Developing a National Accreditation Model for Medication Management in the Iranian Primary Health Care System

Background: Considering the lack of accreditation models for health education and promotion(HEP) activities in the Iranian primary health care (PHC) system we conducted the present study to develop a national accreditation model for HEP actions in the Iranian PHC system.Methods: After a comprehensive review on the accreditation models in PHC field, especially those concentrated on the HEP programs, an initial HEP accreditation model was developed.Then, applying the Delphi technique, 18 experts in the Iranian PHC system with field experience in HEP programs were invited to assess the initial model. In the two-round Delphi study,aggregation was provided on the opinions and the standards and indicators were finalized.Conventional content analysis was applied to make sense of the data collected in the study.Results: The developed HEP accreditation model encompassed 62 indicators and five standards.The standards were as follow: "resources for HEP programs", "educational needs assessment of the target groups", "methods of providing a community with education", "management of health volunteers’ actions" and "evaluation of HEP programs".Conclusion: The standards and indicators found in the present study may serve as an educational rationale for health educators while designing high-quality health education/promotion programs. This model may be helpful for health policy-makers and stakeholders while planning to assess the continuous quality improvement of HEP services delivered in the PHC systems.

Factors associated with the uptake of national essential public health service package for hypertension and type-2 diabetes management in China's primary health care system: a mixed-methods study

The existence of a treatment gap for persons with mental disorders has led the WHO to implore leaders around the world to integrate mental health services into the community or primary health care system. Whilst there are strengths, there are great challenges to the integration process that are hindering the implementation of this initiative in developing countries. The aim of this paper is to synthesize evidence from various researchers regarding the strengths and challenges to the integration of mental health services into the primary or community health care system in developing countries. The sources of information included Pubmed, Medline, Google Scholar, Ebsco Host, and the WHO website. Seventeen (17) studies met the inclusion criteria out of the search results of 2,200. The challenges most reported were inadequate support and supervision structures; lack of key resources, limited Knowledge, inadequate training, and lack of experience of healthcare providers in mental health; time constraints for the primary healthcare workers; lack of regulatory measures to encourage the integration. The strengths most reported were health care workers’ acceptance of responsibility to provide mental health services in the community setting. This paper has proven a number of strengths and challenges regarding the integration of mental health services into the primary or community health care system. It is hoped that this paper will assist stakeholders and policymakers in overcoming the majority of the challenges identified in the integration of mental health services in the primary health care system.

Developing an effective system for measurement and improvement of primary health care (PHC) based on the conditions and characteristics of the countries' health systems is one of the World Health Organization (WHO) recommendations. This study will aim to develop a framework to assess the Iranian sub-national PHC system performance using the WHO measurement framework for PHC. This is a mix-method study with a triangulation design. The Iranian sub-national PHC Measurement Framework (PHCMF) will be developed through a review of the WHO's PHC measurement conceptual framework (for selecting key performance indicators (KPIs)), literature review (academic database), PHC-related national documents, consultations with national experts, and the Delphi technique for finalizing the framework. The required data for calculating selected KPIs is expected to encompass qualitative and quantitative data. Discussion: Iranian PHC system performance is not measured based on the holistic and scientific framework and international standards. The information obtained from this project will guide managers and policymakers to be aware of the current situation and the success rate of the PHC system in achieving the desired goals, as well as identify strengths and weaknesses of the PHC system and provide the solution to better policy formulation.

Background:Despite huge advances in improving most health indicators, Iranian primary health care (PHC) has faced several problems in improving the quality of care inside the health care system. Developed countries with similar problems have used various models of PHC governance for improving quality in their PHC system. This study aimed to obtain health professionals’ perspectives about the suitable pillars and components of Iran’s PHC governance model.Methods:A purposeful sampling method was used to select seven participants who had a minimum of five years of experience in PHC and background education in the field of medical sciences. Between Jan and Jun 2015, three focus group discussions (FGD) were conducted with seven PHC experts in Tabriz. Data were analyzed using the conventional content analysis method.Results:The eight main categories including quality improvement, management and leadership, community involvement and customer participation, effectiveness of PHC, human resource development, safety, health care evaluation and audit, and health information management plus 51 sub-categories were identified according to participants’ expects about the essential pillars and components for Iranian PHC governance model.Conclusion:Pillars that suggested for designing Iran’s PHC governance model are presented according to internal informed expert’s opinions and taking into account PHC system real status. By adding the degree of importance for each component and proper performance indicators to this collection, assessing the progress of the PHC system towards excellence will be possible and it will prevent any mental judgments about system performance.

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.

Brazil and Turkey are among the few high-middle-income countries that explicitly chose to strengthen their primary health care (PHC) systems as the centerpiece of much broader health system reforms aiming to narrow inequities in access to care. This comparative case study reviews the organization of Brazil and Turkey’s PHC systems to derive lessons that can apply to other countries that may consider reforming the organization of PHC systems as a way to address health inequities. The analysis uses the Flagship Framework to investigate how the organization of PHC delivery in Brazil and Turkey can lead to measurable improvements in access to care. It compares (1) the degree of decentralization in PHC service delivery responsibilities, (2) the use of multi-professional PHC teams, and (3) patient impanelment strategies. The comparative analysis offers three important lessons. First, changes in the organization of PHC systems can contribute to observable improvements in the level and distribution of health outcomes, but organizational strategies do not guarantee eliminating disparities in access. Second, PHC systems can operate in health systems with varying degrees of decentralization, but the level of decentralization may influence implementation. Third, relying on multi-professional PHC teams that serve geographically empaneled populations can improve equitable access to care, but course corrections may be needed to address evolving health demands.

—Health gains oftentimes associated with income growth have been stubbornly slow in Nigeria in the past 25 years. One plausible reason for this stagnation is underperformance in the country's primary health care (PHC) system. The Primary Health Care Performance Indicators conceptual framework is used to examine Nigeria's PHC system and possible causes of underperformance. Analysis was conducted using a variety of sources including recent facility level information from the World Bank Service Delivery Indicators Survey. Results show that Nigeria has a relative abundance of PHC centers, reasonable geographic access to PHC, and relatively high health worker density. However, the performance of the PHC system is hindered by (1) segmented supply chains; (2) a lack of financial access to PHC; (3) a lack of infrastructure, drugs, equipment, and vaccines at the facility level; and (4) poor health worker performance. Altogether, these factors reflect two overarching system-level challenges—financing and governance—that are key root causes of the dysfunctions observed in the PHC system in Nigeria. Compared with peer African countries, Nigeria ranks low on nearly all PHC performance indicators. The government has taken important steps to address these root causes of underperformance, but policy gaps remain in achieving sustainable and equitable provision of PHC for the people of Nigeria.

ObjectiveThe rapid adoption of Artificial Intelligence (AI) in health service delivery underscores the need for awareness, preparedness, and strategic utilization of AI’s potential to optimize Primary Health Care (PHC) systems. This study aims to equip Iran’s PHC system for AI integration by envisioning potential futures while addressing past challenges and recognizing current trends.MethodThis study developed a conceptual framework based on the “Future Triangle” (FT) and the “Health Systems Governance” (HSG) models. This framework delineates the characteristics associated with the ‘pulls on the future’ for desired and intelligent PHC, as identified by a panel of experts. Additionally, the ‘weights of the past’—referring to the challenges faced by Iran’s PHC system in utilizing AI—, and the ‘push of the present’—which captures the impacts of AI implementation in global primary care settings—were extracted through a review of relevant literature. The integration and analysis of the collected evidence facilitated the formulation of a range of potential future scenarios, including both optimistic and pessimistic scenarios.FindingsThe interaction between the three elements of the FT will shape the future states of Iran’s PHC, whether optimistic or pessimistic. Building an optimistic scenario for an AI-driven PHC system necessitates addressing past challenges, including deficiencies in the referral and family doctor systems, the absence of evidence-based decision-making, neglect of essential community health needs, fragmented service delivery, high provider workload, and inadequate follow-up on the health status of service recipients. Consideration must also be given to the current impacts of AI in primary care, including comprehensive, coordinated, and need-based service delivery with systematic and integrated monitoring, quality improvement, early disease prevention, precise diagnosis, and effective treatment. Furthermore, fostering a shared vision among stakeholders by defining and advocating for a future system characterized by foresight, resilience, agility, adaptability, and collaboration is essential.ConclusionEnvisioning potential future states requires a balanced consideration of the influence of past, present, and future, recognizing the dual potential of AI to drive either positive or negative outcomes. Achieving the optimistic future or the “utopia of intelligent PHC” and avoiding the pessimistic future or the “dystopia of intelligent PHC” requires coherent planning, attention to the tripartite considerations of the future, past, and present, and a clear understanding of the roles, expectations, and needs of stakeholders.

General Practitioners are the backbones of the primary health care and whole health system around the world. United nation declaration in Alma Ata about primary health care and WHO reinforcement regarding the importance of robust primary health care for universal health coverage are major catalysts to sensitize the government to implement triaging of patients through primary care by general practitioners. Nepal lacks strong primary health care system utilizing general practitioners as frontline health service providers in the community level. This has made people travel a long distance risking high expenses to get basic healthcare. The overcrowding in tertiary care hospitals is a result of improper triaging and referral system. General practitioners in Nepal work in emergency departments of hospitals and medical colleges, do private practices and a small number of GPs work in health departments of Ministry of Health and Population. Proper mobilization of GPs and establishing primary health care system is paramount to achieve equity, efficiency and effectiveness in health services. Current health policies and program must be reviewed and updated based on the evidences from the studies. CME (Continuous Medical Education) was organized in Chitwan for General Practitioners as a regular program of GPEMAN(General Practice and Emergency Medicine Association of Nepal). Participants were asked about primary health care system in Nepal and its opportunities and barriers. Majority of participants 84% (32 out of 38) pointed out that poor health policy and lack of recognition of General Practice for primary health care as first contact physicians by the government are the major challenges and barriers. Evidences will guide government and concerned stakeholders to establish robust primary healthcare system to increase access, efficiency, effectiveness of health service and to reduce out-of-pocket expenditure and disease burden in the community.

Supportive supervision and mentoring (SSM) is crucial to primary care quality and effectiveness. Yet, there is little clarity on how to design and implement SSM and make it sustainable in primary health care (PHC) systems. The 3 African Health Initiative partnership projects introduced strategies to do this in Ethiopia, Ghana, and Mozambique. We describe: (1) how each partnership adapted SSM implementation strategies, (2) the dynamics of implementation and change that ensued after intervening within PHC systems, and (3) insights on the SSM sustainability as a mainstay of PHC. Researchers from each project collaboratively wrote a cross-country protocol based on those objectives. For this, they adapted implementation science frameworks-the Exploration, Preparation, Implementation, and Sustainment model and the Consolidated Framework for Implementation Research-through a qualitative theme reduction process. This resulted in harmonized lines of inquiry on the design, implementation, and potential sustainability of each project's SSM strategy. In-depth interviews and focus group discussions were conducted with stakeholders from PHC systems in each country and thematic analyses ensued. Across the projects, SSM strategies acquired multiple components to address individual, systems, and process-related determinants. Benefits arose from efforts that addressed worker-level attitudes and barriers, promoted a wider learning environment, and enhanced collaborative structures and tools for monitoring performance. Peer exchanges and embedded implementation research were critical to the perceived effectiveness of SSM strategies. Despite differences in their approach to SSM implementation, there are common crucial ingredients across the SSM strategies of the 3 AHI partner projects from which important lessons arise: (1) positioning learning and adaptation opportunities within the routine workings of PHC systems, facilitation, and technical support to reflect and utilize new knowledge; (2) multisectoral collaboration, particularly with academic organizations; and (3) building PHC decision-makers' and implementation teams' capacity for evidence-informed change.

IntroductionIn 2004, Mozambique, supported by large increases in international disease-specific funding, initiated a national rapid scale-up of antiretroviral treatment (ART) and HIV care through a vertical "Day Hospital" approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public-sector PHC services.Case DescriptionIn 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district-level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow-up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non-HIV aspects of primary health care.ConclusionThe integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss-to-follow-up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems.

Background: Primary Health Care (PHC) systems are essential for delivering comprehensive and accessible health services globally, focusing on individuals’ and communities’ fundamental health and well-being. Aims: To assess PHC systems to ensure universal access, regardless of socio-economic status or location, by providing comprehensive services such as illness prevention, treatment, rehabilitation, support, and health promotion. Methods: This study utilised the PICO framework, with methods and results of this systematic review based on PRISMA guidelines. Articles were identified through an initial generic search in PubMed, ScienceDirect, and Scopus databases. Results: After the assessment, a total of 18 articles were selected. The following priorities for PHC policy implementation emerged: enhancing collaboration between public and private sectors, improving information sharing through technology and health literacy, establishing quality evaluation systems, and promoting community-based training programs. Identified challenges include workforce shortages, particularly in rural areas, and inadequate coordination between primary and secondary care. Addressing these challenges and focusing on these priorities can lead to better health outcomes and more effective PHC systems. Conclusion: The Alma-Ata Declaration of 1978 was a transformative milestone in global health. It advocated for "Health for All" through Primary Health Care (PHC). Despite initial challenges, the principles of Alma-Ata have significantly influenced PHC systems worldwide. Keywords: Country-specific health primary care, health care systems, primary healthcare

Background: Accepting community health nursing in the primary care system of each country and focusing on creating a position for community health nurses is of significant importance. The aim of this study was to examine the stakeholders' perception of the requirements for establishing a position for community health nursing in the Iranian primary health care system.Methods: This qualitative study was done using 24 semi-structured interviews conducted from May 2020 to February 2021 in Iran. The participants were selected through purposive sampling and consisted of nursing policy makers, the policy makers of the Health Deputy of Ministry of Health, the managers and the authorities of universities of medical sciences all across the country, community health nursing faculty members, and community health nurses working in health care centers. After recording and transcribing the data, data analysis was performed in MAXQDA10 software, using Elo and Kyngas's directed content analysis approach and based on WHO's community health nursing role enhancement model. The statements for each main category were summarized in SWOT classification. To examine the trustworthiness of the data, Lincoln & Guba's criteria were used.Results: By analyzing the interviews 6 main categories identified consist of creating a transparent framework for community health nursing practice, enhancing community health nursing education and training for practice in the primary health care system and community settings, seeking support, strengthening the cooperation and engagement among the key stakeholders of the primary health care system, changing the policies and the structure of the health system, and focusing on the deficiencies of the health system. Each main categories including the subcategories strengths, weaknesses, opportunities and threats (SWOT).Conclusions: Based on the participants' opinions, focusing on the aforementioned dimensions is one of the requirements of developing a position for community health nursing within the Iranian PHC system. It seems that correct and proper implementation of these strategies in regard with the cultural context of society can help policymakers manage challenges that prevent the performance of community health nursing in the health system.

Background. One of the main activities that plays a significant role in the prevalence of mental illnesses is the issue of referral, and according to the evidence, the lack of proper implementation of the referral system is one of the obvious weaknesses of the primary health care (PHC) system. Therefore, this study aimed to investigate the challenges of referring mental health clients in the PHC system, and the weaknesses in this process were examined from the perspective of mental health experts in health centers. Methods. The present study is a conventional qualitative content analysis. Data were collected through semi-structured interviews with primary health care psychologists. Fifteen people were selected through purposive sampling. After transcription of the interviews, the data were analyzed based on the Graneheim and Landman model. Results. Two themes and twelve categories were acquired through the present study. The theme of intra-centered referential challenges included categories such as weaknesses in health care providers screening and low referrals, clients' lack of trust in health care providers, clients' lack of cooperation, physicians' poor cooperation, and Barriers to clients' desire to visit a psychologist. Outer-centered referential challenges also included a shortage of referral centers, lack of transparency in referrals, lack of direct referrals, poor follow-up, barriers for clients to go to a higher level, and Barriers to clients’ referral to the institute. Conclusion. The findings of the present study show that poor intra-sectoral and inter-sectoral communication is one of the main challenges that has disrupted the referral process in the field of mental health in the primary health care system. It seems that many challenges such as lack of designated referral centers, poor follow-up due to lack of referral feedback, clients' financial inability to refer to a higher level, etc. can be improved by strengthening cross-sectoral communications such as two-way communication with support organizations and psychiatric and psychotherapy centers.