Macinko J, Starfield B, Erinosho T. The impact of primary health care
Transcript of Macinko J, Starfield B, Erinosho T. The impact of primary health care
J Ambulatory Care ManageVol. 32, No. 2, pp. 150–171Copyright c© 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Impact of PrimaryHealthcare on PopulationHealth in Low- andMiddle-Income Countries
James Macinko, PhD; Barbara Starfield, MD, MPH;Temitope Erinosho, PhD
Abstract: This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC)on health outcomes in low- and middle-income countries. Studies were abstracted and assessedaccording to where they took place, the research design used, target population, primary caremeasures, and overall conclusions. Results indicate that the bulk of evidence for PHC effective-ness is focused on infant and child health, but there is also evidence of the positive role PHChas on population health over time. Although the peer-reviewed literature is lacking in rigorousexperimental studies, a small number of relatively well-designed observational studies and the con-sistency of findings generally support the contention that an integrated approach to primary carecan improve health. A few large-scale experiences also help identify elements of good practice. Thereview concludes with several recommendations for future studies, including a focus on better con-ceptualizing and measuring PHC, further investigation into the advantages of comprehensive overselective PHC, need for experimental or quasi-experimental research designs that allow testing ofthe independent effect of primary care on outcomes over time, and a more detailed conceptualframework guiding overall evaluation design that places limits on the parameters under consider-ation and describes relationships among different levels and types of data likely to be collected inthe evaluation process. Key words: developing country, evaluation, population health, primaryhealthcare
THE WORLD HEALTH ORGANIZATION(WHO) formalized its commitment to pri-
mary healthcare (PHC) in 1978, when it wasidentified as central to the achievement of thegoal of “Health for All”and as a key instrumentfor improving health throughout the world(WHO, 1978).
In the decades following Alma Ata, manylow- and middle-income countries have un-
Author Affiliations: Department of Nutrition, FoodStudies, and Public Health, New York University,New York (Drs Macinko and Erinosho); andDepartment of Health Policy and Management, TheJohns Hopkins Medical Institutions, Baltimore,Maryland (Dr Starfield). Dr Erinosho is now withHealth Promotion Research Branch, NationalCancer Institute, Rockville, Maryland.
Corresponding Author: James Macinko, PhD, Depart-ment of Nutrition, Food Studies, and Public Health, NewYork University, 35 W 4th St, 12th Floor, New York, NY10012 ([email protected]).
dergone dramatic changes, including democ-ratization, economic liberalization in an in-creasingly globalized world, redefining therole of the state, and reforming their healthand social services systems. Health reforms, inparticular, have aimed at streamlining health-care financing and decentralizing authorityfor planning and implementation. There isincreasing evidence that not all of these re-forms have strengthened PHC, nor have theyuniformly contributed to improving healthor equity in its distribution (Infante & deMata, 2000; Mackintosh, 2000; Varatharajan &Thankappan, 2004).
In many high-income countries, various at-tributes of primary care have been shownto exert a positive influence on health costs,appropriateness of care, and outcomes formost of the major health indicators (Bindmanet al., 1996; Forrest & Starfield, 1996, 1998;Starfield, 1998; Starfield et al., 2005a, 2005b).
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There is also evidence that countries charac-terized by a strong primary care orientationhave better and more equitable health out-comes than those systems that are orientedtoward specialty care (Macinko et al., 2003;Starfield, 1996; Starfield & Shi, 2002). Nev-ertheless, there is considerable debate abouthow effective PHC has been in improvingpopulation health in low- and middle-incomecountries (Filmer et al., 2000; Lewis et al.,2004).
The 30-year anniversary of the Alma Atameeting, the changing health challenges inthe developing world, and the widespreaddissatisfaction with the status quo have gen-erated interest in a renewed and reinvigo-rated approach to health systems develop-ment based on PHC (“Margaret Chan putsprimary health care,” 2008; Pan AmericanHealth Organization, 2005; WHO, 2008). Toaid in this process, the present review as-sesses the peer-reviewed literature for evi-dence of the effectiveness of previous PHCexperiences with the goal of identifyinglessons learned and providing suggestions forstrengthening the PHC evidence base.
METHODS
The literature review was conductedby searching the US National Library ofMedicine’s PubMed database, the CochraneDatabase of Systematic Reviews, and the In-ternet (via Google) for articles that containedthe phrases “primary care”or “primary healthcare” along with the terms “evaluation” or“impact” in either the title or the abstract.Several journals that publish on healthcarein the developing world were also handsearched. All articles were then culled toidentify additional references. This processrevealed more than 10 000 potential articlesas of July 2008.
From the large potential pool of articles,we excluded all commentaries and non–peer-reviewed works and all articles related to Eu-ropean or other Organization for EconomicCooperation and Development countries. Ab-stracts and study designs were then reviewedto identify articles that addressed the evalua-
tion of PHC programs, systems, and servicesand to exclude articles that (1) did not explic-itly define the scope of the PHC intervention;(2) evaluated only one component of selectiveprimary care services (eg, immunization, oralrehydration therapy); or (3) did not includedata on changes in health outcomes attributedto the PHC intervention. Overall, 36 key arti-cles were retrieved and abstracted.
The Appendix contains a synthesis of themain objectives, study designs, outcomes,PHC measures, and results of the reviewed ar-ticles. We adopt the term “selective”to charac-terize interventions directed at selected indi-vidual health conditions (such as control of di-arrheal diseases) and “integrated” to describeapproaches that are more directed at health ingeneral. In the presentation of results, we dis-tinguish between PHC tasks or services (ie, di-rected at a specific health problem) and PHCfunctions (ie, directed at assuming the mainrole of PHC within health systems, regardlessof the specific health problem).
RESULTS
Figure 1 shows the distribution of new ar-ticles by year on the topic of PHC, which hasincreased each year and, after a relatively sta-ble period from 1995 to 2003, now averagesabout 500 new articles per year.
Table 1 shows characteristics of the 36abstracted studies. Geographically, they arefairly evenly distributed: slightly more than athird are from Africa, about a third are fromLatin America and the Caribbean, a quarterfrom Asia, with the remaining representingmultiple regions. In terms of study design,most (45%) use a pre- and postinterventioncross-sectional design with controls or com-parison groups, about 14% use a case-controldesign, another 11% use multivariable longitu-dinal analyses of ecological data, 1 study usesan experimental design, and 1 uses a cohortapproach. All remaining studies employeda variety of observational designs withoutcontrols.
In terms of outcomes, more than three-quarters of the studies focused on infant orunder-5 mortality, with the remainder dealing
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Figure 1. The number of new articles published in PubMed with “primary health care” in the abstract ortitle, by year (1975–2007).
Table 1. Characteristics of studies reviewed(N = 36)
Number
Domain of studies
Geographic region
Latin America and the
Caribbean Sub-Saharan
12
Africa 16
Asia 8
Other (or multiple regions) 1
Study design
Experimental or
quasi-experimental
5
Prospective study with
control group
1
Repeated (pre/post)
cross-sectional design
with control
16
Case-control 5
Repeated (pre/post)
cross-sectional design
without control
5
Systematic literature review 1
Observation/qualitative
study/single cross-section
3
Main outcome studied
Infant or under-5 mortality 28
Other (child) 1
Other (adult) 7
with maternal mortality, life expectancy, all-cause mortality, and cause-specific mortalityin adults. All but 3 studies measured PHC ex-posure by residence in a geographic area inwhich PHC services were being delivered.The other 3 assessed individual use of spe-cific PHC services. Nearly all studies point to apositive impact of the PHC intervention stud-ied: only 5 articles show no improvement at-tributable to PHC.
The magnitude of impact also varied con-siderably. Reductions in infant and under-5mortality attributed to PHC averaged morethan 40% and varied from 0 to as high as71%, with interventions lasting from 2 yearsto more than 10 years.
Studies on specific PHC tasks
Several studies analyzed the association ofspecific primary care tasks with health out-comes. Moore et al. (2003) conducted a panelstudy of 22 Latin American countries overthe period from 1990 to 1998. The studyfound that the most important contributorto lower under-5 mortality was women’s lit-eracy, followed by vaccination coverage anduse of oral rehydration therapy. A similar anal-ysis conducted by using Demographic andHealth Surveys from 5 East African countriesestimated that nearly three-quarters of the
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attributable risks for mortality in childrenyounger than 1 year might be amenable topreventive services, including antenatal care,immunizations, fertility regulation, and use ofpotable water (Brockerhoff & Derose, 1996).In both studies, the extent to which these ser-vices were part of an integrated PHC systemor the result of an effort targeted only at majorcauses of infant and child mortality is unclear.
Dugbatey (1999) assessed the relationshipbetween a set of “Health for All” policies(health education, nutrition, water and san-itation, and maternal/child health services)and health outcomes at the national level in4 African countries in the 1990s. Througha comparative case study design, the authorshowed that PHC-sensitive conditions (suchas infant mortality) were improved in the2 countries with more comprehensive PHCpolicies (Botswana and Zimbabwe), as op-posed to those with a less coherent set of PHCpolicies (Ghana and Cote d’Ivoire), in spite ofthe latter having higher gross national productper capita (Dugbatey, 1999).
The Bellagio Child Survival Study Groupconcluded that nearly 10 million child deathsworldwide could be averted by tasks or ser-vices including combined use of oral rehy-dration therapy (Victora et al., 2000), immu-nization (England et al., 2001), micronutrientsupplementation, promotion of exclusivebreast-feeding (Arifeen et al., 2001), and oth-ers, all but one of which (neonatal intensivecare) would be expected to be delivered bya PHC system. This estimate is supported byanother study (Berman, 2000) that estimatedthat about 62% of all disability adjusted lifeyears (lost in the adult and child populationof developing countries) would be amenableto primary care services (termed “ambulatoryhealthcare” by Berman). Access to primarycare appears to be particularly important inAfrica; some authors suggest that up to 80%of child deaths occur at home, without thechild having any contact with the health sys-tem (Oluwole et al., 2000)
Integrated management of childhood ill-ness (IMCI) reflects a horizontal primary careapproach in the sense that it combines sev-eral specific interventions. An evaluation of
IMCI programs in Brazil, Peru, Uganda, Egypt,and Tanzania showed that although the ap-proach was in many cases more compre-hensive and effective than individual verticalinterventions, poor access, low levels of uti-lization, and structural weaknesses in healthsystems limit its impact on population health(Bryce et al., 2003; WHO, 2004) A recent re-view suggested that a more comprehensiveapproach to PHC and health systems devel-opment will be required for strategies such asthe IMCI program to flourish (Freedman et al.,2005).
Rohde et al. (2008) identify 13 coun-tries that have implemented comprehen-sive PHC (Thailand, Turkey, Vietnam, Brazil,Sri Lanka, El Salvador, Tunisia, DominicanRepublic, Iran, Kazakhstan, Turkmenistan,China, and Cuba). Their analysis suggests thatthese countries experienced important healthgains and that in comparison with coun-tries having more selective PHC approaches,health improvements—particularly for condi-tions that require sustained and coordinatedcare—seem to “depend on progression tocomprehensive primary health care with a re-liable referral system linking to functioning fa-cilities” (Rohde et al., 2008, p. 958).
Studies of specific primary
care programs
The Navrongo experiment in Ghana wasthe only experimental study identified. In it,villages received 1 of 4 different interven-tions: professional community nurses; vol-untary community health workers (CHWs);a combination of both; and nothing (con-trol). In the nurse-only intervention areas,under-5 mortality fell by 14% during 5 yearsof program implementation, compared withthat before the intervention period (Penceet al., 2007; Phillips et al., 2006). In thevolunteer-only villages, under-5 mortality in-creased by 14%. The professional nurse inter-vention added approximately $2 per capita tothe $6.80 per capita budgeted for PHC ser-vices. Note that the study used a “plausibil-ity” rather than a “probability” design, mean-ing that treatments were not truly randomlyassigned.
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In the Gambia, Hill et al. (2000) comparedPHC and non-PHC communities over a 15-year period. Primary care was assessed by thepresence of a community health nurse as asupervisor to village health workers (VHWs)and traditional birth attendants; presence ofan expanded program of immunization and abasic package of maternal and child health ser-vices; and community participation in health-care provision, priority setting, and fund rais-ing. The study found that although child mor-tality declined in intervention and controlvillages, the decline was generally steeperin PHC villages (Hill et al., 2000). As a typeof natural experiment, the authors reportthat once PHC services were stopped in thevillages (because of lack of funds), the trendreversed and infant mortality increased tolevels higher than those in control (non-PHC)villages.
Velema et al. (1991) studied access and lon-gitudinality of primary care services to a pop-ulation of about 13 000 in Benin. In a matchedcase-control study, 2 factors were partic-ularly influential in predicting death risk:measles vaccination before their first birthday(Odds ratio [OR] = 0.4) and regular con-tact with VHWs (OR = 0.36). The authorsconcluded that regular contact with VHWs,which is consistent with the person-focusedcare over time function of primary care, im-proves the likelihood of child survival.
In Haiti, the activities of an integrated lo-cal health system, based on a PHC model(the Hopital Albert Schweitzer or HAS), wereassociated with infant and under-5 mortalitythat are about half of those in other areaswith similar income levels (Perry et al., 2007).This was accomplished through a decades-long partnership with local communities. Interms of resources, HAS had fewer physiciansand fewer hospital beds per capita than didthe rest of Haiti but more nurses, CHWs, andother outreach and support staff. The HASsystem costs about $19 per capita, includ-ing community development initiatives (Perryet al., 2006).
Other studies of PHC programs using pre-and postintervention measures and control orcomparison groups include the following:
• A large NGO-delivered PHC program(focused on maternal and child healthservices) targeted about 340 000 poorhouseholds in Bangladesh. Services weredelivered through trained family healthvisitors and included regular householdvisits, illustrating the importance of a fam-ily focus in PHC. After 5 to 6 years,program areas experienced a 52% reduc-tion in infant mortality and a 49% re-duction in under-5 mortality, larger de-creases than those experienced in controlareas (Mercer et al., 2004). Another studyin Matlab, Bangladesh, showed the im-pact of a community-based PHC approachemploying supervised and trained VHWs(with referrals to health centers staffedby healthcare professionals) on loweringunder-5 mortality from acute lower respi-ratory tract infections by 32% in 2 years(Fauveau et al., 1992). Prior studies inMatlab had also documented reductionsin under-5 and maternal mortality due todifferent PHC interventions (Chen et al.,1983; Fauveau et al., 1991).
• In a cohort study conducted inPondicherry, India, provision of a broadrange of PHC services, including homevisits by PHC nurses in 12 villages (totalpopulation of about 16 000), decreasedinfant and child mortality by more than65% (Dutt & Srinivasa, 1997). Anothersmaller-scale Indian study assessed theeffects of VHW provision of primaryand maternity care and health educationto pregnant women and grandmothers,resulting in reductions in neonatal mor-tality by 62% and infant mortality by 71%,as compared with preintervention levels(Bang et al., 1999).
• In Liberia (Becker et al., 1993) and Zaire(Chahnazarian et al., 1993; Taylor et al.,1993), a more selective PHC approachwas attributed to reductions in under-5mortality by as much as 28% over a 5-yearperiod, an improvement that was signifi-cantly greater than that reported in com-parison areas.
• A study using 2 waves of nationally repre-sentative surveys in Indonesia found that,
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while holding other village- and maternal-level variables constant, the addition of amaternity clinic and a physician to a vil-lage was found to decrease the odds ofinfant death (relative to an infant born be-fore the clinic existed) by about 15% and1.7%, respectively (Frankenberg, 1995).
• In Bolivia, a comprehensive community-based PHC program (delivered by paidnurses and community volunteers withsome physician support) serving a pop-ulation of about 15 000 successfully re-duced under-5 mortality by more than52% over a 5- to 6-year period, as com-pared with control areas (Perry et al.,1998, 2003). Costs for the program wereestimated at about $10 per person.
• In Pakistan, a case-control study of chil-dren who had diarrhea or acute respira-tory tract infections showed that the useof a traditional healer (as opposed to atrained VHW) raised the odds of a child’sdeath by a factor of 14 (OR = 14.5; 95%confidence interval [CI] = 4.23–49.8),and frequent changing of providers (ie,lack of continuity with a PHC provider)raised the odds of death 8 times (OR = 8;95% CI = 2.22–28.8) (D’Souza & Bryant,1999).
Studies of countrywide PHC experiences
There have been only a few studies that di-rectly test the hypothesis that health systemsbased on a strong PHC orientation (basedon PHC principles) lead to better overallindicators.
By 1985, Costa Rica’s life expectancy hadreached 74 years, and infant mortality de-clined from 60 per 1000 in 1970 to 19 per1000, levels comparable with those in moredeveloped countries. Explanations for thisrapid progress include the development of auniversal social security system and a mul-tidimensional approach to health improve-ment, which included expanding PHC ser-vices, investing in education and sanitation,and improving access to secondary and ter-tiary healthcare services (Haines & Avery,1982; Klijzing & Taylor, 1982; Rosero-Bixby,
1986). PHC improvements beginning in the1970s were estimated to have reduced in-fant mortality by between 40% and 75%(Rosero-Bixby, 1991).
In the 1990s, additional Costa Ricanreforms sought to improve PHC coverageand efficiency. A quasi-experimental studycomparing 3 groups of districts on the basisof when they adopted PHC reforms foundthat, in addition to other improvements inliving standards, PHC reforms significantlyreduced mortality in both adults and children(Rosero-Bixby, 2004a). For every 5 additionalyears after PHC reforms, child mortalitydeclined by 13% and adult mortality by4%. The proportion of the population withinsufficient access to PHC services declinedby 15% in reformed districts compared withonly a 2% decline in districts that did notundergo reforms. The reforms additionally im-proved equity in access by targeting the leastprivileged population first (Rosero-Bixby,2004b).
Brazil’s family health program (FHP) is nowperhaps the largest community-based PHCsystem in the world. In 2007, the programencompassed more than 27 000 community-based teams responsible for providing careto about 85 million people (Brazilian Min-istry of Health, Department of Primary Care,2006). The FHP is based on an explicit strat-egy to provide all core primary care functions,including first-contact access for each newneed, long-term person-focused care, compre-hensive care for most health needs, coordi-nated care when it must be sought elsewhere,and a focus on the family and the community.These functions are achieved through theprogram’s decentralized organization, elimi-nation of copays for services, incentives to lo-cal government for increasing access to theprogram, and multidisciplinary teams com-posed of a physician and a nurse who deliverclinic-based care along with CHWs who makeregular home visits and perform community-based health-promotion activities (Ministry ofHealth of Brazil, 2003). Costs for the pro-gram (which includes access to pharmaceu-ticals) are estimated at between $25 and $35(Macinko et al., 2007). A panel data analysis
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of Brazilian states from 1990 to 2002 showedthat an increase in FHP coverage by 10% wasassociated with an average 4.6% decrease ininfant mortality, controlling for other healthdeterminants, including water supply, livingconditions, doctor and hospital supply, andwomen’s education (Macinko et al., 2006).A follow-up study conducted at the microre-gional level for 1999–2004 showed that the ef-fect of FHP coverage was especially strong forconditions that are known to be sensitive toprimary care (such as postneonatal mortalityand deaths from diarrheal diseases) (Macinkoet al., 2007). Several studies also demon-strated associations between CHWs and lowerinfant mortality in specific Brazilian states(Emond et al., 2002; Svitone et al., 2000).
A few other countrywide observations aresuggestive of the role of PHC in populationhealth improvements, although these studiesdo not explicitly quantify the contribution ofPHC to health improvements or explicitly testthe impact of specific PHC interventions.
Cuba’s universal PHC program uses familyhealth physicians and nurses, who provideuniversal, comprehensive, integrated, and in-tersectorial care to geographically defined ar-eas with a focus on families (Evans et al.,2008; Waitzkin, 1997). Changes in PHC ac-cess, organization, and delivery over the past40 years correspond to about a 40% declinein infant mortality over the same period, evenwhile other indicators such as gross nationalproduct per capita have not substantially in-creased (Riveron Corteguera, 2000). Invest-ments in prevention integrated into PHC mayalso have contributed to the control of car-diovascular diseases, resulting in lower-than-expected mortality and fewer avoidable hos-pitalizations for these and related conditions(Spiegel & Yassi, 2004). Lessons learned fromthe Cuban experience suggest the potentialbenefits of organizing an entire health sys-tem around the PHC approach (Franco et al.,2007).
In Mexico, child mortality declined from 64per 1000 live births in 1980 to 23 per 1000in 2006 (Sepulveda et al., 2006). These re-ductions were consequent to a strategy thatbegan with a number of disease-specific pro-
grams and expanded to a broader strategy thatcombined vertical programs with more com-prehensive PHC and human development ap-proaches, including legislation making accessto maternal and child health services a citi-zen’s right (Frenk et al., 2003). Reyes et al.(1997) also found that in Mexico, primarycare characteristics (such as adequate refer-ral processes, continuity of care, being seenby the same provider, and being attended in apublic facility) had an important, independenteffect on reducing a child’s odds of dying.Similarly, Gutierrez et al. (1999) point to theimportance of access to primary care (as mea-sured by nurse and physician supply) as wellas investments in public health (immunizationand improved water and sanitation) and edu-cation as particularly important for reducinginfant mortality in Mexico.
In Thailand, decreases in under-5 infantmortality occurred after primary care reform,which included developing at least 1 pri-mary care health center for every rural villageby 1990 and a government medical welfarescheme started in 1993. In the correspond-ing decade, under-5 mortality declined by 44%in the poorest population quintile, 41% in thenext poorest quintile, 22% in the third, 23% inthe fourth, and 13% in the wealthiest quintile(Vapattanawong et al., 2007)
In Indonesia, a 20% reduction in infant mor-tality during the early 1990s has been at-tributed to improvements in PHC (Simms &Rowson, 2003). Some evidence for this attri-bution comes from the observation that inthe later 1990s, once primary care spend-ing declined substantially (and hospital spend-ing increased by almost 25%), infant mortal-ity actually increased by 14% in almost everyprovince of the country (Simms & Rowson,2003).
Finally, the 2008 World Health Report onPHC presents numerous case studies of PHCexperiences. Although it does not contain asystematic review of the evidence on the ben-efits of PHC, it reviewed the evidence for thebenefits of PHC components and concludedthat there is an overwhelming justification fora focus on developing and strengthening PHCin all countries (WHO, 2008).
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Studies finding little or no impact of
PHC on health outcomes
In Niger, a prospective study found thatthere was no additional survival advantagefor children in villages with a “village healthteam”present, although the presence of a dis-pensary lowered the odds of death by 32%,as compared with villages with no services(Magnani et al., 1996). In explanation for theapparent lack of an effect, Magnani et al. sug-gest the need for more comprehensive pack-ages of health services than those delivered bythe project, because the single interventionswere possibly offset by continued high levelsof exposure to other unchanged factors.
In the Philippines, the Bohol project pro-vided very low-cost PHC services to a popula-tion of about 400 000 residents for 5 years.The evaluation included pre- and postin-tervention surveys and comparison with acontrol village. The project increased theutilization of some health services but didnot significantly decrease infant mortality(Williamson, 1982). Williamson suggests thatpotential reasons for the lack of an effect in-clude the generally poor quality of health ser-vices provided, a selective rather than a com-prehensive approach to PHC with a strongemphasis on family planning (fertility did de-cline), and overworked and/or inadequatelytrained staff.
In a retrospective study with control com-munities in the Gambia (De Francisco et al.,1994), there were no significant differences(P = .88) in under-5 mortality between vil-lages with VHWs and those without them(35.5/1000 vs 35.8/1000). De Francisco et al.suggest that different health service utiliza-tion patterns (based on the type of child ill-nesses) and preferences for traditional heal-ers may partially explain the lack of effect. Inaddition, there was no indication that theseVHWs were achieving PHC functions, includ-ing provision of good-quality care and refer-ral to trained healthcare professionals whenindicated.
In Brazil, one study found that participa-tion in FHP between 1994 and 1998 did notsignificantly improve child health indicatorsin municipalities with high coverage, as op-
posed to those in municipalities with lowor no coverage. Infant mortality declined by42% and 45.5% in the intervention and con-trol groups, respectively, a nonsignificant dif-ference (Morsch et al., 2001). A possible ex-planation for the lack of an effect might havebeen the inability to control for variables re-lated to the performance of primary care ser-vices, such as the technical quality of care oraccessibility, which vary by municipality.
Finally, in their systematic review of “in-tegration” of primary care in developingcountries, Briggs et al. (2001) discuss an es-sential feature of primary care: the extent towhich it provides a range of services meant toattend to most common healthcare problems.This feature of primary care is more oftentermed “comprehensiveness.” The review ofBriggs et al. (2001) contains only 4 studies,and they conclude that no overall conclusionscan be drawn from their results. As a possibleexplanation for the lack of a conclusivefinding, the authors point to the poor qualityof many of the studies conducted, includingpoor recording of outcomes, inadequaterandomization processes, and control groupsthat were not entirely comparable with exper-imental groups. Moreover, each study definedand measured integration in a differentway.
DISCUSSION
This review of the evidence of the ef-fectiveness of PHC on population health inlow-income countries has shown that sev-eral analyses provide consistent evidenceof the impact of PHC on improved healthoutcomes. Nevertheless, many studies suf-fered from important methodological weak-nesses, including inadequate controls forindividual- or community-level confoundersin multivariable analyses. Reductions in in-fant mortality (the most frequently studiedoutcome) attributed to PHC actions averagedabout 40% and varied from 0% to as highas a 71% over intervention periods rangingbetween 2 and 10 or more years. Costs forcomprehensive PHC programs ranged fromabout $10 to $35 per capita per year.
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Despite the apparent consistency of results,analysis of the studies revealed that PHC hasonly rarely been evaluated in a consistent andreproducible way. Rather, it is often only var-ious aspects of health services that are as-sumed to be part of PHC that have been the fo-cus of attention. For example, all but 3 studiesmeasured PHC exposure as residence withina geographic area in which the PHC programor project was implemented. In addition, thedefinition of the PHC program also varied con-siderably, from the mere presence of a VHWin a community to the use of specific ser-vices to the development of an integratednetwork of health and social services in thecommunity. For this reason, there is little thatcan be gleaned regarding the mechanisms bywhich these PHC approaches might achieveimportant primary care functions, such asfirst-contact access, longitudinality, compre-hensiveness, and coordination of care.
The general failure to use an operationalconceptualization of PHC has also made iden-tification of studies about PHC difficult. Forthis reason, the literature probably containsmore evidence than is discoverable from theabstracts or titles of published articles.
Publication bias is also likely to have lim-ited the scope of this review. Many suc-cessful (as well as unsuccessful) experienceshave simply not been documented in peer-reviewed journals. As an illustration, we wereunable to retrieve any peer-reviewed articlesthat adequately assessed the impact of PHCon population health in Sri Lanka, China, orVietnam, although each country’s PHC ap-proach has been discussed elsewhere as “suc-cessful”(Bloom, 1998; Fritzen, 2007; Halsteadet al., 1985).
In addition, there is little peer-reviewed evi-dence on the role of PHC on improvements inadult health in low- and middle-income coun-tries, because most published studies have fo-cused only on infant and under-5 mortality.Thus, the potential for PHC to help controladult chronic and infectious diseases in the de-veloping world remains largely unexplored.
The studies that found no effect of PHC onhealth indirectly provide support for a com-prehensive approach to PHC: most involvedinterventions that focused only on selective
PHC tasks. They also point to the importanceof accurately measuring variations in the tech-nical quality of primary care delivered, a topicthat certainly deserves far more attention inthe literature reviewed here.
In view of the limitations of these studies,an agenda for the evaluation of the contribu-tion of PHC tasks and functions to populationhealth would benefit from the following con-siderations.
First, a clear conceptualization of primarycare is needed, including specification ofeach of its component features, for example,first-contact access and use, longitudinality(person-focused care over time), comprehen-siveness (addressing the breadth of commonhealth needs), and coordination (integrationof services with other levels of care).
Second, studies should start with a con-ceptual framework to guide the overall eval-uation, design the characteristics under con-sideration, and describe relationships amongdifferent levels and types of data to be col-lected in the evaluation process. This frame-work should provide a model of how primarycare is conceptualized in relation to biologi-cal, social, and environmental influences onhealth (Starfield, 2001).
Third, future studies require clear speci-fication and measurement of the PHC sys-tem, including specific structural character-istics (input and policy), process (servicedelivery modalities), and relevant healthoutcomes and outputs.
Fourth, as noted throughout the PHC lit-erature (Chen et al., 1993; Hill et al., 2000),there is still an urgent need for more rig-orous research designs that allow testing ofthe independent effect of primary care onoutcomes over time. This should includeindividual- and community/contextual-leveldata derived from longitudinal sources, appro-priate control or comparison groups, and con-trol for relevant individual- and contextual-level covariates. Such evaluations will requirea commitment from donor organizations andnational governments to provide necessary re-sources and to ensure the scientific integrityof the research process.
In the short term, 3 approaches couldbe implemented to aid in providing more
Primary Healthcare in Low- and Middle-Income Countries 159
systematic evaluation of primary care, asfollows:
1. Existing or planned cohort studies couldbegin to incorporate PHC measuresthrough the use of validated instrumentssuch as the Primary Care AssessmentTools (Harzheim et al., 2006; Macinkoet al., 2007; Pasarin et al., 2007).
2. Standardized surveys such as the Demo-graphic and Health Surveys or LivingStandards Measurement Surveys couldinclude modules derived from the Pri-mary Care Assessment Tools along withhealth system variables to identify howand where populations are receiving ef-fective PHC services.
3. Researchers could direct their attentionto countries that are currently undergo-ing reform of their primary care system,thus opening the possibility for analy-sis of natural experiments in which re-formed states or municipalities couldbe compared with otherwise similar re-gions without reformed primary caresystems. Better yet, experimental assign-ment of different PHC approaches couldbe used to help phase in reforms andmore rigorously evaluate their impact(King et al., 2007).
Finally, there is a need to encourage thepublication of evaluations of PHC experi-ences, both successful and unsuccessful, sothat the PHC approach can be guided by awider body of high-quality evidence.
CONCLUSION
The WHO proposal for renewing PHC re-inforces the idea that strengthened health sys-tems should be viewed as a necessary (thoughnot sufficient) condition for meeting interna-tionally agreed-upon development goals suchas those contained in the Millennium Devel-
opment Goals (WHO, 2008). Basing healthsystems more strongly on PHC represents animportant strategy to address emerging healthproblems (Fuster & Voute, 2005), scale upexisting interventions, and effectively com-bat health threats such as HIV/AIDS (Buveet al., 2003), tuberculosis (Mahendradhataet al., 2003), chronic illnesses (Rothman &Wagner, 2003), and others.
These observations are also relevant to therenewal of primary care in the United States.Recently, the American Academy of FamilyPhysicians, the American Academy of Pedi-atrics, the American College of Physicians,and the American Osteopathic Association(2007) united to endorse the “Joint Princi-ples of the Patient-Centered Medical Home,”which describes characteristics of a patient-centered medical home (PCMH) as includinga personal physician, physician-directed med-ical practice, whole-person orientation, coor-dinated and integrated care, quality and safety,enhanced access to care, and payment that“appropriately recognizes the added valueprovided to patients. . ..”Lessons learned fromthe evaluation of PHC in the developing worldmay also have relevance to the assessment ofthe PCMH, as it is apparent that definitionsand tools of measurement should be consis-tent, standardized, and based on evidence ofeffectiveness of primary care components.Without greater attention to these aspects, thePCMH model may fall short of reaching itsgoal of renewing a PHC approach to health-care organization and delivery in the UnitedStates.
As national governments, the WHO, andother international organizations move to re-new their PHC strategies, greater clarity inspecifying PHC in terms that allow for morestandardized measurement and investment inrigorous evaluation of PHC effectiveness andits effects on equity will be essential.
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164 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2009A
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than
5y
in
Mat
lab
Pre
sen
ce
of
CH
Ws
Cau
se-s
pecif
ic
un
der-
5
mo
rtal
ity
Fo
ral
lch
ild
ren
you
nge
rth
an5
yin
the
inte
rven
tio
n
area,
ALR
I-sp
ecif
icm
ort
alit
yfr
om
19
86
to1
98
7w
as
28
%lo
wer
inth
ein
terv
en
tio
nar
ea
than
inth
e
co
mp
aris
on
area
(P<
.01
).Fro
m1
98
8to
19
89
,th
e
mo
rtal
ity
was
48
%lo
wer
inth
ein
terv
en
tio
nar
ea
than
inth
eco
ntr
olar
ea.
ALR
I-sp
ecif
icm
ort
alit
yin
all
child
ren
you
nge
rth
an5
yin
the
inte
rven
tio
nar
ea
declin
ed
(P=
.00
3)
by
32
%b
etw
een
19
86
/19
87
and
19
88
/19
89
.
Ben
in(r
ura
l)(V
ele
ma
et
al.,
19
91
)
DC
hild
ren
4–3
5m
o
of
age
Vis
itto
VH
Ws
Un
der-
5
mo
rtal
ity
Meas
les
vaccin
atio
nb
efo
reth
efi
rst
bir
thd
ay(a
n
ind
icat
or
of
access
)re
du
ced
risk
of
deat
h(R
2=
0.4
);
child
ren
inre
gu
lar
co
nta
ct
wit
ha
VH
Wh
adlo
wer
risk
of
deat
h(R
2=
0.3
).
Bh
uta
n(B
oh
ler,
19
94
)E
Infa
nts
VH
Wac
tivit
ies
(heal
th
ed
ucat
ion
,
vaccin
atio
n,
treat
men
t)
Infa
nt
mo
rtal
ity
Infa
nt
mo
rtal
ity
was
red
uced
sign
ific
antl
yfr
om
14
5in
19
84
to4
9in
19
91
(P<
.00
1).
Du
rin
gb
oth
peri
od
s
(19
84
and
19
91
),ch
ild
ren
of
mo
thers
wit
ha
hig
h
bir
thfr
eq
uen
cy
had
sign
ific
antl
yh
igh
er
infa
nt
mo
rtal
ity
(26
8in
19
84
and
93
in1
99
1)
than
tho
se
wit
hlo
wb
irth
freq
uen
cy
(47
in1
98
4an
d1
2in
19
91
)(P
<.0
01
for
19
84
and
P=
.00
2fo
r1
99
1).
(con
tin
ues
)
Primary Healthcare in Low- and Middle-Income Countries 165
Co
un
try
/regio
nP
HC
Main
(refe
ren
ce)
Ty
pe
aP
op
ula
tio
nm
easu
res
ou
tco
me
Imp
act/
resu
lt
Bo
livia
(Perr
yet
al.,
19
98
,2
00
3)
CC
hild
ren
in
inte
rven
tio
n
and
no
nin
ter-
ven
tio
n
areas
Co
mp
reh
en
sive
pu
blic
heal
th
serv
ices,
inclu
din
g
imp
rove
men
to
f
cle
anw
ater
and
san
itat
ion
Un
der-
5
mo
rtal
ity
In1
99
2–1
99
3,u
nd
er-
5m
ort
alit
yw
as2
05
.5/1
00
0
(co
mp
aris
on
areas
)an
d9
8.5
/10
00
(in
terv
en
tio
n
areas
),a
dif
fere
nce
of
10
7/1
00
0d
eat
hs
(P<
.00
1,
95
%C
I=
14
1.3
–7
2.7
)o
r5
2.1
%(9
5%
CI=
35
.2–6
8.8
%)
low
er
mo
rtal
ity
inth
ein
terv
en
tio
n
areas
.P
rogra
mco
sts
est
imat
ed
atab
ou
t$
10
per
cap
ita.
Bo
tsw
ana
Co
ted
’Ivo
ire,
Gh
ana,
and
Zim
bab
we
(Du
gb
atey,
19
99
)
GN
atio
nal
po
licie
s
of
4co
un
trie
s
Heal
thed
ucat
ion
,
foo
d,n
utr
itio
n,
wat
er,
san
itat
ion
,
mat
ern
al/c
hild
heal
thp
olicie
s
Infa
nt
mo
rtal
ity,
life
exp
ecta
ncy
Bo
tsw
ana
and
Zim
bab
we
perf
orm
ed
bett
er
than
Co
te
d’I
voir
ean
dG
han
ain
term
so
fh
eal
tho
utc
om
es.
Th
isre
lati
on
ship
did
no
tap
pear
tob
ere
late
dto
inco
me
on
lyb
ecau
seri
cher
co
un
trie
s(C
ote
d’I
voir
e)
sco
red
wo
rse
than
Zim
bab
we
and
Gh
ana.
Th
e
auth
or
co
nclu
des
that
“po
licie
sfo
rmu
late
dan
d
imp
lem
en
ted
inac
co
rdan
ce
wit
hkey
PH
C
pri
ncip
les
co
uld
acco
un
tfo
rim
pro
vem
en
tsin
nat
ion
alh
eal
thst
atu
s.”
Bra
zil(M
acin
ko
et
al.,
20
06
,2
00
7)
AB
razi
lian
po
pu
lati
on
(sta
tes
and
mic
rore
gio
ns)
Pro
po
rtio
no
f
po
pu
lati
on
co
vere
db
yth
e
FH
P
Infa
nt
mo
rtal
ity
A1
0%
incre
ase
inFH
Pco
vera
gew
asas
socia
ted
wit
ha
4.5
%d
ecre
ase
inin
fan
tm
ort
alit
y,co
ntr
ollin
gfo
ral
l
oth
er
heal
thd
ete
rmin
ants
(P<
.01
).A
ccess
tocle
an
wat
er
and
ho
spit
alb
ed
sp
er
10
00
were
negat
ively
asso
cia
ted
wit
hin
fan
tm
ort
alit
y,w
here
asfe
mal
e
illite
racy,
fert
ilit
yra
tes,
and
mean
inco
me
were
po
siti
vely
asso
cia
ted
wit
hin
fan
tm
ort
alit
y.T
he
pro
gra
mm
ayre
du
ce
infa
nt
mo
rtal
ity
atle
ast
par
tly
thro
ugh
red
ucti
on
sin
dia
rrh
ea
deat
hs.
Bra
zil(M
ors
chet
al.,
20
01
)
CIn
fan
tsin
dif
fere
nt
mu
nic
ipal
areas
Co
mm
un
ity
heal
th
agen
tsp
rogra
m
co
vera
ge
Infa
nt
mo
rtal
ity
Par
ticip
atio
nin
the
pro
gra
mb
etw
een
19
94
and
19
98
did
no
tsi
gn
ific
antl
yim
pro
vech
ild
heal
thin
dic
ato
rs
co
mp
ared
wit
hn
op
arti
cip
atio
n.T
he
pro
po
rtio
nat
e
infa
nt
mo
rtal
ity
declin
ed
by
42
%an
d4
5.5
%in
the
inte
rven
tio
nan
dco
ntr
olgro
up
s,re
specti
vely
,an
d
the
dif
fere
nces
were
no
tsi
gn
ific
ant.
(con
tin
ues
)
166 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2009C
ou
ntr
y/r
egio
nP
HC
Main
(refe
ren
ce)
Ty
pe
aP
op
ula
tio
nm
easu
res
ou
tco
me
Imp
act/
resu
lt
Bra
zil(N
atal
)(E
mo
nd
et
al.,
20
02
)
CW
om
en
,p
regn
ant
wo
men
,an
d
child
ren
you
nge
rth
an
5y
Co
vera
geb
yV
HW
pro
gra
m
Mat
ern
alan
d
infa
nt
mo
rtal
ity
Aft
er
30
mo
,co
mm
un
ity
surv
eys
rep
ort
ed
asi
gn
ific
ant
red
ucti
on
inin
fan
tm
ort
alit
yfr
om
60
/10
00
to
37
/10
00
;d
ecre
ased
mat
ern
alm
ort
alit
y;im
pro
ved
infa
nt
feed
ing
and
car
eta
kin
gp
racti
ces;
imp
rove
d
imm
un
izat
ion
rate
s;in
cre
ased
rate
so
fco
nsu
ltat
ion
wit
hp
hys
icia
ns;
and
agre
ater
perc
en
tage
of
bir
ths
takin
gp
lace
inco
mm
un
ity
clin
ics
rath
er
than
in
ho
spit
als.
Bra
zil(C
ear
a)(S
vit
on
e
et
al.,
20
00
)
EM
oth
ers
and
child
ren
in
Cear
ast
ate
Co
vera
geb
y
co
mm
un
ity
heal
thag
en
ts
pro
gra
m
Infa
nt
mo
rtal
ity
(by
cau
se)
Perc
en
tage
so
fb
reas
t-fe
ed
ing,giv
ing
OR
T,re
ceiv
ing
pre
nat
alcar
e,va
ccin
atio
nco
vera
ge,in
stit
uti
on
al
delive
ries,
and
infa
nt
mo
rtal
ity
imp
rove
d.P
rogra
m
success
inclu
des
lon
git
ud
inal
ity;
fam
ily
and
co
mm
un
ity
ori
en
tati
on
,fi
rst
co
nta
ct,
and
inte
rsecto
rial
co
llab
ora
tio
n.W
eak
ness
es
inclu
de
refe
rral
mech
anis
ms,
access
bar
riers
,an
dlivin
g
co
nd
itio
ns.
Co
sta
Ric
a
(Ro
sero
-Bix
by,
19
91
,
20
04
a,2
00
4b
)
A,A
Infa
nts
and
wo
men
Dis
tric
tle
vel,
bas
ed
on
wh
en
they
began
the
heal
th
refo
rmp
rocess
Infa
nt
mo
rtal
ity
and
fert
ilit
y
Refo
rmo
fp
rim
ary
car
esi
gn
ific
antl
yre
du
ced
mo
rtal
ity
inb
oth
adu
lts
(2%
)an
dch
ild
ren
(8%
).Fo
reve
ry5
add
itio
nal
year
so
fre
form
,ch
ild
mo
rtal
ity
was
red
uced
by
13
%an
dad
ult
mo
rtal
ity
declin
ed
by
4%
.
Po
pu
lati
on
wit
hlim
ited
access
toh
eal
thse
rvic
es
decre
ased
15
%in
refo
rmar
eas
(on
ly2
%in
no
nre
form
areas
).In
mu
ltiv
aria
tean
alys
es,
fro
m
19
70
to1
98
0,P
HC
acco
un
ted
for
41
%o
fin
fan
t
mo
rtal
ity
declin
es,
oth
er
med
ical
car
e(3
2%
),
socio
eco
no
mic
pro
gre
ss(2
2%
),an
dfe
rtilit
yd
eclin
e
(5%
).
Cu
ba
(Fra
nco
et
al.,
20
07
;R
ivero
n
Co
rtegu
era
,2
00
0)
G,G
Infa
nts
and
adu
lts
Desc
rip
tio
no
fP
HC
serv
ices,
org
aniz
atio
nan
d
serv
ice
delive
ry,
and
po
licie
s
Infa
nt
mo
rtal
ity,
car
dio
vasc
ula
r
dis
eas
e
mo
rtal
ity
(ad
ult
s)
Ch
ange
sin
access
,o
rgan
izat
ion
,an
dd
elive
ryo
fP
HC
ove
r4
0y
asso
cia
ted
wit
h4
0%
declin
ein
infa
nt
mo
rtal
ity
inth
e1
97
0s,
19
80
s,an
d1
99
0,w
hile
socio
eco
no
mic
co
nd
itio
ns
rem
ain
ed
sim
ilar
.
(con
tin
ues
)
Primary Healthcare in Low- and Middle-Income Countries 167
Co
un
try
/regio
nP
HC
Main
(refe
ren
ce)
Ty
pe
aP
op
ula
tio
nm
easu
res
ou
tco
me
Imp
act/
resu
lt
Th
eG
amb
ia(H
illet
al.,
20
00
)
CC
hild
ren
Pre
sen
ce
of
the
PH
Cp
rogra
m
(nu
rses,
CH
Ws,
TB
As,
sup
plies,
serv
ices,
par
ticip
atio
n)
Infa
nt
and
un
der-
5
mo
rtal
ity
Infa
nt
and
un
der-
5m
ort
alit
yd
eclin
ed
inb
oth
PH
Can
d
no
n-P
HC
villa
ges.
Th
ed
eclin
ew
assh
arp
er
inP
HC
villa
ges
(in
fan
tm
ort
alit
y1
34
/10
00
to6
9/1
00
0)
vs
no
n-P
HC
villa
ges
(15
5/1
00
0to
91
/10
00
).Si
nce
19
94
,af
ter
sup
po
rtan
dfu
nd
ing
for
PH
Cd
eclin
ed
,
the
tren
dre
vers
ed
(in
fan
tm
ort
alit
y9
8/1
00
0in
PH
C
villa
ges
vs
78
/10
00
inn
on
-PH
Cvilla
ges)
.
Th
eG
amb
ia(D
e
Fra
ncis
co
et
al.1
99
4;
Gre
en
wo
od
et
al.,
19
90
)
C,C
Ch
ild
ren
you
nge
r
than
5y
Vac
cin
atio
n,
heal
thcar
eu
se,
heal
thed
ucat
ion
,
en
vir
on
men
tal
heal
th,n
utr
itio
n,
treat
men
t,an
d
refe
rral
sb
y
VH
Ws
and
TB
As
Ch
ild
mo
rtal
ity
No
sign
ific
ant
dif
fere
nce
(P=
.88
)in
un
der-
5m
ort
alit
y
betw
een
villa
ges
wit
hV
HW
san
dth
ose
wit
ho
ut
(rat
e
=3
5.5
per
10
00
/yvs
35
.8p
er
10
00
/y).
Gh
ana
(Pen
ce
et
al.
20
07
;P
hillip
set
al.,
20
06
)
AW
om
en
and
child
ren
in
inte
rven
tio
n
areas
Pre
sen
ce
of
a
pro
fess
ion
al
nu
rse,
volu
nte
ers
,an
d
bo
thin
dif
fere
nt
co
mm
un
itie
s
Infa
nt
and
un
der-
5
mo
rtal
ity
Th
est
ud
yco
mb
ined
4ar
ms:
pro
fess
ion
aln
urs
es
(un
der-
5m
ort
alit
yd
eclin
ed
by
14
%in
5y)
,lo
cal
heal
thvo
lun
teers
(un
der-
5m
ort
alit
yin
cre
ased
by
14
%);
aco
mb
inat
ion
of
bo
th(u
nd
er-
5m
ort
alit
y
incre
ased
by
8%
);an
dn
on
ew
inte
rven
tio
ns
(un
der-
5
mo
rtal
ity
decre
ased
by
4%
).
Gh
ana
(Afa
riet
al.,
19
95
)C
Ch
ild
ren
you
nge
r
than
5y
in3
villa
ges
Pro
vis
ion
of
serv
ices
(heal
th
ed
ucat
ion
on
infa
nt
feed
ing,
dis
eas
e
pre
ven
tio
n,an
d
dru
g
dis
trib
uti
on
)
Infa
nt
and
un
der-
5
mo
rtal
ity
PH
Cse
rvic
es
decre
ased
infa
nt
and
child
mo
rtal
ity
and
imp
rove
dth
eh
eal
tho
fch
ild
ren
inth
evilla
ges.
Infa
nt
mo
rtal
ity
declin
ed
fro
m1
14
.6/1
00
0live
bir
ths
in1
98
7to
40
.8/1
00
0live
bir
ths
in1
99
0.U
nd
er-
5
mo
rtal
ity
decre
ased
fro
m1
55
.6/1
00
0live
bir
ths
in
19
87
to6
1.2
/10
00
live
bir
ths
in1
99
0.
(con
tin
ues
)
168 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2009C
ou
ntr
y/r
egio
nP
HC
Main
(refe
ren
ce)
Ty
pe
aP
op
ula
tio
nm
easu
res
ou
tco
me
Imp
act/
resu
lt
Hai
ti(P
err
yet
al.,
20
06
,
20
07
)
CPo
pu
lati
on
co
vere
db
yH
AS
Pro
vis
ion
of
inte
gra
ted
pri
mar
y,
seco
nd
ary,
and
tert
iary
car
eto
peo
ple
livin
g
wit
hin
HA
S
cat
chm
en
tar
eas
Infa
nt
and
un
der-
5
mo
rtal
ity
Infa
nt
and
un
der-
5m
ort
alit
yre
po
rted
50
%lo
weri
ng
in
HA
Sar
eas
than
that
inth
ere
sto
fH
aiti
.In
fan
t
mo
rtal
ity
inH
AS
areas
declin
ed
inth
em
id-1
97
0s
and
has
rem
ain
ed
atar
ou
nd
62
–6
6/1
00
0.In
fan
tm
ort
alit
y
inth
ere
sto
fH
aiti
has
declin
ed
fro
mn
ear
ly4
tim
es
hig
her
(22
4in
19
71
–1
97
3)
toab
ou
t2
tim
es
hig
her
(11
9/1
00
0)
in1
99
9.H
AS
inclu
des
co
mp
reh
en
sive
co
mm
un
ity-
bas
ed
PH
C,in
ters
ecto
rial
acti
on
s,an
d
refe
rral
ho
spit
als.
Ind
ia(B
ang
et
al.1
99
9,
20
05
)
C,C
Neo
nat
es
and
infa
nts
in
inte
rven
tio
n
and
no
nin
ter-
ven
tio
n
areas
Acti
vit
ies
of
CH
Ws
Neo
nat
al,in
fan
t,
and
peri
nat
al
mo
rtal
ity
Ho
me-b
ased
neo
nat
alcar
ere
du
ced
neo
nat
alm
ort
alit
y
atth
een
do
fth
eth
ird
year
of
inte
rven
tio
nb
ym
ore
than
the
targ
ete
d2
5%
.In
inte
rven
tio
nar
eas
,
neo
nat
alm
ort
alit
yre
du
ced
fro
m6
2.0
/10
00
live
bir
ths
atb
aselin
e(1
99
3–1
99
5)
to2
5.5
/10
00
live
bir
ths
atye
ar3
(19
97
–1
99
8),
refl
ecti
ng
a6
2.2
%n
et
perc
en
tage
red
ucti
on
(P<
.01
).Si
milar
ly,in
fan
t
mo
rtal
ity
declin
ed
fro
m7
5.5
/10
00
live
bir
ths
to
38
.8/1
00
0live
bir
ths
(45
.7%
net
red
ucti
on
)an
d
peri
nat
alm
ort
alit
yd
eclin
ed
fro
m6
8.3
/10
00
bir
ths
to4
7.8
/10
00
bir
ths
(71
.0%
net
red
ucti
on
)in
inte
rven
tio
nar
eas
(P<
.01
).G
ain
sw
ere
sust
ain
ed
afte
r7
y.
Ind
ia(D
utt
&Sr
iniv
asa,
19
97
)
BIn
fan
tsfo
llo
wed
fro
mb
irth
to5
yo
fag
e
Ava
ilab
ilit
yo
f
med
ical
facilit
ies,
ante
nat
alan
d
un
der-
5clin
ics,
ho
me
vis
its
by
pu
blic
heal
th
nu
rses,
heal
th
ed
ucat
ion
,
nu
trit
ion
sup
ple
men
ts
Infa
nt
and
child
mo
rtal
ity;
child
surv
ival
ind
ex
Pro
vis
ion
of
adeq
uat
em
atern
alan
dch
ild
heal
th
serv
ices
imp
rove
dch
ild
surv
ival
,d
ecre
ased
infa
nt
and
child
mo
rtal
ity.
Resu
lted
inh
igh
child
surv
ival
ind
exo
f9
1.2
%;in
fan
tm
ort
alit
yd
eclin
ed
fro
m
20
1/1
00
0in
19
67
to6
4/1
00
0live
bir
ths
in1
98
9,
wh
ere
asch
ild
deat
hra
tes
decre
ased
fro
m3
9.4
/10
00
in1
97
0to
18
/10
00
in1
99
2am
on
gch
ild
ren
1–4
yo
f
age.
(con
tin
ues
)
Primary Healthcare in Low- and Middle-Income Countries 169
Co
un
try
/regio
nP
HC
Main
(refe
ren
ce)
Ty
pe
aP
op
ula
tio
nm
easu
res
ou
tco
me
Imp
act/
resu
lt
Ind
ia,N
ep
al,Tan
zan
ia,
To
go
(Bri
ggs
et
al.,
20
01
)
FP
ub
lish
ed
stu
die
sIn
tegra
ted
pri
mar
y
car
ed
elive
ryvs
vert
ical
pri
mar
y
car
ese
rvic
es
Var
ied
Ino
ne
stu
dy,
inte
gra
tio
nsh
ow
ed
ap
osi
tive
eff
ect
on
ou
tpu
ts;in
ano
ther
stu
dy,
inte
gra
ted
pro
gra
ms
had
ou
tco
mes
sim
ilar
toth
ose
of
vert
ical
pro
gra
ms.
In
the
rem
ain
ing
2st
ud
ies,
inte
gra
ted
pro
gra
ms
perf
orm
ed
wo
rse
than
vert
ical
on
es.
Ind
on
esi
a(F
ran
ken
berg
,
19
95
)
DIn
fan
tsSe
rvic
eav
aila
bilit
yIn
fan
tm
ort
alit
yW
ith
ina
villa
ge,an
incre
ase
of
1m
atern
ity
clin
ic
decre
ases
the
od
ds
of
deat
ho
fan
infa
nt
wit
hac
cess
toth
atclin
icb
yab
ou
t1
5%
,re
lati
veto
the
infa
nt
bo
rnb
efo
reth
eclin
icex
iste
d.A
nin
fan
tb
orn
afte
r
heal
thw
ork
ers
are
add
ed
toa
villa
geh
asab
ou
t1
.3%
(P<
.1)
low
er
od
ds
of
deat
hth
anan
infa
nt
bo
rn
befo
reth
ead
dit
ion
of
heal
thw
ork
ers
.
Lib
eri
a(B
ecker
et
al.,
19
93
)
CW
om
en
and
child
ren
in
pro
gra
man
d
no
np
rogra
m
areas
Pre
sen
ce
of
the
Co
mb
atin
g
Ch
ild
ho
od
Co
mm
un
icab
le
Dis
eas
ep
roje
ct
Infa
nt
and
un
der-
5
mo
rtal
ity
Imm
un
izat
ion
and
mal
aria
treat
men
tin
cre
ased
in
inte
rven
tio
nar
eas
and
infa
nt
mo
rtal
ity
declin
ed
by
25
%an
du
nd
er-
5m
ort
alit
yd
eclin
ed
by
28
%fr
om
bas
elin
ele
vels
.N
ote
that
this
was
ase
lecti
veP
HC
inte
rven
tio
nfo
cu
sed
on
teta
nu
san
dch
ild
ho
od
imm
un
izat
ion
s,O
RT,
and
mal
aria
treat
men
t.
Mex
ico
(Reye
set
al.,
19
97
)
DIn
fan
tsP
rim
ary
car
e(n
o.
of
ph
ysic
ian
s
seen
,n
o.o
f
vis
its,
pri
vate
or
pu
blic
ph
ysic
ian
s,
anti
bio
tics,
ho
spit
alre
ferr
al,
access
)
Infa
nt
mo
rtal
ity
fro
mA
RI
Pri
mar
ycar
ep
rocess
es
had
anin
dep
en
den
teff
ect
(co
ntr
ollin
gfo
rin
div
idu
alan
dfa
mily
socio
eco
no
mic
s,ac
cess
tocar
e)
on
AR
Id
eat
hs
(OR
=9
.68
,9
5%
CI=
3.5
9–2
6.1
).Si
gn
ific
ant
pre
dic
tors
inclu
ded
inad
eq
uat
ere
ferr
al,la
ck
of
co
nti
nu
ity
(att
en
ded
by
mu
ltip
lep
hys
icia
ns)
,an
db
ein
g
atte
nd
ed
by
ap
riva
tep
rovid
er
(as
op
po
sed
toa
pu
blic
pro
vid
er)
.
(con
tin
ues
)
170 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2009C
ou
ntr
y/r
egio
nP
HC
Main
(refe
ren
ce)
Ty
pe
aP
op
ula
tio
nm
easu
res
ou
tco
me
Imp
act/
resu
lt
Mo
zam
biq
ue
(Ed
war
d
et
al.,
20
07
)
CC
hild
ren
you
nge
r
than
5y
IMC
Ip
rogra
m
co
vera
ge
Infa
nt
and
un
der-
5
mo
rtal
ity
Imp
lem
en
tati
on
of
acti
vit
ies
asso
cia
ted
wit
hth
eIM
CI
pro
gra
mre
sult
ed
ina
66
%re
du
cti
on
inin
fan
t
mo
rtal
ity
and
a6
2%
red
ucti
on
inu
nd
er-
5m
ort
alit
y.
Nig
er
(Mag
nan
iet
al.,
19
96
)
CC
hild
ren
you
nge
r
than
5y
Geo
gra
ph
ical
pro
xim
ity
and
the
use
of
heal
th
serv
ices
Un
der-
5
mo
rtal
ity
Ch
ild
ren
invilla
ges
wit
ha
dis
pen
sary
were
32
%le
ss
likely
toh
ave
die
dd
uri
ng
the
stu
dy
peri
od
than
were
child
ren
invilla
ges
wit
hn
ose
rvic
es.
No
surv
ival
adva
nta
gein
villa
ges
wit
hth
evilla
geh
eal
th
team
pre
sen
t.
Pak
ista
n(D
’So
uza
&
Bry
ant,
19
99
)
DC
hild
ren
in6
Kar
ach
isl
um
s
Heal
thse
rvic
eu
se
(typ
eo
fp
rovid
er,
lon
git
ud
inal
ity,
abilit
yto
exp
lain
cle
arly
)
Infa
nt
mo
rtal
ity
Th
eu
seo
ftr
adit
ion
alh
eal
ers
(as
op
po
sed
totr
ain
ed
VH
Ws
or
do
cto
rs)
(OR
=1
4.5
2;9
5%
CI=
4.2
3–4
9.8
3)
and
freq
uen
tsw
itch
ing
of
heal
thcar
e
pro
vid
ers
(lac
ko
flo
ngit
ud
inal
ity)
(OR
=8
;9
5%
CI
=2
.22
–2
8.8
1)
asin
cre
asin
gth
eo
dd
so
fin
fan
td
eat
h
fro
mre
spir
ato
ryin
fecti
on
so
rd
iarr
hea.
Th
eP
hilip
pin
es
(William
son
,1
98
2)
CW
om
en
and
child
ren
inth
e
pro
ject
area
PH
Ccen
ters
(mid
wiv
es,
(dru
gst
ore
s,
ho
spit
alu
nit
s)
Infa
nt
mo
rtal
ity
Th
ep
rogra
mh
adn
oeff
ect
on
infa
nt
mo
rtal
ity.
Po
ten
tial
reas
on
sin
clu
de
po
or
qu
alit
yo
rq
uan
tity
of
heal
thse
rvic
es,
ase
lecti
veap
pro
ach
toP
HC
wit
h
em
ph
asis
on
fam
ily
pla
nn
ing
(fert
ilit
yd
idd
eclin
e),
ove
rwo
rked
and
/or
inad
eq
uat
ely
trai
ned
staf
f.
Sen
egal
(Pis
on
et
al.,
19
93
)
EIn
fan
tsin
inte
rven
tio
n
areas
Pre
sen
ce
of
inte
gra
ted
PH
C
pro
gra
min
the
area
of
stu
dy
Un
der-
5
mo
rtal
ity
Un
der-
5m
ort
alit
yd
eclin
ed
fro
m3
50
to8
1d
eat
hs/
10
00
live
bir
ths
fro
m1
97
0to
19
93
.R
ed
ucti
on
sse
en
pri
mar
ily
fro
md
iseas
es
pre
ven
ted
by
imm
un
izat
ion
.
Dia
rrh
ea
and
AR
Isar
elo
wer
than
ino
ther
rura
lar
eas
of
Sen
egal
;o
nly
4%
of
deat
hs
attr
ibu
ted
tom
alar
ia.
Sou
thA
fric
a(C
ole
man
et
al.,
19
98
)
EA
du
lts
wit
h
chro
nic
illn
ess
es
Clin
ics
usi
ng
up
dat
ed
pro
toco
lsfo
rth
e
man
agem
en
to
f
chro
nic
dis
eas
es
Co
ntr
olo
f
chro
nic
dis
eas
es
Th
eu
tiliza
tio
no
fp
roto
co
lsen
able
dlo
cal
nu
rses
to
co
ntr
olclin
ical
co
nd
itio
ns
of
68
%o
fp
atie
nts
wit
h
hyp
ert
en
sio
n,8
2%
of
tho
sew
ith
no
n–in
sulin
-dep
en
den
td
iab
ete
s,an
d8
4%
of
tho
se
wit
has
thm
a.Pat
ien
t-re
po
rted
adh
ere
nce
to
treat
men
tin
cre
ased
fro
m7
9%
to8
7%
(P=
.03
)o
ver
2y.
Decre
ased
uti
liza
tio
no
fh
osp
ital
sfo
rro
uti
ne
car
e.
(con
tin
ues
)
Primary Healthcare in Low- and Middle-Income Countries 171
Co
un
try
/regio
nP
HC
Main
(refe
ren
ce)
Ty
pe
aP
op
ula
tio
nm
easu
res
ou
tco
me
Imp
act/
resu
lt
Sou
thA
fric
a(d
en
Best
en
et
al.,
19
95
)
EC
hild
ren
you
nge
r
than
5y
Pro
vis
ion
of
GO
BI-
FFF
serv
ices
(gro
wth
mo
nit
ori
ng,O
RT,
bre
ast-
feed
ing,
imm
un
izat
ion
,
fam
ily
pla
nn
ing,
foo
d
sup
ple
men
tati
on
,
fem
ale
ed
ucat
ion
)
Un
der-
5
mo
rbid
ity
PH
Cac
tivit
ies
imp
rove
dan
thro
po
metr
ico
fch
ild
ren
you
nge
r
than
5y
betw
een
19
82
and
19
90
.T
he
pre
vale
nce
of
un
derw
eig
ht
incre
ased
fro
m2
8%
to3
1%
fro
m1
98
2to
19
84
,
and
then
declin
ed
to2
3%
and
19
%in
19
88
and
19
90
,
resp
ecti
vely
(P<
.01
).T
he
pre
vale
nce
of
stu
nti
ng
decre
ased
stead
ily
fro
m3
3%
in1
98
2to
17
%in
19
90
.T
he
low
pre
vale
nce
of
low
weig
ht
for
heig
ht
(was
tin
g)
declin
ed
fro
m
5%
in1
98
2to
1%
in1
99
0(P
<.0
1).
Th
ep
reva
len
ce
of
seve
re
mal
nu
trit
ion
incre
ased
fro
m3%
in1982
to14%
in1984
and
then
declin
ed
rap
idly
to5
%in
19
88
and
to4
%in
19
90
.
Zai
re(C
hah
naz
aria
n
et
al.,
19
93
;Tay
lor
et
al.1
99
3)
CW
om
en
and
child
ren
in
pro
gra
man
d
no
np
rogra
m
areas
Pre
sen
ce
of
the
Co
mb
atin
g
Ch
ild
ho
od
Co
mm
un
icab
le
Dis
eas
ep
roje
ct
Un
der-
5
mo
rtal
ity
Inte
rven
tio
nin
clu
ded
teta
nu
san
dch
ild
ho
od
imm
un
izat
ion
s,
OR
T,m
alar
iatr
eat
men
t.U
nd
er-
5m
ort
alit
yd
eclin
ed
by
33
%
fro
mb
aselin
ele
vels
.T
he
inte
rven
tio
nw
as“e
stim
ated
to
hav
ere
du
ced
mo
rtal
ity
atag
es
6–35
mo
by
atle
ast
18%
–23%
asso
cia
ted
wit
hth
ech
ange
inth
ein
cid
en
ce
of
meas
les
and
may
hav
eb
een
resp
on
sib
lefo
rth
efu
ll28%
red
ucti
on
reco
rded
betw
een
19
80
–1
98
4an
d1
98
5–1
98
9.”
Ken
ya,M
adag
ascar
,
Mal
awi,
Tan
zan
ia,
Zam
bia
(Bro
ckerh
off
&D
ero
se,1
99
6)
GN
eo
nat
es,
infa
nts
,
and
child
ren
you
nge
rth
an
5y
fro
m
Dem
ogra
ph
ic
and
Heal
th
Surv
eys
Use
of
pre
nat
alcar
e
and
imm
un
izat
ion
co
vera
ge
Neo
nat
al,in
fan
t,
and
un
der-
5
mo
rtal
ity
Sele
cti
veP
HC
serv
ices
hav
ean
imp
ort
ant
imp
act
on
child
surv
ival
.In
term
so
fat
trib
uta
ble
risk
,in
co
mp
lete
imm
un
izat
ion
sar
ere
spo
nsi
ble
for
34%
of
deat
hs,
lack
of
cle
anw
ater
for
16
%,in
adeq
uat
ep
ren
atal
car
ean
dd
elive
ry
for
11
%,an
dh
igh
fert
ilit
yfo
r1
2%
,w
hile
co
ntr
ollin
gfo
r
oth
er
heal
thd
ete
rmin
ants
(co
vari
ates
inclu
de
socio
eco
no
mic
and
bio
logic
stat
us
and
infr
astr
uctu
re).
Lat
inA
meri
ca
(22
co
un
trie
s)(M
oo
re
et
al.,
20
03
)
AC
hild
ren
in2
2
Lat
inA
meri
can
co
un
trie
s
Vac
cin
atio
nco
vera
ge,
use
of
OR
T,
bre
ast-
feed
ing,
ph
ysic
ian
sup
ply
Un
der-
5
mo
rtal
ity
Fiv
em
ain
vari
able
sw
ere
asso
cia
ted
wit
hre
du
ced
un
der-
5
mo
rtal
ity:
fem
ale
lite
racy,
BC
Gva
ccin
atio
nra
te,ac
cess
to
safe
wat
er,
use
of
OR
T,an
dgro
ssn
atio
nal
pro
du
ct
per
cap
ita.
Ab
bre
via
tio
ns:
ALR
I,ac
ute
low
er
resp
irat
ory
infe
cti
on
;A
RI,
acu
tere
spir
ato
ryin
fecti
on
;C
HW
,co
mm
un
ity
heal
thw
ork
er;
CI,
co
nfi
den
ce
inte
rval
;FH
P,fa
mily
heal
thp
rogra
m;
HA
S,H
osp
ital
Alb
ert
-Sch
weit
zer;
IMC
I,in
tegra
ted
man
agem
en
to
fch
ild
ho
od
illn
ess
;O
RT,
ora
lre
hyd
rati
on
thera
py;
OR
,o
dd
sra
tio
;P
HC
,p
rim
ary
heal
thcar
e;
TB
A,
trad
itio
nal
bir
that
ten
dan
t;V
HW
,villa
geh
eal
thw
ork
er.
aA
,ex
peri
men
tal
or
qu
asi-ex
peri
men
tal;
B,
pro
specti
ved
esi
gn
wit
hco
ntr
ol;
C,
rep
eat
ed
cro
ss-s
ecti
on
ald
esi
gn
wit
hco
mp
aris
on
/co
ntr
ol;
D,
cas
e-c
on
tro
lst
ud
y;E,
rep
eat
ed
cro
ss-s
ecti
on
ald
esi
gn
wit
ho
ut
co
mp
aris
on
co
ntr
ol;
F,sy
stem
atic
lite
ratu
rere
vie
w;G
,o
bse
rvat
ion
/qu
alit
ativ
e/s
ingle
cro
ss-s
ecti
on
.