PRIMARY HEALTH CARE SYSTEMS

(PRIMASYS)
Case study from Cameroon

Abridged Version
WHO/HIS/HSR/17.20

© World Health Organization 2017

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 Primary Health Care Systems
(PRIMASYS)
Case study from Cameroon

1. Overview
Cameroon is a lower middle-income country with around to 66% of health expenditure is out-of-pocket payments.
23 million inhabitants, half of whom live in urban areas. The maternal mortality ratio has increased in Cameroon
This bilingual (English–French) country in Central Africa is during the last 20 years, despite the increasing annual per
made of 10 administrative regions divided into 189 health capita health expenditure, which reached US$ 59 in 2015.
districts. Primary health care (PHC) is provided in line with Growing privatization has led to a low servicing rate for
the health district framework proposed by the World health districts, particularly in rural areas, and there are
Health Organization (WHO) Regional Office for Africa, stark inequalities in the distribution of human resources.
entailing a nurse-based, doctor-supported infrastructure
The epidemiological profile of the country is marked by a
of State-owned, denominational and private integrated
predominance of communicable diseases, including HIV/
health centres. It is supported by a diverse and fragmented
AIDS, malaria and tuberculosis, which represent 23.66%
system of community health workers recruited by priority
of the overall disease burden, along with a remarkable
public health vertical programmes. The 2016 evaluation
increase in mortality due to noncommunicable diseases,
of this sectoral strategy found that 7% of the 189 health
including cardiovascular diseases, cancers, mental illnesses
districts were serviced. The PHC system has achieved
and trauma due to road accidents, accidents at work and
high routine immunization coverage rates, high coverage
occupational diseases. Among children aged under 5
of malaria-preventive technologies and high coverage of
years, lower respiratory tract infections, malaria, diarrhoeal
HIV screening.
diseases and nutritional deficiencies are the main causes
PHC performance in Cameroon is below expectations of morbidity and mortality. Maternal mortality remains
when compared to the current health expenditure, mostly high at 782 deaths per 100 000 live births. Between 2004
because of growing privatization, the weak regulatory and 2014, neonatal mortality slightly decreased from
system and lack of accountability. Cameroon has one of 29 per 1000 to 28 per 1000 live births; during the same
the highest levels of health care expenditure occurring in period, the child mortality rate decreased from 144 per
the informal sector (up to 30%, mostly in primary health 1000 to 103 per 1000 live births, while the infant mortality
care). User fees are usually charged at the point of use, rate decreased from 74 per 1000 to 60 per 1000 live births.
except for some services for specific population groups. Up
 Cameroon case study

2. Key indicators
Table 1 presents key indicators in the PHC sector.

Table 1. Key PHC indicators, Cameroon

Indicator Results Source of information Remarks

Total population of country 23 344 179 World Bank database (2015) From the last general population census of
2007 to 2015 the population increased by
22.4%, or 2.5% annually

Distribution of population 51.5/48.5 Third general population census

(rural/urban) (2007)

Life expectancy at birth 55.5 years World Bank database (2014) Life expectancy has increased gradually
from 51.9 years in 2000

Infant mortality rate 57 per 1000 United Nations Children’s Fund Trends indicate a decrease from 61 per 1000
(UNICEF) (2014) in 2012 and 60.8 per 1000 in 2013

Under-5 mortality rate 87.9 per 1000 World Bank database (2015) Trends indicate a decrease from 150.4 per
1000 in 2000

Maternal mortality ratio 782 per 100 000 Demographic and Health

Survey (2011)

Immunization coverage 73% (rotavirus) UNICEF database (2015)

85% (pneumococcal)

Income inequality (Gini index) 0.389 United Nations Development

Programme (2014)

Total health expenditure as % of 4.1% World Bank database (2014)

gross domestic product (GDP)

PHC expenditure as % of total 27% National Health Accounts (2012) The estimate is derived from expenditure
health expenditure on ambulatory care, immunization, and
traditional medicine, while excluding
expenditures on medicines

% total public sector expenditure     Not reported

on PHC

Per capita public sector Not reported

expenditure on PHC

Out-of-pocket payments as 66.3% World Bank database (2014)

proportion of total expenditure
on health

4
 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)

3. Historical background
The evolution of primary health care (PHC) in Cameroon through vertical programmes carried out in parallel to and
covers two main periods – before and after the International independent of the health system. Indeed, the system
Conference on Primary Health Care, Alma-Ata, 1978, the had not been restructured to integrate PHC; the use of
main outcome of which was the Alma-Ata Declaration on community health workers without proper training was
Primary Health Care (1, 2). Before Alma-Ata, two approaches inefficient; mechanisms to ensure proper community
had been adopted. The first was a medical approach based participation were non-existent; and health workers did
on colonial-inspired vertical programmes (urban public not receive continuing professional development for
hospitals and rural denominational hospitals) in which supervision of community health workers.
good health was synonymous with absence of disease.
The subsequent Reorientation of Primary Health
The selected care was free of charge, and the community
Care  (Reo-PHC) involved a realignment of the National
followed the health workers’ instructions. Following that, a
Health System towards the social goal of Health for All (4).
“health services” approach was applied, characterized by
The purpose of Reo‑PHC was to ensure universal access
the four “demonstration zones of public health action”1
to PHC services through a decentralized management
put in place in 1967 under the inspiration of WHO and
process focused on the health district level, with the
intended to introduce progressively selective health care
institution of the integrated health centre as the first level
and services deemed economically viable. The approach
of contact with the health system (5, 6). The aim was to
introduced the concept of village health teams and village
integrate health activities at the level of the health centre,
dispensing pharmacies managed by local health personnel
while empowering the communities involved in financing
through a cost recovery mechanism underpinned by
and management (7). This reorientation, supported
working capital. Evaluation of the system showed that
by technical and financial partners through regional
(a) community-based health activities had positive effects
pilot experiments, has not, however, fully achieved
and stimulated demand; and (b) communities were willing
the desired objectives.2 National seminars in 1993 and
to contribute (to some extent) to the financing of health
1994 resulted in the development of a legislative and
facilities and activities, including village pharmacies.
regulatory framework3 that placed the health district as
Community involvement was mostly passive.
the foundation stone for PHC implementation, including
In the wake of the Alma-Ata conference, which enshrined the institution of district health management teams and
the notion that health should go beyond the delivery of district dialogue structures in the form of district health
care and promote community involvement in order to committees and district management committees.
make a significant impact on health status (3), Cameroon This restructuring formed the basis of the Health Sector
adopted a series of health reforms in 1982. However, Strategy 2001–2015 and its updated version of 2007.
the Ministry of Public Health found in a 1988 survey
Figure 1 summarizes the historical background of PHC in
that there had been selective implementation of PHC
Cameroon.

1 Zones de démonstration d’action de santé publique.

2 UNICEF study, 1999.
3 Presidential decrees reorganizing the Ministry of Public Health, 7 March 1995, 19 August 2002 and April 2013, and Framework Law 96/03 of 4 January 1996 pertaining to the
health sector.

5
 Cameroon case study

Figure 1: Historical background of PHC in Cameroon

PHC development: Since 1999

Promotion of health district approach,
Health Sector Strategy 2001–2015
• Implementation of PHC: PHC activities carried out at the health
areas level / community health workers to be revamped
• Dialogue structure gradually put in place / functionality
questionable / judiciary framework still expected

Community 1995
development approach Organization of the health system: national, intermediary,
peripheral / health district
• Health = human condition
Health district: health area management
• Community = help attain the condition committee, district health
by participation in decision-making Dialogue management committee, district hospital
structures management committee
Regional special fund for health /
essential drug programme

1993
National Declaration on the Implementation of the
Reorientation of Primary Health Care: partnership
between government and communities based
on co-financing and co-management

1988
PHC implementation found to be vertical without effect,
need for reorientation (Ministry of Public Health)
1982–1988
implementation of Alma-Ata
principles, adopted reforms (1982)

Alma-Ata 1978
Primary health care reforms

Health service approach Post Cameroon independence (1960–1978)

• Health = WHO definition / orientations • 1967: Demonstration of public health actions – zones in 4 areas: gradual
• Community = help deliver services introduction of rationalized and economically sustainable health activities /
health team spirit / village health committee

Medical approach Colonial period and before

• Health = absence of disease
Cameroon independence (1960)
• Community = follow the doctor Dr Eugene Jamot strategy / mobile team / vertical programmes,
colonial interest oriented: hospital development

6
 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)

4. Governance
The health district is the operational unit for primary health the ground. Indeed, the actors have not been appropriately
care.4 Organized in a territory comprising one or more redirected towards this new approach, which probably
municipalities, the district shall, by decree, be managed by explains the low level of development of health districts
a district management team. A district health committee (7%) by the end of 2015 and the lack of involvement of
and a hospital management committee constitute the communities, despite the establishment of a number
dialogue structures responsible for translating community of dialogue structures by the Ministry of Public Health,
participation into practice and promoting the ownership including the 10 regional funds for health promotion.
of health services by local actors (6). According to the
The strategic paper on the Health Sector Strategy
1996 Constitution and the laws and regulations on the
2001–2015 had among its major objectives the
decentralization of the State of 2004, the municipalities
decentralization of the health system, including
are responsible for public health and sociocultural
empowerment of health districts while the central
development. Figure 2 presents information on the
level gave direction in the areas of monitoring, control,
different levels of the health system in Cameroon (8).
regulation and standards. A gradual decrease in the
Co-management of the non-community budget (various number of vertical programmes was intended, while
solidarities) within the partnership framework is interpreted health districts developed expertise in providing
differently by officials of the Ministry of Public Health integrated and comprehensive intervention packages
and community representatives. The former consider it to the population. Indeed, the multiplicity of vertical
their private “turf”, while the latter, though aspiring to be programmes led to systemic inefficiency, duplication of
“co-managers”, lack understanding of the expectations and services and resource wastage, even if the results were
attitudes of the former. Reo-PHC is far from being a reality on satisfactory in terms of coverage of the target population.

Figure 2: Different levels of the health system in Cameroon

Administrative structures Competences Health structures Dialogue structures

• Prime Minister’s Office • Development of concepts, • General, central and teaching hospitals National Council of Health, Hygiene and
• Office of the Minister of Health policies and strategies • Centre Pasteur Social Affairs

• General inspections • Coordination • National Essential Medicines

• General secretariats • Regulation Supply Centre

• General directorates • National laboratory for Medicines

Quality Control
• Central directorates
• Public Health Observatory

10 regional delegations Technical support to health districts • Regional hospitals Regional funds for health promotion
• Regional pharmaceutical
supply centres

189 health districts Implementation of PHC • District hospitals • District health committees
programmes • Health clinics • District management committees
• Medical centres • Local health area committees
• Integrated health care centres • District hospital management boards
• Dispensaries

4 Ministerial decrees No. 0016/A/MSP/SG/DMH/SDH/PFSP/BFSP of 5 November 2001 creating health districts; and No. 0035/A.MSP/CAB of 8 October 1999 fixing the
modalities for creation, organization and operation of health districts.

7
 Cameroon case study

5. Financing
If the health fiscal space has expanded over the last The framework of analysis of the National Health Accounts5
decade with the end of the structural adjustment does not allow determination of the relative magnitude
programme, there is still no taxation directly allocated of expenditures associated with primary health care. The
to health. Cost recovery at the point of care constitutes financial resources for health come from the government,
the main purchasing mechanism for PHC services, and private companies, technical and financial partners,
prepayment through microinsurance, mutual funds nongovernmental organizations (NGOs), households
or health insurance remain of marginal importance. and benefactors. An analysis of the breakdown of current
Addressing the three funding functions of primary health expenditure shows that households contributed 70.42%
care (resource collection, pooling of resources, and in 2012. The share of the Ministry of Public Health’s budget
purchasing of health care and services) is impeded by the in the overall State budget has stagnated at around 4.87%,
lack of specific documentation. far below the commitment under the Abuja Declaration
on HIV/AIDS, Tuberculosis and Other Related Infectious
Prior to Alma-Ata, the majority of certain selected PHC
Diseases, which invited the African States to allocate 15%
services were free, except for medicines and drugs
of their budgets to health (9). Private funding represents
in dispensing pharmacies and remunerated services
55%, of which 52% is paid by households. External
in hospitals and health centres. After Alma-Ata, PHC
financing of PHC programmes was estimated at 65 billion
services were free or partially subsidized on the basis
Central African francs in 2015, mostly geared towards
of standardized but differentiated care between public,
three domains: maternal, child and adolescent health
private and for-profit health facilities. With the onset of
(34%), disease control and health promotion (38%), and
the economic crisis (1985/1986), which resulted in the
health district development and servicing (28%).
imposition of structural adjustment, there were frequent
shortages of subsidized drugs and consumables. Under Purchasing mechanisms for PHC vary according to
the Bamako Initiative (1987), widespread use was made of government priorities, and may be categorized as follows:
cost recovery to access PHC services, with the exception
• Gratuity payments are the main mechanism used
of a few public health programmes such as the Expanded
by the State (public funding) to support the control of
Programme of Immunization.
communicable and noncommunicable diseases for all
PHC funding now has two main sources: (a) community or part of the population.
based, through fee for services at the point of delivery, • Subsidies are in place for the management of certain
purchase of medicines, human investment, donations and diseases with social impact, in order to encourage
legacies; (b) non‑community based, in the form of national the participation of households. Examples include a
solidarity through the public budget and international voucher scheme for pregnant women; obstetric kits;
solidarity through public aid to health development. vitamin A supplements for children aged under 5 years
Since 1994 a regulatory regime for fiscal federalism has and postpartum women; treatment for acute, severe
been in force, with health committees and management and moderate malnutrition; cancer chemotherapy; and
committees of public health facilities given responsibility haemodialysis).
for the pricing of PHC services, determination of • Out-of-pocket payments are the most widespread
the level of the costs, and the allocation of local tax purchasing mechanism, greatly contributing to the
resources generated for the operation according to a inaccessibility of care for many inhabitants. In 2009,
distribution schedule updated in December 2016. As for spending on health care in Cameroon was estimated
denominational and private health care facilities, pricing is at 680 billion Central African francs, more than 75%
more related to market rules and principles, with marginal of which is borne by households. Around 95% of
regulation of prices under the responsibility of the Ministry household expenditure is disbursed at care delivery
of Commerce. points during episodes of disease.6

5 National Health Accounts, 2011 and 2012.

6 WHO data, 2009 and 2010.

8
 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)

• Performance-based payment has been deployed through company health services, commercial
by the government since February 2011 through the insurance schemes, and health mutual funds (158
World Bank-funded Health Sector Investment Support rural community mutual funds covered 1.5% of the
Project in a few regions in the form of a pilot project population compared to the 40% target in 2010, versus
to improve the quality of care and the health of the 43 funds in 2013 covering nearly 43 000 people or 0.2%
population. of the population). Commercial insurance schemes
• Prepayment mechanisms are poorly developed, target the high and intermediate income groups,
contributing to marginal financing of PHC. The including formal sector workers covered by their
open market sector for voluntary health insurance is employers (10, 11). The poor coverage rate of health
dominated by about 15 private insurance companies. insurance schemes partially explains the amount of
The coverage rate by risk-sharing schemes varied expenditure in the informal health sector, estimated
from 0.1% in 2001 to about 2% in 2015, for example at 27%.

6. Human resources
According to data from the third general census, the economically wealthier regions – Centre, Littoral and West
ratio of health personnel to population is 1.07 per 1000 – concentrated 11 777 out of 19 709 health workers, or
inhabitants (8, 12). The differential analysis confirms 59.75% to serve 42.14% of the country’s total population.
that the large deficit of specialists in medicine, maternal This situation has a negative impact on PHC outcomes, for
health, obstetrics, and child care contrasts with the self- example the coverage of preventive services for mother-
sufficiency in nurses and the inadequate absorption by to-child transmission of HIV, which is lower in rural areas,
the public and private sectors. While the prospects for and tetanus immunization coverage (80% in urban areas
an increase in trained personnel are in some respects against 68% in rural areas). The four regions with the
favourable – given the national annual increase of trained lowest numbers of health care staff contribute to more
doctors and pharmacists since 2012, and implementation than three quarters of the 4500 maternal deaths recorded.
of a strategic plan for the development of medico-surgical
The demotivation and frustration of community health
specialities since 2010 – the training in community-
workers are related to abuses of authority and low,
centred health care that has long been the hallmark of
irregular and discriminatory wages. The 5% increase in the
the Yaoundé School of Medicine has been evanescent for
wages in the public sector in 2014 did not catch up with
a decade, while three private schools have been training
the loss of purchasing power of health personnel after the
community health workers since 2013 (13).
wage cuts of 1992 and 1993 and the devaluation of the
Inadequate distribution of staff is a bottleneck in the Central African franc in 1994. Health professionals at the
implementation of PHC. The very high concentration operational level denounce the harsh living conditions
of human resources in urban areas contrasts with the in rural, landlocked areas, the lack of socio-educational
shortage in rural areas. Disparities are sharp between infrastructures, insecurity, sociocultural problems, arbitrary
administrative regions and between districts. The assignments and noncompliance with the regulations
2014 personnel census revealed that 147 districts governing the management of careers (14, 15).
out of 181 had less than 50% of the staff required. The

9
 Cameroon case study

7. Planning and implementation

After Alma-Ata, the implementation of reforms started failed introduction of a Sector-wide Approach (SWAp)
without proper planning or integration of pre-existing in 2006/2007. Multiannual development plans at the
interventions. The 1988 assessment confirmed the relative level of the health districts, consolidated at the regional
effectiveness of vertical programmes independent of level, were developed in a participatory manner using
the health system and not related to the ideals of PHC. the same approach at the national level. However,
However, no structural reform had been initiated to the experiment has not been repeated. On the other
integrate PHC services; community health workers had hand, annual workplans for vertical programmes are
been identified in the communities and recruited without regularly developed and implemented with some
appropriate training and supervision on the ground; and efficiency. Communities have been little involved in
participation of the community in the identification planning whereas they are regularly called upon for
of health priorities was virtually non-existent. These the implementation of interventions at the operational
observations led to a new policy direction, as enshrined in level (for example, social mobilization for immunization,
the 1993 National Declaration on the Implementation of vaccinovigilance).
the Reorientation of Primary Health Care. However, there
The main planning tools in the health sector are the
was no integrated strategy for policy implementation.
Medium-Term Expenditure Framework (sectoral and
Several planning mechanisms have been imposed by
ministerial MTEF) and the programme budgeting.
technical and financial partners as a consequence of the
Community participation remains marginal, and there is
national planning policy being abandoned in the context
a lack of technical staff and management structures to
of the structural adjustment programme (4).
ensure the involvement of the community as a partner,
The first national approach to health sector planning in accordance with the canons of PHC and on the basis
occurred in 2000, though health districts had been of co-financing and co-management as stipulated in
set up in 1994 and the Framework Law on Health had the National Declaration on the Implementation of the
been adopted in 1996. The first Health Sector Strategy Reorientation of Primary Health Care.
2001–2015, updated in 2007, was followed by the

8. Regulatory process
The Cameroonian system has shortcomings in several users. The weak enforcement of laws and regulations
areas, including (a)  the obligation of civil servants pertaining to licensing health professionals and PHC
to be accountable for the deployment of resources services jeopardizes the quality of services (16). Several
and the achievement of objectives; and (b) the informal health care centres and dispensaries as well
capacity to undertake a number of activities, including as street vendors of medicines are diverting up to 27%
monitoring the quality of services; providing the needed of household health expenditures. The National Drug
infrastructure, medical equipment and products in Commission operates in a very approximate manner and
conformity with standards; development of guidelines, the professional orders are still centralized within their
norms and standards; and protection of the interests of legislative frameworks adopted in the early 1980s.

10
 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)

9. Monitoring and information systems

The midterm evaluation of the first Health Sector Strategy and evaluation are confined to each implementation
2001–2010, carried out in 2006/2007, led to its being structure, including programmes, without merging
updated in line with the achievement of the Millennium into an integrated monitoring and evaluation plan, as
Development Goals in 2015. The 2001–2015 Health provided for in the Health Sector Strategy 2001–2015.
Sector Strategy reinforced the role and viability of the PHC activities were taken into account in the pilot phase
health district by strengthening the health district system, of the World Bank-supported Cameroon Health Sector
including through integration of reforms in line with the Investment Support Project through performance-based
Alma-Ata Declaration, leading to greater institutional, funding in some health districts, and in the monitoring
technical and economic autonomy for health districts. and evaluation mechanisms for the National Health
Development Plan 2012–2015. The monitoring and
Overall, monitoring and information systems are
evaluation system for performance-based funding
performing poorly in Cameroon. An evidence-based
has focused on a few performance indicators of the
policy brief (17) noted the following in 2010: (a) only
management process: outcome indicators and impact
one of the health districts went farther than the start-up
indicators regarding relevance, effectiveness, efficiency,
phase in the process leading to autonomy; (b)  routine
equity, accountability and transparency; flows and use
population-related data were poorly reported, including
of financial, human, material and logistic resources; and
in the areas of epidemiology, the budget, mapping of
user satisfaction in terms of preventive and curative
health facility services, infrastructure and equipment,
care under the Minimum Package of Activities and the
and human resources. The updated health sector
Complementary Package of Activities. However, these
strategic paper considered health information as a
activities were monitored and evaluated in less than a
priority ​​intervention area, with the aim of having 90% of
quarter of the health districts in four regions.
health facilities managed using proper documentation.
Specifically, this involves (a) properly organized data A monitoring and evaluation framework was established
collection; (b) analysis of the data; and (c) using the data to align with the 2012–2015 National Health Development
for continued improvement of the quality of services and Plan. Apart from activities within programmes and some
care. An analysis by the Health Metrics Network gave health districts, no planned monitoring and evaluation
the following scores on a scale from 0% to 100%: data activities were carried out. Despite these shortcomings,
management 28%, civil registration system (including some significant results have been recorded by the
registration of births and deaths) 18%, access to census National Institute of Statistics (18) as follows:
information 38%, access to information on health mapping
• Infant and juvenile mortality decreased from 144 per
39%, and access to information on human resources 59%.
1000 to 103 per 1000 between the periods 1999–2004
Very often, information is not considered as a resource,
and 2010–2014 (though not reaching the target of 76
and being transferred to a data collection unit is perceived
per 1000).
by the staff as a form of punishment. The lack of analysis
• Overall HIV prevalence decreased from 5.5% to
and exploitation of data at the local level, the low levels of
4.3% between 2004 and 2014, though with marked
feedback, and inadequate sharing of data between public
disparities between regions and certain social groups.
and private actors within the health pyramid reinforce
• Distribution campaigns for long-lasting insecticide-
the perception that the data collected are useless. These
treated nets achieved a 54.8% coverage rate amongst
weaknesses undermine the monitoring and evaluation
children aged under 5 years in 2014 against 0.9% in 2000.
of the use of resources, the supervision of the servicing
• Free-of-charge care against malaria amongst children
process of health districts, and equity-oriented planning.
aged under 5 years has been effective since 2013.
Though the development of multi-year health • Full vaccination coverage for children aged
development plans at the health district level and 12–23 months increased from 48% to 75%, while
their consolidation at regional level in a structured and immunization coverage against measles rose from 64%
organized manner were put in place in 2008, monitoring to 89% between 2004 and 2014.

11
 Cameroon case study

10. Strategic outlook and considerations

The Cameroonian health system has adopted its the effective transfer of powers from the central State to
Health Sector Strategy for 2017–2026. The strategy is the municipalities. The option chosen was the adoption of
aligned with the Growth and employment strategic performance-based funding as part of the State budget
document 2010–2020 (19), with the development of allocation framework for the purchase of care and services.
the health district as a strategic priority objective and The architecture of universal health coverage has recently
with universal health coverage as the ultimate goal. been adopted, though the weak regulation of the health
The proposed structure of the community-level health sector and the liberalization of training for health care
services aims to strengthen the integration of health professionals continue to conspire to relegate primary
programmes and accelerate the development of the health care and the concepts of community health to
health district model. There is continuing debate on how the background, to the benefit of curative care in a profit-
to implement decentralization of public health through oriented environment.

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Yaoundé, Cameroon; 2012.

12
Authors
Pierre Ongolo-Zogo David Yondo, Jean Serge Ndongo,
Centre for Development of Best Practices Nsangou Moustapha, Christine
in Health, Central Hospital, University of Danielle Evina
Yaoundé
This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the
World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda
Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support
efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care
interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development
and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage
of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and
abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system,
tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points
to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an
audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health
care systems in selected low- and middle-income countries.

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