Our Research
Advancing knowledge of primary healthcare policy and systems
At the Gill-Lebovic Center, we focus on addressing gaps in evidence on PHC systems research. Our mission is to generate knowledge that informs the transformation of PHC systems and improve people’s health. Through partnerships with regional agencies, governments and research institutions, we tackle real-world challenges in PHC systems while fostering the next generation of health systems researchers.
Nuestra Investigación: Cerrando Brechas, Transformando la Salud
En el Centro Gill-Lebovic, nos dedicamos a cerrar las brechas críticas en la investigación de sistemas de atención primaria de salud (APS) en países de ingresos bajos y medianos de las Américas.
Nuestro objetivo: Generar conocimiento que transforme las políticas y sistemas de APS, mejorando la salud de las comunidades.
Nuestro enfoque: A través de alianzas estratégicas con agencias regionales, gobiernos e instituciones de investigación, abordamos los desafíos del mundo real en los sistemas de APS.
Nuestro impacto: Fomentamos el desarrollo de la próxima generación de investigadores en sistemas de salud.
“My research is inspired by the question ‘What is hindering PHC transformation in the Caribbean and Latin America?’ Ultimately, I want my research to improve health systems throughout the Americas, making them fairer and more accessible, especially for the disadvantaged groups.”
Natalia Haughton
GW Affiliation Line
Ongoing Research
Institutions, Policies, and Regulations on Human Subjects Research in the Caribbean and Central America
Researcher: Camila Roberts, Private Sector Development Specialist at World Bank
This study compares the legal and regulatory frameworks governing human subjects research in the Dominican Republic, El Salvador, Guatemala and Honduras. Findings highlight variability in the protections and ethical standards across these countries.
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Governments in Latin America and the Caribbean are making significant strides in establishing ethical standards for health research, guided by universal principles of human dignity and autonomy. International declarations, such as the Declaration of Helsinki and UNESCO's Universal Declaration on Bioethics and Human Rights, serve as pillars for these evolving standards.
Leveraging her legal expertise, Camila delved into the intricate realm of human subjects’ research (HSR) regulations in the Caribbean and Latin America. Her findings shed light on the ethical guidelines and regulatory landscapes faced by public health practitioners across the region.
While all four countries studied adhere to these ethical principles, disparities exist in the development of their regulatory frameworks. The Dominican Republic and El Salvador lead the way with advanced systems, while Guatemala and Honduras have room for growth to fortify their regulations and broaden their impact.
The Pan American Health Organization (PAHO) emerges as a central ally in shaping ethical frameworks for health research in these nations. Through performance assessments and strategic interventions, PAHO contributes to fostering a culture of ethical research practices.
The establishment of national ethics research committees in the Dominican Republic and El Salvador signifies a proactive approach to enforcing ethical standards. These committees wield significant influence and play a crucial role in upholding ethical norms in research activities.
As public health practitioners navigate the diverse regulatory landscapes of these countries, they are encouraged to engage with local experts, prioritize community involvement, and adapt their research methodologies to align with regional ethical standards. By fostering collaboration and knowledge exchange, these practitioners are instrumental in shaping the future of research ethics in the Caribbean and Latin America.
Gaps in Governance and Accountability in PHC Systems in Latin America and the Caribbean
Researcher: Elise Lankiewicz, Policy Associate, amfAR, The Foundation for AIDS Research
This project explores interventions aimed at improving transparency and accountability in PHC systems, such as clinical audits, community monitoring and health committee participation. The goal is to identify which interventions are most effective in different contexts across the region.
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What actually works to improve health systems accountability and transparency in primary healthcare systems in Latin America and the Caribbean? We know transparency and accountability are critical building blocks in assuring that healthcare services are high-quality, user-centered, and trusted by service users. Today there are many different interventions used in health systems to improve transparency and accountability, such as user participation in health committees, clinical audit and feedback, accreditation processes, and community-led monitoring of health services. Yet there have been few systematic assessments of which accountability interventions work in different contexts, despite many countries across the region having committed to strive for more accountable primary care systems. This evidence gap map will be a systematic review of the literature for evaluations that document the impact of transparency and accountability interventions in Latin America and the Caribbean. Results will be synthesized to identify research gaps and opportunities.
Mixed-Methods Case Studies: The Salud Mesoamérica Initiative in El Salvador and Honduras
Researchers: Esther Aranda, DrPH, Research Consultant
Molly Lauria, ICF, Demographic Health Surveys (DHS) Program, Senior Survey Specialist
This study examines how team-level performance management (PM) interventions contributed to performance improvements in the primary healthcare system in El Salvador, specifically investigating how PM feedback and social interactions shaped team behavior and system outcomes.
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Large-scale health programs are assessed to understand their effects, implementation reasons for success or failure, and beneficiaries. Understanding what drives their success or failure is crucial for improving primary healthcare systems in resource-limited settings. This five year case study focuses on the Salud Mesoamerica Initiative (SMI) in El Salvador .
In her dissertation, completed May 2023, Ms. Aranda studied how in-kind incentives influenced the behavior of primary healthcare teams and the performance of the primary healthcare system in El Salvador. As part of the SMI program, El Salvador introduced team-level performance management innovations from 2015 to 2017 to enhance service delivery and care quality in rural areas for its poorest populations. These innovations included target-setting, feedback provision, and rewarding teams with in-kind incentives for meeting or exceeding targets.
Initial study analyzed 27 interviews of individuals deeply involved in implementing the SMI, including primary healthcare team members, government ministry decision-makers, and SMI officials. The analysis revealed that high-stakes workshops and peer exchanges were regularly organized for primary healthcare teams. These events provided feedback through scorecards, recognized teams that achieved targets, and facilitated networking opportunities. Teams found these gatherings valuable for sharing experiences, building connections, and learning from high-performing peers. For instance, teams adopted best practices in maternal care, improving maternal health outcomes in rural areas. Changes in practices, availability of actionable information, and new social connections were crucial for El Salvador's success, highlighting the significant role of social connections in the healthcare system.
Building on these insights, a second study, dives deeper into the institutional, organizational, and team-level conditions influencing program outcomes.Novel arrangements for the organization and delivery of healthcare services, investments in system readiness, joint ministry and SMI field visits, and high-stakes spaces for collective sensemaking and interpreting program performance plausibly contributed to the emergence of novel organizational competencies, a learning and improvement climate, and committed leadership. These contextual conditions help explain how the SMI’s performance management strategies contributed to positive program effects.
Together, these studies provide a comprehensive understanding of how performance management strategies can reshape primary healthcare systems and highlight the critical role of social dynamics in achieving sustained improvements. These findings, especially the emphasis on social interactions, offer valuable insights for policymakers aiming to replicate similar performance management strategies in other resource-limited healthcare systems.
This research, on the SMI in El Salvador and Honduras, is online in collaboration with Molly Lauria, a Gill Lebovic Center Fellow, and Dr. Wolfgang Munar.
Exploring the gaps in evidence on governance research on primary healthcare system reform in Latin America and the Caribbean (LAC)
Researcher: Natalia Haughton, Pan American Health Organization, Technical Officer, Primary Health Care Policy, Planning and Evaluation
This research maps existing evidence on the formal and informal governance rules that influence PHC reforms in LAC. The study aims to inform policymakers and international organizations on how to support PHC transformation and strengthen governance frameworks in the region.
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As part of Natalia’s doctoral dissertation, this is an exploration of the available empirical evidence on the roles of formal and informal rules in primary healthcare system reform processes in LAC. The research systematically maps the literature on health governance and identifies gaps in evidence that could inform regional policy, research, and technical support agendas. Findings can inform policymakers' decisions when designing evidence-based strategies to support PHC system transformation. Commissioners of research in the LAC region, such as the Gill-Lebovic Center, can benefit from using these research findings to focus their research strategies on areas where evidence gaps exist. Finally, international organizations and agencies supporting the Universal Health Coverage agenda and the Primary Healthcare Alliance can use the insights resulting from this research to develop targeted policy dialogue and technical support programs. The dissertation committee comprises Drs. Wolfgang Munar (Chair), Nino Paichadze, and Wayne Psek. Natalia Houghton works with Michael Harriman, a Graduate Research Assistant at the Gill-Lebovic Center.