The PHCPI framework was developed through an extensive literature review, global stakeholder consultations with leading experts, advocates, and policymakers, and a review of over 40 existing health systems frameworks.15 This process revealed that most frameworks used in LMIC prioritize health systems inputs such as funds, human resources, supplies, facilities, and information systems, with less attention to the interactions between providers, families, communities, and patients and the quality of services they provide and receive.
Building off of widely known frameworks,16
19 the PHCPI framework offers a stronger emphasis on people- and community-centered care, supply and demand functions, and integrated service delivery through effective organization and management. The PHCPI framework focuses not just on the traditional system inputs needed to achieve good health outcomes, but also on identifying and mapping the key functions of service delivery that underlie outcome achievement.
The heart of the framework is the Service Delivery domain that captures the interaction of systems and supplies with providers and patients at the moment of care delivery. The first two sub-domains describe aspects of population health management such as local priority setting, community engagement, empanelment, and proactive outreach, as well as team-based organization, facility management capability, information system use, and performance measurement. Together, these sub-domains create the pre-conditions for whether patients have meaningful financial and geographic access to timely care (sub-domain 3) and whether competent and motivated providers are present to deliver safe, respectful care (sub-domain 4). The fifth sub-domain—high-quality PHC—includes the classic primary health care functions described by Barbara Starfield and others, including first-contact accessibility, comprehensiveness, coordination, and continuity.20 In addition, the person-centeredness function captures important and often lacking interpersonal and relational dimensions of primary health care, including trust, respect, communication, and improved patient self-management and activation.
The successful combination of systems, inputs, and service delivery contribute to PHC Outputs. Importantly, this domain is focused not just on crude coverage of services, but on effective coverage of high-quality services focused on both prevention and treatment. The final domain, Outcomes, is influenced by all preceding domains. Drawing from the Universal Health Coverage Monitoring Framework21 and the Global Reference List of 100 Core Health Indicators,22 the domain is focused on morbidity and mortality, as well as key outcomes of people-centered care such as responsiveness to people, equity, efficiency, and resilient health systems. The overall framework explicitly recognizes that PHC systems lie within wider political, cultural, demographic, and socioeconomic contexts that play a critical role in determining their success.