Policy and service delivery proposals to improve primary care services in low-income and middle-income country cities.

The landscape of primary care services in low-income and middle-income country cities is diverse and dynamic, yet the quality of care received is too often low and the financial cost to the patient high. In the second Paper in this Series, we argue that shaping the primary care market is likely to provide larger returns to scale than individual quality improvement initiatives. Among other things, the market can be shaped by regulation and targeted public investment to crowd out poor providers and motivate those that remain to improve. Additional supply-side initiatives for which there is evidence include measures to educate and motivate the workforce, skill substitution and formation of clinical primary care teams, information technology, and improving the supply of medicines and diagnostics. Demand-side measures include reducing out-of-pocket expenses and promoting health literacy and user advocacy. Research is urgently needed into access for people who are unregistered (eg, those who sleep on the streets), those in peri-urban areas and towns, and on cost-effectiveness, and sustainability of beneficial interventions.