Table 1 Elements of enquiry (fixed elements in bold text)

Structures refer to the relatively unchanging elements of primary systems – institutional, infrastructural and economic – that shape and condition the delivery of effective services. Structural elements are broadly classified into governance, financing, human resources and service organization.

A. Key aspects of health system governance, as a high-level function, that can be recognized as being immediately relevant to the performance of PHC systems include:

 1. Existence of a national policy statement on health equity, universal health coverage and/or health rights

 2. Presence of institutional mechanisms to represent citizen voice and civil society engagement in health service organization and planning

 3. Relative role of government, private for-profit and not-for profit sectors, and development partners in the delivery of health services

 4. Extent of de jure decentralization of decisions for health care management and services

 5. Presence of institutional and legal mechanisms for feedback and action on user grievances in the health sector

 6. Presence of institutional mechanisms to engage other sectors (water, agriculture, education, transportation, etc.) for action on social and environmental determinants of health

 7. Existence of systems to identify, measure and respond to disease burden in the population, including emerging health priorities such as multiple morbidity, mental health, and epidemics

B. Arrangements and systems for financing health, and improving financial flows in the health sector that are relevant for PHC systems are enlisted below:

 1. Overall government commitment to tax-funded health care, reflected as total government allocation for health as a proportion of the GDP

 2. Government’s relative commitment for primary-level care, reflected as a proportion for PHC out of total government allocation for health

 3. Extent and magnitude of inequitable and inefficient financing mechanisms, reflected in such measures as proportion of out-of-pocket expenditure, proportion of households experiencing catastrophic health expenditure, prevalence of user fees

 4. Extent (depth) of financial coverage of services and conditions at point of care, that is, selective or comprehensive coverage

 5. Extent and depth of de jure financial decentralization, presence of schemes for financial decentralization

 6. Extent of illegitimate fund outflow due to corruption (where information is available) in the health system

 7. Types and extent of purchasing arrangements in force, including contracting, franchising, social insurance and pay-for-performance

 8. Time trends of increases in health care costs and household expenditure, reflecting growing burden on households

 9. Government and development partner commitment to strengthening horizontal systems, as reflected in the ratio of allocation for general health services with respect to vertical health programmes

C. Aspects of the availability of human resources for health and health worker education and support systems that directly influence the performance of PHC systems include:

 1. Proportions of doctors/nurses/midwives/paramedical workers/community health workers (CHWs) engaged in providing PHC, and relative geographical distribution of each group

 2. Relative distribution of PHC providers in public vs private employment

 3. Proportion of informal and untrained providers out of the total PHC workforce, and schemes to engage them

 4. Proportion of practitioners of traditional, complementary and alternative (TCA) systems of medicine out of the total PHC workforce, and schemes to engage them

 5. Adequacy, quality and appropriateness of professional education and in-service training for different cadres of PHC professionals

 6. Trends in greater professionalization of PHC, such as medical specialization in primary or family care, nurse practitioner programmes, and career advancement for CHWs

D. Service organization refers to the organizational arrangements that can facilitate the efficient, equitable and appropriate delivery of integrated, high-quality PHC services:

 1. Presence of systems for referral and counter-referral between different tiers of care, including gatekeeping, patient transport and information tracking

 2. Policies to deploy PHC teams with clearly identified roles (rather than stand-alone frontline providers) and responsibility for a specified population

 3. Existence of CHW programmes, and scale achieved

 4. Extent of de jure integration of vertical programme structures reflected in a common chain of command, fund flow and infrastructure

 5. Extent of de jure integration of PHC with public health functions reflected in a common chain of command, fund flow and infrastructure

 6. Extent of de jure diversification and substitution of PHC providers

 7. Clearly demarcated strategies for in-service support, including decision support, training, recognition and retention for frontline providers

 8. Extent of use of mobile phone and rapid diagnostic technologies for decision support, treatment support, or advice and counselling

Processes refer to the dynamic phenomena and events that occur in planning, regulating, implementing and monitoring PHC systems, and influence their ultimate performance.

E. It is widely recognized that in the health systems of many LMICs, de facto conditions frequently do not follow de jure governance arrangements. Wherever possible, it is important to ascertain what actually happens (rather than what is expected to happen) in the planning and implementation of PHC services

 1. Effectiveness of systems to identify, measure and respond to disease burden in the population including emerging health priorities such as multiple morbidity, mental health, and epidemics

 2. Prevalence and effectiveness of institutional mechanisms to ensure financial tracking and accountability and counter corruption in the health sector

 3. Effectiveness of institutional mechanisms to represent citizen voice and civil society engagement in health service organization and planning

 4. Effectiveness of institutional mechanisms to engage other sectors (water, agriculture, education, transportation, etc.) for action on social and environmental determinants of health

 5. Status and successes (if evaluated) of prevailing purchasing arrangements, including provider contracting, franchising, social insurance and pay-for-performance

 6. Capacity and environment for decentralization of health system functions and financing decisions at different levels, and character of federal-state-district relationships in the health care sector

 7. Extent of de facto integration of vertical programme structures reflected in a common chain of command, fund flow and infrastructure

 8. Extent of de facto integration of PHC with public health functions reflected in a common chain of command, fund flow and infrastructure

 9. Extent of and successes (if evaluated) in diversification and substitution of PHC providers

 10. Effectiveness of integration and utilization of TCA and informal medical providers in delivery of PHC

 11. Effectiveness of systems for referral and counter-referral between different tiers of care, including triage, patient transport and information tracking

 12. Extent of actual presence of PHC teams with clearly identified roles (rather than stand-alone frontline providers) and responsibility for a specified population

 13. Status and successes (if evaluated) of use of mobile phone and rapid diagnostic technologies for decision support, treatment support, or advice and counselling

F. Regulatory processes reflect the government’s ability to ensure the conditions for fair competition and high quality in markets for PHC. While critically important to curb distortions associated with market failures in mixed health systems, such knowledge is typically not easy to objectively ascertain in a short span of time, and is better understood through key informants, and by tracking existing research.

 1. Government capacity for managing partnership agreements with non-state sector service providers

 2. Government capacity to regulate conflicts of interest, and enact anti-trust laws and fair competition norms in the health care sector

 3. Government capacity to regulate quality of services and medical products in the non-state health care sector, supported with provisions for punitive action

 4. Government capacity to regulate standards of professional education for PHC providers

 5. Effectiveness of institutional and legal mechanisms for feedback and action on user grievances in the health sector

G. Monitoring and information systems are crucial factors in ensuring internal accountability and the alignment of publicly delivered PHC services with their intended functions.

 1. Health worker accountability to communities, as reflected in the prevalence of health worker absenteeism

 2. Regular supervision, performance review of facilities and PHC teams

 3. Existence and reliability of health information management systems for tracking major service delivery indicators and health outcomes

 4. Existence of systems for utilization of anonymous health management information system (HMIS) data to decision-makers at different levels for planning purposes

 5. Existence of institutional mechanisms for supportive supervision of CHWs

Health systems outcomes, as distinct from “health outcomes” (beyond the scope of these health systems assessments), are manifestations of the performance of PHC systems at the frontlines. Key outcome categories include equitable access to PHC services at scale, the appropriateness and responsiveness of those services to people’s needs, and the quality and safety of the services that people ultimately receive.

H. The first and most apparent outcome of a successful country PHC system is equitable access at scale of PHC services.

 1. Geographic availability and equity: the extent and equitable presence of functioning PHC facilities, across rural, peri-urban and urban locations

 2. Socioeconomic equity: the equitable presence of functioning PHC facilities, across locations defined by social (such as sectarian) and economic differences within a country

 3. Extent of acceptance and equitable utilization of functioning PHC services, reflected in the proportion of essential services utilized (such as institutional deliveries, immunization coverage and tuberculosis (TB) treatment completion), in absolute terms, and disaggregated across social and economic categories (where information is available)

 4. Extent of acceptance and equitable utilization of functioning PHC services, reflected in documented social and/or economic barriers to accessing functioning PHC services, in the absence of geographical barriers

I. Appropriate and responsive care: care services must be organized in a manner that is responsive to the long-term needs of users, and reflect the role of PHC services as social and community-embedded institutions

 1. Health coproduction: systems to ensure users’ views are respected and accounted for in arriving at therapeutic decisions

 2. Relational continuity: existence of provisions for user engagement with a single point of contact from the PHC team, over a period of time

 3. Longitudinal continuity: existence of provisions for user engagement with PHC teams across separate illness episodes

 4. Informational continuity: existence of provisions for organized collection of user’s medical information available to the PHC team

 5. Comprehensiveness of services: availability of combination of promotive, preventive and curative services at point of care

 6. Therapeutic comprehensiveness: availability of care and/or appropriate referral for a wide range of complaints and conditions at point of care

 7. Regular availability and utilization of necessary equipment and medical products for treatment of those complaints and conditions at point of care

 8. Productive efficiency: steps taken to minimize expenditure and opportunity cost for users in accessing care, without compromising outcomes

 9. Efficiency of workers: steps taken to assess and streamline frontline worker caseload, duration of consultations and prescribing practices reflect efficiency, without compromising outcomes

 10. Technical efficiency: steps taken to streamline and reduce utilization of resources and costs of providing care, without compromising outcomes

J. Quality and safety of care is of paramount importance and finds reflection equally in the perceptions of users, and in adherence to the technical parameters that guide standard care practices.

 1. User satisfaction with PHC services, for example as reflected in user perception surveys

 2. Frontline provider adherence to standard treatment practices, as reflected in monitoring data or survey results on treatment of major therapeutic categories such as chronic diseases, mental health, maternal & child health, infectious diseases

 3. Existence of arrangements to regularly assess and monitor patient and health worker safety in PHC facilities