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Lancet Glob Health. 2018 Nov;6(11):e1176-e1185. doi: 10.1016/S2214-109X(18)30440-6.

Assessment of quality of primary care with facility surveys: a descriptive analysis in ten low-income and middle-income countries.

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Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and Harvard T H Chan School of Public Health, Boston, MA, USA. Electronic address:
Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
Epidemiology and Health Services Research Unit, Mexican Institute of Social Security, Mexico City, Mexico.
Division of Social Protection and Health, Inter-American Development Bank, Lima, Peru.
Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia.
Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal.
Department of Public Health Sciences-Global Health, Karolinska Institute, Stockholm, Sweden; Maternal and Newborn Centre of Excellence, Makerere University School of Public Health, Kampala, Uganda; INDEPTH Network Maternal and Newborn Working Group, Iganga-Mayuge Health and Demographic Surveillance Site, Iganga, Uganda.



Primary care has the potential to address a large proportion of people's health needs, promote equity, and contain costs, but only if it provides high-quality health services that people want to use. 40 years after the Declaration of Alma-Ata, little is known about the quality of primary care in low-income and middle-income countries. We assessed whether existing facility surveys capture relevant aspects of primary care performance and summarised the quality of primary care in ten low-income and middle-income countries.


We used Service Provision Assessment surveys, the most comprehensive nationally representative surveys of health systems, to select indicators corresponding to three of the process quality domains (competent systems, evidence-based care, and user experience) identified by the Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals Era. We calculated composite and domain quality scores for first-level primary care facilities across and within ten countries with available facility assessment data (Ethiopia, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda).


Data were available for 7049 facilities and 63 869 care visits. There were gaps in measurement of important outcomes such as user experience, health outcomes, and confidence, and processes such as timely action, choice of provider, affordability, ease of use, dignity, privacy, non-discrimination, autonomy, and confidentiality. No information about care competence was available outside maternal and child health. Overall, scores for primary care quality were low (mean 0·41 on a scale of 0 to 1). At a domain level, scores were lowest for user experience, followed by evidence-based care, and then competent systems. At the subdomain level, scores for patient focus, prevention and detection, technical quality of sick-child care, and population-health management were lower than those for other subdomains.


Facility surveys do not capture key elements of primary care quality. The available measures suggest major gaps in primary care quality. If not addressed, these gaps will limit the contribution of primary care to reaching the ambitious Sustainable Development Goals.


Bill & Melinda Gates Foundation.

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