• Step 1: Empanel the target population

    To achieve effective population health management, providers or care teams must be able to list and locate the patients for whom they are responsible. Thus, empanelment – the assignment of a population of patients to a provider or care team - is a logical starting point and a necessary organizational structure for population health management. 1 While empanelment can serve as an organizational foundation for effective population health management, it may not be easily implemented in all settings. In these situations, empanelment should remain an aspiration, but other population health management activities can be implemented at the same time.

    Populations may be empaneled in a variety of ways, including by geography, voluntary enrollment, or insurance scheme. Ideally, the entire population within a given area should be empaneled to provider teams. This may be difficult or impossible in dense urban areas, areas with large and transient migrant populations, and areas with large numbers of private PHC providers who do not coordinate with a government or larger organizational entity. However, empanelment in mixed public/private PHC systems is possible. 2 While a country works towards achieving complete empanelment, stakeholders may choose to start by empaneling certain subgroups of a population with specific health needs.

    Step 2: Use panel data to inform local priority setting

    After a population is empaneled, providers can shift their focus towards proactive care and health management. Data and registers from the empaneled population can help providers to track the health information of individual patients, plan public health services such as immunization campaigns, and explore indicators of access, utilization, and health outcomes that in turn inform local priority setting. 3 The identified priorities will define the mix of services and medical expertise necessary to manage the patient panel.

    Step 3: Based on identified priorities, design systems for outreach in communities and homes

    After identifying priority services, decision-makers and implementers can work with communities to determine which services would be most effectively delivered in communities and homes. Often, preventive care or education-based interventions are best suited to community-based care. Ideally, all people would receive proactive care in their communities, but often it may be more feasible to start with specific groups that require special care or attention, such as pregnant women, people with chronic diseases, or children. When planning proactive population outreach, implementers must consider which cadre of provider would most effectively deliver these services based on cost effectiveness, availability, and training. Community members should be consulted throughout the planning process to ensure acceptability of services.

View case studies for:

Population Health Management Ghana

The Community Health Planning and Strategy (CHPS) program began as a pilot in 1994 and has since been scaled across Ghana, increasing access to community-based primary health care services.

Population Health Management Costa Rica

Costa Rica’s primary health care system is supported by robust care teams that provider community-based care to an empaneled population. As a result, health outcomes in Costa Rica are consistently strong and improving.

Population Health Management Brazil

The Family Health Program was established in Brazil in the 1990s. Under this program, Family Health Teams are responsible for a geographically empaneled group of households.

Relevant resources

Many tools and resources focused on population health management strategies have been created over the last decade. Below is an interactive resource that provides the most useful documents within the context of our defined scope of community engagement, local priority setting, proactive population outreach, and empanelment.
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  • Local priority setting
  • Social determinants of health
  • Responsiveness to people
  • Community engagement
  • Empanelment
  • Proactive population outreach
  • Childhood illness
  • Monitoring and evaluation
  • Resilience of health systems
  • Refugee and migrant health
  • COVID-19
  • NCDs and mental health
  • UHC
  • Infectious disease

A Conceptual Framework for Action on the Social Determinants of Health WHO, 2010

This paper summarizes different conceptual frameworks for understanding the social determinants of health and synthesizes these into a single conceptual framework that aims to highlight the difference between levels of causation, distinguishing between the mechanisms in which social hierarchies are created, and the conditions of daily life which then result. It concludes with policy directions for action and analysis of these policy approaches.
Tags: Local priority setting, Social determinants of health

Commission on Social Determinants of Health - chapter 9 universal PHC WHO, 2019

The Final Report of the Commission on Social Determinants of Health sets out key areas – of daily living conditions and of the underlying structural drivers that influence them – in which action is needed. It provides analysis of social determinants of health and concrete examples of types of action that have proven effective in improving health and health equity in countries at all levels of socioeconomic development."
Tags: Social determinants of health, Responsiveness to people, Community engagement, Empanelment, Local priority setting, Proactive population outreach

Community Case Management Toolkit: Tools for Planning and Design World Vision, 2014

This toolkit is a how-to-guide for community case management policy and strategy, assessment, program design and planning. It is intended to aid health managers at the national and regional levels in designing and implementing community case management and integrated community case management of childhood illnesses. It includes tools for planning and design, toolks for monitoring and evaluation, and operational tools.
Tags: Proactive population outreach, Childhood illness, Monitoring and evaluation

Community engagement for quality, integrated, people-centred and resilient health services WHO, 2017

This webpage gives background and context to the ideas and concepts of community engagement and empowerment rooted in the WHO framework on integrated people-centered health services. It unpacks various community engagement processes and approaches, with links to relevant resources.
Tags: RMNCH, Responsiveness to people, Community engagement

Community engagement framework for quality, people-centred and resilient health services WHO, 2017

Technical experts from the WHO organized a workshop with the aim to develop a comprehensive framework and conceptual model for community engagement. "This workshop report details the process undertaken, the issues discussed and captures the key outputs.It is an essential go-to document that begins to articulate a broader, inclusive approach to enhance the health security of populations while aiding the recovery and resilience of communities and health systems." - grouped with resource below
Tags: Resilience of health systems, Community engagement, Responsiveness to people

Empanelment: A Foundational Component of Primary Health Care JLN, 2016

This document provides guidance for defining empanelment and understanding how to implement empanelement systems in low- and middle-income countries. It is intended for health policy makers, planners and decision makers in ministries of health, and those working at the frontlines of service delivery.
Tags: Empanelment

Empanelment: Establishing Patient-Provider Relationships. Implementation Guide Safety Net Medical Home Initiative, 2013

"This Implementation Guide explains the purpose and process of empanelment and provides step-by-step directions for successful implementation."
Tags: Empanelment

Innovations to Champion Access to Primary Care for Immigrants and Refugees Wellesley Institute, 2017

This guide sets out state of the art recommendations on how best to measure the social determinants of health and the most effective ways of constructing an evidence base which provides the basis for translating evidence into political action. It is designed for practitioners interested in developing and implementing policies and programmes to tackle the social determinants of health inequities.
Tags: Proactive population outreach, Refugee and migrant health, Responsiveness to people

Knowledge Action Portal WHO 2019

“The Knowledge Action Portal (KAP) is a flagship online community-driven platform launched by the WHO Global Coordination Mechanism on the Prevention and Control of Noncommunicable Diseases (WHO GCM/NCD). The KAP presents users with an innovative way to enhance global understanding, interaction, and engagement across sectors for the purpose of fulfilling existing - and initiating new - commitments to noncommunicable disease (NCD) prevention and control."
Tags: Community engagement, COVID-19, NCDs and mental health

Pathways to Population Health Institute for Healthcare Improvement, 2020

This initiative from the Institute for Healthcare Improvement outlines four portfolios of work that health care organizations can undertake to accelerate progress in improving population health: physical and/or mental health; social and/or spiritual well-being; community health and well-being; and communities of solutions. It includes a suite of tools, resources, and case studies that serve to support the practical and actionable implementation of this work.
Tags: Community engagement, Empanelment, Local priority setting, Proactive population outreach, NCDs and mental health, Responsiveness to people

PHC and Health Emergencies WHO, 2019

This document was producted as a part of the WHO's technical series on PHC. It offers actionable information on strengthening the role of PHC in health emergencies, supplemented by country examples of effective emergency response and opportunities for action. The sections related to people centered-care and community engagement are especially relevant to Population Health Management.
Tags: Community engagement, Empanelment, Local priority setting, Proactive population outreach, COVID-19, Resilience of health systems, Responsiveness to people

Practitioner Expertise to Optimize Community Health Systems CHW Central, 2017

This document outlines various service delivery challenges to the development and implementation of high-performing community health worker programs and the ways in which environments have shaped implementers responses to these challenges. It provides key insights into design principles for high-performing CHW programs, accompanied by targeted recommendations and next steps.
Tags: Proactive population outreach

Priority setting in primary health care: a framework for local catchments Rural Remote Health, 2011

This article presents a conceptual framework for local prioriity setting, underpinned by 13 interconnected factors spanning economic, political, policy, empidemiological, moral, evidentiary, and evaluative domains. The framework extends current knowledge about the considerations and trade-offs involved in setting priorities and provides a heuristic tool for healthcare decision-makers in rural areas.
Tags: Local priority setting, UHC

Priority-setting for achieving universal health coverage WHO Bulletin, 2015

This article elaborates various criteria and approaches to priority setting for universal health coverage. It briefly covers the practical steps for priority setting that decision makers can apply to advance priority setting for UHC in their context as well as practical challenges and limitations to consider as a part of the priority setting process.
Tags: Local priority setting, UHC

Promoting the health of refugees and migrants: draft global action plan, 2019–2023 WHO, 2019

The draft framework presents a series of priorities and guiding principles to promote the health of refugees and migrants. The framework is intended to be a resource for Member States in meeting the complex health needs of refugees and migrants.
Tags: Proactive population outreach, Local priority setting, Refugee and migrant health, Responsiveness to people

Universal Health Coverage Monitoring & Planning Tool Partners in Health, 2018

This tool was designed to assist countries with the planning and implementation of health interventions identified during the priority setting process. It is intended to achieve two major objectives: 1) assessing disease burden and UHC needs at the facility and catchment area level (and other subnational levels) and 2) comparing these projections to current service delivery needs to determine estimates of the health system inputs needed.
Tags: Local priority setting, UHC

Using Geographic Information Systems to Understand a Community's Primary Care Needs Dulin et al., 2010

This article presents a model for applying of geographic information systems to community- and patient-level data to rapidly identiy areas most in need of increased access to primary care services. "This model can be used to plan health services delivery as well as to target and evaluate interventions designed to improve health care access."
Tags: Proactive population outreach, Local priority setting

WHO Region of the Americas: Health of refugees and migrants. Regional situation analysis, practices, experiences, lessons learned and ways forward WHO and PAHO, 2013

"This report discusses current migration trends in the Region, key regional policy frameworks and legal instruments, and health challenges faced by migrants and their host communities, emphasizing the special challenges faced by refugees, irregular and regular migrants who, because of their situation, are in conditions of high vulnerability, while examining health determinants, conditions of migration, and health issues associated with migration." It is itended to contribute to the development of a draft global action plan and provide Member States and partners in the Region with informationt on past and ongoing public health interventions and practices to address refugee and migrant health, as well as a a path forward.
Tags: Proactive population outreach, Local priority setting, Refugee and migrant health, Responsiveness to people

Exemplars in Global Health - Community Health Workers Exemplars in Global Health, 2020

Exemplars in Global Health aims to help public health decision-makers around the world identify and analyze countries that have made extraordinary progress in important health outcomes and disseminate the key takeaways. The lessons and topics contained in this growing list of Exemplar narratives will be a resource to leaders committed to improving health and achieving success in their countries, including via Community Health Workers. Users can learn more about Community Health Workers and Community Health Worker exemplars on the Exemplars in Global Health webpage.
Tags: Responsiveness to people, Community engagement, Proactive population outreach

Exemplars in Global Health - Vaccine Delivery Exemplars in Global Health, 2020

Exemplars in Global Health aims to help public health decision-makers around the world identify and analyze countries that have made extraordinary progress in important health outcomes and disseminate the key takeaways. The lessons and topics contained in this growing list of Exemplar narratives will be a resource to leaders committed to improving health and achieving success in their countries, including via Vaccine Delivery. Users can learn more about Vaccine Delivery on the Exemplars in Global Health webpage.
Tags: Infectious disease, Responsiveness to people, Proactive population outreach

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. WHO. WHO Community engagement framework for quality, people-centred and resilient health services. World Health Organization; 2017. 
  2. Black RE, Taylor CE, Arole S, Bang A, Bhutta ZA, Chowdhury AMR, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel. J Glob Health. 2017 Jun;7(1):010908. 
  3. Sarrami-Foroushani P, Travaglia J, Debono D, Braithwaite J. Implementing strategies in consumer and community engagement in health care: results of a large-scale, scoping meta-review. BMC Health Serv Res. 2014 Sep 18;14:402.