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. 2025 Mar 7;25(1):353.
doi: 10.1186/s12913-025-12412-6.

Performance measurement systems in primary health care: a systematic literature review

Carlos Jefferson de Melo Santos  1   2 , Ava Santana Barbosa  3 , Ângelo Márcio Oliveira Sant'Anna  3
Affiliations

Performance measurement systems in primary health care: a systematic literature review

Carlos Jefferson de Melo Santos et al. BMC Health Serv Res. .

Abstract

Background: Performance measurement systems (PMS) are increasingly recognized as essential tools in healthcare services. However, there remains a significant gap in the literature regarding their development, implementation, and impact on primary health care (PHC). This study aims to systematically review peer-reviewed literature to identify and analyze existing constructs, methodologies, and challenges associated with PMS in primary care settings worldwide.

Methods: This systematic review follows the PRISMA guidelines regarded as the gold standard for evidence synthesis in scientific and grey literature. The quality of the selected studies was assessed using the Rosalind Franklin Qualitative Research Appraisal Instrument (RF-QRA), focusing on transferability, reliability, credibility, and confirmability.

Results: From an initial pool of 167 articles, 14 studies were selected for in-depth analysis. These studies highlighted several challenges, including difficulties in evaluating PMS post-implementation within primary care units, limited evidence on the longitudinal monitoring of performance indicators, and inconsistencies in methodological approaches. The findings also revealed that regional, operational, and cultural contexts influenced the most PMS adaptations.

Conclusions: This systematic review offers a comprehensive diagnosis of the best PMS models implemented globally over the past five years, emphasizing heterogeneity, diversification, and reliability. The findings underscore the potential for PMS to inform public policies to achieve high-performance primary healthcare systems and enhance decision-making processes at both operational and managerial levels.

Keywords: Decision support systems; Operational research; Performance Indicators; Performance measurement systems; Primary health care.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Research project approved by the ethics committee of the Federal University of Bahia under the guidelines of Circular Letter No. 209/2013 CONEP/CNS/GB/MS and internal regulations number 04/2019 and 05/2022. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Review protocol based on Page et al. [46]
Fig. 2
Fig. 2
Number of indicators per classification area
Fig. 3
Fig. 3
Framework of Performance Measurement Systems (PMS) in Primary Healthcare, based on studies included in the systematic review. The framework is structured into three layers: (1) The nine main categories of indicators identified in the review (Layer 1), (2) The subcategories or specific dimensions associated with each category (Layer 2), and (3) The methodological approaches employed in the analyzed studies (Layer 3). This hierarchical visualization illustrates the interconnections between categories, dimensions, and methodologies, highlighting their role in addressing operational, contextual, and technological challenges in primary healthcare systems
Fig. 4
Fig. 4
Number of manuscripts by country where the research took place or corresponding author's country
Fig. 5
Fig. 5
Number of manuscripts per publication journal
Fig. 6
Fig. 6
Number of manuscripts by year of publication of the manuscript
Fig. 7
Fig. 7
Network visualization of term co-occurrence in performance measurement systems
Fig. 8
Fig. 8
Network visualization of term co-occurrence in social determinants and cost tracking
Fig. 9
Fig. 9
Network visualization of term co-occurrence in continuity and coordination of care
See this image and copyright information in PMC

References

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