Measurement pillar
Strong primary health care systems have been recognized as critical to achieving Universal Health Coverage (UHC), and to meeting the global Sustainable Development Goals (SDG) targets[1][2][3]. As a first step to improving PHC systems, several efforts have been made to examine and measure their performance including the ones developed by the Primary Health Care Performance Improvement network[4], the World Health Organization (WHO) – United Nations Children’s Fund (UNICEF)[5], and Canadian Institute for Health Information[6].
In India too, the need for developing a performance measurement framework for comprehensive primary health care (CPHC) has been felt recently- at both national and subnational levels. In recognition of the fragmented nature of primary health care provision in the country, high out of pocket expenditures on primary-level care and issues of quality in care provision, several reforms have been proposed to strengthen the public primary health care system in the country. In particular, the Ayushman Bharat program aims to strengthen peripheral health centres that provide free care to people- termed as Health and Wellness Centres (HWC)[7]. This program presents a new opportunity for strengthening India’s primary health care system. There has been much interest at both national and sub-national levels in understanding the HWC intervention better and measuring the performance of PHC in India in the light of these new reforms.
Why do we need a CPHC performance measurement framework specific to India?
- There is no existing source that provides standardized, comprehensive information on the delivery of primary health care services across the country.
- There are currently no locally developed primary health care performance frameworks that captures unique aspects and values/priorities of India’s health system and policies[8]. The transnational frameworks available are generalized frameworks and need to be adapted to the Indian policy context.
- We need a performance framework that can link to locally available data sources to a large extent and minimize the burden of collecting additional data.
Aim of the measurement pillar of the project
To develop and implement a framework and index to measure performance of the CPHC system at district and state level in India.
The framework and related indices can:
- Measure performance of district/state CPHC system over time.
- Enable comparative analysis of CPHC system performance across districts/states.
- Identify high/low performing districts/states.
- Identify aspects of CPHC performance that need attention.
Methods
A structured protocol developed by the team based upon the internal expertise and literature that describe methodologies for developing PHC performance frameworks in other contexts is followed.
Activities undertaken
- Review of international frameworks
- Review of Indian policy documents and Indian monitoring frameworks and indices
- Stakeholder and expert consultations- Series of consultations undertaken with project nodal agency- NHSRC, Statistics div. MOHFW, and NHM division, MoHFW.
[1] Hsieh, Vivian Chia-Rong, et al. “Universal coverage for primary health care is a wise investment: evidence from 102 low-and middle-income countries.” Asia Pacific Journal of Public Health 27.2 (2015): NP877-NP886.
[2] Pettigrew, Luisa M., et al. “Primary health care and the Sustainable Development Goals.” The Lancet 386.10009 (2015): 2119-2121.
[3] Stigler, Florian L., et al. “No universal health coverage without primary health care.” The Lancet 387.10030 (2016): 1811.
[4] Veillard, Jeremy, et al. “Better measurement for performance improvement in Low‐and Middle‐Income countries: the primary health care performance Initiative (PHCPI) experience of conceptual framework development and indicator selection.” The Milbank Quarterly 95.4 (2017): 836-883.
[5] World Health Organization and the United Nations Children’s Fund (UNICEF). (2022). Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens.
[6] Canadian Institute for Health Information. (2013a). A Performance Measurement Framework for the Canadian Health System
[7] National Health Systems Resource Centre Government of India. (2018). Ayushman Bharat- Comprehensive Primary Health Care through Health and Wellness Centers Operational Guidelines.
[8] There is one framework developed for Kerala developed specific to Kerala (refer Nambiar et al. 2020b)