BackgroundPrimary health care and its strengthening through performance measurement is essential for sustainably working towards universal health coverage. Existing performance frameworks and indicators to measure primary health care capture system functions like governance, financing and resourcing but to a lesser extent the function of services delivery and its heterogeneous nature. Moreover, most frameworks have weak links with routine information systems and national health priorities, especially in the context of high- and middle-income countries. This paper presents the development of a tool that responds to this context with the aim to create primary health care performance intelligence for the 53 countries of the WHO European Region.MethodsThe work builds-off of an existing systematic review on primary care and draws on priorities of current European health policies and available (inter)national information systems. Its development included: (i) reviewing and classifying features of primary care; (ii) constructing a set of tracer conditions; and (iii) mapping existing indicators in the framework resulting from (i). The analysis was validated through a series of reviews: in-person meetings with country-nominated focal points and primary care experts; at-distance expert reviews; and, preliminary testing with country informants.ResultsThe resulting framework applies a performance continuum in the classical approach of structures-processes-outcomes spanning 6 domains – primary care structures, model of primary care, care contact, primary care outputs, health system outcomes, and health outcomes – that are further classified by 26 subdomains and 63 features of primary care. A care continuum was developed using a set of 12 tracer conditions. A total of 139 indicators were mapped to the classification, each with an identified data source to safeguard measurability. Individual indicator passports and a glossary of terms were developed to support the standardization of the findings.ConclusionThe resulting framework and suite of indicators, coined the Primary Health Care Impact, Performance and Capacity Tool (PHC-IMPACT), has the potential to be applied in Europe, closing the gap on existing data collection, analysis and use of performance intelligence for decision-making towards primary health care strengthening.

We examine the marginal effects of decentralized public health spending by incorporating estimates of behavioural responses to changes in health spending in benefit incidence analysis. The analysis is based on a panel dataset of 207 Indonesian districts over the period from 2001 to 2004. We show that district public health spending is largely driven by central government transfers, with an elasticity of around 0.9. We find a positive effect of public health spending on utilization of outpatient care in the public sector for the poorest two quartiles. We find no evidence that public expenditures crowd out utilization of private services or household health spending. Our analysis suggests that increased public health spending improves targeting to the poor, as behavioural changes in public health care utilization are pro-poor. Nonetheless, most of the benefits of the additional spending accrued to existing users of services, as initial utilization shares outweigh the behavioural responses.

World Bank Working Papers are published to communicate the results of the Bank's work to the development community with the least possible delay. The manuscript of this paper therefore has not been prepared in accordance with the procedures appropriate to formally-edited texts. Some sources cited in this paper may be informal documents that are not readily available. This volume is a product of the staff of the International Bank for Reconstruction and Development/The World Bank. The fi ndings, interpretations, and conclusions expressed in this volume do not necessarily refl ect the views of the Executive ix Acknowledgments T he full report was prepared and edited by Maryanne Sharp, Sr. Operations Offi cer and Team Leader and Ioana Kruse, Public Health Specialist. Chapter 4 (Financing) was drafted by Sylke von Thadden, Public Finance Specialist and Chapter 5 (Governance and Accountability) was drafted by Elif Yavuz, Health Economist. Background papers on Nutrition and Early Childhood Development were contributed by Emanuela Galasso, Senior Economist, DECRG in collaboration with Ann Weber and Michael Amior. Lubna Bhayani, Health Economist contributed to health sector fi nancing, the private sector, results-based fi nancing, and nutrition. Yuko Okamura, Junior Professional Offi cer, contributed the analysis of determinants of child health outcomes to Chapter 2 (Sector Outcomes and Demographic Trends). The peer reviewers were Mukesh Chawla, Sector Manager, HDNHE; Jesko Hentschel, Sector Manager, ECSHD; and Mead Over, Senior Fellow, Center for Global Development. The team is grateful to the Health Systems for Outcomes team, who fully fi nanced the report (www.worldbank.org/hso). The sector manager is Eva Jarawan, AFTHE. The team would especially like to thank Bruno Maes, Resident Representative, UNI-CEF and his team, including Valerie Taton, Nathalie Peters, and Paola Valenti, for their useful comments. The team also greatly appreciates the contributions and comments

The Institute of Social Studies is Europe's longest-established centre of higher education and research in development studies. On 1 July 2009, it became a University Institute of the Erasmus University Rotterdam (EUR). Postgraduate teaching programmes range from six-week diploma courses to the PhD programme. Research at ISS is fundamental in the sense of laying a scientific basis for the formulation of appropriate development policies. The academic work of ISS is disseminated in the form of books, journal articles, teaching texts, monographs and working papers. The Working Paper series provides a forum for work in progress which seeks to elicit comments and generate discussion. The series includes academic research by staff, PhD participants and visiting fellows, and award-winning research papers by graduate students.