PHC Progression Model: a novel mixed-methods tool for measuring primary health care system capacity

Abstract

High-performing primary health care (PHC) is essential for achieving universal health coverage. However, in many countries, PHC is weak and unable to deliver on its potential. Improvement is often limited by a lack of actionable data to inform policies and set priorities. To address this gap, the Primary Health Care Performance Initiative (PHCPI) was formed to strengthen measurement of PHC in low-income and middle-income countries in order to accelerate improvement. PHCPI's Vital Signs Profile was designed to provide a comprehensive snapshot of the performance of a country's PHC system, yet quantitative information about PHC systems' capacity to deliver high-quality, effective care was limited by the scarcity of existing data sources and metrics. To systematically measure the capacity of PHC systems, PHCPI developed the PHC Progression Model, a rubric-based mixed-methods assessment tool. The PHC Progression Model is completed through a participatory process by in-country teams and subsequently reviewed by PHCPI to validate results and ensure consistency across countries. In 2018, PHCPI partnered with five countries to pilot the tool and found that it was feasible to implement with fidelity, produced valid results, and was highly acceptable and useful to stakeholders. Pilot results showed that both the participatory assessment process and resulting findings yielded novel and actionable insights into PHC strengths and weaknesses. Based on these positive early results, PHCPI will support expansion of the PHC Progression Model to additional countries to systematically and comprehensively measure PHC system capacity in order to identify and prioritise targeted improvement efforts.

Keywords: Primary care; capacity; global health; measurement; primary health care; universal health coverage.

Figure 1

The Primary Health Care Performance Initiative conceptual framework. Focal areas for the PHC Progression Model are highlighted in yellow; other areas of the framework are also included in the Vital Signs Profile but assessed using different a methodology, reflecting available quantitative data. PHC, primary healthcare; NCDs, non-communicable diseases; RMNCH, reproductive, maternal, newborn, and child health.

Figure 2

Timeline of the development of the PHC Progression Model. LMIC, low-income and middle-income country; PHC, primary healthcare; PHCPI, Primary Health Care Performance Initiative.

Figure 3

Structure of the PHC Progression Model and its relationship to the Vital Signs Profile (VSP). Each of the 32 measures of the PHC Progression Model contains a rubric outlining four performance categories (Levels 1–4). Measures are grouped thematically, according to the PHCPI conceptual framework. Raw measure scores are averaged by theme into nine subscores, which are in turn averaged to calculate the three scores that appear in the Capacity pillar of the VSP. Subscores and VSP scores are rounded to the tenths place. PHC, primary healthcare; PHCPI, Primary Health Care Performance Initiative.