Leadership and running a primary care clinic

A primary care clinic is run by a team: clinicians, nurses and midwives, pharmacy and laboratory staff, data clerks, cleaners, guards and community health workers. The person in charge does not need to do everything. Their job is to make sure the right work is done by the right person, safely, every day.

The bigger picture

WHO's operational framework for primary health care (2020) names 14 levers for strengthening primary health care. Four are core strategic levers (political commitment and leadership; governance and policy; funding; engagement of communities and other stakeholders). Ten are operational, and a clinic manager works with most of them every week: models of care, the primary care workforce, physical infrastructure, medicines and other health products, digital technologies, systems for improving quality of care, and monitoring and evaluation.

Basics of leading a clinic team

• Clear roles: a written list of who does what each day (triage, consultations, dispensing, registers, cleaning, stock), with a named deputy for every task.
• A short daily huddle (5 to 10 minutes): who is on duty, expected workload, stock-outs, broken equipment, any patient safety concern from yesterday.
• A monthly team meeting: review a few indicators (lesson 6), incidents (lesson 7) and one improvement project (lesson 3). Write down decisions and who will act.
• Fairness and respect: share unpopular duties, give credit, address conflict early and privately, and protect staff from violence and abuse.
• Look after staff: safe workload where possible, breaks, protective equipment, vaccination, and support after distressing events.

Task sharing

Task sharing means trained staff with shorter training take on tasks usually done by more highly trained staff, so that more people get care. WHO's OptimizeMNH recommendations (2012) give examples:

Source: WHO and UNICEF. Operational framework for primary health care: transforming vision into action, 2020. WHO. OptimizeMNH: optimizing health worker roles through task shifting, 2012.

Supervision is the main way to keep the quality of care high once staff are trained, especially when tasks are shared. Supportive supervision is about helping staff solve problems and learn, not catching them out.

What WHO suggests

WHO's guideline on community health worker programmes (2018) suggests these supportive supervision strategies, which apply to any clinic team:

• A supervisor-to-supervisee ratio that allows meaningful, regular support.
• Supervisors who are trained for the role.
• Coaching and mentoring.
• Using observation of care, performance data and community feedback.
• Making the quality of supervision a priority, not just its frequency.

A supervision visit in five steps

1. Prepare: look at the facility's data (lesson 6) and the actions agreed last time.
2. Observe: sit in on a few consultations with the patient's permission (for example, a child with fever, a family planning client), using the protocol as a checklist.
3. Check systems: stock of tracer medicines, equipment, registers, infection prevention.
4. Listen: to staff, and to patients or the health committee where possible.
5. Feed back and agree actions: privately, specific, starting with what went well; agree two or three actions with names and dates.

Mentoring and clinical learning

• Mentoring is longer-term support from a more experienced clinician: case discussion, practising skills together, being available by phone or message for advice.
• Short regular case reviews in the clinic (for example, 30 minutes a week) keep skills alive. Choose real cases, including a death or a near miss (lesson 7), and discuss them without blame.
• Record competence for key procedures (for example, implant insertion, newborn resuscitation) and repeat skills practice for rarely used skills.

I saw you check the danger signs carefully and explain the medicine well. One thing to add next time is the respiratory rate count: let's practise it together now.

Source: WHO guideline on health policy and system support to optimize community health worker programmes, 2018 (recommendation 6). WHO. Delivering quality health services: a global imperative for universal health coverage, 2018 (clinical audit and feedback; morbidity and mortality review).

WHO describes quality health care as having seven characteristics: effective, safe, people-centred, timely, equitable, integrated and efficient. Most quality problems in primary care are not about one careless person; they come from how the work is organised. That is why improvement focuses on processes.

Methods WHO describes for improving clinical care

• Clinical standards and protocols: agreed one-page protocols for common conditions.
• Clinical audit and feedback: measure care against a standard and feed results back to the team.
• Morbidity and mortality reviews: review deaths and serious complications to learn, without blame.
• Team-based improvement cycles: repeated small tests of change, sometimes with several clinics learning together.

A simple improvement cycle (plan, do, study, act)

1. Choose one problem that matters and that the team can influence. Example: only 40% of people with hypertension have controlled blood pressure.
2. Measure the baseline with a simple indicator and a clear definition. Example: of patients seen for hypertension this month, the percentage with BP below 140/90.
3. Find the causes with the team: ask "why?" several times. Example: no medicine at the pharmacy, no dose step-up at reviews, patients miss appointments.
4. Plan one small change and who does what. Example: use the treatment protocol card at every review and step up the dose if BP is not controlled.
5. Do it for a short time (2 to 4 weeks), then study the result on the same indicator.
6. Act: keep the change, adapt it, or try a different one. Then start the next cycle.

Clinical audit in practice

Source: WHO, OECD and World Bank. Delivering quality health services: a global imperative for universal health coverage, 2018. WHO. Quality health services: a planning guide, 2020.

In a busy clinic the most dangerous place is the queue: a child with severe pneumonia or a woman with eclampsia can deteriorate while waiting behind people who need a refill. Triage on arrival finds them.

Triage at the door

Use a recognised tool such as the WHO, MSF and ICRC Interagency Integrated Triage Tool (IITT) for adults and adolescents, and WHO emergency triage (ETAT) danger signs for children. A trained nurse or health worker sorts every patient within minutes of arrival:

Organising the flow

• Map the patient journey once with the team: arrival, registration, triage, waiting, consultation, laboratory, pharmacy, exit. Time each step for a day. The longest wait is where to start.
• Separate streams where space allows: emergencies; children; antenatal and family planning; chronic disease refills; people with cough or fever (infection prevention).
• Do routine measurements (weight, BP, temperature) at triage or in the waiting area, not in the consulting room.
• Keep emergency equipment and medicines in one place, checked daily (oxygen, bag-valve-mask, glucose, magnesium sulfate, adrenaline).

People with chronic conditions

• Give appointment dates, and spread them across the week.
• Stable patients need fewer visits. For example, WHO recommends that people established on HIV treatment are seen every 3 to 6 months and receive 3 to 6 months of medicines at a time. Use the same idea for stable hypertension and diabetes where national policy allows.
• Fast-track refills for stable patients, with a nurse or trained health worker following the protocol.
• Keep a list of who missed their appointment and give it to community health workers for follow-up.

Source: WHO, MSF and ICRC. Interagency Integrated Triage Tool (age 12 and over), 2023. WHO and ICRC. Basic emergency care: approach to the acutely ill and injured, 2018. WHO. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring, 2021 (differentiated service delivery).

A protocol is useless without the medicine. Medicines and other health products are one of WHO's operational levers for primary health care, and the availability of essential medicines is a global (SDG) indicator. WHO's primary health care measurement framework (2022) tracks a set of 32 tracer essential medicines for primary care, based on the WHO Model List of Essential Medicines.

Records

• Keep a stock card (or electronic record) for every item: date, received, issued, losses or adjustments, balance, and expiry date of each batch.
• Count physical stock regularly (for example monthly) and correct the card. Investigate any difference.
• Record stock-out days. Average monthly consumption calculated from months with stock-outs will be too low.

Ordering on consumption

Most systems use a minimum and maximum stock level, set nationally or by the district. A worked example:

Storage

• Issue first expiry, first out (FEFO): put the batch that expires soonest at the front.
• Store off the floor and away from walls, in a clean, dry, secure and ventilated room, protected from direct sun. Keep a temperature record.
• Cold chain items (oxytocin, vaccines, some test kits): fridge between 2 and 8 degrees, temperature recorded twice a day, never frozen unless the label says so.
• Separate and record expired or damaged stock; dispose of it according to national rules.
• Two people sign for controlled medicines; keep them locked.

When stock runs low

• Tell the district early (with the stock card figures), not when the shelf is empty.
• Agree substitutes with the clinicians, following national guidance (for example, another first-line antihypertensive in the same protocol).
• Prescribe rationally: protocols reduce waste from unnecessary antibiotics and injections.

Source: WHO and UNICEF. Primary health care measurement framework and indicators, 2022. WHO. Model List of Essential Medicines, 23rd list, 2023. WHO. Good storage and distribution practices for medical products (Technical Report Series 1025, Annex 7), 2020. WHO and UNICEF. Operational framework for primary health care, 2020.

Every register line is a patient. Registers are summarised into a monthly report, which goes to the district health management information system (HMIS). Many countries now use DHIS2, an open-source web platform, for this. Good data let the clinic and district see coverage, plan stock and staff, and find gaps.

From register to report

1. Record every contact completely, at the time, in the right register (outpatient, antenatal, family planning, HIV, TB, NCD, immunisation).
2. At month end, tally each data element using the national definitions.
3. Check the totals (below) and have a second person verify.
4. Submit on time (on paper, or entered into DHIS2 at the facility or district).
5. Keep a copy and use it at the monthly team meeting.

Checking data quality

WHO's data quality review toolkit looks at four dimensions. A clinic can check the first two itself:

Using data in the clinic

• Choose a few indicators that the team can act on, for example: percentage of hypertension patients with controlled BP, first antenatal contact before 12 weeks, implants and IUDs provided, tracer medicine stock-out days, children under 5 with fast breathing correctly treated.
• Show them as wall charts and discuss them monthly (lesson 3).
• Look at numerators and denominators: a rise in percentage can mean fewer people were counted.
• Protect confidentiality: registers are locked away; data shown on walls are numbers, never names.

Source: WHO. Data quality review: a toolkit for facility data quality assessment, module 1, framework and metrics (version update December 2020). WHO and UNICEF. Primary health care measurement framework and indicators, 2022.

WHO estimates that in high-income countries about 1 in 10 patients in hospital is harmed by care, and that unsafe hospital care in low- and middle-income countries causes 134 million adverse events and about 2.6 million deaths each year. Harm is not only a hospital problem: about half of the global burden of harm from care starts in primary and ambulatory care, for example missed diagnoses, medication errors and unsafe injections.

The global action plan

The WHO Global Patient Safety Action Plan 2021 to 2030 sets a vision of zero avoidable harm, with seven strategic objectives. For a clinic, the most relevant are: make zero avoidable harm a way of thinking; make every clinical process safe; engage patients and families; protect and train health workers; and keep information flowing so that risks are reduced.

Types of incident

Reporting and learning

• Make reporting easy: a simple form or book, open to every member of staff, including near misses.
• Staff report only if they are protected from blame. Aim for a just culture: no punishment for honest errors, while reckless behaviour is still dealt with.
• Review incidents in the monthly team meeting. For serious incidents, reconstruct the timeline and keep asking "why?" until you reach the system causes (root cause analysis).
• Act on the findings and tell the reporter what changed: if nothing changes, people stop reporting.
• Be open with the patient and family: explain what happened, apologise, and say what is being done.

Common safety risks in primary care, and simple defences

• Medication errors: protocols with doses, clear labels, checking allergies, dose-banded tables for children. WHO's Medication Without Harm challenge aimed to halve severe avoidable medication-related harm.
• Missed danger signs: triage at the door (lesson 4) and safety-netting advice to every patient.
• Infections from care: hand hygiene, safe injections, sterilisation of instruments.
• Lost results and referrals: a results and referral book, checked weekly.

Source: WHO. Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care, 2021. WHO. Patient safety incident reporting and learning systems: technical report and guidance, 2020.

Primary health care rests on three components: integrated health services, multisectoral policy and action, and empowered people and communities. Engagement of communities is one of the four core strategic levers in WHO's operational framework. A clinic that listens to its community is used more, trusted more and finds problems earlier.

Levels of engagement

WHO's community engagement guide (2020) describes a continuum from less to more participation:

Community health workers

• Community health workers link households to the clinic: health promotion, finding people with danger signs, following up people who miss appointments, and, where trained, treating common conditions.
• They need the same support as clinic staff: clear tasks, supplies, supportive supervision (lesson 2), fair pay or recognition, and a clinic that welcomes their referrals.
• Include them in the monthly meeting and share data on their work.

Feedback and accountability

• Health committees or facility boards: meet regularly with clinic staff, review a few indicators and complaints, and help solve problems such as water, security or transport.
• Make complaints easy and safe, and reply to them. Post what changed ("You said, we did").
• Include groups who are rarely heard: adolescents, people with disabilities, displaced people, minority languages.

Source: WHO. Community engagement: a health promotion guide for universal health coverage in the hands of the people, 2020. WHO and UNICEF. Operational framework for primary health care, 2020. WHO guideline on health policy and system support to optimize community health worker programmes, 2018.

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