reyes et al.(1997) also found that in Mexico, primarycare characteristics (such as adequate refer-ral processes, continuity of care, being seenby the same provider, and being attended in apublic facility) had an important, independenteffect on reducing a child’s odds of dying.Similarly, Gutierrez et al. (1999) point to theimportance of access to primary care (as mea-sured by nurse and physician supply) as wellas investments in public health (immunizationand improved water and sanitation) and edu-cation as particularly important for reducinginfant mortality in Mexico.

In Thailand, decreases in under-5 infantmortality occurred after primary care reform,which included developing at least 1 pri-mary care health center for every rural villageby 1990 and a government medical welfarescheme started in 1993. In the correspond-ing decade, under-5 mortality declined by 44%in the poorest population quintile, 41% in thenext poorest quintile, 22% in the third, 23% inthe fourth, and 13% in the wealthiest quintile(Vapattanawong et al., 2007)

In Indonesia, a 20% reduction in infant mor-tality during the early 1990s has been at-tributed to improvements in PHC (Simms &Rowson, 2003). Some evidence for this attri-bution comes from the observation that inthe later 1990s, once primary care spend-ing declined substantially (and hospital spend-ing increased by almost 25%), infant mortal-ity actually increased by 14% in almost everyprovince of the country (Simms & Rowson,2003).

Finally, the 2008 World Health Report onPHC presents numerous case studies of PHCexperiences. Although it does not contain asystematic review of the evidence on the ben-efits of PHC, it reviewed the evidence for thebenefits of PHC components and concludedthat there is an overwhelming justification fora focus on developing and strengthening PHCin all countries (WHO, 2008).

Primary Healthcare in Low- and Middle-Income Countries 157

Studies finding little or no impact of

PHC on health outcomes

In Niger, a prospective study found thatthere was no additional survival advantagefor children in villages with a “village healthteam”present, although the presence of a dis-pensary lowered the odds of death by 32%,as compared with villages with no services(Magnani et al., 1996). In explanation for theapparent lack of an effect, Magnani et al. sug-gest the need for more comprehensive pack-ages of health services than those delivered bythe project, because the single interventionswere possibly offset by continued high levelsof exposure to other unchanged factors.

In the Philippines, the Bohol project pro-vided very low-cost PHC services to a popula-tion of about 400 000 residents for 5 years.The evaluation included pre- and postin-tervention surveys and comparison with acontrol village. The project increased theutilization of some health services but didnot significantly decrease infant mortality(Williamson, 1982). Williamson suggests thatpotential reasons for the lack of an effect in-clude the generally poor quality of health ser-vices provided, a selective rather than a com-prehensive approach to PHC with a strongemphasis on family planning (fertility did de-cline), and overworked and/or inadequatelytrained staff.

In a retrospective study with control com-munities in the Gambia (De Francisco et al.,1994), there were no significant differences(P = .88) in under-5 mortality between vil-lages with VHWs and those without them(35.5/1000 vs 35.8/1000). De Francisco et al.suggest that different health service utiliza-tion patterns (based on the type of child ill-nesses) and preferences for traditional heal-ers may partially explain the lack of effect. Inaddition, there was no indication that theseVHWs were achieving PHC functions, includ-ing provision of good-quality care and refer-ral to trained healthcare professionals whenindicated.

In Brazil, one study found that participa-tion in FHP between 1994 and 1998 did notsignificantly improve child health indicatorsin municipalities with high coverage, as op-

posed to those in municipalities with lowor no coverage. Infant mortality declined by42% and 45.5% in the intervention and con-trol groups, respectively, a nonsignificant dif-ference (Morsch et al., 2001). A possible ex-planation for the lack of an effect might havebeen the inability to control for variables re-lated to the performance of primary care ser-vices, such as the technical quality of care oraccessibility, which vary by municipality.

Finally, in their systematic review of “in-tegration” of primary care in developingcountries, Briggs et al. (2001) discuss an es-sential feature of primary care: the extent towhich it provides a range of services meant toattend to most common healthcare problems.This feature of primary care is more oftentermed “comprehensiveness.” The review ofBriggs et al. (2001) contains only 4 studies,and they conclude that no overall conclusionscan be drawn from their results. As a possibleexplanation for the lack of a conclusivefinding, the authors point to the poor qualityof many of the studies conducted, includingpoor recording of outcomes, inadequaterandomization processes, and control groupsthat were not entirely comparable with exper-imental groups. Moreover, each study definedand measured integration in a differentway.

DISCUSSION

This review of the evidence of the ef-fectiveness of PHC on population health inlow-income countries has shown that sev-eral analyses provide consistent evidenceof the impact of PHC on improved healthoutcomes. Nevertheless, many studies suf-fered from important methodological weak-nesses, including inadequate controls forindividual- or community-level confoundersin multivariable analyses. Reductions in in-fant mortality (the most frequently studiedoutcome) attributed to PHC actions averagedabout 40% and varied from 0% to as highas a 71% over intervention periods rangingbetween 2 and 10 or more years. Costs forcomprehensive PHC programs ranged fromabout $10 to $35 per capita per year.

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Despite the apparent consistency of results,analysis of the studies revealed that PHC hasonly rarely been evaluated in a consistent andreproducible way. Rather, it is often only var-ious aspects of health services that are as-sumed to be part of PHC that have been the fo-cus of attention. For example, all but 3 studiesmeasured PHC exposure as residence withina geographic area in which the PHC programor project was implemented. In addition, thedefinition of the PHC program also varied con-siderably, from the mere presence of a VHWin a community to the use of specific ser-vices to the development of an integratednetwork of health and social services in thecommunity. For this reason, there is little thatcan be gleaned regarding the mechanisms bywhich these PHC approaches might achieveimportant primary care functions, such asfirst-contact access, longitudinality, compre-hensiveness, and coordination of care.

The general failure to use an operationalconceptualization of PHC has also made iden-tification of studies about PHC difficult. Forthis reason, the literature probably containsmore evidence than is discoverable from theabstracts or titles of published articles.

Publication bias is also likely to have lim-ited the scope of this review. Many suc-cessful (as well as unsuccessful) experienceshave simply not been documented in peer-reviewed journals. As an illustration, we wereunable to retrieve any peer-reviewed articlesthat adequately assessed the impact of PHCon population health in Sri Lanka, China, orVietnam, although each country’s PHC ap-proach has been discussed elsewhere as “suc-cessful”(Bloom, 1998; Fritzen, 2007; Halsteadet al., 1985).

In addition, there is little peer-reviewed evi-dence on the role of PHC on improvements inadult health in low- and middle-income coun-tries, because most published studies have fo-cused only on infant and under-5 mortality.Thus, the potential for PHC to help controladult chronic and infectious diseases in the de-veloping world remains largely unexplored.

The studies that found no effect of PHC onhealth indirectly provide support for a com-prehensive approach to PHC: most involvedinterventions that focused only on selective

PHC tasks. They also point to the importanceof accurately measuring variations in the tech-nical quality of primary care delivered, a topicthat certainly deserves far more attention inthe literature reviewed here.

In view of the limitations of these studies,an agenda for the evaluation of the contribu-tion of PHC tasks and functions to populationhealth would benefit from the following con-siderations.

First, a clear conceptualization of primarycare is needed, including specification ofeach of its component features, for example,first-contact access and use, longitudinality(person-focused care over time), comprehen-siveness (addressing the breadth of commonhealth needs), and coordination (integrationof services with other levels of care).

Second, studies should start with a con-ceptual framework to guide the overall eval-uation, design the characteristics under con-sideration, and describe relationships amongdifferent levels and types of data to be col-lected in the evaluation process. This frame-work should provide a model of how primarycare is conceptualized in relation to biologi-cal, social, and environmental influences onhealth (Starfield, 2001).

Third, future studies require clear speci-fication and measurement of the PHC sys-tem, including specific structural character-istics (input and policy), process (servicedelivery modalities), and relevant healthoutcomes and outputs.

Fourth, as noted throughout the PHC lit-erature (Chen et al., 1993; Hill et al., 2000),there is still an urgent need for more rig-orous research designs that allow testing ofthe independent effect of primary care onoutcomes over time. This should includeindividual- and community/contextual-leveldata derived from longitudinal sources, appro-priate control or comparison groups, and con-trol for relevant individual- and contextual-level covariates. Such evaluations will requirea commitment from donor organizations andnational governments to provide necessary re-sources and to ensure the scientific integrityof the research process.

In the short term, 3 approaches couldbe implemented to aid in providing more

Primary Healthcare in Low- and Middle-Income Countries 159

systematic evaluation of primary care, asfollows:

1. Existing or planned cohort studies couldbegin to incorporate PHC measuresthrough the use of validated instrumentssuch as the Primary Care AssessmentTools (Harzheim et al., 2006; Macinkoet al., 2007; Pasarin et al., 2007).

2. Standardized surveys such as the Demo-graphic and Health Surveys or LivingStandards Measurement Surveys couldinclude modules derived from the Pri-mary Care Assessment Tools along withhealth system variables to identify howand where populations are receiving ef-fective PHC services.

3. Researchers could direct their attentionto countries that are currently undergo-ing reform of their primary care system,thus opening the possibility for analy-sis of natural experiments in which re-formed states or municipalities couldbe compared with otherwise similar re-gions without reformed primary caresystems. Better yet, experimental assign-ment of different PHC approaches couldbe used to help phase in reforms andmore rigorously evaluate their impact(King et al., 2007).

Finally, there is a need to encourage thepublication of evaluations of PHC experi-ences, both successful and unsuccessful, sothat the PHC approach can be guided by awider body of high-quality evidence.

CONCLUSION

The WHO proposal for renewing PHC re-inforces the idea that strengthened health sys-tems should be viewed as a necessary (thoughnot sufficient) condition for meeting interna-tionally agreed-upon development goals suchas those contained in the Millennium Devel-

opment Goals (WHO, 2008). Basing healthsystems more strongly on PHC represents animportant strategy to address emerging healthproblems (Fuster & Voute, 2005), scale upexisting interventions, and effectively com-bat health threats such as HIV/AIDS (Buveet al., 2003), tuberculosis (Mahendradhataet al., 2003), chronic illnesses (Rothman &Wagner, 2003), and others.

These observations are also relevant to therenewal of primary care in the United States.Recently, the American Academy of FamilyPhysicians, the American Academy of Pedi-atrics, the American College of Physicians,and the American Osteopathic Association(2007) united to endorse the “Joint Princi-ples of the Patient-Centered Medical Home,”which describes characteristics of a patient-centered medical home (PCMH) as includinga personal physician, physician-directed med-ical practice, whole-person orientation, coor-dinated and integrated care, quality and safety,enhanced access to care, and payment that“appropriately recognizes the added valueprovided to patients. . ..”Lessons learned fromthe evaluation of PHC in the developing worldmay also have relevance to the assessment ofthe PCMH, as it is apparent that definitionsand tools of measurement should be consis-tent, standardized, and based on evidence ofeffectiveness of primary care components.Without greater attention to these aspects, thePCMH model may fall short of reaching itsgoal of renewing a PHC approach to health-care organization and delivery in the UnitedStates.

As national governments, the WHO, andother international organizations move to re-new their PHC strategies, greater clarity inspecifying PHC in terms that allow for morestandardized measurement and investment inrigorous evaluation of PHC effectiveness andits effects on equity will be essential.

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than

5y

in

Mat

lab

Pre

sen

ce

of

CH

Ws

Cau

se-s

pecif

ic

un

der-

5

mo

rtal

ity

Fo

ral

lch

ild

ren

you

nge

rth

an5

yin

the

inte

rven

tio

n

area,

ALR

I-sp

ecif

icm

ort

alit

yfr

om

19

86

to1

98

7w

as

28

%lo

wer

inth

ein

terv

en

tio

nar

ea

than

inth

e

co

mp

aris

on

area

(P<

.01

).Fro

m1

98

8to

19

89

,th

e

mo

rtal

ity

was

48

%lo

wer

inth

ein

terv

en

tio

nar

ea

than

inth

eco

ntr

olar

ea.

ALR

I-sp

ecif

icm

ort

alit

yin

all

child

ren

you

nge

rth

an5

yin

the

inte

rven

tio

nar

ea

declin

ed

(P=

.00

3)

by

32

%b

etw

een

19

86

/19

87

and

19

88

/19

89

.

Ben

in(r

ura

l)(V

ele

ma

et

al.,

19

91

)

DC

hild

ren

4–3

5m

o

of

age

Vis

itto

VH

Ws

Un

der-

5

mo

rtal

ity

Meas

les

vaccin

atio

nb

efo

reth

efi

rst

bir

thd

ay(a

n

ind

icat

or

of

access

)re

du

ced

risk

of

deat

h(R

2=

0.4

);

child

ren

inre

gu

lar

co

nta

ct

wit

ha

VH

Wh

adlo

wer

risk

of

deat

h(R

2=

0.3

).

Bh

uta

n(B

oh

ler,

19

94

)E

Infa

nts

VH

Wac

tivit

ies

(heal

th

ed

ucat

ion

,

vaccin

atio

n,

treat

men

t)

Infa

nt

mo

rtal

ity

Infa

nt

mo

rtal

ity

was

red

uced

sign

ific

antl

yfr

om

14

5in

19

84

to4

9in

19

91

(P<

.00

1).

Du

rin

gb

oth

peri

od

s

(19

84

and

19

91

),ch

ild

ren

of

mo

thers

wit

ha

hig

h

bir

thfr

eq

uen

cy

had

sign

ific

antl

yh

igh

er

infa

nt

mo

rtal

ity

(26

8in

19

84

and

93

in1

99

1)

than

tho

se

wit

hlo

wb

irth

freq

uen

cy

(47

in1

98

4an

d1

2in

19

91

)(P

<.0

01

for

19

84

and

P=

.00

2fo

r1

99

1).

(con

tin

ues

)

Primary Healthcare in Low- and Middle-Income Countries 165

Co

un

try

/regio

nP

HC

Main

(refe

ren

ce)

Ty

pe

aP

op

ula

tio

nm

easu

res

ou

tco

me

Imp

act/

resu

lt

Bo

livia

(Perr

yet

al.,

19

98

,2

00

3)

CC

hild

ren

in

inte

rven

tio

n

and

no

nin

ter-

ven

tio

n

areas

Co

mp

reh

en

sive

pu

blic

heal

th

serv

ices,

inclu

din

g

imp

rove

men

to

f

cle

anw

ater

and

san

itat

ion

Un

der-

5

mo

rtal

ity

In1

99

2–1

99

3,u

nd

er-

5m

ort

alit

yw

as2

05

.5/1

00

0

(co

mp

aris

on

areas

)an

d9

8.5

/10

00

(in

terv

en

tio

n

areas

),a

dif

fere

nce

of

10

7/1

00

0d

eat

hs

(P<

.00

1,

95

%C

I=

14

1.3

–7

2.7

)o

r5

2.1

%(9

5%

CI=

35

.2–6

8.8

%)

low

er

mo

rtal

ity

inth

ein

terv

en

tio

n

areas

.P

rogra

mco

sts

est

imat

ed

atab

ou

t$

10

per

cap

ita.

Bo

tsw

ana

Co

ted

’Ivo

ire,

Gh

ana,

and

Zim

bab

we

(Du

gb

atey,

19

99

)

GN

atio

nal

po

licie

s

of

4co

un

trie

s

Heal

thed

ucat

ion

,

foo

d,n

utr

itio

n,

wat

er,

san

itat

ion

,

mat

ern

al/c

hild

heal

thp

olicie

s

Infa

nt

mo

rtal

ity,

life

exp

ecta

ncy

Bo

tsw

ana

and

Zim

bab

we

perf

orm

ed

bett

er

than

Co

te

d’I

voir

ean

dG

han

ain

term

so

fh

eal

tho

utc

om

es.

Th

isre

lati

on

ship

did

no

tap

pear

tob

ere

late

dto

inco

me

on

lyb

ecau

seri

cher

co

un

trie

s(C

ote

d’I

voir

e)

sco

red

wo

rse

than

Zim

bab

we

and

Gh

ana.

Th

e

auth

or

co

nclu

des

that

“po

licie

sfo

rmu

late

dan

d

imp

lem

en

ted

inac

co

rdan

ce

wit

hkey

PH

C

pri

ncip

les

co

uld

acco

un

tfo

rim

pro

vem

en

tsin

nat

ion

alh

eal

thst

atu

s.”

Bra

zil(M

acin

ko

et

al.,

20

06

,2

00

7)

AB

razi

lian

po

pu

lati

on

(sta

tes

and

mic

rore

gio

ns)

Pro

po

rtio

no

f

po

pu

lati

on

co

vere

db

yth

e

FH

P

Infa

nt

mo

rtal

ity

A1

0%

incre

ase

inFH

Pco

vera

gew

asas

socia

ted

wit

ha

4.5

%d

ecre

ase

inin

fan

tm

ort

alit

y,co

ntr

ollin

gfo

ral

l

oth

er

heal

thd

ete

rmin

ants

(P<

.01

).A

ccess

tocle

an

wat

er

and

ho

spit

alb

ed

sp

er

10

00

were

negat

ively

asso

cia

ted

wit

hin

fan

tm

ort

alit

y,w

here

asfe

mal

e

illite

racy,

fert

ilit

yra

tes,

and

mean

inco

me

were

po

siti

vely

asso

cia

ted

wit

hin

fan

tm

ort

alit

y.T

he

pro

gra

mm

ayre

du

ce

infa

nt

mo

rtal

ity

atle

ast

par

tly

thro

ugh

red

ucti

on

sin

dia

rrh

ea

deat

hs.

Bra

zil(M

ors

chet

al.,

20

01

)

CIn

fan

tsin

dif

fere

nt

mu

nic

ipal

areas

Co

mm

un

ity

heal

th

agen

tsp

rogra

m

co

vera

ge

Infa

nt

mo

rtal

ity

Par

ticip

atio

nin

the

pro

gra

mb

etw

een

19

94

and

19

98

did

no

tsi

gn

ific

antl

yim

pro

vech

ild

heal

thin

dic

ato

rs

co

mp

ared

wit

hn

op

arti

cip

atio

n.T

he

pro

po

rtio

nat

e

infa

nt

mo

rtal

ity

declin

ed

by

42

%an

d4

5.5

%in

the

inte

rven

tio

nan

dco

ntr

olgro

up

s,re

specti

vely

,an

d

the

dif

fere

nces

were

no

tsi

gn

ific

ant.

(con

tin

ues

)

166 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2009C

ou

ntr

y/r

egio

nP

HC

Main

(refe

ren

ce)

Ty

pe

aP

op

ula

tio

nm

easu

res

ou

tco

me

Imp

act/

resu

lt

Bra

zil(N

atal

)(E

mo

nd

et

al.,

20

02

)

CW

om

en

,p

regn

ant

wo

men

,an

d

child

ren

you

nge

rth

an

5y

Co

vera

geb

yV

HW

pro

gra

m

Mat

ern

alan

d

infa

nt

mo

rtal

ity

Aft

er

30

mo

,co

mm

un

ity

surv

eys

rep

ort

ed

asi

gn

ific

ant

red

ucti

on

inin

fan

tm

ort

alit

yfr

om

60

/10

00

to

37

/10

00

;d

ecre

ased

mat

ern

alm

ort

alit

y;im

pro

ved

infa

nt

feed

ing

and

car

eta

kin

gp

racti

ces;

imp

rove

d

imm

un

izat

ion

rate

s;in

cre

ased

rate

so

fco

nsu

ltat

ion

wit

hp

hys

icia

ns;

and

agre

ater

perc

en

tage

of

bir

ths

takin

gp

lace

inco

mm

un

ity

clin

ics

rath

er

than

in

ho

spit

als.

Bra

zil(C

ear

a)(S

vit

on

e

et

al.,

20

00

)

EM

oth

ers

and

child

ren

in

Cear

ast

ate

Co

vera

geb

y

co

mm

un

ity

heal

thag

en

ts

pro

gra

m

Infa

nt

mo

rtal

ity

(by

cau

se)

Perc

en

tage

so

fb

reas

t-fe

ed

ing,giv

ing

OR

T,re

ceiv

ing

pre

nat

alcar

e,va

ccin

atio

nco

vera

ge,in

stit

uti

on

al

delive

ries,

and

infa

nt

mo

rtal

ity

imp

rove

d.P

rogra

m

success

inclu

des

lon

git

ud

inal

ity;

fam

ily

and

co

mm

un

ity

ori

en

tati

on

,fi

rst

co

nta

ct,

and

inte

rsecto

rial

co

llab

ora

tio

n.W

eak

ness

es

inclu

de

refe

rral

mech

anis

ms,

access

bar

riers

,an

dlivin

g

co

nd

itio

ns.

Co

sta

Ric

a

(Ro

sero

-Bix

by,

19

91

,

20

04

a,2

00

4b

)

A,A

Infa

nts

and

wo

men

Dis

tric

tle

vel,

bas

ed

on

wh

en

they

began

the

heal

th

refo

rmp

rocess

Infa

nt

mo

rtal

ity

and

fert

ilit

y

Refo

rmo

fp

rim

ary

car

esi

gn

ific

antl

yre

du

ced

mo

rtal

ity

inb

oth

adu

lts

(2%

)an

dch

ild

ren

(8%

).Fo

reve

ry5

add

itio

nal

year

so

fre

form

,ch

ild

mo

rtal

ity

was

red

uced

by

13

%an

dad

ult

mo

rtal

ity

declin

ed

by

4%

.

Po

pu

lati

on

wit

hlim

ited

access

toh

eal

thse

rvic

es

decre

ased

15

%in

refo

rmar

eas

(on

ly2

%in

no

nre

form

areas

).In

mu

ltiv

aria

tean

alys

es,

fro

m

19

70

to1

98

0,P

HC

acco

un

ted

for

41

%o

fin

fan

t

mo

rtal

ity

declin

es,

oth

er

med

ical

car

e(3

2%

),

socio

eco

no

mic

pro

gre

ss(2

2%

),an

dfe

rtilit

yd

eclin

e

(5%

).

Cu

ba

(Fra

nco

et

al.,

20

07

;R

ivero

n

Co

rtegu

era

,2

00

0)

G,G

Infa

nts

and

adu

lts

Desc

rip

tio

no

fP

HC

serv

ices,

org

aniz

atio

nan

d

serv

ice

delive

ry,

and

po

licie

s

Infa

nt

mo

rtal

ity,

car

dio

vasc

ula

r

dis

eas

e

mo

rtal

ity

(ad

ult

s)

Ch

ange

sin

access

,o

rgan

izat

ion

,an

dd

elive

ryo

fP

HC

ove

r4

0y

asso

cia

ted

wit

h4

0%

declin

ein

infa

nt

mo

rtal

ity

inth

e1

97

0s,

19

80

s,an

d1

99

0,w

hile

socio

eco

no

mic

co

nd

itio

ns

rem

ain

ed

sim

ilar

.

(con

tin

ues

)

Primary Healthcare in Low- and Middle-Income Countries 167

Co

un

try

/regio

nP

HC

Main

(refe

ren

ce)

Ty

pe

aP

op

ula

tio

nm

easu

res

ou

tco

me

Imp

act/

resu

lt

Th

eG

amb

ia(H

illet

al.,

20

00

)

CC

hild

ren

Pre

sen

ce

of

the

PH

Cp

rogra

m

(nu

rses,

CH

Ws,

TB

As,

sup

plies,

serv

ices,

par

ticip

atio

n)

Infa

nt

and

un

der-

5

mo

rtal

ity

Infa

nt

and

un

der-

5m

ort

alit

yd

eclin

ed

inb

oth

PH

Can

d

no

n-P

HC

villa

ges.

Th

ed

eclin

ew

assh

arp

er

inP

HC

villa

ges

(in

fan

tm

ort

alit

y1

34

/10

00

to6

9/1

00

0)

vs

no

n-P

HC

villa

ges

(15

5/1

00

0to

91

/10

00

).Si

nce

19

94

,af

ter

sup

po

rtan

dfu

nd

ing

for

PH

Cd

eclin

ed

,

the

tren

dre

vers

ed

(in

fan

tm

ort

alit

y9

8/1

00

0in

PH

C

villa

ges

vs

78

/10

00

inn

on

-PH

Cvilla

ges)

.

Th

eG

amb

ia(D

e

Fra

ncis

co

et

al.1

99

4;

Gre

en

wo

od

et

al.,

19

90

)

C,C

Ch

ild

ren

you

nge

r

than

5y

Vac

cin

atio

n,

heal

thcar

eu

se,

heal

thed

ucat

ion

,

en

vir

on

men

tal

heal

th,n

utr

itio

n,

treat

men

t,an

d

refe

rral

sb

y

VH

Ws

and

TB

As

Ch

ild

mo

rtal

ity

No

sign

ific

ant

dif

fere

nce

(P=

.88

)in

un

der-

5m

ort

alit

y

betw

een

villa

ges

wit

hV

HW

san

dth

ose

wit

ho

ut

(rat

e

=3

5.5

per

10

00

/yvs

35

.8p

er

10

00

/y).

Gh

ana

(Pen

ce

et

al.

20

07

;P

hillip

set

al.,

20

06

)

AW

om

en

and

child

ren

in

inte

rven

tio

n

areas

Pre

sen

ce

of

a

pro

fess

ion

al

nu

rse,

volu

nte

ers

,an

d

bo

thin

dif

fere

nt

co

mm

un

itie

s

Infa

nt

and

un

der-

5

mo

rtal

ity

Th

est

ud

yco

mb

ined

4ar

ms:

pro

fess

ion

aln

urs

es

(un

der-

5m

ort

alit

yd

eclin

ed

by

14

%in

5y)

,lo

cal

heal

thvo

lun

teers

(un

der-

5m

ort

alit

yin

cre

ased

by

14

%);

aco

mb

inat

ion

of

bo

th(u

nd

er-

5m

ort

alit

y

incre

ased

by

8%

);an

dn

on

ew

inte

rven

tio

ns

(un

der-

5

mo

rtal

ity

decre

ased

by

4%

).

Gh

ana

(Afa

riet

al.,

19

95

)C

Ch

ild

ren

you

nge

r

than

5y

in3

villa

ges

Pro

vis

ion

of

serv

ices

(heal

th

ed

ucat

ion

on

infa

nt

feed

ing,

dis

eas

e

pre

ven

tio

n,an

d

dru

g

dis

trib

uti

on

)

Infa

nt

and

un

der-

5

mo

rtal

ity

PH

Cse

rvic

es

decre

ased

infa

nt

and

child

mo

rtal

ity

and

imp

rove

dth

eh

eal

tho

fch

ild

ren

inth

evilla

ges.

Infa

nt

mo

rtal

ity

declin

ed

fro

m1

14

.6/1

00

0live

bir

ths

in1

98

7to

40

.8/1

00

0live

bir

ths

in1

99

0.U

nd

er-

5

mo

rtal

ity

decre

ased

fro

m1

55

.6/1

00

0live

bir

ths

in

19

87

to6

1.2

/10

00

live

bir

ths

in1

99

0.

(con

tin

ues

)

168 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2009C

ou

ntr

y/r

egio

nP

HC

Main

(refe

ren

ce)

Ty

pe

aP

op

ula

tio

nm

easu

res

ou

tco

me

Imp

act/

resu

lt

Hai

ti(P

err

yet

al.,

20

06

,

20

07

)

CPo

pu

lati

on

co

vere

db

yH

AS

Pro

vis

ion

of

inte

gra

ted

pri

mar

y,

seco

nd

ary,

and

tert

iary

car

eto

peo

ple

livin

g

wit

hin

HA

S

cat

chm

en

tar

eas

Infa

nt

and

un

der-

5

mo

rtal

ity

Infa

nt

and

un

der-

5m

ort

alit

yre

po

rted

50

%lo

weri

ng

in

HA

Sar

eas

than

that

inth

ere

sto

fH

aiti

.In

fan

t

mo

rtal

ity

inH

AS

areas

declin

ed

inth

em

id-1

97

0s

and

has

rem

ain

ed

atar

ou

nd

62

–6

6/1

00

0.In

fan

tm

ort

alit

y

inth

ere

sto

fH

aiti

has

declin

ed

fro

mn

ear

ly4

tim

es

hig

her

(22

4in

19

71

–1

97

3)

toab

ou

t2

tim

es

hig

her

(11

9/1

00

0)

in1

99

9.H

AS

inclu

des

co

mp

reh

en

sive

co

mm

un

ity-

bas

ed

PH

C,in

ters

ecto

rial

acti

on

s,an

d

refe

rral

ho

spit

als.

Ind

ia(B

ang

et

al.1

99

9,

20

05

)

C,C

Neo

nat

es

and

infa

nts

in

inte

rven

tio

n

and

no

nin

ter-

ven

tio

n

areas

Acti

vit

ies

of

CH

Ws

Neo

nat

al,in

fan

t,

and

peri

nat

al

mo

rtal

ity

Ho

me-b

ased

neo

nat

alcar

ere

du

ced

neo

nat

alm

ort

alit

y

atth

een

do

fth

eth

ird

year

of

inte

rven

tio

nb

ym

ore

than

the

targ

ete

d2

5%

.In

inte

rven

tio

nar

eas

,

neo

nat

alm

ort

alit

yre

du

ced

fro

m6

2.0

/10

00

live

bir

ths

atb

aselin

e(1

99

3–1

99

5)

to2

5.5

/10

00

live

bir

ths

atye

ar3

(19

97

–1

99

8),

refl

ecti

ng

a6

2.2

%n

et

perc

en

tage

red

ucti

on

(P<

.01

).Si

milar

ly,in

fan

t

mo

rtal

ity

declin

ed

fro

m7

5.5

/10

00

live

bir

ths

to

38

.8/1

00

0live

bir

ths

(45

.7%

net

red

ucti

on

)an

d

peri

nat

alm

ort

alit

yd

eclin

ed

fro

m6

8.3

/10

00

bir

ths

to4

7.8

/10

00

bir

ths

(71

.0%

net

red

ucti

on

)in

inte

rven

tio

nar

eas

(P<

.01

).G

ain

sw

ere

sust

ain

ed

afte

r7

y.

Ind

ia(D

utt

&Sr

iniv

asa,

19

97

)

BIn

fan

tsfo

llo

wed

fro

mb

irth

to5

yo

fag

e

Ava

ilab

ilit

yo

f

med

ical

facilit

ies,

ante

nat

alan

d

un

der-

5clin

ics,

ho

me

vis

its

by

pu

blic

heal

th

nu

rses,

heal

th

ed

ucat

ion

,

nu

trit

ion

sup

ple

men

ts

Infa

nt

and

child

mo

rtal

ity;

child

surv

ival

ind

ex

Pro

vis

ion

of

adeq

uat

em

atern

alan

dch

ild

heal

th

serv

ices

imp

rove

dch

ild

surv

ival

,d

ecre

ased

infa

nt

and

child

mo

rtal

ity.

Resu

lted

inh

igh

child

surv

ival

ind

exo

f9

1.2

%;in

fan

tm

ort

alit

yd

eclin

ed

fro

m

20

1/1

00

0in

19

67

to6

4/1

00

0live

bir

ths

in1

98

9,

wh

ere

asch

ild

deat

hra

tes

decre

ased

fro

m3

9.4

/10

00

in1

97

0to

18

/10

00

in1

99

2am

on

gch

ild

ren

1–4

yo

f

age.

(con

tin

ues

)

Primary Healthcare in Low- and Middle-Income Countries 169

Co

un

try

/regio

nP

HC

Main

(refe

ren

ce)

Ty

pe

aP

op

ula

tio

nm

easu

res

ou

tco

me

Imp

act/

resu

lt

Ind

ia,N

ep

al,Tan

zan

ia,

To

go

(Bri

ggs

et

al.,

20

01

)

FP

ub

lish

ed

stu

die

sIn

tegra

ted

pri

mar

y

car

ed

elive

ryvs

vert

ical

pri

mar

y

car

ese

rvic

es

Var

ied

Ino

ne

stu

dy,

inte

gra

tio

nsh

ow

ed

ap

osi

tive

eff

ect

on

ou

tpu

ts;in

ano

ther

stu

dy,

inte

gra

ted

pro

gra

ms

had

ou

tco

mes

sim

ilar

toth

ose

of

vert

ical

pro

gra

ms.

In

the

rem

ain

ing

2st

ud

ies,

inte

gra

ted

pro

gra

ms

perf

orm

ed

wo

rse

than

vert

ical

on

es.

Ind

on

esi

a(F

ran

ken

berg

,

19

95

)

DIn

fan

tsSe

rvic

eav

aila

bilit

yIn

fan

tm

ort

alit

yW

ith

ina

villa

ge,an

incre

ase

of

1m

atern

ity

clin

ic

decre

ases

the

od

ds

of

deat

ho

fan

infa

nt

wit

hac

cess

toth

atclin

icb

yab

ou

t1

5%

,re

lati

veto

the

infa

nt

bo

rnb

efo

reth

eclin

icex

iste

d.A

nin

fan

tb

orn

afte

r

heal

thw

ork

ers

are

add

ed

toa

villa

geh

asab

ou

t1

.3%

(P<

.1)

low

er

od

ds

of

deat

hth

anan

infa

nt

bo

rn

befo

reth

ead

dit

ion

of

heal

thw

ork

ers

.

Lib

eri

a(B

ecker

et

al.,

19

93

)

CW

om

en

and

child

ren

in

pro

gra

man

d

no

np

rogra

m

areas

Pre

sen

ce

of

the

Co

mb

atin

g

Ch

ild

ho

od

Co

mm

un

icab

le

Dis

eas

ep

roje

ct

Infa

nt

and

un

der-

5

mo

rtal

ity

Imm

un

izat

ion

and

mal

aria

treat

men

tin

cre

ased

in

inte

rven

tio

nar

eas

and

infa

nt

mo

rtal

ity

declin

ed

by

25

%an

du

nd

er-

5m

ort

alit

yd

eclin

ed

by

28

%fr

om

bas

elin

ele

vels

.N

ote

that

this

was

ase

lecti

veP

HC

inte

rven

tio

nfo

cu

sed

on

teta

nu

san

dch

ild

ho

od

imm

un

izat

ion

s,O

RT,

and

mal

aria

treat

men

t.

Mex

ico

(Reye

set

al.,

19

97

)

DIn

fan

tsP

rim

ary

car

e(n

o.

of

ph

ysic

ian

s

seen

,n

o.o

f

vis

its,

pri

vate

or

pu

blic

ph

ysic

ian

s,

anti

bio

tics,

ho

spit

alre

ferr

al,

access

)

Infa

nt

mo

rtal

ity

fro

mA

RI

Pri

mar

ycar

ep

rocess

es

had

anin

dep

en

den

teff

ect

(co

ntr

ollin

gfo

rin

div

idu

alan

dfa

mily

socio

eco

no

mic

s,ac

cess

tocar

e)

on

AR

Id

eat

hs

(OR

=9

.68

,9

5%

CI=

3.5

9–2

6.1

).Si

gn

ific

ant

pre

dic

tors

inclu

ded

inad

eq

uat

ere

ferr

al,la

ck

of

co

nti

nu

ity

(att

en

ded

by

mu

ltip

lep

hys

icia

ns)

,an

db

ein

g

atte

nd

ed

by

ap

riva

tep

rovid

er

(as

op

po

sed

toa

pu

blic

pro

vid

er)

.

(con

tin

ues

)

170 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2009C

ou

ntr

y/r

egio

nP

HC

Main

(refe

ren

ce)

Ty

pe

aP

op

ula

tio

nm

easu

res

ou

tco

me

Imp

act/

resu

lt

Mo

zam

biq

ue

(Ed

war

d

et

al.,

20

07

)

CC

hild

ren

you

nge

r

than

5y

IMC

Ip

rogra

m

co

vera

ge

Infa

nt

and

un

der-

5

mo

rtal

ity

Imp

lem

en

tati

on

of

acti

vit

ies

asso

cia

ted

wit

hth

eIM

CI

pro

gra

mre

sult

ed

ina

66

%re

du

cti

on

inin

fan

t

mo

rtal

ity

and

a6

2%

red

ucti

on

inu

nd

er-

5m

ort

alit

y.

Nig

er

(Mag

nan

iet

al.,

19

96

)

CC

hild

ren

you

nge

r

than

5y

Geo

gra

ph

ical

pro

xim

ity

and

the

use

of

heal

th

serv

ices

Un

der-

5

mo

rtal

ity

Ch

ild

ren

invilla

ges

wit

ha

dis

pen

sary

were

32

%le

ss

likely

toh

ave

die

dd

uri

ng

the

stu

dy

peri

od

than

were

child

ren

invilla

ges

wit

hn

ose

rvic

es.

No

surv

ival

adva

nta

gein

villa

ges

wit

hth

evilla

geh

eal

th

team

pre

sen

t.

Pak

ista

n(D

’So

uza

&

Bry

ant,

19

99

)

DC

hild

ren

in6

Kar

ach

isl

um

s

Heal

thse

rvic

eu

se

(typ

eo

fp

rovid

er,

lon

git

ud

inal

ity,

abilit

yto

exp

lain

cle

arly

)

Infa

nt

mo

rtal

ity

Th

eu

seo

ftr

adit

ion

alh

eal

ers

(as

op

po

sed

totr

ain

ed

VH

Ws

or

do

cto

rs)

(OR

=1

4.5

2;9

5%

CI=

4.2

3–4

9.8

3)

and

freq

uen

tsw

itch

ing

of

heal

thcar

e

pro

vid

ers

(lac

ko

flo

ngit

ud

inal

ity)

(OR

=8

;9

5%

CI

=2

.22

–2

8.8

1)

asin

cre

asin

gth

eo

dd

so

fin

fan

td

eat

h

fro

mre

spir

ato

ryin

fecti

on

so

rd

iarr

hea.

Th

eP

hilip

pin

es

(William

son

,1

98

2)

CW

om

en

and

child

ren

inth

e

pro

ject

area

PH

Ccen

ters

(mid

wiv

es,

(dru

gst

ore

s,

ho

spit

alu

nit

s)

Infa

nt

mo

rtal

ity

Th

ep

rogra

mh

adn

oeff

ect

on

infa

nt

mo

rtal

ity.

Po

ten

tial

reas

on

sin

clu

de

po

or

qu

alit

yo

rq

uan

tity

of

heal

thse

rvic

es,

ase

lecti

veap

pro

ach

toP

HC

wit

h

em

ph

asis

on

fam

ily

pla

nn

ing

(fert

ilit

yd

idd

eclin

e),

ove

rwo

rked

and

/or

inad

eq

uat

ely

trai

ned

staf

f.

Sen

egal

(Pis

on

et

al.,

19

93

)

EIn

fan

tsin

inte

rven

tio

n

areas

Pre

sen

ce

of

inte

gra

ted

PH

C

pro

gra

min

the

area

of

stu

dy

Un

der-

5

mo

rtal

ity

Un

der-

5m

ort

alit

yd

eclin

ed

fro

m3

50

to8

1d

eat

hs/

10

00

live

bir

ths

fro

m1

97

0to

19

93

.R

ed

ucti

on

sse

en

pri

mar

ily

fro

md

iseas

es

pre

ven

ted

by

imm

un

izat

ion

.

Dia

rrh

ea

and

AR

Isar

elo

wer

than

ino

ther

rura

lar

eas

of

Sen

egal

;o

nly

4%

of

deat

hs

attr

ibu

ted

tom

alar

ia.

Sou

thA

fric

a(C

ole

man

et

al.,

19

98

)

EA

du

lts

wit

h

chro

nic

illn

ess

es

Clin

ics

usi

ng

up

dat

ed

pro

toco

lsfo

rth

e

man

agem

en

to

f

chro

nic

dis

eas

es

Co

ntr

olo

f

chro

nic

dis

eas

es

Th

eu

tiliza

tio

no

fp

roto

co

lsen

able

dlo

cal

nu

rses

to

co

ntr

olclin

ical

co

nd

itio

ns

of

68

%o

fp

atie

nts

wit

h

hyp

ert

en

sio

n,8

2%

of

tho

sew

ith

no

n–in

sulin

-dep

en

den

td

iab

ete

s,an

d8

4%

of

tho

se

wit

has

thm

a.Pat

ien

t-re

po

rted

adh

ere

nce

to

treat

men

tin

cre

ased

fro

m7

9%

to8

7%

(P=

.03

)o

ver

2y.

Decre

ased

uti

liza

tio

no

fh

osp

ital

sfo

rro

uti

ne

car

e.

(con

tin

ues

)

Primary Healthcare in Low- and Middle-Income Countries 171

Co

un

try

/regio

nP

HC

Main

(refe

ren

ce)

Ty

pe

aP

op

ula

tio

nm

easu

res

ou

tco

me

Imp

act/

resu

lt

Sou

thA

fric

a(d

en

Best

en

et

al.,

19

95

)

EC

hild

ren

you

nge

r

than

5y

Pro

vis

ion

of

GO

BI-

FFF

serv

ices

(gro

wth

mo

nit

ori

ng,O

RT,

bre

ast-

feed

ing,

imm

un

izat

ion

,

fam

ily

pla

nn

ing,

foo

d

sup

ple

men

tati

on

,

fem

ale

ed

ucat

ion

)

Un

der-

5

mo

rbid

ity

PH

Cac

tivit

ies

imp

rove

dan

thro

po

metr

ico

fch

ild

ren

you

nge

r

than

5y

betw

een

19

82

and

19

90

.T

he

pre

vale

nce

of

un

derw

eig

ht

incre

ased

fro

m2

8%

to3

1%

fro

m1

98

2to

19

84

,

and

then

declin

ed

to2

3%

and

19

%in

19

88

and

19

90

,

resp

ecti

vely

(P<

.01

).T

he

pre

vale

nce

of

stu

nti

ng

decre

ased

stead

ily

fro

m3

3%

in1

98

2to

17

%in

19

90

.T

he

low

pre

vale

nce

of

low

weig

ht

for

heig

ht

(was

tin

g)

declin

ed

fro

m

5%

in1

98

2to

1%

in1

99

0(P

<.0

1).

Th

ep

reva

len

ce

of

seve

re

mal

nu

trit

ion

incre

ased

fro

m3%

in1982

to14%

in1984

and

then

declin

ed

rap

idly

to5

%in

19

88

and

to4

%in

19

90

.

Zai

re(C

hah

naz

aria

n

et

al.,

19

93

;Tay

lor

et

al.1

99

3)

CW

om

en

and

child

ren

in

pro

gra

man

d

no

np

rogra

m

areas

Pre

sen

ce

of

the

Co

mb

atin

g

Ch

ild

ho

od

Co

mm

un

icab

le

Dis

eas

ep

roje

ct

Un

der-

5

mo

rtal

ity

Inte

rven

tio

nin

clu

ded

teta

nu

san

dch

ild

ho

od

imm

un

izat

ion

s,

OR

T,m

alar

iatr

eat

men

t.U

nd

er-

5m

ort

alit

yd

eclin

ed

by

33

%

fro

mb

aselin

ele

vels

.T

he

inte

rven

tio

nw

as“e

stim

ated

to

hav

ere

du

ced

mo

rtal

ity

atag

es

6–35

mo

by

atle

ast

18%

–23%

asso

cia

ted

wit

hth

ech

ange

inth

ein

cid

en

ce

of

meas

les

and

may

hav

eb

een

resp

on

sib

lefo

rth

efu

ll28%

red

ucti

on

reco

rded

betw

een

19

80

–1

98

4an

d1

98

5–1

98

9.”

Ken

ya,M

adag

ascar

,

Mal

awi,

Tan

zan

ia,

Zam

bia

(Bro

ckerh

off

&D

ero

se,1

99

6)

GN

eo

nat

es,

infa

nts

,

and

child

ren

you

nge

rth

an

5y

fro

m

Dem

ogra

ph

ic

and

Heal

th

Surv

eys

Use

of

pre

nat

alcar

e

and

imm

un

izat

ion

co

vera

ge

Neo

nat

al,in

fan

t,

and

un

der-

5

mo

rtal

ity

Sele

cti

veP

HC

serv

ices

hav

ean

imp

ort

ant

imp

act

on

child

surv

ival

.In

term

so

fat

trib

uta

ble

risk

,in

co

mp

lete

imm

un

izat

ion

sar

ere

spo

nsi

ble

for

34%

of

deat

hs,

lack

of

cle

anw

ater

for

16

%,in

adeq

uat

ep

ren

atal

car

ean

dd

elive

ry

for

11

%,an

dh

igh

fert

ilit

yfo

r1

2%

,w

hile

co

ntr

ollin

gfo

r

oth

er

heal

thd

ete

rmin

ants

(co

vari

ates

inclu

de

socio

eco

no

mic

and

bio

logic

stat

us

and

infr

astr

uctu

re).

Lat

inA

meri

ca

(22

co

un

trie

s)(M

oo

re

et

al.,

20

03

)

AC

hild

ren

in2

2

Lat

inA

meri

can

co

un

trie

s

Vac

cin

atio

nco

vera

ge,

use

of

OR

T,

bre

ast-

feed

ing,

ph

ysic

ian

sup

ply

Un

der-

5

mo

rtal

ity

Fiv

em

ain

vari

able

sw

ere

asso

cia

ted

wit

hre

du

ced

un

der-

5

mo

rtal

ity:

fem

ale

lite

racy,

BC

Gva

ccin

atio

nra

te,ac

cess

to

safe

wat

er,

use

of

OR

T,an

dgro

ssn

atio

nal

pro

du

ct

per

cap

ita.

Ab

bre

via

tio

ns:

ALR

I,ac

ute

low

er

resp

irat

ory

infe

cti

on

;A

RI,

acu

tere

spir

ato

ryin

fecti

on

;C

HW

,co

mm

un

ity

heal

thw

ork

er;

CI,

co

nfi

den

ce

inte

rval

;FH

P,fa

mily

heal

thp

rogra

m;

HA

S,H

osp

ital

Alb

ert

-Sch

weit

zer;

IMC

I,in

tegra

ted

man

agem

en

to

fch

ild

ho

od

illn

ess

;O

RT,

ora

lre

hyd

rati

on

thera

py;

OR

,o

dd

sra

tio

;P

HC

,p

rim

ary

heal

thcar

e;

TB

A,

trad

itio

nal

bir

that

ten

dan

t;V

HW

,villa

geh

eal

thw

ork

er.

aA

,ex

peri

men

tal

or

qu

asi-ex

peri

men

tal;

B,

pro

specti

ved

esi

gn

wit

hco

ntr

ol;

C,

rep

eat

ed

cro

ss-s

ecti

on

ald

esi

gn

wit

hco

mp

aris

on

/co

ntr

ol;

D,

cas

e-c

on

tro

lst

ud

y;E,

rep

eat

ed

cro

ss-s

ecti

on

ald

esi

gn

wit

ho

ut

co

mp

aris

on

co

ntr

ol;

F,sy

stem

atic

lite

ratu

rere

vie

w;G

,o

bse

rvat

ion

/qu

alit

ativ

e/s

ingle

cro

ss-s

ecti

on

.