• The following principles should be prioritized, either at the same time or one after another, to improve the design of health systems that support and sustain good governance and leadership in primary health care.

    Step 1: Strengthen primary health care policies and leadership

    National stakeholders must work together to define the scope and mechanisms of quality PHC policies in their context, and then to develop and implement those policies. It is important to have both high-quality policies on PHC but also high-quality policies on quality itself. This reflects the central role of PHC in health care service delivery. Foundational to the development of a national quality policy and strategy is consensus on how PHC policies and priorities are defined and how quality is measured in the local context.5 Stakeholders, including those in state and non-state and health and non-health sectors, need a shared vision to develop and enact policies promoting equitable access to high-quality primary health care.

    This must be in place to ensure the success of the quality management infrastructure, which relies on the framework of PHC policies and the engagement of stakeholders at every level to be established successfully.

    Step 2: Strengthen quality management infrastructure

    In order to ensure access to quality, person-centered health systems, national health policies, strategies, and plans must be accompanied by a strong, transparent quality management infrastructure that integrates standardized care plans, diagnostic protocols, training programs, and accreditation systems.6 This step follows and coincides with the institutionalization of PHC policies and leadership.

    Step 3: Ensure social accountability mechanisms are integrated throughout the system

    While designing PHC policies and accompanying quality management infrastructure, stakeholders should regularly assess and build mechanisms for social accountability. Specific social accountability strategies will differ based on context, but at the most basic level, they should include opportunities for community members to identify and seek solutions to problems observed in their local health systems. Processes for both surfacing and responding to these concerns should be designed from the outset and integrated as much as possible into PHC policies from the local to the national level.

Relevant resources

Many tools and resources focused on developing health system governance and leadership structures have been created over the last decade, particularly from the World Health Organization and through projects funded by the US Agency for International Development (USAID). Below is an interactive resource that provides the most useful documents within the context of our defined scope of PHC policies and leadership, quality management infrastructure, and social accountability.
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Social Accountability: An Introduction to the Concept and Emerging Practice Malena, et al., World Bank, 2004

This Social Development working paper highlights different social accountability initiatives that were led or supported by the World Bank in the first several years of their focus on this type of work.  In addition to providing a detailed account of different tools that can be used by citizens and civil society to monitor and assess policies and budgets, expenditures, and service provider performance, the working paper identified several factors that the authors assess as key factors needed for social accountability to be successful. 
Tags: Social accountability

The Community Scorecard (CSC) Toolkit CARE, 2013

This practitioner guide provides a detailed overview of how civil society organizations and their partners can design and implement one of the most heavily-utilized social accountability tools – the community scorecard (CSC).  Based on CARE’s extensive use of the CSC in different contexts and sectors, the technical guidance is broken down into five key phases (planning and preparation, conducting the scorecard with the community, conducting the scorecard with the providers, interface meeting and action planning, and action implementation and monitoring).  The guide also provides samples of different components of the CSC tools that practitioners can readily adapt to their own contexts.
Tags: Social accountability

Our Money, Our Responsibility: A Citizens’ Guide to Monitoring Government Expenditures Ramkumar, International Budget Partnership, 2008

This seminal report highlights how civil society-led accountability efforts can improve the effectiveness, equity, and impact of budget execution, procurement, impact measurement, and audit and legislative oversight.  The paper is designed to provide information to civil society organizations about the process associated with each of these governance activities as well as numerous case studies that present successful efforts by practitioners to oversee and improve accountability for these processes in their countries.
Tags: Social accountability

Doing Accountability Differently: A Proposal for the Vertical Integration of Civil Society Monitoring and Advocacy Fox, et al., Accountability Research Center and U4, 2016

Focusing on strategic social accountability rather than traditional tool-based approaches, this paper is divided into two distinct by complementary parts.  The first part provides a conceptual framework for key elements to achieving vertical integration in social accountability, highlighting the need for accountability efforts to integrate participation and oversight at all levels of policy processes and implementation (local, subnational, national, and global).  The second part provides a detailed case study of one such effort to employ vertical integration into an education-focused social accountability program in the Philippines.
Tags: Social accountability

Social Accountability Resources and Tools Wilcox and Shanklin, USAID Maternal and Child Survival Program, 2017

This helpful annotated bibliography provides an extensive list of resources for different social accountability tools developed for or used in the health sector.  The resources range from conceptual and theoretical frameworks for social accountability to address different problems in health to practical guidance for specific tools.  Each resource is accompanied with a brief description to help the reader best identify what resources or tools may be most applicable to their needs.
Tags: Social accountability

Institutional Roles and Relationships Governing the Quality of Health Care: Country Experiences, Challenges, and Lessons Learned USAID Health Finance & Governance program, 2016

This report documents experiences, challenges, tested solutions, and practical ideas for countries as they strengthen governance, improve quality health services, and pursue UHC. It elaborates on critical components of governance for quality health care, specifically looking at: policy strategies, regulation, non-state actors, political will, reliable data, continuous improvement, knowledge sharing, and financing links. The report provides examples of experiences, challenges, and lessons learned in establishing an institutional architecture for governing for quality service delivery.
Tags: PHC policies, Quality management infrastructure, Governing for quality

Defining Institutional Arrangements When Linking Financing to Quality in Health Care: A Practical Guide USAID Health Finance & Governance Program, 2018

The guide is for planners and policymakers. It explores how payers can use health financing levers to drive health sector performance. It contains strategies for payers to leverage power to enhance the quality of care, describes possible institutional arrangements among payers and other actors, and proposes processes to establish or improve institutional arrangements in a country.
Tags: PHC policies, Quality management infrastructure, Financing quality

Governing for Quality Improvement in the Context of UHC USAID Health Finance & Governance Program, 2016

These country case studies explore how Ethiopia, Mexico, Uganda, Ghana, the Philippines, Malaysia, and Tanzania have progressed toward prioritizing and governing to improve quality health service delivery. There are key lessons on quality reforms – including successes and challenges in promoting quality of care – and descriptions of key inputs and processes to governing quality of care including regulation, law and policies, leadership and management, and planning.
Tags: PHC policies, Quality management infrastructure, Policy strategy

Strategizing national health in the 21st century: a handbook World Health Organization, 2016

This handbook provides approaches for developing national health policies, strategies, and plans. It explores key elements of national health planning, drawing on country experience, existing work, and literature reviews. It can be looked at as a whole or as independent chapters, which include priority setting, strategic and operational planning, budgeting, monitoring and evaluation, and cross-cutting themes such as law and regulation and intersectoral planning.
Tags: PHC policies, Quality management infrastructure, Policy strategy

AA40 Technical series on Primary Health Care – Primary health care: transforming vision into action: Operational Framework World Health Organization, 2018

This framework discusses the policy and operational levers that represent key elements of health systems and that can be used to accelerate progress on primary health care. It provides resources for countries to use, actions that can be taken, and indicators to track progress. The goal of the framework is to assist countries in efforts towards improving PHC through governance at the national and subnational level, by individuals, and global partners.
Tags: PHC policies, Quality management infrastructure, Governing for quality

Global learning laboratory for quality World Health Organization, 2019

The WHO Global Learning Laboratory (GLL) for Quality UHC provides a platform for users to engage one another through webinars, learning pods, and other approaches to discuss critical areas in quality, including through national quality policies and strategies. The GLL includes a national quality policy and strategy area for “consideration of focused policies and strategies to facilitate quality integration across all levels of the health system.”
Tags: PHC policies, Quality management infrastructure, Policy strategy

PRIMASYS case studies World Health Organization, 2017

Covering key aspects of PHC systems, the PRIMASYS case studies explore policy development and implementation, financing, integration of PHC into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance. The knowledge generated through these case studies can be translated into the development and implementation of national PHC policies, programs, and health systems reforms.
Tags: PHC policies, Quality management infrastructure, Roles and responsibilities

Handbook for national quality policy and strategy: A practical approach for developing policy and strategy to improve quality of care World Health Organization, 2018

This handbook describes eight essential elements to be considered by teams developing national quality policy and strategy, including national health goals and priorities; local definition of quality; stakeholder mapping and engagement; situational analysis; governance and organizational structure, among others. The handbook explores arguments for developing national policy and strategy on quality of health care, the process required to do so, and tools to support the process.
Tags: PHC policies, Quality management infrastructure, Policy strategy

Health in all policies: Framework for country action World Health Organization, 2014

HiAP is a systematic approach to taking health implications into account for decisions across sectors, in an effort to improve population health and health equity. This framework is the founding statement and “starter’s kit” on health in all policies (HiAP), including guidance on six key components to its implementation and suggestions on the roles and responsibilities of government structures and health authorities. The framework provides examples of HiAP in practice in different country contexts as well as implementation recommendations.
Tags: PHC policies, Quality management infrastructure, Policy strategy

WHO National Health Planning Tool World Health Organization, 2010

This online repository of WHO tools is designed to assist national and sub-national health authorities in elaborating health policies, strategies, and plans. It contains diagnostic tools for assessment, monitoring, and evaluation, as well as tools to support priority setting, identify effective strategies, costing scenarios, resource planning and budgeting, and programming and implementation. This is useful for a deeper look at tools developed by WHO and other sources for national health planning efforts.
Tags: PHC policies, Quality management infrastructure, Governing for quality

AA40 Technical series on Primary Health Care – Quality in primary healthcare World Health Organization, 2018

This report makes the case for quality improvement as a core function of PHC, providing perspectives of different levels of the health system on improving PHC quality, and citing a number of principles and interventions that can form part of efforts to achieve such change. This paper includes some interventions for improving quality, and encourages a learning agenda that focuses on questions around what is working, how it is working, and how it can be scaled up.
Tags: PHC policies, Governing for quality

Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies World Health Organization, 2010

This handbook focuses on the six core components, or building blocks, of health systems identified by the WHO: service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance. The leadership and governance section includes a policy index and introduces the components and related indicators. It describes possible sources of information and available measurement strategies, and proposes core and supplemental indicators that may be used depending on the country health system attributes and needs.
Tags: PHC policies, Roles and responsibilities

Bangladesh Health Population and Nutrition Sector Development Program Strategic Investment Plan 2016-2021 Ministry of Health and Family Welfare, Bangladesh, 2016

This document is a detailed guide to Bangladesh’s health sector strategic development plan, but is applicable on a broader scale as an example of a national country strategy. It details strategies and plans that emphasize quality, effective service provision, and equity. It is a useful reference for PHC policy reform efforts, recognizing many of the key steps and pathways described for establishing strong PHC policies.
Tags: PHC policies, Policy strategy

Plan for People’s Health Protection, Care and Promotion 2016-2020 Ministry of Health, Vietnam, 2016

This document is an example of a national country plan. It includes an assessment of the performance of each building block of the health system, describes the major tasks and solutions moving forward, in addition to financing needs, monitoring and evaluation plan, and the country’s approach for organization implementation of the major tasks. Primary health care is fundamental to this plan; it is a useful reference for a successful plan for strengthening PHC policies.
Tags: PHC policies, Policy strategy

Health Sector Transformation Plan for 2015/16 through 2019/20 The Federal Democratic Republic of Ethiopia Ministry of Health, 2015

This is an example of a comprehensive national plan focusing on quality management through a national policy and strategy. It includes a situational assessment reviewing community ownership, health status, and equity. It describes a policy framework accompanied by a strategic assessment, and strategic objectives, and performance measures. This is an ambitious and detailed strategic transformation plan that could be of use for other country stakeholders looking for examples, or benchmarking opportunities for planning.
Tags: Quality management infrastructure, National quality strategy

Quality Assurance Strategic Plan for Ghana Health Service 2007-2011 Ghana Health Service, 2007

While this document was developed with a focus on improving quality assurance in Ghana, it is a useful reference as a detailed guide to developing quality management programs. With guidance to the steps for and reasoning behind developing organizational infrastructure and leadership, performance measurement, and involving the community in meaningful ways, it can be used as a toolkit for quality management efforts.
Tags: Quality management infrastructure, National quality strategy

Quality and accreditation in health care services: a global review World Health Organization, 2003

This review describes structures and activities promoting quality in health care used at national and international levels, catalogues examples of quality concepts and tools in use in health care, and analyzes the operation of national health service accreditation programs. It consolidates recommendations from WHO and International Society for Quality in Health Care quality assurance consultations between 1988 and 2000, and includes key questions for consideration for national quality strategy in low- and middle-income countries focusing on policy, organization, methods, and resources.
Tags: Quality management infrastructure, Governing for quality

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.


  1. Everybody’s business: strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva: World Health Organization; 2007. https://www.who.int/healthsystems/strategy/everybodys_business.pdf
  2. Tarantino L, Laird K, Ottosson A, Frescas R, Mate K, et al. 2016. Institutional Roles and Relationships Governing the Quality of Health Care: Country Experiences, Challenges, and Lessons Learned. Bethesda, MD: Health Finance & Governance Project, Abt Associates and USAID Applying Science to Strengthen and Improve Systems Project, URC. https://pdfs.semanticscholar.org/9380/35679705e03f91b2397e07cec89622719378.pdf
  3. Brinkerhoff DW and Bossert TJ. Health Systems 20/20 Policy Brief: Health Governance: Concepts, Experience, and Programming Options. United States Agency for International Development, February 2008. https://www.hfgproject.org/health-governance-concepts-experience-programming-options/
  4. Quality and accreditation in health care services: a global review. World Health Organization; 2013. https://www.who.int/hrh/documents/en/quality_accreditation.pdf
  5. Cico A, Koon A, Haile M, Laird K. 2018. Exploring the Institutional Arrangements for Linking Health Financing to the Quality of Care: Lessons from Indonesia, the Philippines, and Thailand. Rockville, MD: Health Finance & Governance Project, Abt Associates Inc. https://www.hfgproject.org/exploring-the-institutional-arrangements-for-linking-health-financing-to-the-quality-of-care-lessons-from-indonesia-the-philippines-and-thailand/
  6. Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care. Geneva: World Health Organization; 2018. https://www.who.int/servicedeliverysafety/areas/qhc/nqps_handbook/en/