In 1978, representatives from 134 countries gathered in Alma-Ata in the former USSR and declared that primary health care, “based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people's full participation”,1 was key to delivering health for all by the year 2000. Recent years have seen a renewed interest in primary health care, particularly in low-income and middle-income countries. Reasons for this renewed interest include profound inequities in health; inadequate progress towards the Millennium Development Goals, especially in sub-Saharan Africa;2, 3, 4 major shortfalls in the human resources needed to improve delivery of cost-effective interventions;5, 6 and the fragmented and weakened state of health systems in many countries.7
Key messages
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Financial incentives can be used to influence provider and patient behaviours, but can also have undesirable effects
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User fees reduce the use of both essential and non-essential health services. However, removal of user fees needs to be implemented with care since it can have undesirable consequences. Alternative health financing strategies have not been adequately assessed
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Task shifting, for example from doctors to nurses and from health professionals to lay providers, offers opportunities for expanding coverage and addressing human resource shortfalls
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Although multiple vertical programmes can lead to service duplication, fragmentation, and inefficiency, the effects of strategies to integrate primary health-care services have not been assessed adequately
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Quality improvement strategies, including those tailored to address identified barriers, can have important, although modest, effects on primary health-care quality
More generally, there have been calls to redress the balance between the now dominant vertical, disease-focused programmes and the horizontal, systems-focused perspective that underpins most approaches for primary health care.8 The GAVI Alliance, for example, has committed US$800 million over a 5-year period to help countries overcome health system weaknesses that impede sustainable increases in immunisation coverage,9 and the Global Fund to Fight AIDS, Tuberculosis and Malaria is also calling for integrated responses.10
Strengthening health systems to improve the delivery of cost-effective interventions is complicated by differing ideas of what constitutes primary health care. This is affected, in part, by financial and human resources and the underlying political and ideological perspective of different countries. The broader approach for primary health care is seen as encompassing equitable distribution, community participation, an emphasis on prevention, the use of appropriate technology, and the involvement of of a diverse range of health and other departments.11 By contrast, narrower views of primary health care, often from high-income settings, emphasise the first contact of the patient with the health care system and focus specifically on the roles of health professionals.12, 13
There are also differing iseas of what constitutes health systems. WHO's building blocks of health systems include leadership and governance, financing, service delivery, health workforce, medical products and technologies, and information and evidence.14 A taxonomy of health system arrangements provides additional categorisation, distinguishing between governance arrangements (political, economic, and administrative authority in the management of health systems),15 financial arrangements (funding and incentive systems, as well as financing), delivery arrangements (human resources for health, as well as service delivery), and interventions (programmes, services, and technologies).16 Most descriptions of health system elements omit the implementation strategies to support the use of cost-effective interventions.17, 18
In this overview we summarise the evidence from systematic reviews on the effects of governance, financial and delivery arrangements, and implementation strategies that have the potential to improve the delivery of cost-effective interventions in primary health care in low-income and middle-income countries. We do not address specific clinical or public health interventions but rather the health system arrangements and implementation strategies that support their delivery in primary health care. We discuss how the available evidence relates to both the aspirations of the Alma-Ata Declaration and a taxonomy of health system arrangements (panel 1). We have also reviewed indicators of the relevance of reviews to primary health care in low-income and middle-income countries, graded the strength of evidence, and identified applicability and equity considerations.