EVALUATING PRIMARY HEALTH CARE POLICIES: A STEP...

EVALUATING PRIMARYHEALTH CARE POLICIES: A

STEP TOWARDS IDENTIFYING HUMAN RESOURCE ISSUES

IN COMMUNE HEALTH STATIONS IN VIETNAM

John Rule, Duc Anh Ngo, Tran Thi Mai Oanh, Alison Short,

Augustine Asante, Graham Roberts & Richard Taylor

www.hrhhub.unsw.edu.au

An AusAID funded initiative

Le

ad

ersh

ip a

nd

ma

na

ge

me

nt

ACKNOWLEDGEMENTS

This document was reviewed internally by HRH Hub staff and two external reviewers.

Thank you to Professor Nick Zwar, Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, UNSW and Dr Michael O’Rourke, Adjunct Senior Lecturer, Public Health, School of Public Health, University of Sydney for helpful review comments. Thank you also to Dr John Dewdney, Visiti ng Fellow, HRH Hub, for comments and directi on on initi al draft s of the document and Lisa Thompson, Project Offi cer, HRH Hub, for helpful editi ng comments.

Thank you to all research team members at Health Strategy and Policy Insti tute, Hanoi, Vietnam, for their feedback aft er presentati on of an early draft of the document at a workshop held in Hanoi in June 2012.

© Human Resources for Health Knowledge Hub 2013

Suggested citati on:Rule, J et al. 2013, Evaluati ng Primary Health Care Policies: A Step in Identi fying Human Resource Issues in Commune Health Stati ons in Vietnam, Human Resources for Health Knowledge Hub, Sydney, Australia.

Nati onal Library of Australia Cataloguing-in-Publicati on entry

Rule, John

Evaluati ng Primary Health Care Policies: A Step in Identi fying Human Resource Issues in Commune Health Stati ons in Vietnam / John Rule ... [et al.]

9780733432330 (pbk.)

Primary health care—Low and middle-income countriesPrimary health care—VietnamPrimary health care—Commune Health Stati ons

Rule, John.University of New South Wales, Human Resources for Health Knowledge Hub.

Duc Anh Ngo.University of South Australia

Tran Thi Mai Oanh.Health Strategy and Policy Insti tute Vietnam

Alison Short.University of New South Wales, Human Resources for Health Knowledge Hub.

Augusti ne Asante.University of New South Wales, Human Resources for Health Knowledge Hub.

Graham Roberts.University of New South Wales, Human Resources for Health Knowledge Hub.

Richard Taylor.University of New South Wales, Human Resources for Health Knowledge Hub.

362.1

The Human Resources for Health Knowledge Hub

This report has been produced by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales.

Hub publicati ons report on a number of signifi cant issues in human resources for health (HRH), currently under the following themes:

• leadership and management issues, especially at district level

• maternal, newborn and child health workforce at the community level

• intranati onal and internati onal mobility of health workers

• HRH issues in public health emergencies.

The HRH Hub welcomes your feedback and anyquesti ons you may have for its research staff . For further informati on on these topics as well as a list of the latest reports, summaries and contact details of our researchers, please visit www.hrhhub.unsw.edu.au or email [email protected]

This research has been funded by AusAID. The viewsrepresented are not necessarily those of AusAID or the Australian Government.

Published by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales.

Level 2, Samuels Building,School of Public Health and Community Medicine,Faculty of Medicine, The University of New South Wales,Sydney, NSW, 2052,Australia

Telephone: +61 2 9385 8464

Facsimile: +61 2 9385 1104

Web: www.hrhhub.unsw.edu.au

Email: [email protected]

Twitt er: htt p://twitt er.com/HRHHub

Please send us your email address and be the fi rst to receive copies of our latest publicati ons in Adobe Acrobat PDF.

Rule, J et al.Approaches to evaluati ng primary health care in low- and middle-income countries

CONTENTS

2 Acronyms

3 Executi ve summary

4 Background

4 Why is evaluati on of primary health care important?

4 Defi ning primary health care in lower- and middle-income countries

5 Previous eff orts to evaluate primary health care in lower- and middle-income countries

6 Rati onale for this literature review

8 Literature review method

10 Findings

10 Overview of fi ndings

11 Studies focused directly on informing policy development

11 Studies concerned with questi ons of quality and equity

12 Studies which developed performance indicators

13 A study using a results-based logic model

13 Summary of fi ndings

16 Conclusion

17 References

20 Appendix

LIST OF TABLES

7 Table 1. Characteristi cs of PHC from Alma Ata declarati on

9 Table 2. Data base search terms

9 Table 3. Exclusion parameters

10 Table 4. Example studies of PHC initi ati ves and diff erent evaluati on methodologies

14 Table 5. Summary of health performance indicators

15 Table 6. Examples of core CHS performance indicators from China CHS Logic Model

1


ACRONYMS

ART Anti retroviral therapy

CHS Commune Health Stati on or Community Health Service

HIV Human immunodefi ciency virus

HRH Human resources for health

HRH Hub Human Resources for Health Knowledge Hub

HSPI Health Strategy and Policy Insti tute (Vietnam)

PHC Primary health care

LMICs Low- and middle-income countries

MDG Millennium Development Goal

NGO Non government organisati on

TB Tuberculosis

WHO World Health Organizati on

A note about the use of acronyms in this publicati on

Acronyms are used in both the singular and the plural, e.g. NGO (singular) and NGOs (plural).

Acronyms are also used throughout the references and citati ons to shorten some organisati ons with long names.

2


EXECUTIVE SUMMARY

This literature review is part of a collaborative project between the Health Strategy and Policy Institute (HSPI), based in Hanoi, Vietnam and the Human Resources for Health Knowledge Hub (HRH Hub), University of New South Wales. There is interest in finding a realistic, policy-relevant methodology and approach that can be used to evaluate the performance and effectiveness of the primary health care (PHC) system in Vietnam.

This review documents the ways in which PHC has been evaluated in low- and middle income countries (LMICs), with a focus given to countries that have undergone health sector reforms similar to Vietnam. It will inform a PHC policy analysis currently being conducted by HSPI and assist in conducting operational research to evaluate the effectiveness of Commune Health Stations (the basic unit of the PHC network) in the changing health system of Vietnam.

The review has been a step in the response to the situation in Vietnam where health system reform has had a significant impact on primary health care delivery and the area of human resources for health (HRH). Vietnam’s health system faces many challenges in HRH development within the primary health care network, for example, ensuring and maintaining the quality of HRH in rural areas. Other inputs in the primary health care network such as leadership and governance, health financing, health service delivery and health information systems will be of interest but the focus of the collaboration between HSPI and the Human Resources for Health Knowledge Hub, UNSW is specifically on human resources in primary health care.

Studies from LMICs using an explicit methodology or framework for measuring PHC effectiveness were collated. Databases of published articles were searched and a review of grey literature undertaken to identify relevant reports. Relevant studies were then classified according to study design, methods of data collection and evaluation of outcomes. PHC is a complex social intervention and the realist review approach was used with the aim of directing attention to the contexts in which the interventions were applied.

The review found that there is no consistent approach for assessing the effectiveness of PHC interventions in LMICs. Some presented a case study of PHC policy

implementation; others were disease specific or related to a specific health response context.

Some studies focused on PHC services using descriptive case studies or cross sectional data to assess user satisfaction with services and patient health outcomes. Other studies used documentary analysis, policy review or quantitative surveys in an attempt to assess effectiveness of PHC programs at the district or sub-national level.

Notably, one study in China, aiming to assess the impact of significant investment in PHC renewal programs, used a results-based logic model with input from local stakeholders, to develop a set of core community health facility indicators. This is a promising approach and could be potentially applicable in other LMIC contexts, including Vietnam.

It would be useful to develop an evidence-based approach which is applicable to LMICs for assessing the effectiveness of PHC programs and interventions; but there is no agreed approach which can be identified in the literature.

This review contributes to the development of an approach by identifying a possible role for operational and implementation research studies, which evaluate policy outcomes and consider important matters such as quality and user views of PHC effectiveness.

This document is focused on the diff erent approaches to evaluati ng PHC eff ecti veness that may be of use in Vietnam, the collaborati ve project between HRH Hub and HSPI anti cipates the completi on of a further report which will summarise policy development and challenges in the primary health care network at a grassroots level in Vietnam. In relati on to human resources for health at the primary health care level further informati on will be gathered on: the number of health workers; the distributi on of doctors, pharmacists and nurses; health care workforce structure at a commune level; and recruitment and retenti on policies.

3


A major diffi culty has been that there are no control programs with which to compare PHC interventi ons to other possible interventi ons in LMICs.

BACKGROUND

Why is evaluation of primary health care

important?

There have been calls for large scale evaluati ons of PHC and a community focused operati onal research agenda may best meet this need [Gillam 2008]. Evaluati on and research needs to be context specifi c and rely on the commitment of local actors [Gillam 2008; Kruk et al. 2010].

In the context of progress toward the MDGs,

More detailed analysis and evaluati on within and across countries would be invaluable in guiding investments for primary health care. [Rohde et al. 2008, p.950]

Despite PHC being the main subject of the World Health Report [2008] and the topic of a special themed issue of the Lancet in 2008, where contributors argued that PHC is important in tackling health inequality in every country, there is no literature suggesti ng the best methods for evaluati on of PHC.

A major diffi culty has been that there are no control programs with which to compare PHC interventi ons to other possible interventi ons in LMICs. Consequently, few systemati c reviews of the impact of PHC in developing countries have been undertaken [Rohde et al. 2008; Macinko et al. 2009; Kruk et al. 2010]. Some assessment of primary care initi ati ves, and the ways in which they contribute to meeti ng health system goals in LMICs, needs to be developed; despite the fact that formal meta-analysis and comprehensive assessment of PHC interventi ons may not be possible [Kruk et al 2010].

Defi ning primary health care in lower- and

middle-income countries

Prior to the Alma-Ata Declarati on of 1978 (Table 1, page 7), PHC had been used as a strategy for expanding health services in LMICs and, with the declarati on, it became a central concept in global health [Kruk et al. 2010; Negin et al. 2010]. The World Health Organizati on (WHO) Report [2000], assessed work in the previous two decades, noti ng that PHC programs in developing countries could be considered as ‘parti al failures’. The core of this criti cism was that programs had failed to deliver access to health for all. This may have been because health service

delivery had not been able to respond to many problems encountered in developing countries; such problems included lack of access to essenti al drugs and lack of health care workers. Having no traditi on of PHC programs, insuffi cient structural support across government for implementati on and the limited experience of ministries of health were also signifi cant factors limiti ng PHC implementati on [Chabot 1984; Chen 1986; Diallo et al. 1993; Shonubi et al. 2005].

Another interpretati on of the WHO Report [2000] fi ndings is that in the two decades following the declarati on of Alma-Ata, changes in economic philosophy, promoted strongly by the World Bank and based on market forces and competi ti on, led to the replacement of PHC by ‘Health Sector Reform’.

As a result, a sharp decline in the use of the PHC followed in many countries. People in resource poor setti ngs sti ll had no access to basic services and gaps conti nued to widen [Hall & Taylor 2003]. MacDonald [2007] has argued that the global inequity in the availability of PHC is because the WHO principles of PHC have been undermined and sidelined.

The WHO Report [2008] was less criti cal of PHC than the 2000 report, and stated that PHC sti ll did have the potenti al to deliver progress towards the MDGs. The report stated that features of PHC could improve health outcomes in resource constrained setti ngs.

These features included: person-centredness; comprehensive and integrated care; conti nuity of care; and parti cipati on of pati ents, families and communiti es in the provision of health care. The 2008 document also referred to PHC as a set of values and principles and characterised PHC as a ‘movement’, which needed to respond to the pressures of globalisati on.

4


The positi oning of PHC in strategy documents, such as the WHO Western Pacifi c Regional Strategy for Health Systems [2010], suggests that the promise of PHC values can sti ll be realised. In additi on, the Western Pacifi c Regional Strategy document says that there is a ‘consensus’ that countries which have developed PHC programs achieve bett er health outcomes, and,

... do bett er at achieving the four goals of health systems: improved health and health equity, universal coverage with fi nancial risk protecti on, responsiveness to the populati on’s desire for health services, and effi cient use of resources. [WHO, 2010, p.3]

PHC has been variously defi ned as: a strategy which must deal with ‘social, economic and politi cal causes and consequences of poor health’ [MacDonald 2007, p. 9]; a set of values or principles, a policy reform focus or a movement, and, a level of service provision [Rohde et al. 2008; WHO 2010]. PHC is necessarily adapted for changing circumstances and is more broadly viewed than it was 30 years ago [Chan 2008].

Notwithstanding diffi culti es experienced in implementi ng PHC, including competi ti on with an increasing number of verti cal and disease specifi c initi ati ves, PHC is an approach which has the potenti al to contribute towards the achievement of the MDGs in LMICs [Walley et al. 2008; Rohde et al. 2008; Kruk et al. 2010].

Previous eff orts to evaluate primary

health care in lower- and middle-income

countries

PHC interventi ons are by their nature complex and deal simultaneously with several health programs making it diffi cult to determine the specifi c contributi on of a PHC interventi on [Hill et al. 2000; Walley et al. 2008; Baum 2008]. In terms of PHC provision in LMICs, the trend for private sector engagement in service delivery and support of health systems is becoming more evident, parti cularly in countries that have undergone health system reforms characterised by the shift from state-owned to market-driven health systems [Palmer et al. 2003; Banatvala & Amery 2006]. There is also variability of progress in implementi ng PHC within countries, and variability in determining what is the cause and eff ect

of the verti cal programs and other interventi ons [Walley et al. 2008].

Kruk and colleagues [2010] found in their review that primary care programs were assisted by other program interventi ons such as community demand building. These are not specifi c health sector inputs and this complicates the evaluati on of PHC interventi ons since program inputs may originate in other sectors. Reforms which might be occurring, for example within the social services area, may substanti ally impact on health outcomes or health access and equity [Macinko 2009 et al.].

It is diffi cult to measure and assess the level of parti cipati on in decisions about health rights and access in countries where the majority of the populati on may not be engaged in decision making about health resource allocati ons [Beaglehole & Bonita 1997, p. 222]. It has also been argued that the best method for determining user views and community opinion about the value of PHC is a research area that requires more rigorous data collecti on, interpretati on and development [Schneider & Palmer 2002].

Not only are there complex factors in evaluati ng the implementati on and impact of PHC programs and initi ati ves, as described above, but there is a further issue of considering how knowledge developed from evaluati on is taken up in a policy context.

Some authors have argued that the uti lisati on of new knowledge does not always occur in an orderly and logical sequence [Stone 2002; Ogden et al. 2003; Ogilvie et al. 2005]. They suggest that evaluati on methods that are iterati ve and process-oriented may in fact be more likely to be infl uenti al and bring about change.

PHC interventi ons are by their nature complex and deal simultaneously with several health programs making it diffi cult to determine the specifi c contributi on of a PHC interventi on.

5


There have been only a small number of relati vely well-designed observati onal studies, and a lack of rigorous experimental or quasi-experimental studies evaluati ng the impact of PHC on health outcomes in LMIC [Macinko et al. 2009].

Kruk and colleagues [2010] reviewed 76 papers discussing primary care programs in LMICs but noted that there were many shortcomings in the available evaluati on research. They identi fi ed that nearly two-thirds of the studies employed a pre-experimental or observati onal design, almost one-third employed a quasi-experimental design and only four studies employed an experimental design. Their conclusion was that it appeared that primary care initi ati ves are contributi ng to increased access to services and equity of access; but because there is no control program with which to compare PHC, it is impossible to rule out alternati ve explanati ons for changes that may be observed.

Labonte and Sanders [2010] conducted a synthesis of grey literature and studies which set out to evaluate Comprehensive Primary Health Care in selected countries of Asia. Several key points from their review, which considered 77 studies in 12 countries, are worth noti ng and apply equally to this current literature review:

• Some of the literature reports use of mix of methods and analysis which is processed in fi eld conditi ons - hence much of the literature may not follow rigorous scienti fi c, quanti tati ve evidence collecti on methods.

• There are possibly many PHC initi ati ves that have not been subject to any formal evaluati on that would lead to the publicati on of informati on on their success or not, but nevertheless will have valuable lessons to inform the ways in which primary care initi ati ves take shape in LMICs.

• The diversity of PHC initi ati ves across and within countries makes it diffi cult to develop indicators that can be applied in all contexts.

Rationale for this literature review

PHC interventi ons in LMICs have gone through several stages of implementati on including those occurring in parallel with major restructures of the health system. PHC initi ati ves are currently seen as a

way to ensure the realisati on of MDGs and there have been calls to “get back to the basics” of PHC programs [Chan 2012]. Thus, in order to determine how best to assess the performance and eff ecti veness of PHC, the important fi rst step is to understand how PHC has been evaluated and what performance indicators have been used.

There have been att empts, as described earlier, to review the literature on PHC evaluati on. However, the complexity of systemati cally reviewing the health eff ects of any social interventi on [Ogilvie et al. 2005] have made the task diffi cult. The realist review methodology has been developed to address some of the diffi culti es in synthesising complex interventi ons, but a realist review sti ll att empts to provide substanti al detail and address questi ons of context [Pawson et al 2005; Sheppard et al. 2009]. The realist review has therefore been selected as the best method for this literature review.

6


TABLE 1: CHARACTERISTICS OF PHC FROM ALMA ATA DECLARATIONAdapted from Gillam [2008]

• Evolves from the economic conditi ons and socio-cultural and politi cal characteristi cs of a country and its communiti es.

• Is based on the applicati on of social, biomedical, and health services research and public health experience.

• Tackles the main health problems in the community through preventi ve, curati ve, and rehabilitati ve services as appropriate.

• Includes educati on on prevailing health problems; promoti on of food supply and proper nutriti on; an adequate supply of safe water and basic sanitati on; maternal and child health care, including family planning; immunisati on against the main infecti ous diseases; preventi on and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essenti al drugs.

• Involves all related sectors and aspects of nati onal and community development.

• Requires maximum community and individual self-reliance and parti cipati on in the planning, organisati on, operati on, and control of services.

• Develops the ability of communiti es to parti cipate through educati on.

• Should be sustained by integrated, functi onal, and mutually supporti ve referral systems, leading to bett er comprehensive health care for all, giving priority to those most in need.

• Relies on health workers, including physicians, nurses, midwives, auxiliaries, and community workers as well as traditi onal practi ti oners, trained to work as a team and respond to community’s expressed health needs.

7


LITERATURE REVIEW METHOD

The following databases were searched for arti cles writt en in English: MEDLINE, EMBASE, the Cumulati ve Index of Nursing and Allied Health Library, the WHO Library, and the Cochrane Library. Two searches by project staff were performed in October 2011 to ensure that all relevant data had been captured at that ti me. The search was limited to English language texts. Additi onal key arti cles, conference publicati ons, and texts were identi fi ed through discussion with colleagues and by scanning the reference lists of selected papers.

The review also included an examinati on of documents which might be considered ‘working papers’, referred to by experts who have had recent fi eld experience establishing evaluati ve frameworks for assessing PHC performance and interventi ons.

The realist review method used here, searches for evidence; appraises studies; synthesises evidence and aims to draw conclusions; acknowledging that there will always be limitati ons on the nature and quality of the informati on that can be retrieved [Pawson et al. 2005].

One possible approach to the review would have been to search the evaluati on literature and data bases for major health service evaluati on methods and then examine the extent to which these had been applied to evaluati on of PHC in LMICs. This may have assisted with establishing search terms around evaluati on methods. However the intenti on of the literature review was to fi nd evaluati on approaches which also addressed questi ons of context within health systems, not just at a health service delivery level. The data base search terms from Table 2 (page 9) and exclusion parameters as outlined in Table 3 (page 9) were decided upon and found to be suffi cient, as initi al searches did capture the range of evaluati on methods.

Initi al database searches using terms from Table 2 yielded 2,150 results. When congruence amongst the search terms was applied there were 422 arti cles found which met the criteria of providing informati on on approaches to evaluati ng PHC in LMICs. Abstracts from the 422 arti cles were retrieved and were read by a review team in the light of exclusion parameters.

Many of the retrieved abstracts showed that arti cles concentrated on a specifi c disease or single health care interventi ons in the context of PHC programs.

These studies were therefore excluded, according to this literature review focus. Studies from developed country contexts were excluded due to the substanti ally diff erent needs and prioriti es in LMICs.

Some studies were found which argued for the rapid and ongoing implementati on of PHC projects [Chabot 1984; Chen 1986; Ramasoota 1997; Van Balen 2004], however these studies did not have an explicit evaluati on methodology and were therefore not included. Some studies functi oned as ‘opinion pieces’ about the potenti al of PHC or limitati on of PHC interventi ons, with no evidence provided that a systemati c evaluati on of PHC eff ecti veness or outcomes had been undertaken. Again these studies were excluded according to the exclusion parameters as outlined in Table 3.

From the 422 abstracts 15 arti cles were selected for further reading and analysis. These selected arti cles:

• Showed changes over ti me in evaluati on approaches.

• Dealt with diff erent levels of interventi on.

• Covered a range of methodologies.

• Were relevant to situati ons where major reforms had occurred or were underway within country health systems.

8


TABLE 2: DATA BASE SEARCH TERMS

• Primary health care • Developing countries • Evaluati on • Access

• Primary care • Underdeveloped countries • Assessment • Accessibility

• Grass-roots health care • Low- and middle-income countries • Quality of care

• Commune health centre • Transiti onal countries and/or transiti onal economies

TABLE 3: EXCLUSION PARAMETERS

• Studies were excluded if they did not contain an explicit methodology or criteria for evaluati on and assessment of PHC service delivery or interventi ons.

• Studies were excluded if they had a specifi c disease focus or focused only on health outcomes in one parti cular health service area.

9


FINDINGS

Overview of fi ndings

There were very few quanti tati ve studies, experimental and quasi experimental studies identi fi ed; a point which had been noted by Kruk and colleagues [2010]. Table 4 (below) summarises the level of interventi on, methodologies used and the country, or region, of the 15 selected studies. A realist review does not aim to be exhausti ve or enti rely comprehensive, directs att enti on towards the diff erent approaches which have been applied in the fi eld and describes the context in which those approaches were applied.

Of the 15 selected arti cles over half were mixed method studies. The authors argued that the strength of these mixed method studies was that they captured contextual informati on and data through qualitati ve methods and combined this with quanti tati ve indicators developed to assess program outcomes, and health impacts. Detailed informati on

about the studies – aims, study design and outcomes can be found in the Appendix.

The selected studies were reviewed again and four diff erent types of studies were identi fi ed:

A. Studies focused on directly informing policy development, oft en providing a narrati ve account of the development of PHC at a country and policy level.

B. Studies concerned with the questi on of ‘quality’ and ‘equity’ and monitoring implementati on in relati on to service uti lisati on and community sati sfacti on.

C. Studies which att empted to develop a set of health performance indicators to measure eff ecti veness of PHC interventi ons.

D. A study using a results-based logic model, reported in detail and incorporati ng many of the tools from 1 – 3.

TABLE 4: EXAMPLE STUDIES OF PHC INITIATIVES AND DIFFERENT

EVALUATION METHODOLOGIES

LEVEL OF INTERVENTIONS METHODOLOGIES USED

Nitayrumphong [1990] • • Thailand

Birt [1990] • • Vietnam

Diallo et al. [1993] • • Senegal

Bloom [1998] • • China/Vietnam

Hill et al. [2000] • • Gambia

Moore et al. [2003] • • Lati n America

Duong et al. [2004] • • Vietnam

Shonubi et al. [2005] • • Lesotho

Perks et al. [2006] • • Lao

Fritzen [2007] • • Vietnam

Hansen et al. [2008] • • Afghanistan

Pongpirul et al. [2009] • • Thailand

Ditt on & Lehane [2009] • • Thailand

Wong et al. [2010] • • China

Negin et al. [2010] • Fiji

Count

ries

or R

egio

n

Sub-

nati o

nal

Mixe

dM

etho

d

Distric

t or

Loca

l

Nati on

al

Quanti

tati v

e

Qualit

ati ve

10


The next secti ons provide details of studies under the groupings (A) – (D)

(A) Studies focused on directly informing

policy development

The review found studies which provided an account of the economic and politi cal contexts and policies in which the PHC programs are delivered. For example, studies by Fritzen [2007], Pongpiril and colleagues [2009] and Negin and colleagues [2010] appeared useful for their potenti al to inform policy development. The study by Negin and colleagues [2010] included a document review and semi-structured key informant interviews – which extracted informati on about the slow decline of the use of PHC faciliti es in Fiji and subsequently generated recommendati ons for a range of strategies for revitalising community health centre acti viti es.

The review found eight narrati ve or descripti ve studies of the ways which PHC initi ati ves have been implemented. Three studies att empted a comparison at district level and two studies took a case study approach assessing policy impacts and outcomes, such as service uti lisati on, at a local level.

All studies found that the goals of PHC initi ati ves should conti nue to be pursued and provided policy focused recommendati ons to overcome barriers to implementati on.

(B) Studies concerned with questions of

quality and equity

The Quality Assurance Project was initi ated to measure the eff ecti veness of PHC in developing countries uti lising a quality assessment approach [Brown et al. 1990]. Quality assurance methods were intended to help PHC program managers defi ne clinical guidelines and standard operati ng procedures. The authors suggested that as well as evaluati ng populati on coverage or the technological merits of health interventi ons, health providers might assess the quality of services compared with prescribed standards.

Walker [1983] noted that there were studies which described the outcomes of parti cular interventi ons, for example, the supply of nutriti on services, but very litt le work had been carried out in connecti on with questi ons of quality, access or equity.

The Quality Assurance Project promoted a method of direct observati on of pati ent/provider encounters as a way of ensuring that quality, as understood by clients, would be assessed, rather than quality as understood by the providers and managers of PHC programs. Some specifi c strategies were recommended by Brown and colleagues [1990] and these included:

• Reviewing a program’s clinical and managerial standards or norms.

• Assessing pati ent and community sati sfacti on with the services provided.

• Reviewing supervisory systems and management acti viti es to see if they are delivering outcomes as intended.

• Assessment of the adequacy of faciliti es, logisti cs and equipment for various programs.

During the 1990s, a number of studies in developing and less developed countries engaged with this quality assurance approach [Nicholas et al. 1991; Reerink & Saueborn 1996; Valadez et al. 1996].

Whitt aker [1999] reviewed the use of a quality framework using structure, process and outcome variables in developing countries and identi fi ed challenges in assessing and implementi ng quality improvement. Some of the challenges noted were: staff and managerial fati gue, professional health care providers’ concerns about intrusion by ‘less qualifi ed’ staff , and overcoming providers’ beliefs that quality improvement is impossible in contexts where there are seriously limited resources.

Some of the challenges noted were: staff and managerial fati gue, professional health care providers’ concerns about intrusion by ‘less qualifi ed’ staff , and overcoming providers’ beliefs that quality improvement is impossible in contexts where there are seriously limited resources.

11


In the literature, the quality assurance approach to PHC seems to disappear around the year 2000; this was concurrent with the criti cism being made of PHC at that ti me:

... that it [PHC] did not establish whether it was actually bringing about a quanti fi able change in the health of populati ons in the early 1990s. Its data, analysis and evaluati on systems were weak at a ti me when there was a demand for evidence-based demonstrati ons in health status. [Hall & Taylor 2003, p. 20]

Elements of the quality assurance approach conti nue to be included, for example, in the work of Labonte and Sanders [2010]. They propose that as well as measuring PHC eff ecti veness specifi cally in terms of health outcomes or health sector achievements; eff ecti veness can be assessed in terms of PHC processes and principles, including:

• The explicit value of health equity in services.

• The integrati on of rehabilitati ve, curati ve, preventi ve and health promoti on.

• The extent to which there is community involvement and citi zen parti cipati on.

• The extent to which there is collaborati on and involvement with other sectors.

• The extent to which there is acti on of non-medical determinants of health.

• Whether rights based approaches have been incorporated.

The problem with approaches to PHC research concentrati ng on quality, equity and parti cipati on is that there is no method for agreeing on measurement indicators. For example, how is equity in health services to be measured? Are there any standards by which to measure concepts such as community involvement and citi zen parti cipati on?

Braveman and Gruskin [2003] view equity as a principle that is diffi cult to measure in health care provision. Schneider and Palmer [2002] argue that measuring parti cipati on or sati sfacti on with services is a diffi cult exercise in establishing the truth about people’s opinions and should not be limited to snapshot assessments.

The emphasis on quality assessment in PHC is important but no metrics, or agreed upon measurements or tools, have emerged from the broad concepts; certainly no metrics that can be applied in all circumstances.

(C) Studies which developed performance

indicators

Two signifi cant review arti cles by Kruk and Freedman [2008] and Kruk and colleagues [2010] deal with the issue of assessing health system performance in developing countries and reviewing the contributi on of PHC initi ati ves in LMICs. They note that assessing the contributi on of PHC in developing countries is challenging; there are shortcomings in the available evaluati on research; and there are very few systemati c reviews of the impact of PHC on health in developing countries.

In att empti ng to develop a framework they identi fy three categories related to the performance dimension of eff ecti veness. A porti on of the summary table developed by Kruk and Freedman [2008] on the eff ecti veness dimension is shown on page 14 and those marked in bold were suggested by the authors as sample indicators for developing country contexts. However, even those indicators may not be especially sensiti ve, or relevant for all country situati ons.

While these indicators may be helpful to policy makers interested in assessing the eff ects of diff erent policies, they aim to construct a common framework that could be used across diff erent health systems. The problem with this approach is that health systems are not necessarily comparable across countries [Banatvala & Amery 2006; Walley et al. 2008] so, in fact, a method which allows the development of local context specifi c indicators would be more valuable.

The next secti on provides some informati on on a method used to develop indicators for community health service faciliti es in urban China. This has signifi cant advantages over the assessment criteria proposed by Labonte and Sanders [2010] and Kruk and colleagues [2010], because the method includes a way of developing relevant indicators informed by a comprehensive analysis of the components of PHC program eff ecti veness and effi ciency and guided by

12


the needs defi ned through extensive consultati on with relevant stakeholders.

(D) A study using a results-based logic

model

Recent work to develop a set of PHC performance indicators which can be used to identi fy Community Health Service (CHS) Facility prioriti es in urban China is reported by Wong and colleagues [2010]. The arti cle also contains details of the specifi c steps taken to develop a China CHS Logic Model (adapted from the Canadian PHC results-based logic model).

The authors describe the Logic Model as ‘heuristi c’; in the sense that it is being used as a possible method, requiring further investi gati on, in a situati on where it is known that populati on-based reporti ng on health outcomes is not perfect. In China there is no established nati onal reporti ng system for the CHS faciliti es, although some level of monitoring and reporti ng focused on examining structural components of the service, such as fi nancing and faciliti es management, does occur.

Examples of core performance indicators developed for the project are shown on page 15. Sources of data to measure indicators were to include health authority records, CHS facility data and pati ent surveys. In the China CHS Logic Model, 31 input categories were identi fi ed, 64 acti vity level indicators and 105 output indicators were developed.

When the Results-Based Logic Model and the performance indicators were applied the informati on compiled was used to eff ecti vely infl uence policy outcomes. In one district the incidence of measles was found to be higher due to immigrant children not being immunised because of lack of human resources and facility space. This informati on provided the evidence to commence discussions with CHS facility managers about strategies to change this situati on. In both districts where the model was piloted, the coordinati on between CHS and other services was identi fi ed as being poor and fi ndings provided evidence of the need for more formal and structured dialogue between faciliti es.

The methodology required the constructi on of a provisional China CHS Logic Model with performance framework and relevant indicators through policy analysis and literature review. Secondly, a

series of stakeholder consultati ons to review the framework and indicators was held. This included the development of partnerships with the two health districts that were to pilot the framework. Thirdly, a set of indicators to measure diff erent inputs, acti viti es, outputs and outcomes in the Logic Model was designed.

Components of the model included the social, cultural, policy, legislati ve/regulatory and physical contexts as well as populati on characteristi cs. Inputs including fi scal, material and humans resources for health featured in the model. PHC products and services including the volume, distributi on and type were noted, for example informati on on health promoti on, disease preventi on and rehabilitati ve services. The model also included eff ecti veness indicators for immediate, intermediate and fi nal outcomes.

This study provides a promising approach because indicators were developed based on intensive consultati on with relevant stakeholders, rather than based on the discreti on of evaluators, researchers or funding agencies with a set of pre-designed indicators.

Summary of fi ndings

This literature review has found that there are few studies systemati cally evaluati ng the implementati on of PHC programs in LMICs. From the studies examined, the authors of this literature review made a classifi cati on, not simply in terms of methodology or study design, but also in terms of the relati onship to policy impacts.

One group of studies, largely observati onal and qualitati ve in method, att empted to inform policy development by providing detailed informati on about the historical background of PHC interventi ons.

This literature review has found that there are few studies systemati cally evaluati ng the implementati on of PHC programs in LMICs.

13


Another group of studies att empted to address the questi ons of quality, access and equity of access to PHC services, but these studies did not develop any informati ve metrics.

Some studies developed a set of indicators which could be applied and assist in the measurement of performance; however, there may be limitati ons in terms of transferability from one country context to another.

The most promising approach has been used in China where a results-based logic framework has been

developed through consultati on and partnership, and a set of performance measurement indicators relevant to the local context were developed and applied. The strength of this approach led to policy acti on by health service, including recommendati ons in regard to human resource allocati on and coordinati on of services. The Logic Model needs iterati ve review, as argued by Wong and colleagues [2011], and the PHC indicators are being modifi ed on an ongoing basis.

TABLE 5: SUMMARY OF HEALTH PERFORMANCE INDICATORS

Adapted from [Kruk & Freedman, 2008]

PERFORMANCE DIMENSION CATEGORY SAMPLE INDICATORS

• Infant mortality*

• Maternal mortality

Health status • Neonatal mortality

• Incidence of low birth weight

Eff ecti veness (outcomes) • Survival rates for lung cancer

• Being treated with respect• Length of wait for care

Pati ent sati sfacti on • Administrati ve simplicity

• Percepti on of access to specialists

• Adequacy of ti me spent with physician

Availability

• Physicians, nurses, hospitals per 1000 populati on• Percentage of populati on within 10km of a clinic

Eff ecti veness (outputs) Access to care • Referral rates for women with obstetric complicati ons

Uti lisati on• TB case detecti on rates• ART treatment rates for people with advanced HIV

* Indicators marked in bold were suggested as sample indicators for developing country contexts.

14


TABLE 6: EXAMPLES OF CORE CHS PERFORMANCE INDICATORS

FROM CHINA CHS LOGIC MODEL

Excerpt from [Wong et al. 2010]

CATEGORY N EXAMPLES OF CORE INDICATORS

Health Human Resources • % of qualifi ed health care providers (physicians, nurses, nurse practi ti oners) in CHS

Inputs (n=31 with three examples shown here)

Material Resources • % of sub-districts who have at least one community health centre

Fiscal Resources • Amount of fi nancial investment for capital infrastructure

Policy and governance • % of CHS faciliti es that can be reimbursed through publicly funded health insurance

Acti viti es (n=64 with three examples shown here)

Health care management • % of PHC providers who completed a two-way referral of pati ents

Clinical level • % of CHS faciliti es who can off er Chinese traditi onal medicine

Type • % of PHC organisati ons who currently provide health educati on, illness preventi on

Volume • % of pati ents with hypertension who have health care coordinated by case manager

Outputs (n=105 with three examples shown here)

• % of pati ents who have a regular doctor

• % of pati ents who were referred to other doctors and have informati on back

Quality • % of pati ents who report that they were given enough ti me to discuss fears and concerns

• % of pati ents who rated the quality of CHS good or excellent

15


The aim of this literature review, as part of a collaborati ve initi ati ve between HSPI and the HRH Knowledge Hub, was to identi fy the diff erent approaches to evaluati ng PHC initi ati ves in LMICs. It is anti cipated that informati on from this review will serve as a methodological platf orm for future studies in Vietnam, through HSPI. The aim of future studies will be to determine how best to assess the performance and eff ecti veness of CHSs in Vietnam.

This is congruent with the argument put by Gillam [2008] that any study which att empts to evaluate PHC will need to be context specifi c and will rely on the commitment of local actors to best determine how it will be conducted. In the context of a renewed interest in the potenti al of PHC to deliver global health goals, in countries where major health sector reforms and challenges are conti nuing, the fi ndings of the review are relevant to calls for a more evidence based approach to the assessment of the benefi ts of PHC initi ati ves.

This review has found that there is no internati onally standardised methodology or approach to PHC research, but that over the last thirty years there has been a range of approaches used. These have been, mostly, observati onal and descripti ve accounts of the success and diffi culti es of implementi ng PHC programs. The review found that there had also been signifi cant interest in assessing the ‘quality’ of PHC services; questi ons of quality, access and equity of access remain important.

The review found only a few examples of studies where metrics and indicators were developed and tested. It is important to note that indicators developed in one country or context will not always be relevant in another context and it may

not be possible to develop a set of internati onally standardised evaluati on tools.

The background literature which described the changes over the last 30 years in implementati on of PHC (and indeed interest in implementi ng PHC initi ati ves) suggests that any approach used needs to be capable of adaptati on and change over ti me. The review found that the development of a results-based logic model combined with indicators for assessing local situati ons appeared to be an approach which had the potenti al for applicati on in LMICs. Such applicati ons need further investi gati on, since other examples may exist which have not yet been documented through research studies or be available in published literature.

The approach of coming to an agreement about quanti fi able indicators is relevant to the project in Vietnam, as HSPI is positi oned to begin that discussion with partners and stakeholders. Stakeholder consultati ons at a nati onal through to local Commune Health Stati on level will be important to establish what those indicators may be. HSPI is ideally placed to negoti ate the components of the broader results-based framework, defi ning the areas of PHC eff ecti veness and effi ciency as relevant in Vietnam.

... any study which att empts to evaluate PHC will need to be context specifi c and will rely on the commitment of local actors to best determine how it will be conducted.

CONCLUSION

16


REFERENCES

Banatvala, N & Amery, J (2006), ‘Public health in poorer countries’, in Pencheon, D, Guest, C, Melzer, D & Muir Gray, JA (eds), Oxford Handbook of Public Health Practice, 2nd edn, Oxford University Press, Oxford, UK pp. 292-300.

Baum, F (2008), ‘The harder it is to research the more signifi cant it is likely to be: comprehensive primary health care and the challenges it poses for researchers in the 21st century’, General Practice and Primary Health Care Research Conference: Program & Abstracts, Primary Health Care Research and Informati on Service, Australia. www.phcris.org.au/conference/brownse.php?id=6371&spindex=4

Beaglehole, R & Bonita, R (1997), Public Health at the crossroads, Cambridge University Press, Cambridge.

Birt, C (1990), ‘Establishment of Primary Health Care in Vietnam’, British Journal of General Practice, vol. 40, pp. 341-344.

Bloom, G (1998), ‘Primary health care meets the market in China and Vietnam’, Health Policy, vol. 44, pp. 233-252.

Braveman, P & Gruskin, S (2003), ‘Defi ning Equity in Health’, Journal of Epidemiology and Community Health, vol. 57, pp. 254-258.

Brown, L D, Franco, L M, Rafeh, N & Hatzell, T (1990), ‘Quality Assurance of Health Care in Developing Countries’, viewed October 2011, htt p://www.quaproject.org/pubs/PDFs/DEVCONT.pdf

Chabot, H (1984), ‘Primary health care will fail if we do not change our approach’, The Lancet, vol. 324 (8398), August, pp.340-1.

Chan, M (2008), ‘Return to Alma-Ata’, The Lancet, vol. 372(9542), pp.865-866.

Chan, M (2012), ‘Best days for public health are ahead of us, says WHO Director-General’, Address to the Sixty-fi ft h World Health Assembly, Geneva, Switzerland, viewed May 2012, htt p://www.who.int/dg/speeches/2012/wha_20120521/en/index.html

Chen, L (1986), ‘Primary health care in developing countries: Overcoming operati onal, technical, and social barriers’, The Lancet, vol. 328 (8518), November, pp.1260 – 1265.

Diallo, I, Molouba, R & Sarr, L (1993), ‘Primary health care: From aspirati on to achievement’, World Health Forum, vol. 14 (4), pp. 349-355.

Ditt on, M J & Lehane, L (2009), ‘Towards realising primary health care for the rural poor in Thailand: Health policy in acti on’, viewed October 2011, htt p://rspas.anu.edu.au/rmap/newmandala/2009/08/05/primary-health-care-and-the-ruralpoor-in-thailand

Duong, D V, Binns, C W & Lee, A H (2004), ‘Uti lizati on of delivery services at the primary health care level in rural Vietnam’, Social Science and Medicine, vol.59, pp. 2585-2595.

Foong, A L, Ng, S F & Lee, C K C (2005), ‘Identi fying HIV/AIDS primary care development needs’, Journal of Advanced Nursing, vol. 50 (2), April, pp. 134–142.

Fritzen, S (2007), ‘Legacies of primary health care in an era of health sector reform: Vietnam’s commune clinics in transiti on’, Social Science and Medicine, vol. 64, pp. 1611 -1623.

Gillam, S (2008), ‘Is the declarati on of Alma Ata sti ll relevant to primary health care?’, BMJ, 336 (7643), pp. 536-538.

Haddad, S, Fournier, P & Potvin, L (1998), ‘Measuring lay people’s percepti ons of the quality of primary health care services in developing countries. Validati on of a 20-item scale’, International Journal for Quality in Health Care, 10 (2), pp. 93-104.

Hall, J & Taylor, R (2003), ‘Health for all beyond 2000: The demise of the Alma-Ata Declarati on and primary health care in developing countries’, Medical Journal of Australia, 178 (1), pp.17-20.

Hansen, P M, Peters, D H, Viswanathan, K, Rao, K D, Mashkoor, A & Burnham, G (2008), ‘Client percepti ons of the quality of primary care services in Afghanistan’, International Journal for Quality in Health Care, vol. 20, pp. 384-391.

Hill, A, Macleod W, Joof, D, Gomez, P, Ratcliff e, A A & Walraven, G (2000), ‘Decline of mortality in children in rural Gambia: The infl uence of village-level primary health care’, Tropical Medicine and International Health, vol.5, pp. 107-118.

Kringos, D S, Boerma, W & Peliny, M (2009), ‘Measuring mechanisms for quality assurance in primary care systems in transiti on: test of a new

17


instrument in Slovenia and Uzbekistan’, Quality in Primary Care, vol.17, issue 3, June, pp.165-177.

Kruk, M E, & Freedman, L P (2008), ‘Assessing health system performance in developing countries: A review of the literature’, Health Policy, 85: 263-267.

Kruk, M E, Porignon, D, Rockers, P C & Lerberghe, W V (2010), ‘The contributi on of primary care to health and health systems in low- and middle-income countries: a criti cal review of major primary care initi ati ves’, Social Science & Medicine 70 (6): 904-911.

Labonte, R & Sanders, D (2010), ‘Draft Synthesis of grey literature from select Asian countries about Comprehensive Primary Health Care (CPHC) experiences’. Report produced for the Revitalising Health for All: Learning from Comprehensive Primary Care Experiences, a T-Corti Collaborati on. Available from Insti tute of Populati on Health University of Ott owa.

MacDonald, T H (2007), The Global Right to Human Health, Radcliff e, Oxford.

Macinko, J, Starfi eld, B & Erinosho, T (2009), ‘The impact of primary health care on populati on health in low- and middle-income countries’, Journal of Ambulatory Care Management, 32 (2): 150-171.

Moore, D, Casti llo, E, Richardson, C & Reid, R J (2003), ‘Determinants of health status and the infl uence of primary health care services in Lati n America, 1990-98’, International Journal of Health Planning & Management 18 (4): 279-292.

Negin, J, Roberts, G & Lingam, D (2010), ‘The Evoluti on of Primary Health Care in Fiji: Past, Present and Future’, Working Paper Series Six, Nossal Insti tute for Global Health, viewed October 2011, htt p://ni.unimelb.edu.au/__data/assets/pdf_fi le/0010/542449/wp6.pdf

Nicholas, D D, Heiby, J R & Hatzell, T A (1991), ‘The Quality Assurance Project: introducing quality improvement to primary health care in less developed countries’, Quality Assurance in Health Care 3(3): 147-165.

Nitayarumphong, S (1990), ‘Evoluti on of primary health care in Thailand: what policies worked?’, Health Policy and Planning, 5: 246-254.

Nordberg, E (1993), ‘Health centres. Potenti al is sti ll there’, Health Action (4): 4-5.

Ntoburi, S, Wagai, J, Irimu, G & English, M (2008), ‘Debati ng the quality and performance of health systems at a global level is not enough, nati onal debates are essenti al for progress’, Tropical Medicine and International Health, April; 13(4): 444–447.

Ogden, J, Walt, G & Lush, L (2003), ‘The politi cs of “branding” in policy transfer: the case of DOTS for tuberculosis control’, Social Science and Medicine 57:179-188.

Ogilvie, D, Hamilton,V, Egan, M & Petti crew, M (2005), ‘Systemati c review of health eff ects of social interventi ons: 1. Finding the evidence: how far should you go?’, Journal of Epidemiology and Community Health 59: 804-808.

Palmer, N, Mills, A, Wadee, H, Gilson, L & Schneider, H (2003), ‘A new face for private providers in developing countries: what implicati ons for public health?’, Bulletin of the World Health Organization, vol. 81(4), pp. 292-297.

Pawson, R, Greenhalgh, T, Harvey, G & Walshe, K (2005), ‘Realist review – a new method of systemati c review designed for complex policy interventi ons’, Journal of Health Services Research and Policy, vol. 10(1), pp. 21-34.

Perks, C, Toole, M J, & Phouthonsy, K (2006), ‘District health programmes and health sector reform: case study in the Lao People’s Democrati c Republic’, Bulletin of the World Health Organization, vol. 84(2), pp. 132-138.

Pongpirul, K, Starfi eld, B, Srivanichakorn, S & Pannarunothai, S (2009), ‘Policy characteristi cs facilitati ng primary health care in Thailand: A pilot study in transiti onal country’, International Journal for Equity in Health, vol. 8, March pp.1-8.

Ramasoota, D (1997), ‘The future of Primary Health Care in Thailand’, Regional Health Forum, vol. 2(1), pp. 1-7.

Reerink, I H, & Sauerborn, R (1996), ‘Quality of primary health care in developing countries: recent experiences and future directi ons’, International Journal for Quality in Health Care, vol. 8(2), pp. 131-139.

Roemer, M I, & Montoya-Aguilar, C (1988), ‘Quality assessment and assurance in primary health care’, WHO Offset Publication (105), pp. 1-78.

18


Rohde, J, Cousens, S, Chopra, M, Tangcharoensathien, V, Black, R, Bhutt a, Z A & Lawn, J E (2008), ‘30 years aft er Alma-Ata: has primary health care worked in countries?’, The Lancet, vol. 372(9642), pp. 950-61.

Schneider, H & Palmer, N (2002), ‘Getti ng to the truth? Researching user views of primary health care’, Health Policy & Planning, vol. 17(1), pp. 32-41.

Segall, M, Tipping, G, Lucas, H, Dung, T V, Tam, N T, Vinh, D X & Huong, D L (2002), ‘Economic transiti on should come with a health warning: the case of Vietnam’, Journal of Epidemiology & Community Health, vol. 56(7), pp. 497-505.

Sheppard, S, Lewin, S, Straus, S, Clarke, M, Eccles, M P, Fitzpatrick, R, Wong, G & Sheikh, A (2009), ‘Can we systemati cally review studies that evaluate complex interventi ons?’, PLOS Medicine, vol. 6, issue 8, August, pp.1-8.

Shonubi, A M O, Odusan, O, Oloruntoba, D O, Agbahowe, S A & Siddique, M A (2005), ‘“Health for all” in a least-developed country’, Journal of the National Medical Association, vol. 97(7), pp. 1020-1026.

Stone, D. (2002), ‘Using knowledge: the dilemmas of bridging research and policy’, Compare, vol. 32, pp. 285 – 296.

Taylor, C E (1992), ‘Surveillance for equity in primary health care: policy implicati ons from internati onal experience’, International Journal of Epidemiology, vol. 21(6), pp. 1043-1049.

Valadez, J J, Brown, L D, Vargas W V & Morley D (1996), ‘Using lot quality assurance sampling to assess measurements for growth monitoring in a developing country’s primary health care system’, International Journal of Epidemiology, vol 25(2), pp. 381-387.

Van Balen, H (2004), ‘Disease control in primary health care: a historical perspecti ve’, Tropical Medicine & International Health, vol 9(6), pp. 22-26.

Walker, G J (1983), ‘Medical care in developing countries. Assessment and assurance of quality’, Evaluation & the Health Professions, vol. 6(4), pp. 439-452.

Walley, J, Lawn, J E, Tinker, A, de Francisco, A, Chopra, M, Rudan, I, Bhutt a, Z A, Black, R E & Lancet Alma-Ata Working Group (2008), ‘Primary health care: making

Alma-Ata a reality’, The Lancet, vol. 372(9642), pp.1001-1007.

Whitt aker, M (1999), ‘Towards Strategic Quality Management of Health Care’, Journal of Health Management, 1:215.

Wong, S T, Yin, D, Batt acharyya, O, Wang, B, Liu, L & Bowen, C (2010), ‘Developing a Performance Measurement Framework and Indicators for Community Health Service Faciliti es in Urban China’, BMC Family Practice, 11:91.

Wong, S T, Brown, A J, Varcoe, C, Lavoie, J, Smye, V, Godwin, O, Litt lejohn, D & Tu, D (2011), ‘Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study’, International Journal for Equity in Health, 10:38 htt p://www.equityhealthj.com/content/10/1/38

World Health Organisati on (1978), The Global Meeting on Future Strategic Directions for Primary Health Care: a framework for future strategic directions (Global Report – Alma Ata Declarati on); www.who.int/primary-health-care

World Health Organisati on (2000), World Health Report 2000. World Health Systems: Improving Performance, World Health Organisati on Press, Geneva.

World Health Organisati on (2008), World Health Report 2008. Primary health care: now more than ever, World Health Organisati on Press, Geneva htt p://www.who.int/whr/2008/whro8_en.pdf

World Health Organisati on (2010), Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care, World Health Organisati on Press, Geneva.

19


AP

PE

ND

IX

TITL

E O

F TH

E ST

UD

Y/R

EPO

RT

KEY

QU

ESTI

ON

/OB

JECT

IVE

OF

THE

STU

DY

DES

IGN

COM

MEN

TS

Evol

uti o

n of

pri

mar

y he

alth

car

e in

Tha

iland

: wha

t pol

icie

s w

orke

d?

[Nita

yrum

phon

g 19

90]

To a

sses

s th

e st

rate

gies

im

plem

ente

d fo

r th

e de

velo

pmen

t of P

HC

in

Thai

land

focu

sing

on

trai

ning

of

‘gra

ss-r

oot’

PH

C w

orke

rs.

A d

escr

ipti v

e st

udy

that

se

t out

to a

naly

se c

hang

es

usin

g a

set o

f agr

eed

upon

in

dica

tors

from

196

5 to

198

6.

It w

as a

ssum

ed o

r im

plie

d th

at c

hang

es in

infa

nt

mor

talit

y ra

tes,

mal

e an

d fe

mal

e lif

e ex

pect

ancy

, m

alar

ia m

orbi

dity

, nut

riti o

nal s

tatu

s an

d di

seas

es

whi

ch w

ere

prev

enta

ble

thro

ugh

imm

unis

ati o

n w

as

att r

ibut

able

to th

e N

ati o

nal H

ealth

Dev

elop

men

t pl

an. W

hils

t com

mun

ity in

volv

emen

t, c

olla

borati o

n w

ith N

GO

s, in

tegr

ati o

n of

hea

lth p

rogr

am a

nd

inte

r-se

ctor

al c

olla

borati o

n at

the

oper

ati o

nal l

evel

w

ere

note

d, th

e lin

k be

twee

n th

ese

and

chan

ges

in

indi

cato

rs w

as n

ot e

mpi

rica

lly te

sted

.

Esta

blis

hmen

t of p

rim

ary

heal

th

care

in V

ietn

am [B

irt 1

990]

The

stud

y ai

med

to d

escr

ibe

exam

ples

of p

rim

ary

heal

th

care

dev

elop

men

t.

Des

cripti v

e ca

se s

tudy

dr

awin

g on

bas

ic

dem

ogra

phic

and

ep

idem

iolo

gica

l dat

a.

The

stud

y fo

und

that

em

ergi

ng m

odel

s of

PH

C in

Ho

Chi M

inh

city

and

Don

g N

ai P

rovi

nce

wer

e m

eeti n

g he

alth

car

e pr

ioriti e

s es

tabl

ishe

d by

the

Min

istr

y of

H

ealth

.

Prim

ary

heal

th c

are:

from

asp

irati o

n to

ach

ieve

men

t [D

iallo

et a

l. 19

93]

The

stud

y ai

med

to

revi

ew S

eneg

al’s

resp

onse

to

initi

ati v

es a

imed

at

stre

ngth

enin

g PH

C.

Des

cripti v

e st

udy

base

d on

som

e qu

anti t

ati v

e da

ta

from

an

oper

ati o

nal l

evel

ev

alua

ti on

of fi

ve d

istr

ict

heal

th c

entr

es.

The

stud

y id

enti fi

ed

barr

iers

whi

ch le

d to

the

PHC

stra

tegy

bei

ng d

iscr

edite

d in

the

eyes

of m

edic

al

staff

in

the

publ

ic s

ecto

r –

due

to d

rug

dist

ribu

ti on

and

supp

ly p

robl

ems,

dem

oral

izati

on

of p

erso

nnel

, de

velo

pmen

t of c

land

esti n

e pr

ivat

e pr

acti c

e.

The

auth

ors

note

d th

e diffi

culty

in s

electi n

g a

met

hodo

logy

.

Prim

ary

heal

th c

are

mee

ts th

e m

arke

t in

Chin

a an

d Vi

etna

m

[Blo

om 1

998]

The

pape

r ai

med

to o

utlin

e th

e ch

ange

s w

hich

had

take

n pl

ace

in th

e he

alth

sec

tors

of

Chi

na a

nd V

ietn

am d

urin

g th

e tr

ansiti o

n to

a m

arke

t ec

onom

y an

d de

scri

be h

ow

that

tran

siti o

n infl u

ence

d he

alth

sec

tor

perf

orm

ance

.

Nar

rati v

e ac

coun

t of

impa

ct o

n in

fras

truc

ture

de

velo

pmen

t, h

ealth

m

anag

emen

t sys

tem

, co

mm

unity

mob

ilisati o

n,

heal

th fi

nanc

e sy

stem

and

pl

anni

ng u

sing

pri

ncip

les

of

PHC.

In b

oth

coun

trie

s it

was

iden

ti fi e

d th

at c

hild

and

in

fant

mor

talit

y ha

d de

clin

ed a

nd li

fe e

xpec

tanc

y ha

d co

nti n

ued

to g

row

, no

evid

ence

was

ava

ilabl

e in

rega

rds

to s

ub-n

ati o

nal t

rend

s. P

riva

te h

ealth

se

rvic

es w

ere

prov

idin

g gr

eate

r ch

oice

for

som

e,

but l

imiti

ng a

cces

s fo

r th

ose

who

cou

ld n

ot aff o

rd

user

pay

s fe

es b

eing

intr

oduc

ed. F

acto

rs w

hich

co

ntri

bute

d to

hea

lth im

prov

emen

ts w

ere

not

clea

rly

isol

ated

in th

is re

port

.

20


TITL

E O

F TH

E ST

UD

Y/R

EPO

RT

KEY

QU

ESTI

ON

/OB

JECT

IVE

OF

THE

STU

DY

DES

IGN

COM

MEN

TS

Dec

line

of m

orta

lity

in c

hild

ren

in r

ural

Gam

bia:

the

infl u

ence

of

villa

ge-le

vel p

rim

ary

heal

th c

are

[Hill

et

al.

2000

]

The

stud

y ai

med

to a

sses

s th

e eff

ecti

ven

ess

of P

HC

prog

ram

s.

Long

itudi

nal c

ompa

rati v

e st

udy.

Dat

a on

infa

nt a

nd c

hild

mor

talit

y w

as c

olle

cted

ov

er a

15

year

per

iod

in 4

0 vi

llage

s an

d co

mpa

riso

ns

wer

e dr

awn

betw

een

thos

e w

ith a

nd w

ithou

t PH

C.

The

stud

y fo

und

that

sup

ervi

sion

of t

he P

HC

syst

em

wea

kene

d aft

er

1994

and

mor

talit

y ra

tes

rose

si

gnifi

cant

ly.

Det

erm

inan

ts o

f hea

lth s

tatu

s an

d th

e infl u

ence

of p

rim

ary

care

se

rvic

es in

Lati

n A

mer

ica

1990

-98

[Moo

re e

t al.

2003

]

The

stud

y ai

med

to e

xam

ine

the

fact

ors,

incl

udin

g th

e im

pact

of t

he p

rovi

sion

of

PHC

serv

ices

, whi

ch w

ere

asso

ciat

ed w

ith u

nder

-fi v

e m

orta

lity

rate

s in

22

coun

trie

s of

Lati

n A

mer

ica

and

the

Cari

bbea

n du

ring

the

1990

s.

Multi v

aria

te a

naly

sis

draw

ing

on a

ggre

gate

d da

ta fr

om

Wor

ld B

ank

and

the

Uni

ted

Nati

ons

Chi

ldre

ns F

und.

Mis

sing

dat

a po

ints

from

cou

ntri

es m

eant

that

man

y va

riab

les

had

drop

ped

from

the

anal

ysis

. Phy

sici

ans

per

1000

peo

ple

wer

e si

gnifi

cant

ly a

ssoc

iate

d w

ith

low

er u

nder

-fi ve

mor

talit

y ra

tes

but s

o w

ere

thre

e no

n-he

alth

car

e in

dica

tors

. Fem

ale

liter

acy

rate

s w

ere

foun

d to

be

high

ly c

orre

late

d, a

long

with

two

othe

r no

n-he

alth

fact

ors.

The

stu

dy d

esig

n co

uld

not s

how

th

at o

bser

ved

impr

ovem

ents

of u

nder

-fi ve

mor

talit

y ra

tes

wer

e du

e to

pri

mar

y he

alth

car

e in

terv

enti o

ns.

Uti l

izati

on

of d

eliv

ery

serv

ices

at t

he

prim

ary

heal

th c

are

leve

l in

rura

l Vi

etna

m [D

uong

et a

l. 20

04]

The

stud

y in

vesti

gat

ed fa

ctor

s infl u

enci

ng th

e uti

lisati o

n of

del

iver

y se

rvic

es a

t the

pr

imar

y he

alth

car

e le

vel.

Qua

nti t

ati v

e su

rvey

, foc

us

grou

p di

scus

sion

s an

d in

-de

pth

inte

rvie

ws.

The

stud

y id

enti fi

ed

that

cos

ts o

f ser

vice

s w

as a

n im

port

ant f

acto

r; b

ut in

som

e di

stri

cts

soci

al, c

ultu

ral

and

relig

ious

fact

ors

and

the

nati o

nal t

wo-

child

pol

icy

wer

e ba

rrie

rs to

ser

vice

uti l

isati

on.

The

met

hod

did

not s

pecifi c

ally

add

ress

eff e

c ti v

enes

s of

Com

mun

e H

ealth

Cen

tre

oper

ati o

ns.

“Hea

lth fo

r All”

in a

Lea

st-D

evel

oped

Co

untr

y [S

honu

bi e

t al.

2005

]Th

e arti c

le d

escr

ibes

and

pr

ovid

es a

n ev

alua

ti on

of th

e he

alth

car

e sy

stem

in L

esot

ho

base

d on

pri

mar

y he

alth

car

e pr

inci

ples

.

A n

arrati v

e de

scri

pti o

n of

th

e st

ruct

ure

of th

e he

alth

sy

stem

is p

rovi

ded.

Thi

s in

clud

ed a

sys

tem

of h

ealth

ce

ntre

s an

d cl

inic

s, e

ach

serv

ing

appr

ox 1

0,00

0 pe

ople

ac

cess

ible

to p

eopl

e w

ithin

1-

2 ho

urs

wal

k.

The

repo

rt c

oncl

uded

that

edu

cati o

n w

as th

e m

ost

eff e

cti v

e m

eans

of p

rovi

ding

a s

usta

inab

le s

oluti

on

to

heal

th p

robl

ems

in L

esot

ho a

nd p

erha

ps o

ther

low

- in

com

e co

untr

ies.

A v

ery

sim

ple

tool

cal

led

a vi

sual

an

alog

sca

le w

as u

sed

to a

sses

s th

e eff

ecti

ven

ess

of th

e sy

stem

dur

ing

visi

ts to

var

ious

hea

lth

insti

tuti

ons

by

the

auth

ors.

Fea

ture

s of

the

syst

em,

whi

ch in

clud

ed p

ati e

nt re

tain

ed m

edic

al re

cord

s an

d en

suri

ng e

asy

acce

ss to

faci

liti e

s re

gard

less

of

soci

oeco

nom

ic s

tatu

s, re

side

nce

or n

atur

e of

the

illne

ss, w

ere

high

ly ra

ted.

21


TITL

E O

F TH

E ST

UD

Y/R

EPO

RT

KEY

QU

ESTI

ON

/OB

JECT

IVE

OF

THE

STU

DY

DES

IGN

COM

MEN

TS

Dis

tric

t hea

lth p

rogr

amm

es a

nd

heal

th-s

ecto

r re

form

: cas

e st

udy

in th

e La

o Pe

ople

’s D

emoc

rati c

Re

publ

ic [P

erks

et a

l. 20

06]

The

stud

y so

ught

to e

valu

ate

the

relati o

nshi

p be

twee

n ce

ntra

lly m

anag

ed d

isea

se-

spec

ifi c

prog

ram

s an

d pr

imar

y he

alth

car

e de

liver

y in

one

parti c

ular

dis

tric

t.

Doc

umen

t rev

iew

, col

lati o

n of

impa

ct d

ata

and

eval

uati o

n w

orks

hops

.

Dat

a as

sess

ed in

clud

ed fa

cilit

y uti

lisati o

n, m

ater

nal

mor

talit

y an

d in

fant

and

chi

ld m

orta

lity

stati

sti c

s.

Lega

cies

of p

rim

ary

heal

th c

are

in a

n ag

e of

hea

lth s

ecto

r re

form

: Vi

etna

m’s

com

mun

e cl

inic

s in

tr

ansiti o

n [F

ritz

en 2

007]

The

pape

r ai

med

to e

valu

ate

the

stra

tegy

and

out

com

es

of th

e att

em

pt in

Vie

tnam

to

revi

talis

e th

e gr

assr

oots

in

fras

truc

ture

of P

HC

agai

nst

the

back

drop

of t

he c

ount

ry’s

ec

onom

ic tr

ansiti o

n.

A d

escr

ipti v

e ac

coun

t of

inte

rrel

ated

dev

elop

men

ts

of m

arketi s

ati o

n an

d de

cent

ralis

ati o

n w

as li

nked

to

dat

a fr

om th

e W

orld

Ba

nk a

nd M

inis

try

of H

ealth

. A

stu

dy o

f 88

clin

ics

– ev

alua

ti ng

proj

ect o

utpu

ts,

the

stre

ngth

of o

ther

PH

C co

mpo

nent

s an

d cl

inic

co

vera

ge –

was

con

duct

ed.

Hav

ing

som

e em

piri

cal d

ata

to in

form

the

anal

ysis

pr

ovid

ed fo

r a

repo

rt w

hich

exp

lore

d th

e th

eoreti c

al

cove

rage

of t

he r

ural

pop

ulati

on

acce

ss to

bas

ic

heal

th s

ervi

ce th

roug

h th

e ne

twor

k of

pub

lic c

linic

s an

d us

eful

ly id

enti fi

ed

disr

upti o

ns s

uff e

red

beca

use

of th

e tr

ansiti o

n to

a m

arke

t eco

nom

y. T

he s

tudy

al

so id

enti fi

ed

that

equ

itabl

e ac

cess

to b

asic

hea

lth

serv

ices

for

poor

est s

egm

ents

of t

he p

opul

ati o

n re

mai

ns p

robl

emati

c.

Det

erm

inan

ts o

f pri

mar

y ca

re

serv

ice

qual

ity in

Afg

hani

stan

[H

anse

n et

al.

2008

]

The

stud

y ai

med

to d

escr

ibe

the

leve

l of q

ualit

y of

ca

re p

rovi

ded

by a

genc

ies

impl

emen

ti ng

basi

c he

alth

pr

ogra

ms

and

iden

ti fy

fact

ors

asso

ciat

ed w

ith v

ariati o

ns in

qu

ality

.

Cros

s se

cti o

nal s

urve

y,

with

out c

ontr

ol, o

f a ra

ndom

sa

mpl

e of

25

heal

th fa

ciliti

es.

Th

e st

udy

incl

uded

hea

lth

wor

kers

, pati

ent

s an

d ca

reta

kers

inte

rvie

ws.

Dat

a w

as d

raw

n fr

om 1

553

heal

th w

orke

r in

terv

iew

s an

d 57

19 o

bser

vati o

ns. A

‘sca

le o

f qua

lity

care

’ was

de

velo

ped

usin

g m

easu

re fr

om c

linic

al c

onsu

ltati o

ns

e.g.

com

mun

icati

on

and ti m

e sp

ent w

ith p

ati e

nts.

Th

is d

emon

stra

ted

sign

ifi ca

nt v

ariati o

ns s

uch

as

high

per

form

ance

of N

GO

faci

liti e

s, s

ignifi c

ant

regi

onal

var

iati o

ns, a

nd th

e infl u

ence

of g

ood

clin

ical

su

perv

isio

n.

Polic

y ch

arac

teri

sti c

s fa

cilit

ati n

g pr

imar

y he

alth

car

e in

Tha

iland

: A

pilo

t stu

dy in

tran

siti o

nal c

ount

ry

[Pon

gpir

ul e

t al.

2009

]

The

pilo

t stu

dy a

imed

to

ass

ess

impo

rtan

t pr

imar

y he

alth

car

e po

licy

char

acte

risti

cs,

suc

h as

eq

uita

ble

dist

ribu

ti on

of

reso

urce

s ac

ross

pro

gram

s in

a c

onte

xt w

here

ther

e ar

e lim

ited

data

base

s.

Nar

rati v

e sy

nthe

sis

from

exp

ert i

nter

view

s an

d do

cum

ent r

evie

w.

Que

sti o

nnai

re s

urve

y of

5

seni

or p

olic

ymak

ers,

5

acad

emic

ians

and

77

prim

ary

care

pra

cti ti

oner

s.

The

stud

y pr

ovid

ed u

sefu

l inf

orm

ati o

n ab

out r

egio

nal

vari

ati o

ns in

PH

C de

liver

y an

d re

com

men

ded

a w

ider

st

udy

be im

plem

ente

d.

22


TITL

E O

F TH

E ST

UD

Y/R

EPO

RT

KEY

QU

ESTI

ON

/OB

JECT

IVE

OF

THE

STU

DY

DES

IGN

COM

MEN

TS

Tow

ards

real

isin

g pr

imar

y he

alth

ca

re fo

r th

e ru

ral p

oor

in T

haila

nd:

Hea

lth p

olic

y in

acti

on

[Ditt

on &

Le

hane

, 200

9]

The

aim

was

to e

valu

ate

a Pr

imar

y Ca

re U

nit i

n Th

aila

nd.

Case

stu

dy d

raw

ing

data

fr

om o

bser

vati o

n, re

view

of

pati

ent

list

s an

d re

cord

s,

docu

men

t rev

iew

and

key

pe

rson

nel i

nter

view

s.

Use

d St

arfi e

ld’s

con

cept

ual f

ram

ewor

k of

eva

luati

ng;

fi r

st c

onta

ct c

are,

long

itudi

nalit

y, c

ompr

ehen

sive

ness

an

d co

ordi

nati o

n. P

olic

y an

d pr

acti c

e im

plic

ati o

ns

wer

e dr

awn

from

the

stud

y. R

esul

ts c

ould

not

be

gene

ralis

ed a

nd s

tudy

lack

ed e

xter

nal v

alid

ity.

The

evol

uti o

n of

pri

mar

y he

alth

ca

re in

Fiji

: Pas

t, p

rese

nt a

nd fu

ture

[N

egin

et a

l. 20

10]

The

stud

y ai

med

to

unde

rsta

nd th

e ev

oluti

on

of P

HC

in F

iji; h

ow p

olic

ies

had

chan

ged

over

ti m

e an

d th

e ro

le o

f var

ious

ac

tors

in infl u

enci

ng p

olic

y de

velo

pmen

t.

The

stud

y us

ed d

ocum

ent

revi

ew, s

emi-s

truc

ture

d ke

y in

form

ant i

nter

view

s an

d W

alt a

nd G

ilson

’s h

ealth

po

licy

tria

ngle

to a

naly

se a

nd

colla

te in

form

ati o

n.

Empi

rica

l dat

a ga

ther

ed th

roug

h hi

stor

ical

do

cum

ents

and

lite

ratu

re s

earc

h, a

s w

ell a

s 14

in

terv

iew

s, p

rovi

ded

data

on

the

slow

dec

line

of P

HC

and

use

of P

HC

faci

liti e

s. A

rang

e of

fact

ors

from

th

e en

d of

WH

O fu

ndin

g, d

omesti c

inst

abili

ty a

nd

cultu

ral c

hang

es in

Fiji

an v

illag

es w

ere

iden

ti fi e

d as

im

pacti

ng

on P

HC

prov

isio

n. A

rang

e of

str

ateg

ies

for

revi

talis

ing

com

mun

ity h

ealth

cen

tre

acti v

iti es

in a

w

ay th

at fo

cuse

d on

‘qua

lity’

of h

ealth

ser

vice

s w

ere

reco

mm

ende

d.

Dev

elop

ing

a pe

rfor

man

ce

mea

sure

men

t fra

mew

ork

and

indi

cato

rs fo

r co

mm

unity

hea

lth

serv

ice

faci

liti e

s in

urb

an C

hina

[W

ong

et a

l. 20

10]

The

stud

y ai

med

to d

evel

op

a Ch

ina

resu

lts b

ased

Log

ic

Mod

el a

nd a

set

of r

elev

ant

PHC

indi

cato

rs to

mea

sure

Co

mm

unity

Hea

lth S

tati o

n pr

ioriti e

s.

A fr

amew

ork

and

indi

cato

rs

wer

e de

velo

ped

with

con

tent

va

lidati

on

ensu

red

thro

ugh

polic

y an

alys

is, c

riti c

al re

view

of

lite

ratu

re, a

nd s

take

hold

er

cons

ultati o

n.

The

fram

ewor

k an

d in

dica

tors

to m

easu

re in

puts

, acti v

iti es

, out

puts

and

out

com

es w

ere

appl

ied

in

two

dist

rict

s to

gen

erat

e da

ta a

bout

ope

rati o

ns. D

ata

was

then

sha

red

with

Com

mun

ity H

ealth

Stati o

n m

anag

ers

for

cons

ider

ati o

n of

cha

nges

in p

olic

y an

d pr

acti c

e.

23

ALSO AVAILABLE IN THE LEADERSHIP

AND MANAGEMENT REVIEW SERIES

• Reviews on: Timor-Leste Fiji Lao People’s Democrati c Republic Papua New Guinea Solomon Islands Cambodia

• HIV and human resources challenges in Papua New Guinea: An overview

To obtain publicati ons or to subscribe to our email news visit www.hrhhub.unsw.edu.au or email [email protected]

THE KNOWLEDGE HUBS FOR

HEALTH INITIATIVE

The Human Resources for HealthKnowledge Hub is one of four hubsestablished by AusAID in 2008 as part of the Australian Government’s commitment to meeti ng the Millennium Development Goals and improving health in the Asia and Pacifi c regions.

All four Hubs share the common goal of expanding the experti se and knowledge base in order to help inform and guide health policy.

Human Resource for Health Knowledge HubUniversity of New South Wales

Some of the key themati c areas for this Hub include governance, leadership and management; maternal, newborn and child health workforce; public health emergencies; and migrati on.


Health Informati on Systems Knowledge HubUniversity of Queensland

Aims to facilitate the development and integrati on of health informati on systems in the broader health system strengthening agenda as well as increase local capacity to ensure that cost-eff ecti ve, ti mely, reliable and relevant informati on is available, and used, to bett er inform health development policies.

www.uq.edu.au/hishub

Health Finance and Health Policy Knowledge HubThe Nossal Insti tute for Global Health (University of Melbourne)

Aims to support regional, nati onal and internati onal partners to develop eff ecti ve evidence-informed nati onal policy-making, parti cularly in the fi eld of health fi nance and health systems. Key themati c areas for this Hub include comparati ve analysis of health fi nance interventi ons and health system outcomes; the role of non-state providers of health care; and health policy development in the Pacifi c.

www.ni.unimelb.edu.au

Compass: Women’s and Children’s HealthKnowledge HubCompass is a partnership between the Centre for Internati onal Child Health, University of Melbourne, Menzies School of Health Research and Burnet Insti tute’s Centre for Internati onal Health.

Aims to enhance the quality and eff ecti veness of WCH interventi ons and focuses on supporti ng the Millennium Development Goals 4 and 5 – improved maternal and child health and universal access to reproducti ve health. Key themati c areas for this Hub include regional strategies for child survival; strengthening health systems for maternal and newborn health; adolescent reproducti ve health; and nutriti on.

www.wchknowledgehub.com.au

Human Resources for Health Hub

Send us your email and be the fi rst to receive copies of future publicati ons. We also welcome your questi ons and feedback.

HRH Hub @ UNSW

School of Public Health and Community MedicineSamuels Building, Level 2, Room 209The University of New South WalesSydney, NSW, 2052Australia

T +61 2 9385 8464

F + 61 2 9385 1104

[email protected]


htt p://twitt er.com/HRHHub

H HR

A strategic partnership initiative funded by the Australian Agency for International Development

EVALUATING PRIMARY HEALTH CARE POLICIES: A STEP...

Documents

Transcript of EVALUATING PRIMARY HEALTH CARE POLICIES: A STEP...