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Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes. On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68-0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes-integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider's advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039). Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes.

Primary health care (PHC) has been recognized as a core component of effective health systems since the early part of the twentieth century. However, despite notable progress, there remains a large gap between what individuals and communities need, and the quality and effectiveness of care delivered. The Primary Health Care Performance Initiative (PHCPI) was established by an international consortium to catalyze improvements in PHC delivery and outcomes in low- and middle-income countries through better measurement and sharing of effective models and practices. PHCPI has developed a framework to illustrate the relationship between key financing, workforce, and supply inputs, and core primary health care functions of first-contact accessibility, comprehensiveness, coordination, continuity, and person-centeredness. The framework provides guidance for more effective assessment of current strengths and gaps in PHC delivery through a core set of 25 key indicators (“Vital Signs”). Emerging best practices that foster high-performing PHC system development are being codified and shared around low- and high-income countries. These measurement and improvement approaches provide countries and implementers with tools to assess the current state of their PHC delivery system and to identify where cross-country learning can accelerate improvements in PHC quality and effectiveness.

Context: The Primary Health Care Performance Initiative (PHCPI), a collaboration between the Bill and Melinda Gates Foundation, The World Bank, and the World Health Organization, in partnership with Ariadne Labs and Results for Development, was launched in 2015 with the aim of catalyzing improvements in primary health care (PHC) systems in 135 low- and middle-income countries (LMICs), in order to accelerate progress toward universal health coverage. Through more comprehensive and actionable measurement of quality PHC, the PHCPI stimulates peer learning among LMICs and informs decision makers to guide PHC investments and reforms. Instruments for performance assessment and improvement are in development; to date, a conceptual framework and 2 sets of performance indicators have been released. Methods: The PHCPI team developed the conceptual framework through literature reviews and consultations with an advisory committee of international experts. We generated 2 sets of performance indicators selected from a literature review of relevant indicators, cross-referenced against indicators available from international sources, and evaluated through 2 separate modified Delphi processes, consisting of online surveys and in-person facilitated discussions with experts. Findings: The PHCPI conceptual framework builds on the current understanding of PHC system performance through an expanded emphasis on the role of service delivery. The first set of performance indicators, 36 Vital Signs, facilitates comparisons across countries and over time. The second set, 56 Diagnostic Indicators, elucidates underlying drivers of performance. Key challenges include a lack of available data for several indicators and a lack of validated indicators for important dimensions of quality PHC. Conclusions: The availability of data is critical to assessing PHC performance, particularly patient experience and quality of care. The PHCPI will continue to develop and test additional performance assessment instruments, including composite indices and national performance dashboards. Through country engagement, the PHCPI will further refine its instruments and engage with governments to better design and finance primary health care reforms.

Background Primary health care is a critical foundation of high-quality health systems. Health facility management has been studied in high-income countries, but there are significant measurement gaps about facility management and primary health care performance in low and middle-income countries. A primary health care facility management evaluation tool (PRIME-Tool) was initially piloted in Ghana where better facility management was associated with higher performance on select primary health care outcomes such as essential drug availability, trust in providers, ease of following a provider’s advice, and overall patient-reported quality rating. In this study, we sought to understand health facility management within Uganda's decentralized primary health care system. Methods We administered and analyzed a cross-sectional household and health facility survey conducted in Uganda in 2019, assessing facility management using the PRIME-Tool. Results Better facility management was associated with better essential drug availability but not better performance on measures of stocking equipment. Facilities with better PRIME-Tool management scores trended towards better performance on a number of experiential quality measures. We found significant disparities in the management performance of primary health care facilities. In particular, patients with greater wealth and education and those living in urban areas sought care at facilities that performed better on management. Private facilities and hospitals performed better on the management index than public facilities and health centers and clinics. Conclusions These results suggest that investments in stronger facility management in Uganda may strengthen key aspects of facility readiness such as essential drug availability and potentially could affect experiential quality of care. Nevertheless, the stark disparities demonstrate that Uganda policymakers need to target investments strategically in order to improve primary health care equitably across socioeconomic status and geography. Moreover, other low and middle-income countries may benefit from the use of the PRIME-Tool to rapidly assess facility management with the goal of understanding and improving primary health care performance.

Background: Primary health care (PHC) systems require motivated and well-trained frontline providers, but are increasingly challenged by the growing global shortage of health care workers. Burnout, defined as emotional exhaustion, depersonalization, and low personal achievement, negatively impacts motivation and may further decrease productivity of already limited workforces. The objective of this review was to analyze the prevalence of and factors associated with provider burnout in low and middle-income countries (LMICs). Methods: We performed a systematic review of articles on outpatient provider burnout in LMICs published up to 2016 in three electronic databases (EMBASE, MEDLINE, and CAB). Articles were reviewed to identify prevalence of factors associated with provider burnout. Results: A total of 6,182 articles were identified, with 20 meeting eligibility criteria. We found heterogeneity in definition and prevalence of burnout. Most studies assessed burnout using the Maslach Burnout Inventory. All three dimensions of burnout were seen across multiple cadres (physicians, nurses, community health workers, midwives, and pharmacists). Frontline nurses in South Africa had the highest prevalence of high emotional exhaustion and depersonalization, while PHC providers in Lebanon had the highest reported prevalence of low personal achievement. Higher provider burnout (for example, among nurses, pharmacists, and rural health workers) was associated with high job stress, high time pressure and workload, and lack of organizational support. Conclusions: Our comprehensive review of published literature showed that provider burnout is prevalent across various health care providers in LMICs. Further studies are required to better measure the causes and consequences of burnout and guide the development of effective interventions to reduce or prevent burnout.

Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.

Disrespect and abuse (D & A) experienced by women during facility-based childbirth has gained global recognition as a threat to eliminating preventable maternal mortality and morbidity. This study explored the frequency and associated factors of D & A in four rural health centres in Ethiopia. Experiences of women who delivered in these facilities were captured by direct observation of client-provider interaction (N = 193) and exit interview at time of discharge (N = 204). Incidence of D & A was observed in each facility, with failure to ask woman for preferred birth position most commonly observed [n = 162, 83.9%, 95% confidence interval (95% CI) 78.0–88.5 %]. During exit interviews, 21.1% (n = 43, 95% CI 15.4–26.7%) of respondents reported at least one occurrence of D & A. Bivariate models using client characteristics and index birth experience showed that women’s reporting of D & A was significantly associated with childbirth complications [odds ratio (OR) = 7.98, 95% CI 3.70, 17.22], weekend delivery (OR = 0.17, 95% CI 0.05, 0.63) and no previous delivery at the facility (OR = 3.20, 95% CI 1.27, 8.05). Facility-level fixed-effect models found that experience of complications (OR = 15.51, 95% CI 4.38, 54.94) and weekend delivery (OR = 0.05, 95% CI 0.01–0.32) remained significantly and most strongly associated with self-reported D & A. These data suggest that addressing D & A in health centres in Ethiopia will require a sustained effort to improve infrastructure, support the health workforce in rural settings, enforce professional standards and target interventions to improve women’s experiences as part of quality of care initiatives. Les impertinences et abus (D&A) subis par les femmes lors d’accouchements en milieu hospitalier sont mondialement reconnus comme une menace à l’élimination de la mortalité et de la morbidité maternelles évitables. La présente étude a exploré la fréquence et les facteurs associés aux D & A dans quatre centres de santé ruraux en Ethiopie. Les expériences des femmes ayant accouché dans ces établissements ont été appréhendées par l’observation directe de l’interaction client-prestataire (N=193) et l’entrevue des patientes au moment de la sortie (N=204). Une incidence des D & A a été observée dans chacun des établissements, où l’on ne s’enquiert pas souvent de la position préférée de la cliente lors de l’accouchement [n=162, 83,9%, intervalle de confiance de 95% (IC 95%) 78,0-88,5%]. Au cours des entrevues à la sortie, 21,1% (n=43, IC 95% 15,4-26,7%) des personnes interrogées ont fait état d’au moins un cas de D &A. Les modèles bivariés utilisant les caractéristiques et l’indice d’expérience des clientes en matière d’accouchement ont montré qu’il y avait une notable corrélation entre les femmes déclarant avoir été victimes de D&A et les complications lors de l’accouchement [odds ratio (OR)=7,98, IC 95% 3,70, 17,22], les accouchements du week-end (OR=0,17, IC 95% 0,05, 0,63) et le fait de n’avoir jamais accouché dans cette formation sanitaire (OR=3,20, IC de 95% 1,27, 8,05). Les modèles à effets fixes au niveau des formations sanitaires ont montré que l’expérience d’accouchements compliqués (OR=15,51, IC de 95% 4,38, 54,94) et de fin de semaine (OR=0,05, IC de 95% 0,01-0,32) avait une très importante et forte corrélation avec les D&A autodéclarés. Ces données suggèrent que la lutte contre les D &A dans les centres de santé d’Éthiopie exige un effort soutenu pour améliorer les infrastructures, soutenir le personnel de santé des zones rurales, appliquer les normes professionnelles et cibler les interventions de renforcement des expériences des femmes dans le cadre des initiatives d’amélioration de la qualité des soins. 女性在机构分娩中经历的无礼和粗暴行为（D&A）会妨碍消 除可预防孕产妇死亡和疾病, 这一点已得到全球共识。本研究 分析埃塞俄比亚四家农村卫生中心发生D&A的频率及其相关 因素。通过直接观察医患互动 （N=193） 和出院时访谈 （N=204） 来调查妇女在这些机构分娩时的体验。每家机构 均观察到了D&A, 最常见的是未询问妇女她们希望采用哪种分 娩姿势[n=162, 83.9%, 95% 置信区间 （95% CI） 78.0- 88.5%]。 在出院访谈中, 21.1%（n=43, 95% CI 15.4- 26.7%）的受访者表示至少经受了一次D&A。采用患者特征 和当次分娩体验的双因素模型显示, 妇女报告经历D&A与分娩 并发症[比值比（OR）=7.98, 95% CI 3.70-17.22]、周末分 娩（OR=0.17, 95% CI 0.05-0.63）和初次在该机构分娩 （OR=3.20, 95% CI 1.27-8.05）显著相关。在机构水平固定 效应模型中, 并发症（OR=15.51, 95% CI 4.38-54.94）和周末 分娩（OR=0.05, 95% CI 0.01-0.32）仍然与自报D&A高度相 关。上述数据提示, 要解决埃塞俄比亚卫生中心的D&A问题, 需要持续改善基础设施, 支持农村地区的卫生工作人员, 强化 职业标准, 实施针对性干预措施来改善妇女卫生保健。 La falta de respeto y el abuso (FR&A) sufrido por las mujeres durante el parto en las instalaciones ha ganado reconocimiento mundial como una amenaza para la eliminación de la mortalidad y la morbilidad materna prevenible. Este estudio exploró la frecuencia y los factores asociados de FR&A en cuatro centros rurales de salud en Etiopía. Las experiencias de las mujeres que dieron a luz en estas instalaciones fueron captadas por la observación directa de la interacción cliente-proveedor (N=193) y en la entrevista de salida cuando la paciente fue dada de alta (N=204). La incidencia de FR&A fue observada en cada instalación. La falla más comúnmente observada fue la falta de preguntas a las mujeres sobre sus posiciones de nacimiento preferidas [n=162, 83.9%, intervalo de confianza del 95% (IC 95%) 78.0-88.5%]. Durante las entrevistas de salida, el 21.1% (n=43, IC 95% 15.4-26.7%) de las encuestadas informaron al menos una ocurrencia de FR&A. Los modelos bivariables que usan las características del cliente y el índice de la experiencia de nacimiento mostraron que los reportes de la FR&A de las mujeres se asociaron significativamente con las complicaciones del parto, [razón de probabilidad (RP)=7.98, IC 95% 3.70, 17.22], el parto durante el fin de semana (RP=0.17, IC 95% 0.05, 0.63) y no haber tenido ningún parto anterior en la instalación de salud (RP=3.20, IC 95% 1.27, 8.05). Los modelos de efectos fijos a nivel de institución encontraron que la experiencia de las complicaciones (OR=15.51, IC 95% 4.38, 54.94) y el parto durante el fin de semana (OR=0.05, IC 95% 0.01-0.32) se mantuvieron significativamente y más fuertemente asociados con los auto-reportes de la FR&A. Estos datos sugieren que abordar los problemas de la FR&A en centros de salud en Etiopía requerirá un esfuerzo sostenido para mejorar la infraestructura, apoyar a la fuerza de trabajo de salud en entornos rurales, aplicar estándares profesionales y focalizar intervenciones para mejorar las experiencias de las mujeres como parte de las iniciativas de la calidad de la atención.

Background In many countries, rates of facility-based childbirth have increased substantially in recent years. However, insufficient attention has been paid to the acceptability and quality of maternal health services provided at facilities and, consequently, maternal health outcomes have not improved as expected. Disrespect and abuse during childbirth is increasingly being recognized as an indicator of overall poor quality of care and as a key barrier to achieving improved maternal health outcomes, but little evidence exists to describe the scope and magnitude of this problem, particularly in urban areas in low-income countries. Methods This paper presents findings from an assessment of the prevalence of disrespectful and abusive behaviors during facility-based childbirth in one large referral hospital in Dar es Salaam, Tanzania. Client reports of disrespect and abuse (D&A) were obtained through postpartum interviews immediately before discharge from the facility with 1914 systematically sampled women and from community follow-up interviews with 64 women four to six weeks post-delivery. Additionally, 197 direct observations of the labor, delivery, and postpartum period were conducted to document specific incidences of disrespect and abuse during labor and delivery, which we compared with women’s reports. Results During postpartum interviews, 15 % of women reported experiencing at least one instance of D&A. This number was dramatically higher during community follow-up interviews, in which 70 % of women reported any experience of D&A. During postpartum interviews, the most common forms of D&A reported were abandonment (8 %), non-dignified care (6 %), and physical abuse (5 %), while reporting for all categories of D&A, excluding detention and non consented care, was above 50 % during community follow-up interviews. Evidence from direct observations of client-provider interactions during labor and delivery confirmed high rates of some disrespectful and abusive behaviors. Conclusions This study is one of the first to quantify the prevalence of disrespect and abuse during facility-based childbirth in a large public hospital in an urban setting. The difference in respondent reports between the two time periods is striking, and more research is needed to determine the most appropriate methodologies for measuring this phenomenon. The levels and types of disrespect and abuse reported here represent fundamental violations of women’s human rights and are symptomatic of failing health systems. Action is urgently needed to ensure acceptable, quality, and dignified care for all women.

Background There is emerging evidence that disrespect and abuse (D&A) during facility-based childbirth is prevalent in countries throughout the world and a barrier to achieving good maternal health outcomes. However, much work remains in the identification of effective interventions to prevent and eliminate D&A during facility-based childbirth. This paper describes an exploratory study conducted in a large referral hospital in Dar es Salaam, Tanzania that sought to measure D&A, introduce a package of interventions to reduce its incidence, and evaluate their effectiveness. Methods After extensive consultation with critical constituencies, two discrete interventions were implemented: (1) Open Birth Days (OBD), a birth preparedness and antenatal care education program, and (2) a workshop for healthcare providers based on the Health Workers for Change curriculum. Each intervention was designed to increase knowledge of patient rights and birth preparedness; increase and improve patient-provider and provider-administrator communication; and improve women’s experience and provider attitudes. The effects of the interventions were assessed using a pre-post design and a range of tools: pre-post questionnaires for OBD participants and pre-post questionnaires for workshop participants; structured interviews with healthcare providers and administrators; structured interviews with women who gave birth at the study facility; and direct observations of patient-provider interactions during labor and delivery. Results Comparisons before and after the interventions showed an increase in patient and provider knowledge of user rights across multiple dimensions, as well as women’s knowledge of the labor and delivery process. Women reported feeling better prepared for delivery and provider attitudes towards them improved, with providers reporting higher levels of empathy for the women they serve and better interpersonal relationships. Patients and providers reported improved communication, which direct observations confirmed. Additionally, women reported feeling more empowered and confident during delivery. Provider job satisfaction increased substantially from baseline levels, as did user reports of satisfaction and perceptions of care quality. Conclusions Collectively, the outcomes of this study indicate that the tested interventions have the potential to be successful in promoting outcomes that are prerequisite to reducing disrespect and abuse. However, a more rigorous evaluation is needed to determine the full impact of these interventions.

Table 1 The three types of continuity and examples of each* Definition Intervention Examples Relational An ongoing therapeutic relationship between a patient (and often their family) with one or more providers Empanelment and multidisciplinary team-based care Costa Rica’s Equipos Básicos de Atención Integral en Salud care team structure13 Informational The use of information on past events and personal circumstances to make current and future care appropriate for each patient and family Electronic data systems that are interoperable with unique patient identifiers across settings Public-sector electronic health record system in Nepal9 Managerial A consistent and coherent approach to the management of a patient’s health conditions, that is responsive to changing needs over time Management standards of care and multidisciplinary team-based care Patient-centred medical home models in tribal populations in Alaska14 *Adapted from Haggerty, et al (2003).6 Relational continuity Of the three types of continuity, relational continuity is most prominently experienced by patients and communities. [...]both additional resources and system redesign with an aim towards integration are required. Multidisciplinary teams bolster facility-based workforces, and when properly supervised and trained, enable more standardised, integrated care.11 12 Examples from Costa Rica13 and indigenous communities in Alaska14 demonstrate that these multidisciplinary teams can serve poor, rural populations, providing high-quality community-based services, including regular follow-up, referral tracking, medication adherence counselling, risk modification and early warning to clinical worsening.12 This type of team-based care enables improved managerial continuity, and is particularly important for patients with multiple chronic conditions, for whom many disconnected episodes of care can lead to complex treatment plans that are difficult to incorporate into their lives.5 15 Pragmatic strategies to improve continuity in primary care For many LMIC health systems, improving continuity will be greatly challenging, requiring long-term, iterative improvement initiatives aimed at both increasing resources and redesigning care delivery. For these reasons, empanelment has been heralded as a priority for LMIC health systems by global partnerships such as the Primary Healthcare Performance Initiative (www.improvingphc.org) and the Joint Learning Network (www.jointlearningnetwork.org).16 17 In Costa Rica, empanelment systems have been in place for decades, even in the absence of digital data architecture, using community health systems and multidisciplinary teams to provide strong relational, informational and managerial continuity.13 Nonetheless, to date, for most LMICs, empanelment is either very weak or completely non-existent.5 To achieve the goals of patient-centred universal health coverage, this should be a priority for development partners and governments in