Quality assurance management methods applied to a local-level primary health care system in rural Nigeria

Introduction. Management of primary health care (PHC) systems in less developed countries is often impeded by factors such as poorly trained personnel, limited financial resources, and poor worker morale. This study explored the ability of local-level PHC supervisors in rural Nigeria to use quality assurance (QA) management methods to improve the quality of the PHC system. Methods. PHC supervisors from Bama Local Government Area were trained for 3 days in the use of QA methods and tools. The supervisors targeted the supervisory system and the health information system (HIS) for improvement. Health worker performance in diarrhoea case management was assessed, using a simulated case, to measure the impact of supervision. A HIS audit assessed data collection forms used by 17 PHC facilities. Gaps in quality were monitored over a 2-month study period and flaws in work processes were modified. Results. PHC supervisors introduced a checklist during monthly visits to facilities to monitor how workers managed cases of diarrhoea. Performance in history-taking, physical examination, disease classification, treatment and counselling improved over the evaluation period. The HIS audit found that a variety of reporting forms were used at PHC facilities. After HIS reporting was standardized, the number of health facilities using a daily disease registry significantly improved during the study period. Conclusions. QA management methods were used by PHC supervisors in Nigeria to improve supervision and the HIS. QA management methods are appropriate for improving the quality of the PHC in Nigeria and in other less developed countries where at least a minimal PHC infrastructure exists.     

Where there is no policy: governing the posting and transfer of primary health care workers in Nigeria

The posting and transfer of health workers and managers receives little policy and research attention in global health. In Nigeria, there is no national policy on posting and transfer in the health sector. We sought to examine how the posting and transfer of frontline primary health care (PHC) workers is conducted in four states (Lagos, Benue, Nasarawa and Kaduna) across Nigeria, where public sector PHC facilities are usually the only form of formal health care service providers available in many communities. We conducted in‐depth interviews with PHC workers and managers, and group discussions with community health committee members. The results revealed three mechanisms by which PHC managers conduct posting and transfer: (1) periodically moving PHC workers around as a routine exercise aimed at enhancing their professional experience and preventing them from being corrupted; (2) as a tool for improving health service delivery by assigning high‐performing PHC workers to PHC facilities perceived to be in need, or posting PHC workers nearer their place of residence; and (3) as a response to requests for punishment or favour from PHC workers, political office holders, global health agencies and community health committees. Given that posting and transfer is conducted by discretion, with multiple influences and sometimes competing interests, we identified practices that may lead to unfair treatment and inequities in the distribution of PHC workers. The posting and transfer of PHC workers therefore requires policy measures to codify what is right about existing informal practices and to avert their negative potential. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd     

WHO's Service Availability and Readiness Assessment of primary health care services of commune health centers in a rural district of Northern Vietnam

The objective of this study was to assess the availability and readiness of the primary health care (PHC) services of commune health centers (CHCs) in Quoc Oai, a rural district of Northern Vietnam based on the World Health Organization's Service Availability and Readiness Assessment (SARA) tool. The study was done in 2 steps. First, the heads of the 21 CHCs of Quoc Oai district were interviewed using SARA, a quantitative survey, and the responses were then validated by direct observations of each facility. The results showed that although the average number of health staffs in each CHC met the national standards (at least 5 staffs per CHC), its allocation within each CHC was not properly met because some CHCs had only 2 health staffs. Several health equipment and facilities were not fully available in many CHCs, and although the majority of the PHC services were available at the CHCs, their readiness remained limited. Several significant correlates between the availability of health care workers and the availability of the facilities and the PHC services were observed, suggesting that they depend upon and affect one another in the health system. Using the SARA‐based inventory, the study helps health managers and policy makers to prioritize efforts and allocate resources more appropriately. To be effective, attention should be given to how to make facilities, services, and human resources for health ready for PHC activities—more investment and support from the system (from higher to lower level) and the government.     

围产保健与儿童保健监测的方法与应用

目的：研究最佳围产保健与儿童保健的监测方法与应用,为母婴与儿童提供及时,系统的保健服务。方法：新婚妇女在婚前检查时建立围产保健册、随后开始月经监测,确定早孕后,定期作产前复查等监测。直到产后42d为止;新生儿应在出生42d内建立儿童保健册,然后根据监测对象的年龄 常规体检的原则,完成相应年龄段的询问,体检、实验室检查与评价。监测全程均有质量控制措施,所有的监测结果均录入计算机。实现计算机化管理。结果：该监测系统已经在我国的32个县（市）中实施,覆盖地区的总人口超过2千万,从1993年至,围产保健监测系统已成地连续运转了8年,儿童保健监测系统已成功地连续运转了4年。结论：该围产保健与儿童保健监监适合我国,国情,运转顺利,对促进和提高当地的围产保健与儿童保健工作水平,提高我国人口素质将发挥重要作用。     

Internal migrants' experiences with and perceptions of frontline health workers: A nationwide study in 13 Indian cities

The role of frontline health workers is crucial in strengthening primary health care in India. This paper reports on the extent of services provided by frontline health workers in migrants' experiences and perceptions of these services in 13 Indian cities. Cluster random sampling was used to sample 51 055 households for a quantitative survey through interviewer‐administered questionnaires. Information was sought on the receipt of health workers' services for general health care overall (from the head/other adult member of the household) and maternal and immunization services in particular (from mothers of children <2 years old). Purposively, 240 key informants and 290 recently delivered mothers were selected for qualitative interviews. Only 31% of the total respondents were aware of the visits of frontline health workers, and 20% of households reported visits to their locality during past month. In 4 cities, approximately 90% of households never saw health workers in their locality. Only 20% of women and 22% of children received antenatal care and vaccination cards from frontline health workers. Qualitative data confirm that the frontline health workers' visits were not regular and that health workers limited their services to antenatal care and childhood immunization. It was further noted that health workers saw the migrants as“outsiders.” These findings warrant developing migrant‐specific health‐care services that consider their vulnerability and living conditions. The present study has implications for India's National Urban Health Mission, which envisions addressing the health care needs of the urban population with a focus on the urban poor.     

河北省赵县孕产妇和儿童健康管理现状研究

目的：调查分析河北省赵县基本公共卫生服务项目中孕产妇和儿童健康管理实施现状,为改进服务质量提供研究资料和建议。方法根据国家基本公共卫生服务规范要求的服务内容设计调查问卷,主要包括体格检查、化验和咨询指导,现场观察乡镇卫生院妇幼保健人员的产前保健和儿童保健服务过程,并对保健人员进行访谈以了解其对自己的工作量、收入和提供喂养咨询指导的看法。结果调查共观察了88名孕妇的产前保健和194名儿童的保健服务。产前保健中有80％以上的孕妇进行了体格检查,但进行实验室化验者不足5％。保健人员很少提供咨询指导,没有孕妇得到母乳喂养方面的指导。儿童保健中98．5％的儿童测量了体重和身长,但分别只有6．2％和4．6％对照生长标准曲线进行了评价。只有21．6％的儿童家长接受了喂养指导。结论赵县基本公共卫生服务项目中产前保健和儿童保健的体格检查部分工作开展较好,但实验室化验和咨询指导方面的服务质量有待提高;保健人员反映工作量大、收入低,同时需要更多高质量的培训。     

Telepsychiatry Consultation for Primary Care Treatment of Children and Adolescents Receiving Child Protective Services in Chile: Mixed Methods Feasibility Study

BackgroundChildren and adolescents living under the supervision of child protective services have complex mental health care needs. The scarcity and uneven distribution of specialized mental health teams in Chile may limit the provision and quality of care for this vulnerable population. Telepsychiatry can address such health inequities.ObjectiveThe objective of this study was to evaluate the feasibility of a telepsychiatry consultation program for primary health care (PHC) treatment of children and adolescents living under the supervision of child protective services.MethodsWe developed a telepsychiatry consultation program for two rural PHC clinics located in central Chile (Valparaíso Region) and evaluated its implementation using a mixed methods study design. The program consisted of videoconferencing mental health consultation sessions scheduled twice per month (each 90 minutes long), over a 6-month period, delivered by child and adolescent psychiatrists based in Santiago, Chile. We described the number of mental health consultation sessions, participant characteristics, perceived usefulness and acceptability, and experiences with the telepsychiatry consultation program.ResultsDuring the 6-month study period, 15 videoconferencing mental health consultation sessions were held. The telepsychiatry consultation program assisted PHC clinicians in assigning the most adequate diagnoses and making treatment decisions on pharmacotherapy and/or psychotherapy of 11 minors with complex care needs. The intervention was perceived to be useful by PHC clinicians for improving the resolution capacity in the treatments of this patient population. Limitations such as connectivity issues were resolved in most sessions.ConclusionsThe telepsychiatry consultation program was feasible and potentially useful to support PHC clinicians in the management of institutionalized children and adolescents with complex psychosocial care needs living in a poorly resourced setting. A larger scale trial should assess clinical outcomes in the patient population. Regulations and resources for this service model are needed to facilitate sustainability and large-scale implementation.     

Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.     

柳州市基层医疗卫生机构儿童保健服务能力调查

目的:了解柳州市基层医疗卫生机构儿童保健服务能力现状,为相关部门制定政策提供参考依据。方法:采用普查的方式调查柳州市123家基层医疗卫生机构的辖区基本情况、人员及设施设备投入和服务开展情况。结果:123家基层医疗卫生机构中,每万常住人口拥有基层医疗卫生机构儿童保健医生0.32名、注册护士0.25名,每平方公里儿童保健医生0.0070名、注册护士0.0055名。39.84%的机构无执业(助理)医师,32.52%的机构近5年有儿童保健人员到上级医院进修。儿童保健门诊用房面积达到自治区要求的机构不足40%;视力检查、听力筛查、心理行为发育评估和膳食营养分析工具配置率分别为89.43%、36.59%、22.76%和9.76%。开展的7项儿童保健服务中,心理行为发育测验(24.39%)、耳及听力保健服务(74.80%)开展比例低,其他5项均超过90%。城乡机构间儿童保健服务人员、设施设备投入和服务开展情况存在差异,贫困县情况更严峻。结论:柳州市基层医疗卫生机构儿童保健服务能力与国家标准相比,还存在一定差距。政府有必要合理配置医疗资源,加强儿童保健人员的培养,规范儿童保健门诊建设,全面提高基层医疗卫生机构儿童保健服务能力。     

Primary health care and public policy

The health problems of Ecuador are similar to those in other developing countries where the standard of living is low, and housing and sanitation are inadequate. Women, children, and those living in rural areas are those most severely affected. National policy has been to attempt to increase access to health care in rural areas through the construction of new facilities and the appointment of highly paid medical staff. However, little attention was paid to sociocultural factors, which caused the peasantry to reject the medical care system, or to problems of internal efficiency which inhibited utilization. Since the 1970s various national and international organizations have attempted to implement primary health care (PHC) through the use of trained community health workers (CHWs). The primary problems faced by the CHWs were shortages of medicines and supplies, an almost total lack of supervision, and lack of transportation available to take staff to isolated villages. The poor supervision is blamed for the 17% drop out rate among CHWs since 1980. Independent PHC programs have also been established in Ecuador by voluntary organizations. These work best when coordinated with governmental programs, in order to allow monitoring and to avoid the duplication of services. Problems with the establishment of PHC programs in Ecuador will continue, as the government has no clear cut policy, and difficulties financing on a broad national scale. Other problems include the absence of effective supervision and logistical support for even small pilot programs, and inconsistencies in the training and role definition for CHWs. These problems need to be met in the implementation of a national PHC policy.     

湖南省妇幼保健机构保健工作现状调查

目的:了解湖南省各级妇幼保健机构保健工作现状,为各级卫生行政部门的决策提供科学依据。方法:采用全国妇幼卫生机构管理信息网络报告系统进行网络直报,调查湖南省137所各级妇幼保健机构,包括1所省级机构、14所市州级机构、122所县区级机构,调查内容包括:各级妇幼保健机构基本情况、人力资源情况、保健医疗技术服务情况、群体保健工作开展情况等。采用SPSS 15.0和Excell 2003对数据进行整理和统计分析。结果:①基本情况:调查机构专/兼职从事群体保健工作的卫技人员平均为15人,省级为124人,市州级为17人,县区级为14人。②保健门诊:全省平均每所妇幼保健机构妇女保健门诊6 475人次,儿童保健门诊7 821人次。③保健业务开展情况:湖南省2007年度各级妇幼保健机构妇女保健管理、产前诊断管理和生殖保健与计划生育开展的机构比例分别为98.5%、12.4%和84.7%,辅助生殖开展的机构比例略低,为6.6%;开展儿童生长发育、营养、发展促进和高危儿管理的机构比例在70%以上,其余各项均低于50%;平均开办培训班6次,培训人员429人次,接待进修人员26人次,群体保健管理人员下基层平均646人次。结论:各级政府对妇幼保健机构投入不足,保健机构的人力资源有待优化和加强,群体保健工作须进一步深入,同时提高妇幼保健信息化管理。     

Assessment of the managerial functions in primary health care settings

During October 1988 to June 1990, the authors developed a conceptual framework with which to measure the quality of prenatal care in primary health care (PHC) settings. That framework was applied during June-December 1990 to the public maternal and child health facilities in the Irbid Governorate of North Jordan which provide prenatal care. Management is an essential component of quality prenatal care. The authors describe the indicators of the managerial functions practiced in the PHCs and report upon the extent to which they are performed. Management was analyzed at the levels of both structure and process. The 31 managers of the PHCs providing prenatal care in the Irbid Governorate were interviewed about their various management functions. General information was also collected on the personnel and facilities available at the centers. The managers were of mean age 37 years with an average 2 years of experience managing their facilities. The managers in all but two facilities were male physicians. Study findings suggest that the management functions of prenatal care services in PHC settings are inadequately performed. The indicators suggest that the controlling function was better performed than the planning, organizing, and directing functions.     

Mothers' perspectives on the quality of postpartum care in Central Shanghai, China.

OBJECTIVES: To investigate mothers' perspectives on the quality of postpartum care services in central Shanghai, China. DESIGN: Semi-structured interviews. SETTING: Two maternal and child health posts in two subdistricts in LW District, Central Shanghai, China. STUDY PARTICIPANTS: Fifty postpartum mothers who attended the maternal and child health posts in the two subdistricts in LW District, Central Shanghai, China. MAIN OUTCOME MEASURES: Mothers' perceived quality and adequacy of postpartum services. RESULTS: A majority of the mothers (90%; n = 45) were primiparas (first time mothers). Half did not consider the postpartum services to be of high quality. They defined high quality as 'full satisfaction of the mother and the child'. Their perception of quality was influenced by their concern about child care, an area in which they expressed the need for further improvement. CONCLUSION: Mothers indicated that to improve quality of services further, greater emphasis should be placed on: (1) health education on childcare; (2) more time allocation for discussion with health workers during their postpartum home visits so their questions and concerns could be addressed effectively; (3) access to health workers in times of need rather than during officially prescribed home visits; and (4) provision of continuous training for maternal and child health workers with respect to childcare. The findings will be relevant to health workers and policy makers involved in planning and implementation of maternal and child health services in similar urban settings in developing countries.     

Minimum primary health care interventions for child survival: Setting the research agenda

With the purpose of exposing some of the underlying issues, the first part of the article discusses the background and assumptions inherent to the idea of minimum primary health care interventions for child survival. The second part puts forward some areas for study, based upon their potential importance to child health and survival. International and national approaches to ‘minimum interventions’ are seen as being rooted in their political contexts, including the wider debate over the relationships between economic growth, development and the meeting of basic needs. To have relevance for health planning and management, it is argued that research agendas concerned with the impact of primary health care (PHC) interventions upon child survival must be: country-specific; start with ‘what is’; and take entire national frameworks into account, including the respective roles and effects of the private and public sectors. Potentially useful research activities are discussed in the areas of coverage and resource allocation, and with regard to the development of minimum norms and standards. Proposals are made for setting a research agenda for PHC programmes in Mexico.     

2011年江西省九江市妇幼保健机构现状及发展对策分析

目的掌握江西省九江市各级妇幼保健机构的发展现状,为机构自身规范化建设及卫生行政部门的科学决策提供指导依据。方法借助全国妇幼保健机构监测信息网络报告系统,对2011年九江市15所妇幼保健机构人力资源、设备资源配置和服务运营等资料进行调查。结果九江市及辖区各区县妇幼保健机构普遍存在人员编制不足、人员素质偏低、设备落后、业务经费紧张等问题。结论九江市妇幼保健机构应合理进行人员配置,努力提高妇幼保健队伍人员素质;增加资金投入,改善设备条件;积极拓宽筹资渠道,实现经费筹资方式多元化,从而保证妇幼保健机构的可持续性发展。     

Improving the quality of child health services: participatory action by providers.

OBJECTIVE: To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. DESIGN: Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. SETTING: Primary care clinics in Guinea and Kenya. STUDY PARTICIPANTS: Health care providers and child caregivers. INTERVENTIONS: Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. MAIN OUTCOME MEASURES: Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. RESULTS: On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. INTERVENTION: sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. CONCLUSION: COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.     

A Cost-Effective Model for Increasing Access to Mental Health Care at the Primary Care Level in Nigeria

BACKGROUND: Although effective treatment modalities for mental health problems currently exist in Nigeria, they remain irrelevant to the 70% of Nigeria's 120 million people who have no access to modern mental health care services. The nation's Health Ministry has adopted mental health as the 9th component of Primary Health Care (PHC) but ten years later, very little has been done to put this policy into practice. Mental Health is part of the training curriculum of PHC workers, but this appears to be money down the drain. AIMS OF THE STUDY: To review the weaknesses and problems with existing mode of mental health training for PHC workers with a view to developing a cost-effective model for integration. METHODS: A review and analysis of current training methods and their impact on the provision of mental health services in PHC in a rural and an urban local government area in Nigeria were done. An analysis of tested approaches for integrating mental health into PHC was carried out and a cost-effective model for the Nigerian situation based on these approaches and the local circumstances was derived. RESULTS: Virtually no mental health services are being provided at the PHC levels in the two local government areas studied. Current training is not effective and virtually none of what was learnt appears to be used by PHC workers in the field. Two models for integrating mental health into PHC emerged from the literature. Enhancement, which refers to the training of PHC personnel to carry out mental health care independently is not effective on its own and needs to be accompanied by supervision of PHC staff. Linkage, which occurs when mental health professionals leave their hospital bases to provide mental health care in PHC settings, requires a large number of skilled staff who are unavailable in Nigeria. In view of past experiences in Nigeria and other countries, a mixed enhancement-linkage model for mental health in PHC appears to be the most cost-effective approach for these Nigerian communities. DISCUSSION: Nigeria is currently experiencing a 'double epidemic', and with high infant and maternal mortality rates, the burden of mental health problems is still invisible to policy makers. Meagre resources allocated to mental health need to be utilised maximally with cost-effective interventions. This mixed enhancement-linkage model draws on the strengths of both models, while taking into account their limitations. Concrete conclusions cannot be drawn until the model developed is fully tested. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This model has the potential of making mental health services available, accessible and acceptable in these communities. This should reduce the burden of suffering for the mentally ill by providing treatment and restorative care, promoting mental health and preventing mental illness in the populace. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The current mental health policy for Nigeria focuses on enhancement as the mode in which mental health can be successfully integrated into PHC and so far this has not been successful. Results emerging from this model can be presented to policy makers thereby supporting replication in other parts of the country. This could ultimately lead to a change in the mental health policy on training for mental health at the PHC level. IMPLICATIONS FOR FURTHER RESEARCH: Mental health services and mental health economics research are still at the stage of infancy in Nigeria. This study provides baseline information and should stimulate further research in these two vital areas.     

Primary health care is viable.

'Selective primary health care' and other recent vertical health strategies have been justified on the grounds that the broad primary health care (PHC) approach cannot be afforded by developing countries in the present constrained economic circumstances. This judgement is too sweeping. A simulated case example is presented, starting with baseline health expenditure data that are representative of the situation in many developing countries. It is assumed that real economic growth occurs and that government funding of health care is allowed to grow in parallel. Two annual growth rates are considered: 2 and 5 per cent. Two restrictive conditions are applied: none of the main health services is subjected to absolute cuts; and, additional funds from existing or new sources of finance are not considered. It is shown that, even with slow growth rates, substantial increases in the funding of priority (rural and PHC) services can be achieved if the growth in expenditures of lower-priority services is curtailed. Also, savings from improved health service efficiency can be channelled to priority services. The message is that the PHC approach is viable even with slow economic growth. What is required is the technical capacity to identify and plan resource flows in the health sector, and the political will to effect resource allocations according to PHC priorities. A strategic policy like PHC should not be 'adjusted' out of effective existence because of reversible economic problems. Rather, actions should be taken to reverse the adverse economic environment. International health-related agencies should continue to support countries to develop national health systems based on PHC, and should campaign for reforms in the world economy to create at least the minimum economic conditions necessary for PHC implementation.     

The cost and efficiency of public and private health care facilities in Ogun state,Nigeria

During the 1980s, Nigeria faced difficult economic conditions resulting in a severely constrained budget for public health services. To assess more carefully the costs and efficiency of the public and private health sectors, the Federal Ministry of Health in Nigeria undertook a comprehensive survey of health care facilities in Ogun State in 1987, the analysis of which is presented in this study. The findings suggest that there is potential to increase service delivery within existing budgets by more cost-effective allocation of inputs. Many public and private providers are not operating at full technical capacity. It also appears that public facilities are not using cost-minimizing combinations of high and low-level health workers, in particular, too many low-level staff are being used to support high-level workers. The cost analysis indicates that there are short-run increasing returns to scale for inpatient and nearly constant returns to scale for outpatient services. Economies of scope for joint production of inpatient and outpatient services are not being realized. A major implication of such analysis is that improved resource allocation decisions heavily depend on the existence of information systems at the health facility level which carefully integrate financial information with other appropriate and adequate measures of service inputs, health care quality, facility utilization and ultimately health status.     

Evaluation of primary health care reform in Estonia

Estonia began to reform its health care system by reorganizing primary health care (PHC). Ten years ago, the health care system was inefficient, supply was biased towards institutional care, and PHC was almost non-existent in the western understanding: it was provided by different specialists in policlinics, and the financial basis of the system was in crisis. The reform had the following aims: to develop PHC by introducing family medicine, to guarantee the whole population access to family doctors' services, and to secure stable funding for these services. In 1998, a new phase in the reform was introduced through the creation of a new funding system for primary care services. The aim of this paper is to present a practically applicable set of indicators to evaluate PHC reform in terms of health economics criteria and then to apply these indicators in evaluation of the Estonian PHC reform.