New tool helps countries identify misalignments between UHC and PHC strategies and goals

JLN Joint Learning Network
Originally posted on The Joint Learning Network on October 13, 2015.

Primary health care is often the first point of care for many patients in low- and middle-income countries. All too often, it is also the weakest link in the health system.

To address this challenge, members of the Joint Learning Network for Universal Health Coverage (JLN) Primary Health Care technical initiative co-developed a diagnostic UHC Primary Health Care Self-Assessment Tool, referred to as the UHC-PHC Self-Assessment Tool, a multi-stakeholder survey to help countries assess whether their national, state or district health financing approaches are well aligned with primary care initiatives, efforts, and programs.

“Aligning health financing and primary health care strategies and goals is vital to advance the vision of universal health coverage—health care for all without financial impoverishment—within limited resources,” says Dr. Nathan Blanchet, Program Director at Results for Development Institute, and team lead for the PHC technical initiative facilitation team.

Practitioners and policymakers can use the rapid diagnostic to quickly document and assess how health insurance or financial overage institutions interact with other PHC actors and programs. Most importantly, the UHC PHC Self-Assessment Tool helps practitioners identify key areas of improvements and potential interventions.

Over a two-year period, with support from technical facilitators at Results for Development Institute, JLN members defined the scope of the tool, documented their own experiences, conducted interviews with key primary health care stakeholders in their own countries, and developed the outline and survey questions contained in the tool.

Early pilots in India (Tamil Nadu and Kerala states), Indonesia (Tangerang District and Bandar Lampung city), Ghana (Upper East Region), and Malaysia (nationally) helped identify challenges, including weak integration of the private sector and minimal incentives to promote preventive and comprehensive care.

The results of those pilots will be documented and disseminated in the coming months. Highlights from the pilots are outlined below.


Malaysia’s national-level pilot found that while health financing and primary care efforts are well coordinated across government institutions, there is little alignment between the public and private sector, which delivers approximately 50 percent of services. The lack of coordination alerted the Ministry of Health to a need for increased engagement with the private sector.


A cross-organizational team from the National Health Insurance Authority, the Ghana Health Service, and the district health management teams who supervise the health centers and community health compounds (CHPS) tested the tool in the Upper East Region, with the goal of identifying linkages and misalignments at the regional and district levels. The team found that preventive and promotive services are underfunded, and the National Health Insurance Scheme, the primary purchaser, does not incentivize preventive services and its payments mechanisms may deter community outreach.


Indonesia’s pilot focused on the district and city-levels in parallel with the roll out of a national policy aimed at unifying multiple health coverage policies and packages. The pilot revealed that the BPJS Kesehatan capitation payment system incentivized providers to deliver curative services over preventative and promotive services. For example, the pilot found that private providers are less motivated to promote antenatal care and family planning for BPJS members under the current capitation system. Plans to continue to improve and customize the survey tool and launch pilots across other more diverse districts and regions are currently ongoing in order to identify local variations across the decentralized country.  They have also suggested specific policy and operational modifications, including the integration of preventive services in capitation and increased notice of the capitation budget to improve financial planning.


Both Kerala and Tamil Nadu states in India piloted the UHC PHC Self-Assessment Tool. In Tamil Nadu, the Tamil Nadu Health Systems Project, under the State Department of Health, led piloting of the tool. The piloting team found that budget allocation is not aligned to the work load or expected outputs of projected primary care services. As a result, there is an insufficient budget available for additional medicines, diagnostic equipment, and human resources. The absence of incentives has led to less motivated providers, particularly those who work in remote regions or who work with a high patient load.  In addition, the existing State Health Insurance program covers tertiary care without any continuity of care or linkage to primary care, neither for gatekeeping management nor for follow-ups. In Kerala, the State Health System Resource Center of the Department of Health and Family Welfare piloted the Self-Assessment Tool under the leadership of the Secretary of Health. Piloting in Kerala showed similar findings as in Tamil Nadu, including a need to increase prioritization of primary health care services. They suggested several methods to do so, including the following: increasing funds for infrastructure and manpower at the PHC level, allocating funds for preventive and promotive services, and increased outpatient screening. In addition, the insurance scheme Rashtriya Swasthya Bima Yojna (RSBY) should include outpatient services in its insurance coverage.

In the coming months, each country that piloted the tool will document their process, findings and results. Those experiences will be made available on the JLN website.

Click here to download the UHC PHC Self-Assessment Tool.  

For more information about the JLN’s work on Primary Health Care check out the following articles:

Nathan Blachet is a Program Director at Results for Development Insitute (R4D) and team lead for the primary health care technical facilitation team of the Joint Learning Network. Cicely Thomas, Program Officer at R4D, and Ruth Kidane, Senior Program Associate at R4D, are also members of the PHC technical facilitation team.