Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region

Introduction This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region. Methods We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions. Results From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Communitybased services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges. Conclusion Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.