Contribution of health system governance in delivering primary health care services for universal health coverage: A scoping review

Abstract

Background: The implementation of the primary health care (PHC) approach requires essential health system inputs, including structures, policies, programs, organization, and governance. Effective health system governance (HSG) is crucial in PHC systems and services, as it can significantly influence health service delivery. Therefore, understanding HSG in the context of PHC is vital for designing and implementing health programs that contribute to universal health coverage (UHC). This scoping review explores how health system governance contributes to delivering PHC services aimed at achieving UHC.

Methods: We conducted a scoping review of published evidence on HSG in the delivery of PHC services toward UHC. Our search strategy focused on three key concepts: health system governance, PHC, and UHC. We followed Arksey and O'Malley's scoping review framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to guide our methodology. We used the World Health Organization's framework on HSG to organize the data and present the findings.

Results: Seventy-four studies were included in the final review. Various functions of HSG influenced PHC systems and services, including:1) formulating health policies and strategic plans (e.g., addressing epidemiological and demographic shifts and strategic financial planning), 2) implementing policy levers and tools (such as decentralization, regulation, workforce capacity, and supply chain management), 3) generating intelligence and evidence (including priority setting, monitoring, benchmarking, and evidence-informed decision-making), 4) ensuring accountability (through commitments to transparency), and 5) fostering coordination and collaboration (via subnational coordination, civil society engagement, and multisectoral partnerships). The complex interplay of these HSG interventions operates through intricate mechanisms, and has synergistic effects on PHC service delivery.

Conclusion: PHC service delivery is closely linked to HSG functions, which include formulating strategic policies and plans responsive to evolving epidemiological and demographic needs, utilizing digital tools, decentralizing resources, and fostering multisectoral actions. Effective policy implementation requires robust regulation, evidence-based decision-making, and continuous monitoring. Accountability within health systems, alongside community engagement and civil society collaboration, is vital for realizing PHC principles. Local health institutions should collaborate with communities-end users of these systems-to implement formal rules and ensure PHC service delivery progresses toward UHC. Sociocultural contexts and community values should inform decision-making aligning health needs and services to achieve universal access to PHC services.

Fig 1. Flow chart showing the selection of studies for this study.