Organisation of services

Service packages are an important tool for influencing service delivery. In order to achieve universal health coverage, service packages should offer comprehensive services of optimized quality. ¹⁴⁵⁶ The following activities can help planners to design and implement such a package across different care delivery sites:

Key activities 

National and sub-national levels

Gather a diverse, representative set of stakeholders

Including a wide range of stakeholders from various aspects of the health system in the process of developing an essential package of health services ensures that services are relevant, acceptable, and appropriate to a diverse population. The WHO has identified three categories of stakeholders that should be involved in priority setting: ⁷⁸

• Government: The role of the government is to plan, initiate, coordinate, and oversee the priority-setting process within and across stakeholders and organisations. The way in which government stakeholders coordinate the priority setting process and decide who specifically will be engaged depends on the economic and political environment of the health system. For example, decentralised environments may need to collaborate more with local governments and health workers; whereas, highly aid-dependent contexts may involve more collaboration with development partners. High-level actors may include policy-makers and planners in the Ministry of Health and other ministries as well as administrative and health authorities at decentralised levels.
• Health workers: health workers are important stakeholders because they can offer insights into the feasibility of prioritised service delivery decisions, including balancing patients’ needs and demands with cost-effectiveness. Health workers in both the public and non-public sectors should be included.
• Patients and communities: To ensure stakeholders are accountable for their decisions, patients and communities should be involved in determining which priorities are set as a part of a democratic process. Patients should be well-informed in advance about the advantages and disadvantages of various options. Citizen-level actors may include patients themselves, community representatives, caregivers, or groups of patients. Particular attention should be given to ensuring a diverse and representative group of citizen-level actors in this process. Other important stakeholders include civil society organisations that can represent a broad range of different groups and interests.

Finally, this group of diverse stakeholders should regularly convene to revise priorities and the essential package of health services as part of a national planning process. As the burden of disease or country context changes, so too will the way that health systems choose to prioritise certain services. 

Explore existing data

A comprehensive essential package of health services should cover health protection, prevention, management, and palliation across key life course needs and disease programs including emergency situations, reproductive health, growth, development, disability, ageing, communicable diseases, noncommunicable diseases, mental health, and violence and injury. ² However, the specific services prioritised within each need will differ between settings. Comprehensive and contextualised services take into account the burden of disease and the highest causes of morbidity and mortality within a setting as well as other national or subnational priorities such as risk factor profiles and projections. ⁴  Stakeholders responsible for developing the essential package of health services should identify the relevant data sources in their country and explore the existing data. 

Prioritise services

If a country has identified a number of different services to expand, it might be necessary to prioritise between them and focus on the highest need services before expanding to others. By extension, it also helps to establish what kind of training health workers need as well as the medicines and supplies that must be available at different levels of care to effectively cover the identified services. 

However, selecting the highest priorities is not always easy and stakeholders may need to identify various criteria to do so. A few examples of criteria for selection include:  prioritising the most cost-effective services; prioritising the services that benefit the worst-off populations, or prioritising services that offer substantial financial risk protection. 

More information on different prioritisation criteria can be found in the WHO report on making fair choices on the path to UHC and in the adjustment to population health needs module.

Integrate services across the health system

Well-organised services are well integrated across the health system. Integrated health service delivery is an approach to strengthening people-centred health systems through the promotion of comprehensive, coordinated services across the continuum of care. ⁹ Integrated models that offer a more comprehensive set of skills and services at the frontline (including diagnostic, pharmaceutical, behavioural, and rehabilitative services) can help to increase the efficiency and timeliness of primary care. ¹⁰¹¹ Integrated models help to promote continuity and coordination through the use of referral networks and strong health information technology systems that promote communication channels among levels of care. ¹² More information on different models and approaches to integrated care can be found here and in the WHO Framework on Integrated, People-Centred Services.  

Regularly revisit and revise services as part of a national planning process

Particularly in countries that have rapidly shifting demographics and the burden of diseases, it is important to establish a regular cadence for revisiting and revising priorities and adapting the essential package of health services as part of a national planning process. Read more about the national priority setting and planning process in the adjustment to population health needs module.

Determining the levels of care at a national or sub-national level and establishing what kind of services will be provided at each level informs how patients will move between levels of care, where they should seek care for various health needs, and dictates how care-seeking is messaged to patients. Additionally, establishing clear levels of care is a first step toward ensuring that primary care is the first point of contact for the population and developing gatekeeping and referral processes.  

Supporting elements

• Policy & leadership
• Adjustment to population health needs
• Information & technology 

Relevant tools & resources

• IMAI Alliance, 2022: Compendium of resources for the integrated management of disease 
• WHO EMRO, 2022: Universal health coverage - about the priority benefits package 
• WHO, 2022: Health technology assessment and benefits package design 
• WHO, 2021: Principles of health benefit packages 
• CGD, 2017: What’s in, what’s out: designing benefits for UHC
• Glassman et al., 2015: Designing a health benefits package: what are the necessary processes?
• WHO, 2016: Framework on Integrated, People-Centered Services
• WHO, 2014: Making fair choices on the path to universal health coverage: final report of the WHO consultative group on equity and universal health coverage
• WHO, 2002: Integrated Management of Adolescent and Adult Illness modules
• WHO, 2013: Package on Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Resource Settings

Determining the levels of care at a national or sub-national level and establishing what kind of services will be provided at each level informs how patients will move between levels of care, where they should seek care for various health needs, and dictates how care-seeking is messaged to patients. Additionally, establishing clear levels of care is a first step toward ensuring that primary care is the first point of contact for the population and developing gatekeeping and referral processes. 

Key activities 

National and sub-national levels

• Define primary, secondary, and tertiary scope of care - The specific services that are delivered at primary, secondary, and tertiary levels will differ between countries based on the needs of the population, capabilities and training of different cadres, burden of disease, and access to medicines and supplies. The two main considerations for organising services across settings are differentiating between services that can and should be provided in community-based care and in facility-based care.
• Align the scope with the health benefits package - When establishing scopes of each level of care, it is important to consult the essential package of health services to ensure that services are comprehensively covered across the health system. 

District or facility level

• Determine who delivers what services - the services provided in each setting must match the s and of health workers to ensure that they are delivered safely and effectively. All members of the primary care workforce should have competencies related to people-centeredness, communication, decision-making, collaboration, evidence-informed practice, and personal conduct to enable them to provide comprehensive PHC services 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. 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. which meet the majority of people’s needs. ¹³
• Provide training as necessary - If the existing competencies at each level of care are inadequate to deliver the established services, it will be important to develop a plan to train health workers and ensure that the services can be safely and effectively delivered by other health workers in the interim. 
• Establish referral protocols and systems - While a comprehensive primary health care system should be able to care for the majority of health conditions, an established referral system is necessary for conditions that require care and coordination with higher levels of care. A two-way referral system is organized to establish effective communication between physicians within the same and at different levels of the health system. The health worker receiving the referral is required to refer the patient back to the referring health worker (ideally the patient’s primary care provider) with clear feedback on the care encounter, any treatment provided to the patient, and what needs follow-up and continued management.

Community-level

• Identify what kind of services can be provided in the community - The types of services that can and should be provided in communities depend on the needs of the population, proximity to health facilities, and access to medicines and supplies. ¹³ Often services that are most easily provided in the community are self-testing and self-care services, community health worker visits at homes, or health educational services, which all require few resources. In places with access to greater resources, it may be possible to provide care for chronic diseases such as antiretroviral treatment adherence for HIV-positive patients or provision of medication for diabetes management. 
• Determine who will get these services - Often it may not be feasible to provide community-based services to all patients at once, and it may be necessary to identify segments of the population that have specific needs that can be well managed in community settings. Different strategies for stratifying patients can be found in the population health management module and include: 
  • Targeting by specific or acute health need—for example, pregnant or postpartum women, post-discharge patients, and children 
  • Targeting by preventive need—for example, vaccines or routine care such as cervical cancer screenings 
  • Targeting by chronic disease—for example, antiretroviral treatment adherence support for HIV-positive patients or provision of medications for diabetes management
  • Targeting by risk strata—selecting groups based on the local burden of disease or greatest contributors to morbidity and mortality 
• Identify where to provide services in the community - services that can be provided to multiple people at once such as health education or prenatal groups should be accessible in common community spaces whereas services that require more privacy and one-on-one interactions with health workers should be delivered in homes or health posts. 
• Determine who will provide services in the community - Services that are provided in communities and homes are often delivered by health workers with less training than doctors or nurses, such as community health workers. When planning community-based health services, it is important to consider the skills and capabilities of these health workers and ensure that they meet the scope of services. Community-based health workers should have clear pathways for referral to facility-based care for patients who require access to services that they are unable to provide. Stakeholders can decide which individuals are most suited to carry out these activities by asking specific questions:
  • Which health workers have the training and competence to deliver the identified services?
  • How will these health workers be supervised and trained to deliver community-based care?
  • How will community-based health workers be integrated into the health system to ensure continuity?

Supporting elements

• Physical infrastructure
• Medicines & supplies
• PHC workforce
• Management of services

In order for a health system to coordinate smoothly between levels of care, primary care should be patients’ first point of contact with the health system. Patients are more likely to receive comprehensive, longitudinal care and the health system is best able to utilize referral systems and care pathways when patients access services through primary care. Additionally, establishing primary care as the first point of contact can prevent the overuse of higher-level services. 

Key activities

National and sub-national levels 

• Promote integrated models of care - In systems that are historically oriented toward hospital-based care or strong vertical programs (such as the Mongolian health system in the 1990s, read the case study here), patients may prefer hospital-based care, and PHC systems may not have received the level of commitment and investment necessary to meet the majority of a person’s health needs. ¹⁴ Such contexts should move to adopt an “integrated” approach, which focuses on building one overarching plan, budget, and accountability framework for the health sector. Under this model, vertical programmes are encouraged to align their requirements with the health sector strategic plan. For example, many countries have included basic HIV, TB, and newborn and child health care services in the essential package of health services, thus supporting a shift to comprehensive PHC. ¹⁵¹⁶¹⁷
• Ensure geographic access to care - Geographic barriers to care can limit access to services. Health systems should ensure that there are facilities situated within a reasonable distance from all communities and that community-based services are available in remote locations. Providing access to transportation can also help resolve geographic barriers. More information on geographic access to care can be found in the access module. 
• Ensure financial access to care - Patients may avoid accessing care or bypass primary care services if they perceive that they are too expensive. Appropriate funding mechanisms should be in place to ensure that patients can seek care without experiencing catastrophic health expenditures. More information on geographic access to care can be found in the access module. 
• Develop referral mechanisms - Referral mechanisms help to ensure that patients can get access to the care they need when their conditions cannot be addressed at the primary care facility. These may be set at the health system level and then further defined at the district or facility level. Strong referral mechanisms will incentivize patients to use primary care as their first point of contact and improve their trust in the system that they will receive appropriate care. See the next action for additional guidance. 

District or facility level 

• Empanel patients - empanelment is the active and ongoing assignment of an individual or family to a primary care provider for the provision of care and is the organizational foundation of population health management. Empanelment ensures that patients know where to access care and can build a longitudinal relationship with health workers.  
• Create - In a gatekeeping model, patients can only receive care from secondary or tertiary facilities if they first seek an approved referral from a primary care provider. Different health systems may choose to make this required or just strongly encouraged. 

Community-level

• Create demand - patient education about how, where, and why to seek care from primary health care services both in the community and the facility can help to promote primary health care as the first point of contact. 
• Establish community-based care - Placing services directly in the community improves geographic access to care. Community-based health workers can also refer patients to primary health care facilities for services beyond their scope, ensuring that patients are accessing the right level of care for their health needs.
• Proactive outreach -  Proactive population outreach can also improve timeliness and access to care, thus improving first contact access. 

Supporting elements

• Policy & leadership
• Funding & allocation of resources
• Information & technology
• Population health management
• Access
• Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” functions

Relevant tools & resources 

• WHO, 2021: Fostering resilience through integrated health system strengthening: technical meeting report
• CGD, 2020: Getting to Convergence: How “Vertical” Health Programs Add Up to A Health System
• JLN, 2019: Empanelment: a foundational component of primary health care 
• R4D, 2019: Should vertical programs be integrated into primary health care?
• WHO, 2016: Framework on Integrated, People-Centered Services
• WHO, 2016: Integrated Care Models: An Overview
• MEASURE Evaluation, 2013: Referral system assessment and monitoring toolkit 
• PAI: Integrating Vertical Programs into Primary Health Care

As discussed above, referral mechanisms help to ensure that patients can get access to care as intended. They also help to reduce care fragmentation as patients move through the health system, making them an effective tool for well-organized service delivery. 

Key activities

Establish broad referral systems

Referrals may occur because an expert opinion, additional services, or better treatment is necessary for a patient and cannot be provided in the original primary care setting. Additionally, referral may occur so that patients can get access to diagnostic or therapeutic tools that are only available at a higher level of care. ¹⁸ There are few overarching resources from LMIC that directly describe processes for establishing broad referral systems. However, resources that are specific to certain conditions such as HIV or diabetes and descriptions of referral processes from individual countries can be useful resources in considering how to structure a referral system. 

Often, in LMICs, patients are able to access higher-level facilities directly and bypass primary care, which can pose challenges for communication and coordination. In fact, more than 60% of patients directly access higher-level facilities on their own, and more than 50% of those who are seeking care at the tertiary level could be treated effectively at a lower-level facility. Establishing a gatekeeping structure in which patients must receive a referral from a primary care health worker to access higher levels of care is an important first step in establishing a functional referral system and increasing efficiency. However, establishing a functional referral system also requires systems for making a referral decision (in which a health care worker determines if a referral is needed and to whom) and for communicating about referrals (in which information can be passed between health care workers throughout the course of a referral). ¹⁹

The Challenge Initiative for Healthy Cities, supported by USAID and the Gates Foundation, implemented a three-year project in India to strengthen city-level health systems, and as part of their work, organised an urban referral system. Referral systems had been established in rural areas throughout India, but urban settings posed unique challenges due to the lack of a single governing body, difficulty empanelling patients to different facilities because of lack of geographic demarcation, and stratification of community groups making it difficult to implement health activities. The project defined their goals in establishing an urban referral system: ¹⁹

• Increase use of services at lower levels
• Reduce self-referral 
• Develop service providers’ capacity to offer services and refer at each level 
• Improve the health system’s ability to transfer patients between levels 
• Improve supportive supervision 
• Improve referral performance monitoring and coordination and referral feedback information 
• Strengthen outreach systems for the provision of referral services to marginalised populations 

With a growing urban population, establishing a well-functioning referral system can increase the efficiency of facilities and help to ensure patient satisfaction by providing the appropriate care at the appropriate place and helping to establish a first point of contact for patients. The project identified eleven steps that can be used as a guide to implementing a referral mechanism:

• Ownership of referral mechanism by local government 
• Constitution of a referral technical committee 
• Baseline assessment of facilities 
• Defining the referral network and linking Urban Primary Health Centres to higher facilities 
• Customising referral tools and a referral directory 
• Piloting of referral tools 
• Training of community-level workers and staff at the facility level 
• Implementing the referral mechanism, with direct support 
• Routine meetings between facility staff and community workers 
• Data generation and monitoring of referral mechanisms 
• Feedback mechanisms and quality improvement

While the activities needed to achieve each step may differ between countries and contexts, this pathway can be used as a guide for countries seeking to establish or improve referral systems. More detail on each of these steps can be found in A Guide for Establishing Referral Mechanism in the Urban Health System of India. 

Refine referral management systems 

Referral management systems are a type of information system that can improve care coordination, reduce care fragmentation, and improve the quality of referrals and transitions. To ensure safe and timely referrals and transitions, any referrals made to support patients beyond the scope of the primary care facility should be well-coordinated across the care continuum, ²⁰ using a two-way referral system. A two-way referral system is organised to establish effective communication between physicians at different levels of the health system. The health worker receiving the referral is required to refer the patient back to the referring health worker (ideally the patient’s primary care provider) with clear feedback on the care encounter, any treatment provided to the patient, and what needs follow-up or continued management. ²¹ The importance of two-way referrals must be emphasised to ensure their consistent and effective use. 

Referral systems at the national level are often made up of a subset of regional referral networks. In order to effectively manage a referral system, the coverage (including the program or health area), scope (national versus local), and types of actors involved (private, public, primary care, speciality care) must be defined and aligned with logical referral pathways. ²² Defining a clear referral process helps to standardise the communication of patient information. It ensures a closed referral loop and that the relevant health workers track patient information. Referral management systems should track the number of referral units, the proportion of referrals fulfilled or not fulfilled, and information on why referrals were not fulfilled on both the patient and provider end (Were patients unable to complete the referral due to geographic or financial barriers?). Closing the loop through referral management tracks whether all relevant patient information is communicated in a timely manner. ²³²⁴

The configuration of a referral system will vary by setting and have a range in complexity: from a more linear referral system (primary care facilities referring to district hospitals) to a more complex referral system that makes referrals across services within the same facility and across levels of care. Data quality mechanisms with norms and protocols, standard referral indicators, and ongoing training and supervision of the referral system should be in place to ensure system performance and appropriate use. Stakeholders can look to the Referral Systems Assessment and Monitoring Toolkit for guidance on how to assess and monitor the performance of referral systems. Additional information on referral systems can be found on the Institute for Healthcare Improvement’s webpage on Closing the Loop on Patient Referrals in Health Care and the Safety 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.  Net Medical Home Initiative presentation on Closing the Loop with Referral Management.

Make information systems interoperable 

An effective, efficient, and integrated information system is vital to the performance of a health system. Poor transfer of patient information among health workers, between patients and their care teams, and across levels of care leads to uninformed care delivery. ²⁵²⁶ Coordination Coordinated care includes organizing the different elements of patient care throughout the course of treatment and across various sites of care to ensure appropriate follow-up treatment, minimize the risk of error, and prevent complications. Coordination of care happens across levels of care as well as across time, and often requires proactive outreach on the part of health care teams as well as informational continuity. relies on the ability of information systems to connect a wide range of data sources across different settings of care and reliably communicate this information at the right time and to the right people. ²⁷ This includes the communication of information to higher levels of care and back to the frontline. The coordinated exchange of information should enable all health workers involved in a person’s care to access, exchange, and use information with the goal of optimising patient well-being. ²¹²⁸ For these reasons, strong information and communication systems are vital to minimise disruptions in the care experience. ²⁷ More information on strengthening information systems is found in the information & technology module.

Some of the information that should be available for referral, counter-referral, and emergency transfer include: ²

Referral:

• Individual’s identification number
• Reason for referral and services needed at referral site
• Information related to illness
• Information related to relevant investigations already undertaken
• Medication list
• Socio-psychological factors
• Practitioner’s contact details

Counter-referral:

• Assessment of current problem
• Investigation undertaken
• Medications prescribed
• Next steps in the care of the individual

Emergency “An extraordinary situation in which people are unable to meet their basic survival needs, or there are serious and immediate threats to human life and well-being. Emergency interventions are required to save and preserve human lives and/or the environment. An emergency situation may arise as a result of a disaster, a cumulative process of neglect or environmental degradation, or when a disaster threatens and emergency measures have to be taken to prevent or at least limit the effects of the eventual impact. (UNDP)” transfer: 

• Provision of medical screening examination and stabilising treatment
• Condition of patient
• Timing of transfer
• Mode of transfer
• Level of care during transfer
• Destination of patient
• Inclusion of pertinent records and images

Support elements

• Information & technology
• Management of services

Relevant tools & resources

• IHI, 2017: Closing the loop on patient referrals in health care
• World Bank, 2017: Improving Linkages and Referrals to the Broader Health System: For Equitable Care Amidst Rapid Growth and Urbanization
• MEASURE Evaluation, 2013: Referral system assessment and monitoring toolkit 

Determining care pathways for common conditions ensures continuity and coordination of care and defines how different levels of care interact to support patients. Well-organized services will be able to achieve this through clearly defined processes that adhere to standards of care, supported by strong communication systems and referral and counter-referral systems.

Key activities

Determine relevant tracer conditions

Relevant tracer conditions will differ across settings depending on the burden of disease and leading causes of morbidity and mortality. Some common examples of conditions that may require a care pathway include chronic health disease, diabetes, cancer, depression, or pregnancy complications. Health system planners can begin by collecting and reviewing data to identify conditions that contribute to morbidity and mortality in the country and require coordination between multiple levels of care. 

Review clinical guidelines for each tracer condition

Care pathways should build upon existing clinical guidelines and operationalize them in the context of the health system. For example, a clinical guideline might recommend referral to an outpatient rehabilitation program for a specific condition. A care pathway would provide details on when to submit the referral and to whom, tailored to the culture, processes, and environment of the health system. ²⁹ Care pathways are therefore dependent upon the presence of well-defined clinical guidelines, clear delineation in the services that are delivered at each care level, and existing referral systems. Three steps can be considered when developing a disease-specific care pathway: ³⁰

1. Assembling the fact base—assembling the fact base is the process of collecting all of the relevant information that can help health system stakeholders identify how and when people should seek care. For instance, some conditions may start with prevention while others may start with detection. This would be an important first step for thinking through what kind of interventions are necessary at each step. For each step, it’s also important to consider what process and outcome measures should be collected to accurately assess the care pathway’s implementation and impact. 
2. Determining when, where, and how to deliver services—after collecting relevant information, health system stakeholders can assess to what degree they are already delivering the different steps in the care pathway and where those steps must be further developed. The process and outcome indicators identified can help with this assessment process. 
3. Identifying what enablers should be in place—finally, health system stakeholders must think about how to ensure that the care pathway is well-supported. For example, health care workers must be motivated and appropriately trained in the pathway, patients must be given relevant information and education to adhere to care as they move along the pathway, health systems must have the necessary information and technology to support the flow of information, and there must be sufficient funding to support the pathway. 

Further detail on each of these steps is included in the document using care pathways to improve health systems. 

Translate clinical guidelines into clear practices

Care pathways should translate clinical guidelines into clear practices that are relevant to the setup of individual facilities as well as the different levels of care. The care pathway will detail how communication takes place between team members and patients, the sequence of care within the team, how to document and monitor outcomes, and identify appropriate resources. 

Supporting elements

• Multi-sectoral approach
• Adjustment to population health needs
• Information & technology
• Management and services

Relevant tools & resources

• WHO, 2022: COVID-19 clinical care pathway
  McKinsey & Company, 2011: Using care pathways to improve health systems

When primary health care services are delivered by a multidisciplinary team, they are more comprehensive and efficient. Effective teams have a mix of health workers with different skills and also function as a singular unit to provide coordinated and comprehensive care. 

Key activities

Create an enabling environment for teams

Settings with limited resources and poor health facility coverage can consider introducing team-based care strategies in their clinical workflows and protocols to improve service delivery. Team-based innovations can be especially impactful for facilities with frequent workforce shortages and limited funds. Myriad LMIC countries have adopted team-based approaches to improve the delivery of care and increase outreach to the communities they serve, such as through integrated community case management (iCCM). In particular, team-based approaches that actively engage communities in health care delivery and include diverse occupations of primary care workers, such as mid-level practitioners and CHWs, will play a central role in scaling high-quality PHC services 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. 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. . Teams can also reduce the burden on physicians and support the delivery of more comprehensive care by making use of the diverse skills of trained health workers, such as nurses, social workers, nutritionists, and CHWs, among others.  Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” facilities may prepare for team-based care organisation in a number of ways: ^313233343536

• Develop an organisational culture for team-based, person-centred care, including through effective management of services
• Implement self-management supports that engage patients as equal partners or “team-members” in managing their health, such as through health education and self-management tools
• Clearly define roles and responsibilities for different team members and provide guidelines and ongoing education for health workers, including by training health care workers in new skills
• Implement quality improvement initiatives and accountability mechanisms to create and enforce accountability between members of the care team, such as through supportive supervision and regular team meetings 
• Adopt the use of information and communication technologies and clinical decision support tools that support timely, coordinated care between patients and members of the care team 

In addition, some institutional barriers to account for include staff retention challenges, patient and health worker attitudes toward team-based care, payment systems that are not designed to reward team-based care, and insufficient legislation and policies for such strategies.

Build the care teams

Defining roles and determining the mix of health workers within a care team involves consideration of the patient panel needs, the human resource supply, and national policies for care delivery. No single “ideal” team composition exists, and though the size and composition of teams can vary dramatically, even small teams of two or three health workers working together can yield benefits to patients beyond what health workers operating individually would be able to achieve.

Stakeholders should address the following three overarching considerations when building a care team tailored to the needs of the population and reflecting existing resources:

Determine the size of the care team

The right size for a care team will depend on the size of the empaneled population, how frequently they actively seek care, and the burden of disease and demographics specific to the panel. This information in conjunction with an understanding of the workload and capacity of each member of the care team can help managers understand how many health workers are necessary to effectively support the needs of their panel. The below process may be useful for determining the size of care teams in empaneled and non-empaneled settings: 

• Empaneled—If the population is already empaneled, determining the size of the care team involves consideration of the size of the patient panel, how frequently they actively seek care, and how often they should be receiving proactive care (see population health management). Additionally, decision-makers should evaluate the workload and capacity of existing health workers. The number of patients a health worker sees each day, the minutes they spend with each patient, and working hours in the day can help determine the capacity of a given health worker, team, or facility. These data can then be remapped to calculate what size care team is needed to provide efficient care while also spending an appropriate amount of time with patients.
• Not empaneled—If the population is not empaneled, implementers may consider establishing empanelment to better understand the size and needs of patients. However, implementers can also estimate the panel by enumerating the patients who actively seek care as well as those for whom the facility should be responsible based on geography. Balancing team size relative to the panel is important; if a care team is too large, continuity may be compromised while a small care team may not be able to appropriately manage their patients. ³⁷

Determine the composition of the care team 

The size and composition of the care team should be considered together. Determining an optimal composition requires consideration of existing provider cadres within the country, including their skills and training, and it may be useful to map the needs of a patient panel to the of various health workers. While each panel will require a different mix of health workers based on health needs, facility capability, and geographic access to specialised services, potential cadres that may be included in team composition include doctors, mid-level practitioners, nurses, clinical assistants, administrative assistants, pharmacists and pharmacy assistants, oral/dental health practitioners, mental health practitioners, vision/eye care practitioners, lab personnel, physiotherapists/occupational therapists, rehab practitioners, social workers, financial assistants, community health workers, and team managers or supervisors. The competencies of these cadres will differ based on training curricula and roles and responsibilities in each country.

Delegate responsibilities

Having determined the composition and size of the care team, facility managers can delegate responsibilities between different health workers and establish processes for how health workers work together and communicate relevant information to one another. However, when delegating responsibilities, it is important to ensure that health workers are capable of delivering a range of services are available in the facilities at all times in order to facilitate patient access to services and promote integration and comprehensiveness.

The Cambridge Health Alliance in the United States has a useful guide for developing care teams, including specific steps to ensure effective delegation of responsibilities:

• Define goals and develop a shared aim—Teams should be able to define their goals for delivering care to their patient panel. These goals can be used as a means to establish team expectations and define performance measurement targets as well as service delivery activities.
• Define specific, measurable outcomes and objectives—It is important to ensure that facility performance measures encompass team-based care and are mapped to team goals.
• Assign roles for each care team member and define and delegate functions and tasks—List all of the tasks completed within the facility during a typical day and delegate each task to a specific member of the care team. The scope of each task should be clear to all members of the care team, and expectations should be recorded and physically accessible (i.e. pinned in a common area or available on a web portal).
• Ensure that each team member is competent to perform their defined and delegated functions and tasks—When delegating tasks, team leaders should ensure that each team member feels that they have the necessary training and skills to perform the expected tasks. Health workers should receive regular in-service training, and there should also be appropriate supportive supervision in place to monitor performance.
• Ensure that clinical and administrative systems are present and able to support team members in their defined work—For instance, if team members are expected to record information about patients or keep appointment records, there should be standardised systems for doing so, and health workers should be trained in their use.
• Create communication structures and processes—When working with a team of health workers, it is important to create protected time, such as regular team meetings, to communicate changes in service delivery and review patients or expectations. Additionally, if patients are seen by multiple health workers, there should be appropriate systems in place for health workers to record relevant information to inform future care and hand-offs between health workers.
• Use data to assess team progress and performance—The use of data is discussed in more detail in the management of services module. However, the presence of systems for data collection and analysis is not sufficient to improve performance; care teams must consider how they will receive and incorporate data on their performance through feedback from managers and facility leaders as well as from health workers. Based on the frequency of performance reports and facility-level improvement systems, care teams may choose to set aside time on a regular basis to review performance and adapt care processes as needed. ³⁷

Build systems for a strong team culture 

Effective care teams must not only have an appropriate mix of health workers with different skill sets, but must also function as a singular unit to provide effective, coordinated, and comprehensive care to their population. Collaborative teamwork requires skills that may not be inherent to all health workers, and these skills may need to be developed and fostered as a team. ³⁸ Coherent and unified teams should share a sense of collective responsibility and have well-defined but flexible roles and work procedures. Strategies to build strong teams include the following:

• Identify a facilitator for team building—One member of the team should be responsible for team building, which may include facilitating team huddles, verbally sharing feedback with the team, or communicating changes in care delivery. This individual does not necessarily need to be the team member with the most education or training, but he or she should have strong interpersonal and leadership skills and understand the goals and purpose of the team. It is important to communicate that this facilitator is not the “leader” of the team, and this person should work to ensure that all members of the team have a voice and contribute to team decisions.  
• Implement regular teamwork training—Teams should have protected time to work on improving their teamwork and understanding how their roles fit with the other members of the care team.
• Ensure that all facility staff concerns are heard—Because transitioning to sharing patients and working in a team may take time and effort, it is important for facility leaders to actively solicit and respond to staff concerns. This can even take place in a structured manner during team meetings. Facility leaders may choose to consider anonymous feedback systems as well.
• Protect time for holding case conferences—Team members can support one another’s continued learning and improvement by reviewing patients together as a team and discussing how they could optimise their specific skills and training to ensure that similar patients receive the best possible care. This practice is particularly relevant when facilities identify errors or near misses. These instances should be debriefed with the whole team. More information on cultivating a safety culture is discussed in the service quality module. ³⁹

An upstream and long-term approach to achieving optimal team performance is interprofessional education. Sensitising health workers to the skill sets and values of other cadres during medical or continuing education may make them stronger collaborators when they are part of care teams in facilities. The WHO recommends six action steps for advancing interprofessional education: ⁴⁰

• Agree to a common vision and purpose for interprofessional education and identify key stakeholders
• Develop interprofessional education curricula according to principles of good educational practice
• Provide organisational support and financial/time allocations for developing the delivery of interprofessional education and staff training
• Introduce interprofessional education into health worker training programs
• Ensure that there are competent staff who are responsible for developing, delivering, and evaluating interprofessional education
• Ensure that leaders of education institutions/work settings are committed to interprofessional education

If interprofessional education seems like a potentially successful long-term strategy in a given context, stakeholders can start by evaluating the current education system and identifying opportunities where interprofessional curricula can be integrated into existing courses or training. There are two considerations for interprofessional education:  1) creating a curriculum for a single provider cadre that draws on lessons and materials from diverse disciplines, and 2) training professionals from different provider cadres together (i.e. doctors, nurses, midwives, CHWs). The WHO has published a case study on the integration of interprofessional education programs focused on the former consideration at Kamuzu College of Nursing in Malawi.

Supporting elements

• PHC workforce
• Information & technology
• Population health management
• Management of services

Relevant tools & resources

• AHRQ, 2016: Creating patient-centered team-based primary care
• Safety 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.  Net Medical Home Initiative, 2013: Implementation guide for continuous and team-based healing relationships
• Safety 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.  Net Medical Home Initiative, 2013: Common Barriers and Strategies to Support Effective Health Care Teams for Integrated Behavioral Health 
• WHO, 2010: Framework for Action on Interprofessional Education & Collaborative Practice

Well-organised services are comprehensive and rooted in local needs 

A well-defined and contextualised essential package of health services is a critical element of well-organised services. The WHO defined a service package as “a list of prioritised interventions and services across the continuum of care that should be made available to all individuals in a defined population. It may be endorsed by the government at a national or subnational level or agreed by actors where care is by a non-State actor.” 

As noted in the definition, essential packages of health services may be developed at a national or subnational level depending on the structure of the health system, but in order to be useful to the populations they serve, they must be contextualised to the setting and rooted in local need. In addition, they must be comprehensive. ⁴

Well-organised services are clearly defined across levels of care

Ensuring that services are well defined across levels of care requires thinking beyond PHC to define the services that are best delivered at each level of care while building a system that promotes primary care as the first point of contact and builds for accessing higher levels of care. In a system with comprehensive primary health care, 95% of patient contact with the health systems should take place in primary care settings with only 5% of patients being referred to secondary care. ⁴¹ The specific services that are delivered at primary, secondary, and tertiary levels will differ between countries based on the needs of the population, capabilities of different provider cadres, the burden of disease, and access to medicines and supplies. 

Well-organised services promote primary care as the first point of contact

PHC systems should act as the first point of contact for the majority of a person’s health needs throughout their life course. ⁴²⁴³⁴⁴ In a health system with primary care as the first point of contact, primary care refers patients (to hospital or specialists) only for those problems not manageable within the primary care setting and coordinates all of the care a person receives at different care settings and levels of care. ³⁴² This management and coordination hinges on the capacity of PHC systems to effectively meet the majority of a person’s needs and demands (Are health workers consistently available and competent? Are services high-quality and accessible?) as well as a person’s care-seeking behaviour (Where do patients seek care and why?).

First contact accessibility is related to improved technical and experiential outcomes as well as reduced utilisation of unnecessary emergency and inpatient services. ⁴²⁴³⁴⁴ While strengthening first contact accessibility is key for expanding coverage, access to care is not enough, and patients must receive high-quality services to tangibly improve health outcomes. Because individuals are active agents in choosing when and where to access care, the public must trust and value primary health care systems as the main source of care. ⁴⁵⁴⁶⁴⁷

Well-organised services ensure appropriate referrals and coordination pathways 

As discussed in the above sections, a well-organised health system should have a comprehensive set of services available to the population that are appropriately distributed across levels of care based on available infrastructure and workforce. Additionally, the system should be structured such that patients’ first point of contact with the health system is at the primary care level. In such a system, it is important that health workers are able to easily refer patients to higher levels of care and receive information back from higher-level facilities (referral and counter-referral, respectively) as well as quickly utilise emergency transfer to appropriately manage their patients and ensure coordination of care. Therefore, not only protocols but also robust and interoperable information systems are necessary to support a comprehensive and coordinated health system. 

Well-organised services have established care pathways 

Well-organised services should define standardised processes for the way in which the health system cares for patients with specific conditions. Care pathways can improve efficiency and ensure that all relevant aspects of care for a given condition are considered and addressed in a standardised manner

A care pathway defines the decision-making about and organisation of care processes that must take place during a defined period of time for patients with a specific condition. ²⁹ A well-functioning care pathway should be developed by considering a country’s organisation of services across levels of care, referral protocols, and best practices for the care of a given condition in order to define and standardise the experience of care for a group of patients. An effective care pathway will translate clinical guidelines into local structures, detail steps in a course of treatment, and standardise care in order to reduce variation in clinical practice and promote evidence-based care. ² Care pathways should define: ²⁹

• Goals and key elements of care for the given condition
• How and when communication occurs between team members, patients, and families
• The sequence of care within a multidisciplinary team 
• Documentation, monitoring, and evaluation of outcomes
• Identification of appropriate resources

Care pathways are especially important for conditions that require coordination across multiple levels of care. Selection of conditions that would benefit from an established care pathway will differ across settings depending on the burden of disease and leading causes of morbidity and mortality. Some common examples of conditions that may require a care pathway include chronic heart disease, diabetes, cancer, depression, or pregnancy complications. These conditions require coordination between multiple levels of care and—in a system with comprehensive care where primary care is the first point of contact—should involve communication back to the primary care provider to promote continuity and coordination. 

Well-organised services are delivered by multidisciplinary teams 

The majority of the available literature and toolkits addressing the implementation of team-based care come from high-income countries (HIC) and may assume certain structural capabilities such as fully integrated electronic information systems, consistent internet connectivity, adequate human resource supply, and patient access to services. ⁴⁸⁴⁹ Regardless, many of the considerations in these resources are relevant or can be adapted to low and middle-income country (LMIC) contexts.

• Competencies The observable abilities—including knowledge, skills, and behaviours—of individual health workers that relate to specific work activities. Competencies are durable, trainable, and measurable. are the observable abilities—including knowledge, skills, and behaviours—of individual health workers that relate to specific work activities. Competencies The observable abilities—including knowledge, skills, and behaviours—of individual health workers that relate to specific work activities. Competencies are durable, trainable, and measurable. are durable, trainable, and measurable.
• Skill mix Skill mix describes the combination of different occupations of health workers (i.e. doctors, nurses, and midwives) in a primary care practice in terms of numbers, diversity, and competencies. describes the combination of different occupations of health workers delivering primary care in terms of numbers, diversity, and competencies
• Gatekeeper systems Gatekeeper systems help to facilitate primary care as the first point of contact and promote continuous, accessible, and coordinated care within a panel. In an “explicit” gatekeeper model, patients can only receive care from secondary or tertiary facilities if they first seek an approved referral from their primary care provider. In this way, primary care serves as the entry point to the health system and improves first-contact accessibility. By contrast, “implicit” gatekeeping occurs if patients are encouraged but not required to visit their primary care provider before seeking secondary or tertiary care. help to facilitate primary care as the first point of contact and promote continuous, accessible, and coordinated care within a panel. In an “explicit” gatekeeper model, patients can only receive care from secondary or tertiary facilities if they first seek an approved referral from their primary care provider. In this way, primary care serves as the entry point to the health system and improves first contact accessibility. By contrast, “implicit” gatekeeping occurs if patients are encouraged but not required to visit their primary care provider before seeking secondary or tertiary care.