Abstract
BackgroundIn Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care.MethodsThis cross-sectional continuous observation time motion study took place from July – September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection.ResultsTwo hundred seventy-five providers were sampled from 60 facilities; 20% could not be observed due to provider absence (2% schedule error, 8% schedule change, 10% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors.ConclusionsThe time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.
Highlights
In Peru, a majority of individuals bypass primary care facilities even for routine services
Of 275 sampled shifts in primary care facilities, 55 (20%) could not be observed: in 6 cases, the named provider did not work at that health facility, in 21 the provider had switched shifts since the weekly schedule was released, and in 28 cases the provider did not show up for a scheduled shift
There were no statistically significant differences between these 55 cases and the 220 providers identified based on the demographics and contract information provided by the Ministry of Health (MOH)
Summary
In Peru, a majority of individuals bypass primary care facilities even for routine services. Primary care is critical to health system efficiency: primary care services that meet population needs and provide effective primary and secondary prevention result in better and more equitable population health benefits than higher cost specialty care [4, 5]. Primary care services are struggling to provide the continuity of care required to prevent and manage illness over time and are perceived to lack the resources and support required for high quality care [10]. Deficits and delays in primary care services result in the majority of the population avoiding routine preventive medical care [10], in frequent bypassing of primary care for pharmacies [11], and, for users of primary care in Lima, in an difficulty obtaining medications prescribed at the visit and dissatisfaction with long wait times [12, 13]
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