# Financial autonomy of facilities providing primary care services in low- and middle-income countries: assessing the evidence to inform the development of a typology and conceptual framework

## TL;DR

This paper explores how financial autonomy affects primary care facilities in low- and middle-income countries, offering a framework to guide future reforms.

## Contribution

The study introduces a new typology and conceptual framework for understanding financial autonomy in primary care settings in low- and middle-income countries.

## Key findings

- Financial autonomy can improve facility performance when aligned with context and supported by accountability.
- The study identifies key contextual factors and prerequisites for effective financial autonomy implementation.
- It highlights gaps in understanding the implications of financial autonomy for purchasing and public financial management.

## Abstract

Provider autonomy is increasingly asserted as an important attribute in health systems, but is rarely interrogated in-depth, particularly at primary care level. This article aimed to examine the current state of evidence on the role of financial autonomy in primary care, focusing on the public sector in low- and middle-income settings (LMICs), and develop a typology and conceptual framework based on it.

The article draws on mixed methods, including a scoping review of the literature (91 documents), 12 expert interviews and the knowledge of the research team. Findings were also discussed with health financing and public financial management experts at a global meeting in 2023 to deepen the reflections.

In the article, we examine the reforms which have been associated with triggering or at least raising the profile of financial autonomy at primary care level as an important attribute, including strategic purchasing reforms, decentralisation and public financial management (PFM) changes. We highlight important considerations for design and implementation of financial autonomy at primary care level and propose an evidence-based typology structured by the budget cycle, which defines specific dimensions of financial autonomy along a continuum. Finally, we examine what evidence exists on the impacts of financial autonomy and develop a conceptual framework to highlight key considerations in terms of contextual influencers of financial autonomy, prerequisites for it to be deployed, and the potential positive and negative effects of financial autonomy at primary care level. This can be used to encourage future research and inform reform processes in this area.

We conclude that financial autonomy at primary care level can contribute to facility performance, if tailored to contextual factors and supported by accountability mechanisms. However, while financial autonomy is prima facie a positive attribute, the understanding of autonomy over what, for which purposes and by whom is still not clearly addressed in the literature, along with the implications for purchasing and PFM (which is key to enable financial autonomy, as well as being affected by it). This is the first study to our knowledge providing an in-depth understanding of provider financial autonomy at primary care level in LMICs, and moves the field forward with its typology and conceptual framework.

The online version contains supplementary material available at 10.1186/s12913-025-13863-7.