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Health systems strengthening in primary care: how will we know when things have improved? « Back to Blogs

Health systems strengthening in low- and middle-income countries is a challenge.

The challenge largely revolves around the need to provide healthcare in both quantity and quality. This is difficult in wealthy countries but is doubly so when there is limited budget to provide universal health coverage of reasonable quality standards. The dilemma has led many to conclude that the hospital sector cannot cope, and the only feasible solution is to strengthen primary care health systems.

There is certainly room for improvement in primary care health systems in many low-income countries. Provision is sometimes patchy, and quality is often variable or poor. This results in inferior outcomes in both communicable and non-communicable diseases. The rapidly growing prevalence of non-communicable diseases in low-income countries has meant that there is now a great deal of interest in what can be done to help.

There is also the issue of how to measure the current strength of primary care systems. It is not easy to deliver improvement when there is no valid and reliable means to measuring provision at baseline and then improvement over time. However, progress is being made. The Primary Health Care Performance Initiative has been developed and launched by the World Health Organization, The World Bank, and the Bill and Melinda Gates Foundation “to catalyze improvements in PHC [primary healthcare] in LMIC [low- and middle-income countries] through better measurement and sharing of effective practice”. (1)

Bitton et al have published a comprehensive paper on the Initiative and the current and future challenges of measuring the strength of primary care. (1) The measurement framework in the Initiative evaluates service delivery (including measures such as adherence to clinical guidelines), outputs (such as control of hypertension or diabetes), and outcomes (such as adult mortality ratios from non-communicable diseases). These are just some examples out of twenty-five indicators of the provision of primary care services.

Of course, indicators in themselves will not improve primary healthcare services. Sustained improvement will only come from investment in infrastructure and primary care workforce development. However, the benefit of the indicators is that they give those who want to improve primary care something to focus on. For example, at BMJ, we have a range of e-learning and clinical decision support resources that enable doctors and other healthcare professionals to adhere to guidelines in important clinical areas (such as hypertension and diabetes). And there is growing evidence of the effectiveness of these resources in improving the practice of doctors and other healthcare professionals in these and other clinical fields.

Dr Kieran Walsh


  1. Bitton ARatcliffe HLVeillard JHKress DHBarkley SKimball MSecci FWong EBasu LTaylor CBayona JWang HLagomarsino GHirschhorn LR. Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries. J Gen Intern Med.2017 May;32(5):566-571.  

Competing interests

Kieran Walsh works for BMJ which produces educational and clinical decision support resources on a range of subjects – including non-communicable diseases.

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