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Quality health services emerge from multiple, interdependent variables within a complex health care system. 

Service quality, or the extent to which health services are high-quality at the point of care-- is the product of the broader health systems environment and of the individuals and providers working within the system. 

To ensure service quality, the following ‘foundations of care’ should be in place: governance and accountability structures, the health workforce, essential medicines and supplies, and health management information systems.

The quality of health services at the Primary carePrimary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.”level is defined as the “degree to which health services for individuals and populations increase the likelihood of desired health OutcomesOutcomes are the effects of the provision and experience of care on processes of care and on patients’ health..” 1

There are two forms of quality: technical quality and experiential quality. Technical quality is the degree to which services meet A standard of careA standard of care is a guideline that explicitly defines what is required to achieve high-quality care for a given service, including how providers should act and the reasonable degree of care a patient should expect to receive based on their specific health needs. and clinical guidelines (A clinical practice guidelineA clinical practice guideline is meant to be a more flexible set of evidence-based recommendations than a standard of care. Providers can consult practice guidelines to help them make decisions about how to manage care for specific clinical conditions, including what screening, diagnostic, or therapeutic actions to use.). Experiential quality measures the process in which

services are delivered and the human interactions that occur during this process, typically using measures such as patient satisfaction and experience measures. 2 3 4

To be considered ‘high-quality’, services should be effective, safe, timely, and efficient. They should also be people-centred, integrated, and equitable. 5 6 7 8 In practice, health services ought to meet the needs of individuals and populations, increase the likelihood of desired health outcomes, and be consistent with evidence-based professional knowledge. 9

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

The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era revealed that quality of care globally is poor, and furthermore, that there is a paucity of data on quality. Thus, every country should make it a priority to better measure and improve the quality of care in their context.(14,15)

Before taking action, countries should first determine where to target measurement and improvement efforts. Read on to learn how to use country data to:

  • Make informed decisions about where to spend time and resources 
  • Track progress and communicate these updates to constituents or funders 
  • Gain new insights into long-standing trends or surprising gaps

Countries can measure their performance using the Vital Signs Profile (VSP). The VSP is a first-of-its-kind tool that helps stakeholders quickly diagnose the main strengths and weaknesses of primary health care in their country in a rigorous, standardized way. The second-generation Vital Signs Profile measures the essential elements of PHC across three main pillars: Capacity, Performance, and Impact. Organization of services is measured in the Quality domain of the VSP (Performance Pillar).

If a country does not have a VSP, they can begin to focus improvement efforts using the subsections below, which address:

Key indications

If your country does not have a VSP, the indications below may help you to start to identify what dimensions of service quality are relevant areas for improvement:

Indications that 'effectiveness' may be a relevant area for improvement include: 10 13

  • High error rates and/or poor adherence to clinical guidelines:  If providers do not have access to evidence-based standards and guidelines or adherence to guidelines is poor, it may result in complications such as diagnostic errors and inadequate treatment and, ultimately, contribute to poor health outcomes.
  • Low patient satisfaction:  If services are not effective, they will likely result in a negative patient experience or high rates of patient dissatisfaction. 
  • Overuse of speciality or hospital services:  Further, if patients are dissatisfied with their primary care experience, they may choose to bypass local facilities or seek unnecessary speciality or emergency services for conditions that can be managed at the primary care level—commonly referred to as ambulatory care sensitive conditions. 

Indications that 'safety' may be a relevant area for improvement include: 10 13 16 17 

  • High error rates or poor adherence to safety protocols:  If standard safety procedures and guidelines are not accessible to providers and care teams, high medication, diagnostic, procedural, and/or diagnostic error rates may result. 
  • A lack of or poor systems for quality improvement:  If facilities do not have systems in place to report errors or improve existing care processes, safety issues in the workplace may be exacerbated.  
  • A lack of or poor management of patient data:  If patient data is poorly managed, coordinated, or communicated across their care journey, resulting in hazards that may cause severe harm to patients. For example, data privacy laws preventing care providers from accessing essential patient information may result in errors or delays in treatment, duplication of diagnostics and treatments, or conflicting treatments.

Indications that 'timeliness' may be a relevant area for improvement include: 10 13 18 19

  • Long wait times:  Long wait times or short appointment durations, as well as delays from symptom onset to diagnosis to treatment, mean care, is not timely. Long wait times can be due to a variety of reasons, including poor provider availability and inefficient facility operations.
  • Provider absenteeism, shortages, or burnout:  Poor provider availability can be due to many factors, such as an imbalance in their workload, a lack of motivation, or supply-side shortages. Regardless of the reason, when providers are unavailable, care will not be timely.
  • A lack of or poorly functioning appointment systems:  Facilities using inefficient appointment systems or lacking appointment systems altogether impede the timely provision of care.
  • Inconvenient operational hours:  Facilities typically operate at hours inconvenient to patients who work or have regular obligations likely delaying access. 

Indications that 'efficiency' may be a relevant area for improvement include: 10 13 20 21 22

  • Reduced productivity, revenue, and access:  Inefficiencies in care, such as extended patient wait times, can hurt productivity and increase wait times for other patients. Patients choosing to seek care elsewhere can, in turn, reduce revenue for providers and facilities. Even if patients choose to return to the facility, inefficient patient flows limit the overall number of patients that can be seen each day, negatively impacting access to care and clinic productivity. 
  • Low patient, provider, and staff satisfaction:  Long wait or patient cycle times are wasteful for everyone involved in a patient’s care. Studies have shown that long cycle times can negatively impact patient, provider, and staff satisfaction and patient experience. 
  • Overuse of speciality and/or hospital services:  Overuse of unnecessary health care services may also indicate that primary care services are inappropriate or inefficient. For example, poorly-managed patient flows may lead patients to seek care elsewhere. 
Key outcomes and impact

Countries that work to make primary care more effective, safe, timely, and efficient in their health system may achieve the following benefits:

  • Improved patient experience and health status:  Adherence to evidence-based standards improves the accuracy and timeliness of care, ultimately supporting better clinical outcomes and patient experience of care. 8 10 12 
  • More efficient, cost-effective care:  Adherence to established standards also promotes the efficient use of resources and time. In addition, timely access to high-quality services allows patients to use the PHC system as the first point of contact with the health system, helping to reduce the utilisation of emergency- or hospital-based services that may result in higher costs for the patient and health system. 8 10 11
  • Trust in PHC as the first point of contact:  Over time, delivering reliable, useful services for a population can help to build patient trust in the health system and enhance the perceived value of PHC. 10 11
  • Health equity:  Timely access to services is critical to achieving health equity for all populations; however, increased access to services will not translate to better health outcomes if these services are not high-quality. Marginalised populations, such as low-income and/or rural communities, are especially at risk of receiving poor-quality services. 10 13
  • Financial protection:  Facility hours and operations that align with patient needs and preferences help to mitigate additional costs for patients, such as those due to missed work hours or the need to find alternative childcare. 8 10 12 
  • Resilience:  “Quality and resilience are closely linked concepts. For health systems to be resilient, they require quality health services that are delivered prior to, maintained during, and improved upon following a public health emergency. Quality health services are pivotal during emergencies and serve as the interface between communities and the health system.”9
     

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

Health systems and communities around the world lose trillions of dollars each year to the broader economic and social costs of poor quality care. Thus, improving the quality of care is a social and economic necessity. 23

  • Explore this page for a curated list of actions that countries can take to improve service quality, which embark on: 
  • Explaining why the action is important for service quality
  • Describing activities/ interventions countries can implement to improve the quality of services
  • Describing the key drivers in the health system that should be improved to maximise the success/impact of actions
  • Curating relevant case studies, tools, &/or resources that showcase what other countries around the world are doing to improve as well as select tools and resources.

Key actions:

  • Improving the quality of care involves three interlinked concepts: quality planning, quality control, and quality improvement: 15 24 25

    • Quality planning includes aims, processes, and goals needed to create an environment for continuous improvement.

    • Quality control entails monitoring established processes to ensure their functionality.

    • Quality improvement is every person working to implement iterative, measurable changes to make health services more effective, safe, and people-centred.

    This action provides guidance on the steps countries can take to make health services more effective, safe, and people-centred via careful planning and iterative, measurable changes. 8 25 26 It contains the following sub-actions:

    Sub-action 1. Create an enabling health systems environment 

    An enabling health system environment includes the supportive conditions (i.e. payment systems, funding flows), governance processes, legislative environment, and culture that creates quality in a health system. Establishing an enabling environment creates concrete accountability and liability for the delivery of quality health services at the national, district, and facility levels and develops a shared understanding of quality across the health system. 10 15 16

    Key activities  

    National and sub-national levels
    • Establish a national commitment to quality. 15 25 26
      • See page 13 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Develop a national strategic direction on quality and SafetySafety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended. , and update the national quality policy, strategy, or plan at least every five years. 15 25 26
      • See pages 14-17 of the WHO’s planning guide for quality health services for step-by-step guidance. Also, see Annex 2 of the guide for a list of questions to consider when planning for quality in a health system. 
    • Select and prioritise a set of quality interventions, including 15 25 26 27
      • Interventions to create an enabling systems environment (i.e. registration and licensing, external evaluation and accreditation, clinical governance, public reporting and benchmarking, training and supervision of the health workforce)
      • Interventions to reduce harm (i.e. safety protocols and checklists, quality improvement protocols and checklists, systems for adverse event reporting)
      • Interventions to improve the clinical effectiveness of care (i.e. standardised clinical forms and decision support tools, context-appropriate clinical standards, pathways and protocols, clinical audits and mortality reviews) 
      • Interventions to engage patients, families, and communities (i.e. Shared decision-makingShared decision-making “is an interactive process in which patients, their families and carers, in collaboration with their health provider(s), choose the next action(s) in their care path following an informed analysis of possible options, their values, and preferences.” tools, services for health literacy and self-care, formalised community engagement mechanisms)
    • Develop a pragmatic quality measurement framework. 26
      • See page 17 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Develop an operational plan and resourcing strategy to ensure the national direction on quality is translated into action. Some of the critical resource considerations include: 15 25 26
      • Time:  Clinicians who spend time in training; records departments; and discussing standards, measurements, and action plans can not spend that time in clinics.
      • Data, information, and guidance:  Clinical and management staff need access to standards, practical guidance on tested quality improvement methods, and examples of results, which must be gathered and developed for local use.
      • Funding: The cost of staff time and how to best use it are critical resource questions at all times. Direct costs of quality improvement programs include quality support staff, training, data collection, and access to information.
      • See pages 17-18 of the WHO’s planning guide for quality health services for step-by-step guidance.
    • Establish a quality directorate, department, or unit to move forward with the development and operationalization of the national direction on quality. 25
      • This directorate should intentionally work across different health sector institutions and stakeholders outside the government (such as health professional associations) to achieve buy-in as well as to gain additional resources for developing and implementing regulations. 28
      • The directorate should also coordinate quality systems with national or local government to ensure valid standards, reliable assessments, consumer involvement, demonstrable improvement, transparency, and public access to quality criteria, procedures, and results. 24
    • Establish well-designed health information and monitoring and evaluation (M&E) systems that routinely collect and publish data on quality health systems at the national, subnational, and local levels. Also, utilise external assessment, such as peer review and accreditation. 15 25 26
    • Cultivate a culture of learning on quality across the health system, and embrace a continuous process of improvement. 15 25 26
      • Implementers’ and governments’ TimelinessTimeliness refers to the ability of the health system to provide PHC services to patients when they need them with acceptable and reasonable wait times and at days and times that are convenient to them. do not always line up—the process of institutionalising quality management infrastructure can take as many as 5-8 years, though individuals might change more quickly. “In using external technical assistance to set up quality systems, attention should be given to ensuring that transferred know-how becomes fully institutionalised.” 24
      • See pages 14-15 of the WHO’s handbook for national quality policy and strategy for additional guidance.
    District level
    • Commit to delivering on national quality goals and priorities26
      • See page 24 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Develop district-level quality structures and operational plans, and update them based on learnings from health facilities and the new or emerging national strategic direction on quality (if relevant). 26
      • See pages 25-26 of the WHO’s planning guide for quality health services for step-by-step guidance.
    • Orient health facilities to district- and national-level quality goals and priorities. 26
      • See pages 25-26 of the WHO’s planning guide for quality health services for step-by-step guidance.
    • Fulfil facility needs for reaching selected aims, and ensure functioning support systems for quality health services. 26
      • See page 29 of the WHO’s planning guide for quality health services for step-by-step guidance.
    • Maintain engagement with the national government on quality health services. 26
      • See pages 26-29 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Foster a positive environment for quality health service delivery, and adapt quality interventions to district-level contexts. 26
      • See pages 30-32 of the WHO’s planning guide for quality health services for step-by-step guidance.
    Facility level
    • Commit to district aims, and identify clear facility improvement aims. 26
      • See pages 40-41 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Establish, organise, and support multidisciplinary quality improvement teams, and prepare for action. 26
      • See pages 41 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Conduct a situational analysis or baseline assessment to understand the current ‘state of quality’ in the facility and to identify gaps.  A key step in improving service quality is evaluating how the facility currently delivers services or processes as well as how much value these services provide to patients. There are a variety of tools and techniques that can be used to evaluate the quality of care at the facility level:
    • Adopt standards of care. 26
      • See pages 42 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Identify and prepare for quality improvement activities by developing an action plan. 26
      • See pages 43 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Undertake continuous measurement of OutcomesOutcomes are the effects of the provision and experience of care on processes of care and on patients’ health.26
      • See pages 44 of the WHO’s planning guide for quality health services for step-by-step guidance. 
    • Focus on continuous improvement—identify what works and does not work, and refine action plans over time. 
      • Build pathways to improvement through supportive supervision, performance monitoring and measurement, and continuing professional development. To avoid duplication and fragmentation, performance monitoring that occurs at the facility level should be aligned with national and subnational monitoring and evaluation efforts. 15 26 29 30
      • Collect and use performance data to make decisions and improve the quality of services.  To ensure that services and processes align with population health needs and context, continuously collect accurate, timely, and reliable population health data as a part of quality processes. These data should, in turn, support local decision-making processes to ensure that services and processes align with the local population’s needs and preferences and achieve desired health outcomes. Approaches should prioritise improvements in areas with the greatest quality deficits to ensure health equity and the efficient use of resources. 9 26
      • Cultivate a culture of learning. Primary carePrimary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” facilities should be designed and managed using systems to identify, react to, and learn from safety incidents and quality gaps. Successful systems require facilities fostering a culture of safety, reporting on errors and near misses, learning from their mistakes, and tracking progress towards safety- and quality-related goals. 9 26
      • See pages 45-46 of the WHO’s planning guide for quality health services for step-by-step guidance. 

    Related elements

    Relevant tools & resources

    Sub-action 2. Implement tools, interventions, and processes to reduce harm and improve the effectiveness of clinical care 

    The presence of quality standards and safety protocols in a facility is often not sufficient to achieve quality gains. Studies show that providers in LMICs often do less than half of the recommended evidence-based care actions, and incorrect diagnosis is a major challenge. These quality gaps are due, in part, to insufficient capacity within the PHC workforce. 10 Here, we describe various activities countries can implement to increase the capacity of staff to provide better services as well as to increase their motivation to improve.

    Key activities

    National and sub-national levels 
    • Reform pre-service education and training. Pre-service education is the first opportunity for providers to receive training that will influence technical quality. However, stagnant medical curricula have resulted in mismatched provider competencies and patient needs, which can lead to quality gaps at the point of care. 15
      • Include ‘principles of quality' in the pre-and in-service training of the PHC workforce as well as in continuous professional development. 15 26
      • Read more about strategies to reform medical education and curricula in the Workforce and Service Availability and Readiness modules.
    • Develop and support the implementation of quality and evidence-based standards at the point of care. Developing clinical standards is often an early step in the national quality policy development process. 15 23 31 32
      • Develop and implement community-based models of care that address multiple dimensions of quality. Design patient care protocols and clinical pathways that emphasise the core dimensions of quality (timeliness, EfficiencyEfficiency refers to the ability of a health system to attain its desired objectives with the available resources, while minimising waste and maximising capacities to deliver care to those who need it., EffectivenessEffectiveness refers to care that is evidenced-based and adheres to established standards and the extent to which a specific intervention, procedure, regimen or service does what it is intended to do for a specified population when deployed in everyday circumstances., safety, people-centeredness, integration, and equity). 
      • See pages 16-17 of the WHO’s technical series on the quality of care and the organisation of services module for additional guidance. 
    • Build structures to ensure that staff receive compensation in a timely and reliable manner and are therefore available and motivated to provide quality services. Such structures may include training for local staff in financial management and accountability systems, such as recordkeeping, to ensure that facilities are using funds for their intended purpose. 27 31
    • Implement integrated care pathways, referral protocols, team-based care models, and other Service delivery platformA service delivery platform refers to the level of a health system at which interventions can be appropriately, effectively, and efficiently delivered.
      that make it easier for providers to proactively and competently manage patient care. 27 31
    • Use population health management approaches to balance provider caseload and increase timeliness and efficiency of care. When providers are overburdened by patient demand, they may not have adequate time to devote to each patient. This challenge can be avoided during empanelment. When planners determine the appropriate size for each panel, they should strongly consider provider burden and the number of available providers. 33
      • See the empanelment deep dive in the population health management module for more information on what empanelment is and how to implement it.
    • Use monetary or non-monetary incentives to improve the motivation, availability, and competencies of staff, such as pensions, insurance, travel, child care, and community support or engagement efforts, among others. Depending on the context, incentives may also be managed at the facility level. 34 35 36
      • See the WHO’s review of incentive and remuneration strategies and the Service Availability and Readiness and Purchasing and Payment Systems modules for additional guidance. 
    • Ensure that staff have the tools, medicines, and supplies they need to deliver quality services using robust supply chain management, supportive policies, and flexible financing. 15 23 31 32
    Local and/or facility level
    • Provide ongoing training and continuing professional development opportunities, such as continuing medical education programs and peer-to-peer learning. 23 31 32
      • Learn more about training and professional development opportunities in the service availability and readiness module.
    • Use protocol-based approaches and decision-making tools to make it easier for clinicians to readily access reliable, evidence-based content at the point of care. 15 23 31 32 UpToDate is one such clinical resource that can give providers the informational tools they need to improve care. 
      • See pages 16-17 of the WHO’s technical series on the quality of care and the service availability and readiness module for additional guidance. 
    • Implement systems for performance monitoring and data-driven decision-making. To ensure adherence to safety and quality standards in practice, promote a continuous culture of quality improvement, and equip providers with the requisite training and resources needed to deliver high-quality services. Staff supervision is one form of applied, individual-level performance measurement and management that can improve Provider competenceProvider competence entails having and demonstrating the knowledge, skills, abilities, and traits to successfully and effectively deliver high-quality services. and help staff to deliver more effective services. 15 23 31 32
      • Learn more about systems for quality improvement in the management of services module.
    • Use team-based models of care to balance provider caseload and increase the timeliness and efficiency of care. If there is an adequate supply of human resources, shifting responsibilities to other staff members may help enable providers to spend more time with patients. How responsibilities are divided between the health workforce depends on their training and competence and should always be planned with optimization of roles in mind. It is crucial to ensure that providers have the relevant competencies to carry out their responsibilities when optimising roles and scopes of practice and that they are part of larger multidisciplinary teams that are structured to meet population health needs. 15 23 31 32
      • Learn more about team-based models of care in the organisation of services module.

    Supporting elements

    • Policies and leadership
    • Multisectoral approach
    • Financing
    • Inputs
    • Management of services and population health
    • Service availability & readiness 
    • Primary care functions

    Relevant tools & resources

    Sub-action 3. Engage and empower patients, families, and communities

    Meaningful community engagement helps to build and strengthen people’s trust in the health system and to solicit feedback that can be used for quality improvement efforts. It is also a critical way to hold health systems accountable for the delivery of People-centred carePeople-centred care is “an approach to care that consciously adopts the perspectives of individuals, carers, families, and communities as participants in and beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care also requires that people have the education and support they need to make decisions and participate in their own care.”—a core element of service quality. Global evidence suggests that community engagement and empowerment mechanisms can promote better care, enhanced patient experience, more effective healthcare utilisation, reduced costs, and improved health outcomes. 23 37

    Key activities 

    National and sub-national levels
    • Generate enabling conditions for community engagement and empowerment.
      • Create fundamental shifts in governance and accountability arrangements. For example, governments might embed values important for community engagement and empowerment, such as transparency, equity, and inclusiveness, into existing governance structures and processes. 
        • See pages 22-23 of the WHO’s community engagement framework for additional guidance. 
        • Adopt policies that promote multisectoral and intersectoral action for health, such as Health in All Policies
          • See the multisectoral approach module for additional guidance. 
    • Establish a shared vision, mission, or purpose. Focus leadership efforts on cultivating a shared vision, mission, and sense of purpose across the health system. For example, seek to design models of care that promote this shared vision of quality health services, and involve patients, families, and community members in this process.  
      • See page 23 of the WHO’s community engagement framework and the policy & leadership module for additional guidance. 
    All levels 
    • Generate enabling conditions for community engagement and empowerment.
      • Resources: Invest in and manage resources to promote the engagement and empowerment of communities. For example, redesign spaces and implement technologies to support participatory processes and collaboration. 
        • See page 23 of the WHO’s community engagement framework and the action ‘improve the way health facilities are designed and managed’ for additional guidance. 
      • A prepared and supported workforce:  Equip health workers with the “soft skills” needed to meaningfully engage with communities, such as value-based decision making, self-awareness, empathy, and CompassionCompassion is the emotional response to another person’s suffering and the authentic desire to take action to relieve their pain or suffering in some way.
        • See page 23 of the WHO’s community engagement framework and the service availability and readiness module for additional guidance.
      • People-centred accountability arrangements:  At the facility level, community engagement mechanisms can provide patients with the means to hold providers accountable for the delivery of services that meet their needs and preferences. Supply-side accountability mechanisms can also help to reinforce service quality and reward providers or care teams for the services that are high-quality and in line with local priorities. 10 30 In addition, successful care models are accountable to patient needs and health outcomes. Accountability can occur at many levels in the health system: 38 39 40 41
        • At the national level, policymakers and planners can reinforce accountability by implementing empanelment schemes and other mechanisms to promote PHC as the first point of contact and equity in access to quality services.
        • At the regional level, referral centres can accept accountability and responsibility for the health outcomes of patients in their catchment areas.
        • At the local level, care teams can take responsibility for the active management of the health of their patient panel, using prompt referrals and proactive outreach.
    • Build capacity for community engagement and empowerment.
      • The WHO’s community engagement framework identifies four capacities necessary to ensure effective implementation of health services and programmes. Effective implementation means that health services and programs align with the local context and that communities are involved in the design, implementation, and improvement of these services and programmes. These capacities include: 15 26 37 42
        • Capacities for shared assessment and analysis of the situation
          • Link M&E frameworks to community and health service feedback mechanisms to ensure that community input informs the design and implementation of health interventions, services, and programmes.
          • Routinely measure and publicly report on the quality of health services from the patient perspective, including measures of patient experience and patient-reported outcomes.
      • Capacities to design context-specific approaches for shared agenda-setting and planning and for defining roles and responsibilities
        • Involve communities in the planning and implementation process in meaningful ways. For example, countries should engage and empower communities to 
          • Contribute to the development of national health plans (including the strategic direction on quality) as well as their operationalization at the subnational level.
          • Collaborate and engage with health professionals and providers through feedback and formal community engagement mechanisms to discuss clinical performance and contribute to the design of improvement activities.
        • Engage communities in the design, organisation, and delivery of services early and often, such as by involving citizen representatives in national and local priority setting exercises.
      • See pages 20-21 of the WHO’s technical series on the quality of care and pages 23-24 of the community engagement framework for people-centred, and resilient health services for additional guidance.
    • Implement strategies to increase Patient engagementPatient engagement is a partnership between patients and their care team. It combines patient activation with interventions to promote positive health behaviours, such as obtaining preventive care or engaging in regular physical exercise. The focus on activation and engagement rather than compliance recognizes that patients manage their own health most of the time and need to be able to make informed decisions about their own health.
      .
      • Enhance health literacy among the population. 25 42 43 44
        • Develop policies and plans on health literacy promotion including operational plans and funding strategies to sustain and implement health literacy programmes across the health system. 
        • Establish well-designed surveillance and risk communication platforms that routinely collect and disseminate health information from and to local communities.
        • Collaborate across sectors for mutual successes, and meet obligations to provide people with accurate, up-to-date information that is unbiased by undue influence from outside the health sector.
        • Capacitate PHC centres and care teams to provide relevant and accessible information to patients and to engage them as equal partners in their care.
        • See pages 31 and 42 of the WHO’s report on engaging patients, carers, and communities for Integrated health servicesHealth services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector and according to their needs throughout the life course. delivery and the health literacy section of the population health management module for additional guidance.
    • Use shared decision-making in clinical settings. 42
      • See pages 5 and 18 of the WHO’s report on engaging patients, carers, and communities for integrated health services delivery for additional guidance. 
    • Build peer support and expert patient groups. 
      • See pages 7 and 23 of the WHO’s report on engaging patients, carers, and communities for integrated health services delivery for additional guidance. 
    • Support patients, families, and communities to participate in self-management and self-care. 
      • See pages 7-8 and 23-25 of the WHO’s report on engaging patients, carers, and communities for integrated health services delivery for additional guidance. 
      • See the self-care section of the population health management module for additional guidance. 

    Supporting elements

    • Multisectoral approach
    • Population health management
    • Workforce
    • Primary care functions

    Relevant tools & resources

  • Integrated models that offer a more comprehensive set of services to patients (including diagnostic, pharmaceutical, behavioural, and rehabilitative services) can help to increase the efficiency and timeliness of primary health care. In communities where it is difficult to access routine and reliable care, integrated care models delivering comprehensive care during a single care interaction may be an especially effective way to improve service quality, especially for patients with complex conditions. 45 46 It is important to make sure the model chosen is patient-centred in order to sustain improvements to the quality of care.

    Key activities

    All levels

    The WHO’s framework on integrated, people-centred health services outlines five interdependent strategies that countries can take to make services more integrated and person-centred. 

    • Create an enabling environment that brings together all stakeholders necessary to undertake system-wide change.
      • See page 9 of the WHO’s framework and the sub-action on creating an enabling environment above or more information. 
    • Bolster participatory governance and promote mutual accountability. 
    • Empower and engage people and communities. 
      • Co-design services with patients. To ensure they are acceptable to patients, seek to understand how well services are functioning from the perspective of the patient, including whether or not the services meet the patients’ need for ComprehensivenessComprehensiveness refers to the provision of holistic and appropriate care across a broad spectrum of health problems, age ranges, and treatment modalities. Comprehensive care should address a wide range of preventive, promotive, chronic, behavioural, and rehabilitative services and include an assessment of a patient’s risks, needs, and preferences at the primary care level.. Co-design is one approach that facilities can use to centre patients’ voices and experiences in this design process. 47 48
      • Routinely measure and publicly report on the quality of health services from the patient perspective, including measures of patient experience and patient-reported outcomes. 15 42
      • See page 5 of the WHO’s framework for the sub-action on engaging patients, families, and communities under action 1 for more information.
    • Promote models of care that prioritise primary care, community-based services, and the co-production of health.
      • Implement integrated care management programs.  Integrated care management is a team-based, patient-centred approach to managing patient care. It is designed to improve patient care and reduce the unnecessary utilisation of services through three core activities: 29 49
        • Proactive coordination with other health care providers and the social sector.  Care teams initiate, monitor, and follow up on patient referrals and visits to other specialists and sectors. Read more about coordination principles and practices here. 
        • Effective clinical management. Care teams deliver clinically effective care, or care that is evidence-based, person-centred, and high-value.
        • Proactive outreach. Teams are proactive in their care of patients and often engage patients in health promotion and disease prevention activities. 
      • Improve the integration of public health and primary care. A WHO Policy brief has identified five broad actions that countries around the world have taken to enhance the integration of primary care and public health. These actions are not meant to be mutually exclusive and can incorporate interventions from more than one action. 50
        • Coordinating Health care servicesHealth care services refer to any intervention, procedure, regimen, or process that health workers use to respond to the needs and demands of their patient population. Depending on the context, services may be provided by public or private providers. for individuals. Interventions can include the coordination of clinical and community services and the establishment of “one-stop-shop” centres, where clinical and community services are brought together at one site.  
        • Applying a population perspective to clinical practice. Interventions can involve using population-based information and analytical tools (risk assessments, clinical epidemiology) to enhance clinical management. 
        • Identifying and addressing community health problems. Interventions can include conducting community health assessments and using clinical encounters and shared data (EHRs) to build community-wide databases and to identify and address underlying community health problems.
        • Strengthening health promotion and disease prevention. Interventions can include the provision of health education to patients and the involvement of patients in the design and implementation of new services or processes at the local level. 
        • Collaborating around policy, training, and research. Interventions can include cross-sectoral education, training, and research. 
    • Coordinate services around the needs and demands of people within and across sectors. 

    Relevant tools & resources

  • Improving the physical design of health facilities and the way services are delivered can facilitate improved access; improve the waiting experience, privacy, and physician/staff-patient communication; reduce patient anxiety; and reduce the risk of infection. 29 51 The changes/design choices countries make should be: 

    • Person-centred and equity-promoting

    • Simple and easy to use for both patients and providers

    • Appropriately tailored to the internet connectivity and literacy of a given context and adaptable to anticipate any changes in service delivery

    • Supported by sufficient resources (staff, information and communication technology)

    Assuming that facilities have sufficient resources and autonomy to make changes to the design of the facility, they may undertake the following sub-actions to improve service quality: 29 

    Sub-action 1. Streamline workflows & reduce waste

    Some studies estimate that up to 40% of clinical office work is redundant or unnecessary. While there is limited data on overhead costs in LMICs, some studies suggest an ideal rate of 35% for primary care facilities. 29 53 When used effectively, various technologies and quality improvement methods can help to reduce waste, cut back on administrative burdens, and increase the timeliness and efficiency of care. In addition, changes to the interior space of a facility can help to improve patient experience, team culture, and person-centeredness of care.

    Key activities

    • Use information and communication technologies to reduce administrative burden and make care safe and efficient. Various technologies can help to reduce waste and increase the efficiency of care, including the use of clinical communication and collaboration solutions like secure text messaging and the use of EHRs to manage patient care, maintain more accurate and complete patient records, and ensure safer transitions of care. 29 54 55
    • Use lean methodologies to streamline workflow. Quality improvement practices like continuous flow and just-in-time processing can help to improve efficiency. More information on these techniques can be found here. 53
    • Implement shared medical appointments or block appointments. Shared medical appointments can decrease wait times and optimise provider time by pairing a group of patients with similar health needs with a single provider. Shared medical appointments have been used extensively for maternal and newborn health and evidence is emerging of success for the management of non-communicable diseases as well. 56 57
    • Optimise the interior space of facilities: Three quick and cost-effective techniques that facilities can use to optimise the physical space of their practice include developing team stations, creating an engaging environment, and incorporating uplifting designs to alleviate patient anxiety. 52
    • Ensure strong communication and appropriate transfer of knowledge during any transition in ambulatory care. Transitions may include handoffs between different providers within a care team, handoffs between shifts, or transitions between facilities or to higher levels of care. 

    Sub-action 2. Rearrange or expand facility operational hours

    To ensure that services are timely, patients must be able to visit health facilities at times and on days that are convenient to them and do not require substantial sacrifice in work or childcare. Because expanded days and hours of service may require more human resources, stakeholders must consider how they can reorganise the health system to accommodate these changes. 

    Key activities 

    Because increased hours may reduce the density of patients throughout the day, fewer providers may be scheduled on each shift, allowing them to be scheduled later (or earlier). This rescheduling may require pilot testing and observation of patient flow to optimise, and it is important to ensure that all services are staggered as well so patients still have access to comprehensive care. 

    • Stagger shifts. Because increased hours may reduce the density of patients throughout the day, fewer providers may be scheduled on each shift, allowing them to be scheduled later (or earlier). This rescheduling may require pilot testing and observation of patient flow to optimise, and it is important to ensure that all services are staggered as well so patients still have access to comprehensive care. 
    • Integrate services. Facilities may currently use designated days for services such as antenatal care or antiretroviral therapy. Instead, facilities should ensure that patients can receive a comprehensive range of services at any time to optimise appointment time and minimise return visits. See action #5 (make care more integrated and person-centred) for additional activities related to care integration.
    • Increase staff or expand service delivery hours. Both of these considerations involve substantial financial inputs from the health system for the compensation of additional staff or extended hours. Stakeholders should consider whether they have the resources necessary to implement these changes. However, facility managers must ensure that staff receive adequate incentives and support to reduce provider burnout and maintain motivation. If staff is asked to work inconvenient hours, health systems may choose to consider additional incentives. 
    • Introduce on-call telephone systems. In areas where patients have access to phones or computers, facilities may choose to have providers available to provide remote consultations during non-clinic hours. Unless there is substantial telemedicine technology in place, these consultations may be limited to acute or emergency care. 

    Sub-action 3. Implement or improve appointment systems 

    Appointment systems can improve access to services at the point of care. These systems need not be complex and should be easy to use for both patients and providers, appropriately tailored to the internet connectivity and literacy in a given context, and adaptable to anticipate any changes in service delivery. These systems, if supported by a sufficient workforce, can improve waiting times and the person-centeredness of service delivery.

    Key activities

    • Use in-person or community-based appointment systems. In areas where some or all of the population lacks access to the internet or phones, appointments can be scheduled through in-person visits to the clinic. If the clinic is not conveniently located, appointment systems should be made available in the community. For instance, CHWs may make referrals or help schedule appointments during routine population outreach activities. Novel, community-based appointment systems are especially needed in settings of fragility, conflict, and vulnerability. 
    • Use appointments made via SMS or telephone and linked with an appointment tracking system (paper or electronic). In areas where patients have reliable access to telephones, appointments may be scheduled by calling or texting the facility. However, there must be an organised system for recording appointment availability for the clinic staff answering phones. Additionally, in low-literacy settings, texting cannot be the only system for requesting appointments.
    • Use electronic portals. Electronic portals may be an efficient option if patients have reliable access to computers or mobile devices and the internet.  Additionally, systems must be in place to ensure that these portals remain up to date, and alternative means of scheduling should be available if any portion of the patient panel does not have access to the internet.
    • Maintain ad-hoc appointments. Even with efficient appointment systems, facility managers should ensure that patients can access care for urgent needs, possibly by reserving specific days or times for walk-in visits or same-day appointments. 

    Sub-action 4. Reduce wait times

    • Introduce group visits. Are there patients whose needs are fairly standardised (certain chronic care conditions, antenatal care) who could receive care in a group context? What sort of logistics would need to be in place to organise these visits? How would this change be effectively communicated to patients? 
    • Use multidisciplinary care coordination. Are there any services that are currently being provided by doctors that can be effectively provided by nurses or CHWs who are in greater supply? What kind of training (if any) would these providers need to be able to provide a wider range of services? Can any of these services be provided outside of the facility? Are there systems in place to simplify the process of patient registration and referral, such as patient registries and referral management systems?
    • Make care more proactive and accessible. Bringing care “to the patient,” using telemedicine appointments or home visits, can help to make care more timely, particularly among patients who face geographic or financial barriers to care or during a time of crisis. Does the patient have a condition that can be managed via phone or a home or community visit? What form of communication would be most efficient for patients and providers (text message, video conference, email, home visits)? Which providers would be responsible for telemedicine or home visits, and how would their workflow need to change to accommodate this responsibility?

    Related elements

    Relevant tools & resources

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

Understanding and identifying the drivers of health systems performance--referred to here as “related elements”--is an integral part of improvement efforts. We define related elements as the factors in a health system that have the potential to impact, whether positive or negative, service quality. Explore this section to learn about the different elements in a health system that should be improved or prioritized to maximize the success of actions described in the “take action” section. 

While there are many complex factors in a health system that can impact service quality, some of the major drivers are listed below. To aid in the prioritization process, we group the ‘related elements’ into:

Upstream elements

We define “upstream elements” as the factors in a health system that have the potential to make the biggest impact, whether positive or negative, on service quality.

Policy & leadership

If governance in a health system is weak or policies are not informed by quality, it is likely to lead to gaps in care. In addition, if legislation, regulatory statutes, and other mechanisms to enforce and institutionalise quality are absent or poorly functioning, it is likely to bring about variation in quality at the point of care. 

To promote a system-wide commitment to quality, countries should establish national policies and strategies for quality health services, including the development of a national strategic direction on quality. See the sub-action on creating an enabling environment for quality, the policy & leadership module, and the WHO’s quality health services planning guide for additional guidance. 26

Critical inputs, service availability and readiness, and management of services

The inputs of a health care system, including human resources, infrastructure, and medicines and supplies, are essential to the delivery of effective, safe care. However, the presence of these inputs does not guarantee service quality. Studies have shown that poor care often happens even when such inputs are available. To achieve better outcomes, facility managers and staff must be available, trained, and motivated to deliver better quality services. For example, quality improvement interventions such as supportive supervision and performance management efforts have been shown to reinforce a local commitment to quality. 10 Learn more in the following modules:

Organisation of services and multi-sectoral approach

The way that services in a health system are designed, organised, delivered, and supported by different service delivery platforms will have a direct impact on service quality. For example, if essential service packages and the standards of care for these packages are fragmented or poorly defined, that fragmentation will likely disrupt service quality at the point of care. Furthermore, if mechanisms are not in place to involve and hold providers accountable to these standards, this lack can lead to variation in quality between the public and private sectors. In addition, service delivery platforms that promote integrated, team-based models of care can help providers to better manage their caseload and hold each other accountable for the needs of patients. For example, team-based models that shift administrative tasks and other duties to nurses or administrative staff can allow providers to spend more time with each patient, helping to improve timeliness and effectiveness of care.

Learn more in the Organisation of services and Multisectoral approach modules.

Information, technology, and data use

Health information systems should enable stakeholders to collect and use data to drive quality improvement at all levels of the health system. During the development of the national strategic direction on quality, planners should define what data should be collected, when, and how. 26

At the facility level, use of health management information systems and data systems can impact service quality in several ways:

  • Efficiency. Timely, reliable, and complete data allow for more streamlined PHC processes. Moreover, the use of information and communication technologies, such as referral systems and electronic health records, can make the collection, use, and coordination of patient data more accessible and efficient, helping to support effective service delivery. 
  • Timeliness. Information systems innovations like appointment systems and telemedicine platforms can make patient flow through a facility more efficient and more timely. Telemedicine also supports timely access in hard-to-reach populations.
  • Safety. Information and technology, including adverse event monitoring and safety reporting, can help promote the implementation of safety standards and the use of safety data at the facility level. 
  • Effectiveness. Information and technology like outcomes monitoring can help promote the implementation of evidence-based standards of care at the facility level. In addition, information and technology platforms can make it easier for providers to access best practices at the point of care.

Learn more about information and communication technology and the use of these systems for quality improvement in the Information & technology and Management of services modules.

Complementary elements

We define “complementary elements” as the factors in a health system that have the potential to make an impact, whether positive or negative, on service quality. However, we consider these drivers as complementary to, but not essential to performance.

Financing for PHC

Limited funds for PHC, limited funds for quality interventions to improve PHC, or tertiary facilities receiving disproportionately large shares of health budgets may lead to inefficiencies at the point of care. For example, if PHC facilities do not have the funds needed to follow established guidelines or motivate staff, they may see patients bypassing cost-effective options at the primary care level and increasing the use of costly alternatives, such as emergency care.

Learn more.

Population health management

Population health management approaches can also have an impact on service quality. For example, streamlining resources and interventions to specific communities and target groups via proactive outreach activities can promote efficiency in service delivery and resource utilisation. In addition, soliciting input from the community can enable local planners to better understand issues in access to timely care and identify feasible and acceptable responses that will tangibly improve the timeliness of care.

Learn more.

Resilient facilities & services

Resilient facilities and services help to ensure that care can remain timely, safe, and accessible even during public health emergencies. In addition, assessments of facility and service preparedness can help to ensure efficiency in the use of limited resources during public health emergencies.

Learn more.

Access

Access is closely related to timeliness. If patients cannot access care where and when they need it, care is not timely. Access strategies that improve financial and geographic access to care will, in turn, support timely service delivery. Furthermore, shorter waiting times and management of facility flow can help to create more efficient interactions and experiences at the facility level.

Learn more.

Primary care functions

Primary care is distinguished by the core functions it provides as well as its ability to deliver on the foundational elements of service quality. As such, the core functions of PHC and service quality are independent but mutually reinforcing. For example, care models that promote the 5Cs, such as integrated health service delivery, can also help to increase the efficiency and timeliness of care. Likewise, service quality interventions that increase the efficiency and timeliness of care, such as virtual appointment systems, can improve the continuity and coordination of care.

Learn more.

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

Countries seeking to improve the resilience of facilities and services can pursue a wide array of potential improvement pathways. The short case studies below highlight promising and innovative approaches that countries around the world have taken to improve. 

PHCPI-authored cases were developed via an examination of the existing literature. Some also feature key learnings from in-country experts. 

East Asia & the Pacific   
Europe & Central Asia
Latin America & the Caribbean
Middle East & North Africa
North America
South Asia
Sub-Saharan Africa
Multiple regions

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

Building consensus on what service quality is and key strategies to fix gaps is an important step in the improvement process.

Below, we define some of the core characteristics of service quality in greater detail:

  • Services are evidence-based 

    Effective PHC servicesPHC services refer to any intervention, procedure, regimen, or process that providers use to respond to the needs and demands of their patient population at the primary care level. Because of PHC’s community-facing orientation, services can be provided virtually or face-to-face in homes, communities, or PHC centres. Depending on the context, services may be provided by public or private providers. are based on the best available scientific research. 6 8 68 69 In practice, evidence-based care includes systematic patient assessments; correct diagnoses; and the provision of appropriate treatments, counselling, and referrals. 10 Even if a service or process is evidence-based, however, it may not necessarily be effective in the local context. For example, if a local facility does not have the resources and staff needed to implement a service or process change, it may limit the EffectivenessEffectiveness refers to care that is evidenced-based and adheres to established standards and the extent to which a specific intervention, procedure, regimen or service does what it is intended to do for a specified population when deployed in everyday circumstances. of the intervention. Services and processes should be highly tailored to the local context to maximise resources and impact. 10 70 PHC centres and care teams can take advantage of quality improvement methods to identify problems and suggest and test solutions in their context.   

    Additional guidance on tailoring solutions to the local context can be found in the local priority setting section of the Population Health Management module. Quality improvement methods and interventions are discussed in the management of services module and the sub-action on creating an enabling systems environment for quality

    Services are appropriate

    Care should adhere to clinical standards. 68 69 A clinical practice guidelineA clinical practice guideline is meant to be a more flexible set of evidence-based recommendations than a standard of care. Providers can consult practice guidelines to help them make decisions about how to manage care for specific clinical conditions, including what screening, diagnostic, or therapeutic actions to use. that explicitly defines what is required to achieve improved health OutcomesOutcomes are the effects of the provision and experience of care on processes of care and on patients’ health. for a given service, including how providers should act and the reasonable degree of care a patient should expect to receive based on their specific health needs. 71 72 To achieve this, minimum standards will need to be established and enforced wherever Primary carePrimary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” is delivered, with neither the overuse nor underuse of the best available techniques. For example, everyone who is likely to benefit from a vaccine should receive one, and not every child with a cold should receive antibiotics. 68 69 73 

    While less formal than a A standard of careA standard of care is a guideline that explicitly defines what is required to achieve high-quality care for a given service, including how providers should act and the reasonable degree of care a patient should expect to receive based on their specific health needs., the use of practice guidelines can also promote more effective care. A practice guideline is meant to be an adaptable set of evidence-based recommendations. Providers can consult practice guidelines to help them make decisions about how to manage care for specific clinical conditions, including what screening, diagnostic, or therapeutic actions to use. 74

    In addition, detailed information on promoting a culture of quality improvement and mechanisms to support such a culture at the national and local levels can be found in Policy and Leadership, Adjustment to Population Health Needs, and Management of Services modules. Content related to building the skills and motivation of facility leaders and staff can be found in Workforce, Service Availability and Readiness, and Management of Services. 

    Services are consistent

    Effective care minimises the variability or inconsistent care practices that can occur in all aspects of service delivery. Consistent care practices are also a key dimension of safe, efficient care. To improve patient safety, clinical productivity, and patient outcomes, countries should aim to reduce: 75 76 77 78

    • Operational variability, which refers to the differences in care provided by primary care providers and staff. It can often be traced back to a single activity or inactivity in the care delivery process. Several strategies can help to reduce operational variability, including the implementation of standard processes, procedures, and checklists and the automation of certain routine tasks and pathways (e.g. computerised order entry). 
    • Knowledge variability, which refers to differences in expertise among primary care providers and staff. Knowledge variability is more difficult to identify and assess because it is based on an individual’s education and experience level as well as their bandwidth to stay up to date with the most current knowledge and information. Various clinical decision support tools, such as UpToDate, can help to bridge this know-do gap and reduce knowledge variability. The use of electronic medical records can also help. 

    Additional strategies for reducing variability are discussed in this module’s sub-action on reducing harm and improving the clinical effectiveness of care. 

    Services are acceptable

    If services are not acceptable to the local population, their effectiveness may be limited. To be effective, services must be trusted and valued by the patients they are designed to serve, taking into account factors such as the Social determinants of healthSocial determinants of health “...are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.”. Research shows that positive user experience (dignity, privacy, respect) can improve patients’ confidence and trust in the health system. In addition, such positive experiences are linked to better technical quality of care. To ensure positive user experiences, PCPs should treat all patients with dignity, autonomy, and respect and clearly communicate about the services and processes that impact the patient’s care. 10

    To be acceptable, services must be person-centred, and relationships between patients and providers must be mutually respectful and trusting. The VSP 2.0 conceptualises people-centeredness, including dimensions of patient-provider respect and trust as separate but related to effectiveness. Detailed information on person-centred care can be found in the Primary Care Functions module. 

    See the “take action” section for tangible next steps countries can take to make care more effective. The following actions may be especially relevant:

    • Action 1. Cultivate a system-wide commitment to quality
    • Action 2. Strengthen accountability between patients and providers
    • Action 3. Capacitate providers to deliver better quality services
  • According to the WHO, “patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.” 79 Patient safety can be operationalised as safe practices being routinely followed in the delivery of care as well as in facilities more broadly. SafetySafety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended. requires certain inputs but also depends upon provider training in safe practices and a facility culture that promotes learning and safety.

    Safety is a broad topic, particularly because what comprises PHC differs substantially between contexts, and data on primary care safety in low- and middle-income countries are scarce. 80 However, to be considered “safe,” care should cultivate trust between patients and providers and minimise harm. 8 10 55

    Care is appropriate and minimizes harm

    Safe care means that providers and services deliver appropriate care (see Effectiveness section) and minimise harm. In practice, safety may be understood through several care processes or moments of care.

    Medicines and supplies safety

    A qualitative study of primary care doctors and nurses found that most providers associated safety with medicines and supplies. 81 While medicine and supplies safety is only one component of ambulatory care safety, it is perhaps the most pervasive in the primary care literature. There are many considerations related to medicines' safety. 

    • Prescribing practices:  Are providers prescribing appropriate medications to patients, for a sufficient amount of time and cost? Do providers have access to and adhere to the most current prescribing practices? The WHO estimates that more than half of medications are prescribed, dispensed, or sold inappropriately. 82 The WHO offers many resources on the rational use of medicines, including 12 interventions that countries can implement here.
    • Medication reconciliation: Do providers know what medications patients are taking? During medication reconciliation, providers can compare the medications that a patient is taking to the medications they are supposed to be taking and make adjustments as necessary. 16 This reconciliation is particularly relevant if patients are being prescribed medications outside of primary care settings. Coordination of care between primary care providers and specialists can help improve medication reconciliation. Many resources on medication reconciliation can be found on WHO’s Patient Safety and the Institute for Healthcare Improvement websites.  Additionally, the United States Agency for Healthcare Research and Quality has a set of innovations and tools to improve medication reconciliation. 
    • Polypharmacy: Are patients taking too many medications? This may be particularly relevant for elderly patients or patients with chronic conditions and may be a concern for microbial resistance. Assessments of polypharmacy can take place during medication reconciliation. 
    • Adherence: Are patients taking the medicines that they are prescribed and at the correct frequency?  The WHO estimates that around half of patients take their medications incorrectly. 82 Primary care providers play an important role in medication adherence. Medication adherence is an individual decision that is informed by multiple factors including lifestyle considerations, side effects, poor provider communication, and lack of involvement in medical decision-making. 83 Particularly when primary care providers and patients have longitudinal, trusting relationships, providers can work with patients to understand and solve challenges related to adherence. Discussions about adherence can also be conducted by community-based providers during home visits or community-based care. 84 
    • Falsified medicines: Are medications what they are supposed to be? Falsified medicines are a safety concern worldwide, particularly in countries where there are no robust quality surveillance systems to ensure that medications meet regulations. 85 This challenge is made even more acute by the often laborious and costly methods used to evaluate medication falsification.  

    The WHO has developed a set of resources on Medication Without Harm that addresses many of these medication-related concerns. Many resources are also available from Universities Allied for Essential Medicines. Additionally, the resource Medicines in Health Systems provides a robust overview of the role of medications in achieving Universal Health Coverage.  

    Supplies safety refers to the presence and appropriate use of supplies. These include but are not limited to the presence of all necessary equipment for ambulatory care, safe use of supplies to ensure safe blood donation, and safe use of supplies to promote infection control. Resources related to these elements of safety include:

    Diagnostic safety

    Graber et al (2002) proposed a three-part framework for considering diagnostic errors: 1) errors of uncertainty, 2) errors caused by system factors, and 3) errors of thinking and reasoning. 16 17 While these categories have significant overlap and should not be considered exhaustive, they provide a useful framework for considering the types of interventions that can be used to address each. 

    • Errors of uncertainty may be particularly relevant in diagnoses in which patients refuse testing, there are limitations in medical knowledge, or there is an unusual disease presentation. 16 These errors may be challenging to systematically address, but as the errors arise, providers should be sure to discuss and debrief them (promoting a culture of learning from mistakes is discussed within Safety Systems).
    • System factor errors are related to problems within the health facility or larger health system. For instance, system errors may occur due to poor communication between staff, delays due to provider absenteeism, or lack of availability of diagnostic equipment. Like errors of uncertainty, these errors should be debriefed with the relevant stakeholders, and tools such as process flow mapping or root cause analysis may be particularly relevant for identifying the drivers of these errors. 
    • Errors of thinking and reasoning have significant overlaps with competence. Diagnostic errors related to thinking and reasoning may be of particular concern during the redistribution of roles and responsibilities among providers or if providers are not given appropriate training. Strategies for addressing competence are discussed in the Provider competenceProvider competence entails having and demonstrating the knowledge, skills, abilities, and traits to successfully and effectively deliver high-quality services. module, but a few options include strengthening pre-service and in-service education, enhanced supervision, and the use of decision-making tools. 16 17

    Administrative and process safety 

    Many administrative and process errors can occur in primary care. While “administrative and process” safety is a broad term; here, we refer to it as the use of administrative controls to safeguard the health of patients and staff during everyday patient care. Such controls may include: 55 86 87 

    • Policies and procedures to ensure service quality, including compliance with standards of care and effective use of resources
    • Workplace or community initiatives to improve awareness of safety requirements and standards of care, such as education campaigns and in-service training
    • Systems for monitoring compliance with quality and safety standards
    • Systems for monitoring, evaluating, and providing feedback on the performance of healthcare staff, services, or processes 

    A failure to follow such controls may result in or be a result of poor information management or a breakdown in communication between staff, patients, and other actors. Some common examples of administrative and process errors include: 55

    • Patient record errors. Staff incorrectly or poorly document patient information, due to a lack of education, a lack of motivation, or a breakdown in the information architecture. For example, care teams record patient data in different places in the electronic or paper-based health record or neglect to input timely, accurate information. 
    • Poor management of diagnostic test requests and results. Staff mismanages patient test results. For example, staff miss a test result or misdiagnose the results due to a lack of knowledge and training. In addition, staff may fail to inform a patient and their care team about test results or update the patient’s chart.
    • Poor transitions of care. Patient information is poorly communicated or coordinated between and within levels of care. Communication failures can occur during patient transition both from the primary care into the hospital setting and vice versa. For example, speciality providers may not have access to patient health records due to data privacy laws, or primary care providers do not have access to patient discharge summaries from the emergency room unless patients hand them a written copy. 

    For a more detailed list of common administrative and process errors and common reasons for these errors, see the WHO’s report on administrative errors, a part of their technical series on safer primary care

    Procedural safety

    While major surgeries are likely not occurring in primary care settings, smaller procedures are common. Like diagnosis, procedural safety has significant overlaps with provider competence. Enhanced pre-service and in-service education can contribute to safer procedures. 

    The WHO Safe Surgery Checklist and Implementation Guide have been used extensively in low, middle, and high-income settings to prevent harm during surgeries. The WHO also has global guidelines on the prevention of surgical site infection. Similarly, the WHO Safe Childbirth Checklist is a valuable resource to ensure adherence to safe childbirth practices.

    Care cultivates respect, trust, and communication between patients and care teams

    Respect, trust, compassion, and communication in patient care 

    Respect and trust between patients and providers help to ensure fair treatment and safer primary care. While sometimes overlooked, patient respect for providers is a critical part of the experiential quality of care and is often influenced by patient perceptions of provider attitudes, competence, and caring behaviours. 88

    CompassionCompassion is the emotional response to another person’s suffering and the authentic desire to take action to relieve their pain or suffering in some way. is one of the most important tools for building trust. 89 Furthermore, compassion has important links to the quality of care. For example, studies have shown that compassion and the touch of a trusted other can help to alleviate another person's experience of pain and to improve stress-related disease. 90

    The VSP 2.0 conceptualises patient-provider respect and trust as separate but related to safety. More detailed information on person-centred care can be found in the Person-Centeredness section of the primary care functions module

    Respect, trust, compassion, and communication in day-to-day facility operations 

    Primary care facilities should be designed and managed with systems in place to identify, react to, and learn from safety incidents. To do so, facilities must foster a culture of safety, report on errors and near misses, learn from their mistakes, and track progress towards safety-related goals. 

    Facilities will be better suited to adapt to safe practices if they can quickly and easily learn from mistakes or errors within the facility. This is often referred to as a “learning organisation.” One study in the United States found that care teams with strong leadership often reported more errors in practice. The authors further investigated these counterintuitive findings and determined that well-led teams foster an environment in which reporting and learning from mistakes are welcomed and encouraged. This prompted the authors to identify qualities of teams and leaders that facilitate organisational learning: 91

    • A safe learning environment where voices are valued. Even in instances where it may seem obvious, facility leaders should be sure to communicate that all voices are welcomed and valued and all providers—regardless of cadre—are invited and encouraged to share concerns. 
    • A compelling vision for what needs to be improved. Leaders should employ clear systems for recording and sharing visions between stakeholders, including providers and community members 
    • Team-based learning infrastructure, in which small groups can contribute lessons and expertise. For instance, if a facility experiences an adverse event, there should be systems in place to allow providers to come together and discuss implications, lessons, and improvement strategies.  

    A conceptual model for learning organisations has identified three “building blocks” for such organisations. These include 1) a supportive learning environment, 2) concrete learning processes and practices, and 3) leadership behaviour that provides reinforcement. The researchers found that these three elements were controlled by different mechanisms, and high performance in one does not predict high performance in others. A corresponding “Learning Organization Survey,” intended to assess an organisation’s learning capability, maps competencies across these three dimensions. The survey is meant to be used at the organisational unit level. This may correspond to a facility department or to a whole facility depending on the size and number of facilities. It characterises a supportive learning environment as one that prioritises psychological safety, appreciation of differences, openness to new ideas, and time for reflection. Concrete learning processes and practices include experimentation, information collection and analysis, education and training, and information transfer to other networks. Finally, the model emphasises the importance of having leaders who prioritise dialogue around problem identification and adaptation. 92

    Respect, trust, and communication during transitions of care

    Ensuring strong communication and appropriate transfer of knowledge during any kind of transition in ambulatory care can help reduce errors and improve safety. Transitions may include handoffs between different cadres of providers within a care team, handoffs between shifts, or transitions between facilities or to higher levels of care. 

    The Joint Commission has developed an infographic on the eight elements necessary for high-quality handoffs. One of these elements includes standardised communication tools, such as I-PASS. I-PASS is a mnemonic for the important components of informational transfer in a handoff: illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by the receiver. 93 Implementation of I-PASS includes a two-hour workshop, a role-playing session, a computer module, a faculty development program, direct observation tools for evaluation and feedback, and process-change campaign materials. A prospective intervention study of I-PASS in the United States found a 23% reduction in the medical-error rate before and after the intervention. 

    See the “take action” section for tangible next steps countries can take to make care safer:

    • Action 1. Cultivate a system-wide commitment to quality
    • Action 2. Strengthen accountability between patients and provider 
    • Action 3. Capacitate providers to deliver better quality services
  • TimelinessTimeliness refers to the ability of the health system to provide PHC services to patients when they need them with acceptable and reasonable wait times and at days and times that are convenient to them. refers to the ability of the health system to provide primary care services to patients when they need them, with acceptable and reasonable wait times, and at days and times that are convenient to them. Timeliness includes two elements:

    • First, patients should be able to physically access care with acceptable and reasonable waiting times. 
    • Second, hours and days of facility operation should allow patients to find a time to visit facilities without sacrificing other obligations and duties such as work or childcare and to access care for emergent needs, including on nights and weekends.

    Timely care minimises waiting times and delays, helping to improve patient satisfaction and reduce utilisation of emergency- or hospital-based services that may result in higher costs for the patient and health system. 23 For example, untimely patient flow and notification systems can lead to delays in preventive care (or other services), and in turn, increase the patient’s risk for developing chronic diseases that cause more mortality, morbidity, and costs for the health system. 94 95 96 Timely care also promotes health equity and improved health outcomes for all segments of the population. 97 For example, timely use of appropriate medications and treatment protocols during emergencies is an important dimension of patient safety and clinical effectiveness. 

    Care is convenient and efficient

    In order to receive appropriate care, patients must be able to access facilities in a way that does not burden them. The following factors are potential barriers to convenient patient access.

    Inconvenient operational hours

    Facility hours may be a barrier to care for individuals who work or have regular obligations. Inconvenience is most often a barrier when facilities do not offer evening or weekend hours. Inconvenient hours of operation can also contribute to long waiting times, short consultations, and provider burnout. 

    A systematic review of public and private healthcare facilities in LMIC found that across multiple settings, waiting times, operational hours, and availability of staff were more favourable in private clinics compared to public ones. 19

    Inefficient appointment systems

    Appointment systems—coupled with effective use of resources and high-quality care—may be an effective starting point for ensuring timely access to care. A 2016 review of primary care experiences in six Latin American countries found substantial gaps in performance regarding waiting times and appointment systems: one-fifth of respondents skipped an appointment due to problems with scheduling, one-third had to wait more than five days for an appointment, and 39% could not schedule an appointment by phone. 98

    Long wait times 

    Long wait times may be attributable to diverse causes including staff shortages, inefficient or absent appointment systems, limited operational hours, and ineffective facility management regarding human resources or patient flow. Facility managers may choose to conduct activities such as process flow mapping (discussed in greater detail in the Management of services module) in order to assess how and why patients are experiencing long waiting times.

    Poor follow-up &/or outreach

    Poor follow-up or outreach with patients may be a barrier to timeliness, particularly among patients who live far from a facility. Providers may choose to follow-up with patients via telephone or home visits to improve timeliness (discussed in greater detail in the population health management and information & technology modules and action #4: make care more integrated and person-centred.)

    Fragmentation in transitions of care

    Poor communication or coordination between primary care and higher levels of care (and vice versa) can lead to delays in patient care. Within a facility, poor communication and transitions of care can lead to prolonged stays and overutilization of services. Patients who face language and cultural barriers are especially vulnerable to poorly managed transitions. There are various strategies that facilities and providers can use to improve transitions of care, including discharge planning, use of standardised referral guidelines, and secure health information exchange.

    For a more detailed list of transitions of care and common challenges and recommendations to improve, see the WHO’s report on transitions of care, a part of their technical series on safer primary care

    Care is geographically and financially accessible 

    In addition, patients’ ability to access timely services is strongly influenced by where they live and what services they can afford. These patients may face substantial external costs if they miss work or require alternative child care in order to access services, which can, in turn, lead to catastrophic health expenditure. 99 In addition, patients who live far from the facility and have limited transportation options are more likely to face barriers to timely care. 

    The VSP 2.0 conceptualises geographic access and financial access as separate but related to timeliness. More detailed information on geographic and financial access to care can be found in the Access module.

    See the “take action” section for tangible next steps countries can take to make care more timely:

    • Action 4. Make care more integrated and person-centred 
    • Action 5. Improve facility design and workflow 
  • EfficiencyEfficiency refers to the ability of a health system to attain its desired objectives with the available resources, while minimising waste and maximising capacities to deliver care to those who need it. in its simplest form can be understood as a ratio of inputs versus outputs, or the success with which health system resources are transformed into valued outputs (e.g. patient consultations) or improved patient outcomes. At the primary care level, efficiency means primary care providers or PHC facilities are able to attain their desired objectives with the available resources, minimise waste, and maximise capacities to deliver care to those who need it most. (100-102, 104)

    Despite this straightforward input-output model, efficiency is the result of many interrelated processes in the health system.(12,100–103) For example, system-level characteristics like good governance can promote the efficient transformation of resources into valued outputs like patient consultations or outcomes like equity or responsiveness. There are two types of efficiency important for service quality:(100–102,104)

    • Technical efficiency (or doing the things right), which refers to the ability of the health sector to attain the highest level of output given a set of inputs. At the point of care, it refers to how resources are used during service provision.
    • Allocative efficiency (or doing the right things), whereby the health sector provides the highest value health services available. ‘Highest-value’ means that resources are allocated so as to maximise the welfare of society. Such decisions should be informed by the needs, values, and preferences of the populations they are designed to serve, preferably via a participatory, deliberative priority-setting process.  

    Efficient health services maximise technical and allocative efficiency and exhibit the following common attributes:

    Care makes the best use of time and money 

    Inefficient care wastes considerable time and money for health systems and communities worldwide.(8) It is estimated that up to one-fifth of health expenditure makes little or no contribution to improving people’s health.(23,105) At the point of care, inefficient care may involve the provision of duplicate services, unnecessary referrals to speciality or hospital services, and avoidable hospital admissions (potentially due to delays in evidence-based, preventive care).(8)

    On the contrary, efficient care avoids the waste of resources, including medicines and supplies and the energy and expertise of staff. For example, providers should use standardised care processes and patient health records (electronic or paper-based) to track a patient’s care carefully, avoid repetition, and iterate on their care plan in a way that makes the best use of resources.(8) For example, providers might consider switching patients to generic medications to cut costs for the patient. In addition, to make the most use of time and expertise, providers should work together as a cohesive team. (8,21)

    Care minimises waste & variability 

    Relatedly, care teams should deliver services in such a way that minimises harm and resource waste. However, much of this work begins upstream. To promote efficient care, health systems and facility managers should take strides to ensure rational use of medicines and supplies (i.e. medicines regulation—see sub-action on creating an enabling a systems environment); optimise human resource mix; reduce corruption, and strengthen the use of information technology infrastructure (i.e. electronic health records). (8) As with any intervention, it is important to use quality improvement methods, culture change, continuing education and professional development, and provider incentives to sustain this shift to a more efficient practice. (21)

    Minimising the variability of care is also an important strategy to minimise harm (discussed in the effectiveness deep dive). Additional guidance on reducing waste and streamlining facility operations is discussed in this module’s action on improving the way facilities are designed and managed

    Care is proactive 

    When care is proactive, there are fewer inputs necessary to get the same health outputs, helping to reduce inefficiencies in care. For example, diagnosing hypertension early can produce good health with medications rather than diagnosing the complications of hypertension, which may require expensive interventions like dialysis. Outreach strategies (discussed in Population Health Management and the COVID-19 strategy on community-based care) are one-way providers and facilities can promote more proactive care. 

    Care models that foster linkages between public health and PHC also help to promote more proactive, efficient care.(10,40,41,106,107)  Services or processes that allow for the prevention and early detection of disease, such as evidence-based screenings and public-health surveillance and outreach, can help to cut costs and improve the health and well-being of the population.(107) More on health promotion and disease prevention activities that can be employed in facilities can be found in the following resources:

    For more information on the potential causes of inefficiencies in primary care, explore this practice-based research project.

  • People-centred carePeople-centred care is “an approach to care that consciously adopts the perspectives of individuals, carers, families, and communities as participants in and beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care also requires that people have the education and support they need to make decisions and participate in their own care.” means organising the health system around the comprehensive needs of people rather than around individual diseases. People-centeredness involves engaging with people, families, and communities as equal partners in promoting and maintaining their health—including through communication, trust, and respect for preferences as well as through ongoing education and support so that they can participate in health care decisions.(108)

    People-centred services put patient needs and values front and centre. While expectations and approaches to people-centred care vary between countries, it generally means 23

    • Services meet communities’ unique needs and preferences. To meet patients’ needs, countries must successfully engage patients, families, and communities in all aspects of design, planning, governance, and delivery of Health care servicesHealth care services refer to any intervention, procedure, regimen, or process that health workers use to respond to the needs and demands of their patient population. Depending on the context, services may be provided by public or private providers..(23,108,109) See the sub-action for engaging patients, families, and communities for additional guidance. 
    • Services are delivered with compassion and respect. Compassion has important links to the quality of care. For example, studies have shown that compassion and the touch of a trusted other can help to alleviate another person's experience of pain and to improve stress-related disease. (23,90)
    • Services promote patient activation, health literacy, and self-care. Engaging and empowering people to participate in their own care is essential to improving health outcomes, increasing patient satisfaction, reducing costs, and improving the clinician experience. Shared decision-makingShared decision-making “is an interactive process in which patients, their families and carers, in collaboration with their health provider(s), choose the next action(s) in their care path following an informed analysis of possible options, their values, and preferences.” is one of the most important approaches to achieving this engagement:  patients and providers work together to make decisions and select treatments and care plans.(23,110)

    The VSP 2.0 conceptualises people-centredness, including dimensions of patient-provider respect and trust as separate, but related to service quality. Learn more

     

  • High-quality services are integrated and person-centred; in integrated and person-centred care, primary care providers or care teams coordinate care around patients’ needs and engage patients as equal partners in healthcare. 38 39 40 41

    The VSP 2.0 conceptualises coordination, including dimensions of integration, as separate but related to service quality.

    Strategies to promote people-centred, integrated care are also discussed in the sub-action on promoting people-centred, Integrated health servicesHealth services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector and according to their needs throughout the life course. delivery. 

     

  • High-quality services are equitable, meaning patients, families, and communities receive the same treatment regardless of personal characteristics such as gender, race, ethnicity, geographical location, and socioeconomic status. In reality, gaps in quality service delivery impact disadvantaged populations the most. Thus, to achieve the goal of high-quality services for all, it will be important to prioritise interventions that translate to better outcomes for these populations.(111)

    Visit the WHO’s webpage on health equity to learn more about health equity and its determinants.
     

    • A clinical practice guideline is meant to be a more flexible set of evidence-based recommendations than a standard of care. Providers can consult practice guidelines to help them make decisions about how to manage care for specific clinical conditions, including what screening, diagnostic, or therapeutic actions to use. 74
    • Compassion is the emotional response to another person’s suffering and the authentic desire to take action to relieve their pain or suffering in some way. 90
    • Comprehensiveness refers to the provision of holistic and appropriate care across a broad spectrum of health problems, age ranges, and treatment modalities. Comprehensive care should address a wide range of preventive, promotive, chronic, behavioural, and rehabilitative services and include an assessment of a patient’s risks, needs, and preferences at the primary care level. 
    • Effectiveness refers to care that is evidenced-based and adheres to established standards and the extent to which a specific intervention, procedure, regimen or service does what it is intended to do for a specified population when deployed in everyday circumstances.
    • Efficiency refers to the ability of a health system to attain its desired objectives with the available resources, while minimising waste and maximising capacities to deliver care to those who need it.
    • Equity in health refers to “the absence of systematic or potentially remediable differences in health status, access to health care and health-enhancing environments, and treatment in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically within and across countries.” 13
    • Extrinsic motivation refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include salary, pensions, insurance, travel, child care, heat, retention allowances, subsidised meals, subsidised clothing, and subsidised accommodation. 34
    • The first level of care is “the entry point into the health care system at the interface between services and community; when the first level of care satisfies several quality criteria, it is called primary care.” 15
    • Health care services refer to any intervention, procedure, regimen, or process that PCPs use to respond to the needs and demands of their patient population.
    • Health in All Policies is “an approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasises the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” 13
    • Integrated health services refers to “the management and delivery of health services so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services through the different functions, activities, and sites of care within the health system.” 13
    • Intrinsic motivation is a feeling of accomplishment driven by organisational goals and the impact of one’s work on patients and communities. 
    • Outcomes are the effects of the provision and experience of care on processes of care and on patients’ health.
    • Patient cycle times, or the office visit cycle time, is the amount of time in minutes that a patient spends at an office visit. The cycle begins at the time of arrival and ends when the patient leaves the office.
    • Patient engagement is a partnership between patients and their care team. It combines patient activation with interventions to promote positive health behaviours, such as obtaining preventive care or engaging in regular physical exercise. The focus on activation and engagement rather than compliance recognizes that patients manage their own health most of the time and need to be able to make informed decisions about their own health.
    • People-centred care is “an approach to care that consciously adopts the perspectives of individuals, carers, families, and communities as participants in and beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care also requires that people have the education and support they need to make decisions and participate in their own care.” 13
    • Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” 15
    • Primary health care (PHC) is “a whole-of-society approach to health that aims to maximise the level and distribution of health and well-being through three components:  (a) primary care and essential public health functions as the core of integrated health services; (b) multisectoral policy and action; and (c) empowered people and communities.” 15
    • PHC services refer to any intervention, procedure, regimen, or process that providers use to respond to the needs and demands of their patient population at the primary care level.(15) Because of PHC’s community-facing orientation, services can be provided virtually or face-to-face in homes, communities, or PHC centres. Depending on the context, services may be provided by public or private providers. 6 7 8
    • Provider availability is defined as the presence of a trained provider at a facility or in the community when expected to provide the services as defined by his or her job description.
    • Provider competence entails having and demonstrating the knowledge, skills, abilities, and traits to successfully and effectively deliver high-quality services.
    • Provider motivation “...in the work context can be defined as an individual’s degree of willingness to exert and maintain an effort towards organisational goals.”(112) Motivation captures intrinsic (Intrinsic motivationIntrinsic motivation is a feeling of accomplishment driven by organisational goals and the impact of one’s work on patients and communities. ) and extrinsic (Extrinsic motivationExtrinsic motivation refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include salary, pensions, insurance, travel, child care, heat, retention allowances, subsidised meals, subsidised clothing, and subsidised accommodation.) characteristics that affect the behaviour and performance of providers in a health system. 
    • Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended. 
    • A service delivery platform refers to the level of a health system at which interventions can be appropriately, effectively, and efficiently delivered.
    • Shared decision making “is an interactive process in which patients, their families and carers, in collaboration with their health provider(s), choose the next action(s) in their care path following an informed analysis of possible options, their values, and preferences.”(113)
    • Social determinants of health “...are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.”(114)
    • A standard of care is a guideline that explicitly defines what is required to achieve high-quality care for a given service, including how providers should act and the reasonable degree of care a patient should expect to receive based on their specific health needs. 71 72
    • Timeliness refers to the ability of the health system to provide PHC services to patients when they need them with acceptable and reasonable wait times and at days and times that are convenient to them.  

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

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