Closing the Primary Health Care Measurement Gap

Joint Learning Network for Universal Health Coverage meeting
Collaborative members discuss challenges in PHC service delivery. R4D/Meredith Kimball
There is strong consensus among countries and partners that strengthening primary health care (PHC) is essential to achieve universal health coverage and the health-related Sustainable Development Goals. However, to strengthen PHC systems countries must first understand what’s working, what’s not working, and whether changes are leading to improvements. Knowing the answers to these questions requires good measurement.

Hosted by the Ghana Health Service, representatives from 10 countries across Africa, Asia, and Latin America, as well as the Primary Health Care Performance Initiative (PHCPI) and Joint Learning Network for Universal Health Coverage (JLN) partner organizations including the World Bank Group, Bill & Melinda Gates Foundation, Results for Development, and Ariadne Labs, met in Accra, Ghana in April 2016 to kick off a new learning collaborative on Primary Health Care Measurement for Improvement.

Measurement is a critical tool for supporting improvement efforts to strengthen primary health care systems to achieve universal health coverage. To this end, members of the PHC Measurement for Improvement Collaborative will co-develop practical tools and approaches – drawing on their collective experiences—to support country policymakers, health system managers, and frontline providers to effectively use data for PHC improvement. In addition, each meeting will allow participants to gain real time feedback to inform reforms in their own countries. As said by Dr. Luis Martinez, Director of New Models for Mexico’s Directorate General of Health Planning and Development within the Federal Ministry of Health,

While we all have challenges and problems, we can also reflect that we all have answers and new information that we can share."


PHC innovations, successes, and measurement gaps

During the meeting, country representatives shared lessons learned from ongoing efforts and successes in measuring and improving PHC service delivery. Participants touched on a number of domains of PHC service delivery, including access to care, the availability of effective services, people-centered care, and organization and management. Overarching issues such as political will and the integration of the private sector, and challenges in accessibility, provider performance, and continuity and coordination of care cut across most country experiences, as did the feeling that there is an immense amount of measurement already taking place in most countries.

Much measurement within the service delivery domain is ongoing at the facility level, and examples given by countries showed an evolution in measurement that mimics the maturity of the countries’ PHC system - for example, moving from coverage, to basic effective coverage, to integral effective coverage. Other discussions that emerged include:

  • Utility of patient-level data for care management that can be aggregated for reporting and improvement at higher levels of the system
  • Involving stakeholders at all levels in data interpretation
  • Developing new data collection tools
  • Improving basic effective coverage through pay-for-performance methods

Experiences were shared with the group, sparking further discussion on the enabling factors for successful measurement for improvement. However, many gaps and challenges were also noted.

Using the PHCPI conceptual framework as a guide, the group collectively prioritized community engagement, patient experience, and provider performance – difficult areas to measure, but crucial for PHC improvement – as key measurement gaps to address as a collaborative.

As the meeting progressed, participants prioritized deeper discussion around the institutionalization of data utilization, identifying many common challenges that countries face in effectively using data for improvement. Countries highlighted the challenges of collecting community-level and private sector data; lack of information system interoperability; and the burden placed on frontline providers when insufficient human resources are available for the collection and interpretation of data. Many countries with diverse landscapes and decentralized PHC models, such as Indonesia, Nigeria, and Mexico, also emphasized the need for adaptable measurement solutions.

How can we address measurement gaps through the co-production of knowledge products and ongoing exchange of tacit knowledge?

By the third and final day of the meeting, the group came to a strong consensus around several areas of work to undertake as a collaborative over the coming year. With objectives to (1) Improve country-level measurement of PHC performance; (2) Address priority measurement gaps countries are facing in order to inform improvement efforts; and (3) Develop strategies for better utilizing measurement to drive improvements in the PHC system within the overarching objectives of attaining UHC and the health-related SDGs, the group prioritized the development of several concrete and interrelated tools, including:

  1. Indicator Inventory: The group prioritized the development of a menu of existing PHC indicators being utilized by countries, inclusive of routine systems and national surveys and complemented by globally recognized indicators, to allow countries to pool together and benefit from their different abilities to measure PHC system performance. Organized according to the domains of the PHCPI conceptual framework as well as level of use in the system (facility, sub-national, national), the inventory would include indicator definitions, rationales, data sources, measurement limitations, directionality, and use cases. Further, the inventory would include a core indicator set identified for each domain and would allow countries to select indicators based on their specific context and level of measurement ability or to identify proxy indicators, encouraging a progression toward more sophisticated measurement over time.
  2. Methods for Addressing Priority Measurement Gaps: While the indicator inventory will provide countries with a menu of existing PHC measures, the collaborative members also identified a set of priority measurement gaps to address – areas that are currently under-measured, or not measured in standardized ways that can be used to drive improvement. This includes community engagement, provider performance, and patient experience. With the goal of working toward a specific knowledge product, the group would develop a process for addressing these measurement gap areas and potentially pilot new measures and tools in their countries. Methods for addressing gaps could include the development of new indicators, new methods for collecting new and existing indicators, and guidance on how to use these measures for improvement purposes.
  3. Process Guide for Translating Data into Improvement: With the indicator inventory and methods for addressing data gaps as foundational components, the group discussed the development of an overarching process guide for transforming PHC measurement into improvement. Guidance would be aligned with the steps of the JLN Measurement for Improvement Cycle (Figure 1), spanning the critical components of measurement for improvement starting with the identification of the problem or question to be answered; how to measure PHC; why, when and where to apply measurement tools; how to analyze data; and how to
    JLN Measurement for Improvement Cycle
    Figure 1: JLN Measurement for Improvement Cycle
    encourage the institutionalization of data use. This comprehensive process guide would provide countries with information and guidance critical to ensuring that measurement is routinely used for PHC improvement throughout the system, combining a wealth of country knowledge and international guidance to define frameworks for different stakeholders and levels of information system maturity.

By the end of the workshop, the participants committed to working together over the next year to develop these global public goods and share knowledge, both within the JLN and more broadly. Further, work will be done to ensure collaboration and harmonization with other global measurement for improvement initiatives, including the Health Data Collaborative and the communities of practice within the Integrated People-Centered Health Services and Health Harmonization in Africa initiatives.

Chloe Lanzara and Meredith Kimball are technical facilitators of the PHC Measurement for Improvement Collaborative at Results for Development.