Component Of Primary Health Care Research Articles

Addressing the Millennium Development Goals From a Surgical Perspective

Surgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs. Survey. District-level health facilities in multiple LMICs A standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons. Data from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of São Tomé and Príncipe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus. Enormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

Primary Health Care in the 21st century: primary care providers and people’s empowerment

International health debates often confront enduring values with new realities. The events and publications surrounding the 30th anniversary of Alma Ata, the Primary Health Care (PHC) focus of the 2008 World Health Report and the report(s) of the Commission on Social Determinants of Health illustrate the durability of PHC values such as equity, self-determination, participation, trans-sectoral collaboration and the right to health (Gilson et al. 2007; Chan 2008; Lawn et al. 2008; Reich et al. 2008; Walley et al. 2008; World Health Organisation 2008; Hanson et al. 2009). Taking into account recent transitions that are changing the relationship between primary care providers and their patients, we examine that the role providers can play in enhancing people’s individual and collective empowerment, an important but rather neglected component of PHC (Walley et al. 2008).

Concept of essential medicines and rational use in public health

The Alma-Ata declaration during the International Conference on Primary Health Care in 1978 reaffirms that health is a fundamental human right and the attainment of the highest possible level of health is a most important worldwide social goal.(1) The Alma Ata declaration has outlined the eight essential components of primary health care and provision of essential medicines is one of them.(1) Medicines are integral parts of the health care and the modern health care is unthinkable without the availability of necessary medicines. They not only save lives and promote health, but prevent epidemics and diseases too. The medicines are undoubtedly one of the weapons of mankind to fight disease and illness. Accessibility to medicines is too the fundamental right of every person.

Improving the quantitative basis of the surgical burden in low-income countries.

For decades, the primary health care paradigm with a focus on maternal and child health programs has been driving funding for health in developing countries [1]. This has led to improvements, although there are doubts that many countries will meet the ambitious Millennium Development Goals 4 and 5 of reducing maternal and childhood mortality by three-quarters and two-thirds, respectively, between 1990 and 2015 [2],[3]. Surgery has not traditionally been considered an essential component of primary health care in low-income countries. This may be changing [4]. Emergency obstetric care, including surgical interventions, is now recognized as a key health service component for reducing maternal and neonatal mortality [5]. The broader contribution of surgical services to improvements in health outcomes in developing countries is also being discussed [6]–[9].

The Role of Traditional Management Practices in Enhancing Sustainable Use and Conservation of Medicinal Plants in West Usambara Mountains, Tanzania

The study on importance of traditional practices in conservation of medicinal plants in West Usambara Mountains, Tanzania was conducted by using focus group discussions, interviews, participant observation, and botanical survey. Nine traditional practices for conservation of wild plants were identified as domestication; beliefs in sacredness of trees; beliefs in sacred forests; respect of cultural forests; protection of plants at the burial sites; selective harvesting; secrecy; collection of deadwood for firewood, and use of energy-saving traditional stoves. Through botanical surveys of sacred forests, cultural forests, farms/homesteads, and burial sites, some 1,518 wild plants belonging to 100 species were identified. A large proportion (85%) of these plants had medicinal value. Of the 173 respondents, 82%, 81%, 74%, and 71% believed that sustainable use and conservation of medicinal plants can be achieved through secrecy, plant protection at burial sites, sacredness of plants and domestication, respectively. About 89% of the respondents pursued domestication (at least five plants each) and 70% had retained sacred trees (at least one tree each), of which the majority had medicinal value. Few respondents were aware of the positive role played by sacred forests and cultural forests (38% and 21%, respectively) in conservation of medicinal plants. It is concluded that the traditional management practices have a significant role in the conservation of biodiversity. This conservation role has a direct connection with human health since most of the plant species have medicinal value, which a majority of the rural people rely on. The paper recommends that traditional management practices should be encouraged since they serve a dual purpose as important conservation strategy and as an essential component of primary health care.

Health-promoting schools

Chronic diseases are now the major causes of death and disability worldwide, and non-communicable diseases (NCD) account for the majority of the global health burden. About half of premature deaths are related to health-risking behaviours that are often established during youth and extend to adulthood. While these diseases might not be curable, they are preventable. Prevention is possible when sustained actions are directed at individuals and families, as well as at the broader social, economic and cultural determinants of NCD. A ‘life-course’ approach to promoting healthy behaviour should begin early in life. The aim of this article is to discuss the impact of the ‘health-promoting school’ (HPS) on improvements in youth health. HPS can be described as a holistic, whole-school approach in which a broad health education curriculum is supported by the environment and ethos of the school. HPS moves beyond individual behavioural change to consider organizational and policy change such as improving the physical and social environment of the school, as well as its curricula and teaching and learning methods. A positive culture for health would facilitate higher levels of health literacy by helping individuals tackle the determinants of health better as they build the personal, cognitive and social skills for maintaining good health. There is reasonable evidence to demonstrate that the whole-school approach using the HPS framework is effective in improving health, ranging from physical activities and healthy eating to emotional health. Schools adopting the HPS framework have demonstrated changes in culture and organizational practice to become more conducive to health improvement. These schools were reported to have better school health policies, higher degrees of community participation, and a more hygienic environment than non-HPS schools, and students in these schools had a more positive health behaviour profile. Health promotion and disease prevention is essential to reduce the healthcare burden of children and adolescents. HPS would help to combat the global burden of childhood obesity by promoting healthy eating behaviours and encouraging higher levels of physical activity. There are gaps in service provision for children and adolescents from both the health and education perspective; the HPS framework has the potential to develop a mechanism of closer integration with the primary healthcare system, making youth health services more school based and student centred. A new model of interconnection between HPS and different components of primary healthcare can be evolved to make services for disease prevention and health promotion more student friendly.

Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa

Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked. Physiological and behavioural research indicates that alcohol independently affects decision-making concerning sex, and skills for negotiating condoms and their correct use. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care), must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.

Technology in global health: the need for essential diagnostics

Technology opens opportunities to address the components of primary health care described by the Alma-Ata Declaration, namely health education, proper nutrition, safe water, maternal and child care, immunisation, prevention and treatment of local diseases, and provision of essential drugs. But the Declaration used the word just once, describing primary health care as being based on “scientifically sound technology made universally accessible at affordable cost”. To us, “scientifically sound” and “universally accessible” are the key descriptors, each requiring separate calls for action. Development of scientifically sound technologies is an upstream process involving laboratory research and field assessment. Certain technologies, such as an effective HIV microbicide or new supplements to combat malnutrition, can provide enormous improvements in health by leapfrogging more intractable challenges. Since Alma-Ata we have seen the proliferation of public–private partnerships that aim to develop such “leapfrog” technologies, particularly drugs and vaccines for HIV, malaria, and tuberculosis.1 These products are undoubtedly needed, but we should recognise that technology development can be serendipitous and its effects surprising. To take one example, a recent analysis predicted that better enteropathogen diagnostics could deliver the world’s greatest improvement in disability-adjusted life years, reducing stunting and its long-term consequences by 12·5%;2–4 a simple, elegant test to detect faecal contamination could be transformational. But this huge potential may be difficult to achieve because priorities such as the UN Millennium Development Goals, which drive much of biomedical funding, target childhood mortality, not morbidity. New technologies might also help awaken the will for change. Then there are the health technologies that are already scientifically sound but for which Alma-Ata’s goal of universal accessibility is the hurdle. Accessibility can fail for diverse reasons, from poor acceptance to shortcomings of provision or infrastructure. Clean water can be delivered with technology as simple as boreholes and latrines, but 1·1–2·6 billion people lack access to these.5 In terms of provision, witness the cryptococcal antigen test, a highly sensitive diagnostic method that identifies the need for treatment of cryptococcal meningitis, a fungal disease common in AIDS. This technology has existed since the 1960s in a straightforward latex-agglutination form,6 but it is unavailable throughout most of Africa, which is a sad irony because the treatment for the infection, fluconazole, is available in much of the region through a donation programme.7 Cost of technology is of course one issue: no matter how efficiently produced, products from developed countries are simply unaffordable in the poorest countries. Notably, HIV assays used in much of Africa are manufactured in Ireland, Korea, Japan, and so on and incur high costs and erratic supply. Philanthropic donation can help meet high costs and has increased since Alma-Ata (for example, Pfizer’s donation of fluconazole and Merck’s of ivermectin), but these exceptional programmes are few and insufficient. A more sustainable solution is to augment production of health technologies locally which, although well underway with booming biotechnology industries in India, China, and Brazil, has generally not trickled down to the poorest areas. An exception comes from bednets: in Arusha, Tanzania, a local textile manufacturer has retooled itself, now profitably making 18 million bednets each year with longlasting permethrin granules provided royalty-free from Sumitomo Chemical (figure). This venture both supplies a crucial health-improving technology and provides wages that can pay for good-quality health care if needed. Such technology-transfer schemes are needed to improve the supply of and demand for health products in the next 30 years, but they will require innovative relations between the health-care and business sectors. Figure Local production of insecticidal bednets to prevent malaria in Arusha, Tanzania Historically, the emphasis for health technology has been on drugs—starting in 1977 when WHO published the Model List of Essential Medicines, a valuable document that provides countries and organizations with vetted guidance on drug choices.8 Alma-Ata maintained this emphasis, describing the need for provision of essential drugs, as did UN Millennium Development Goal 8e. Mention of other technologies, such as diagnostics, was lacking. Yet our knowledge of pathogens and diseases has expanded, and better diagnostic resolution is needed for 21st-century health care. Much of the problem of drug-resistant tuberculosis ironically stems from the insensitivity of sputum smear for diagnosis and unavailability of culture and drug-resistance testing. Interestingly, one expert panel ranked tests for infectious diseases as the most important biotechnology for improvement of health in developing countries, ahead of drug discovery, vaccine development, and genetically modified crops.9 In this new era, we could use a WHO Model List of Essential Diagnostics to guide policy and research and to advance Alma-Ata’s aspirations of better health for all.

The merit of mandatory interprofessional education for pre-health professionalstudents

Background: Since the World Health Organization identified interprofessional education (IPE) as an important component of primary health care in 1978, health sciences educators continue to debate when it might be best to introduce IPE into the academic training of health professionals. While IPE continues to be offered at increasingly early stages in students’ professional development, few if any IPE initiatives have targeted undergraduate pre-health professional students who are likely to enter health professional programs.Objectives: To design, execute and evaluate the effectiveness of a mandatory IPE initiative targeting students in their first year of a general undergraduate health science education.Methods: An integrated exercise was created to introduce students to eight health professions and the underlying concepts of interprofessionalism through self-directed independent research, problem-based learning and collaborative group discussions. A two-part questionnaire was developed using a seven point Likert scale to assess the participants’ perceived changes in knowledge, interests, and attitudes.Results: A total of 161 students (99.4%) completed both instruments. Pre and post-exercise responses (n = 161) indicated meaningful improvements in students’ knowledge on the specific roles of different health professionals (p < 0.001), knowledge on the value of interprofessionalism (p < 0.001), interests in pursuing the various health professions as future careers (p = 0.075), and attitudes towards IPE (p < 0.001). Post-exercise data also revealed that students acquired valuable knowledge and gained a strong interest in learning more about the various health professions as a result of this exercise.Conclusions: Participation in this short, one-time IPE exercise resulted in profound changes in attitudes, interests, and knowledge amongst participating students. Based on these changes, mandatory IPE for pre-health professional students is merited but additional research on this topic is necessary.

ABS73: Evaluation of patient response to respiratory educators in primary care

Introduction:Despite evidence that asthma education is effective, it is not a component of primary health care in Alberta. With a strategic plan, there is potential to reduce respiratory costs in tertiary care [1,2]. Objectives: To establish a continuum of care for managing patients with asthma and COPD by providing access to educators in primary care physicians (PCPs) offices with the goal to: Improve patient quality of life, respiratory disease management by PCPs, and establish a universal respiratory education program for primary care. Subjects/method: RCT, adult and pediatric patients with Asthma or COPD. Respiratory educators work with 50 PCP offices. Control group completes baseline questionnaires, spirometry testing, and receives an education booklet. Intervention patients do the same plus receive education from a Respiratory Educator. Patients are followed by PCP throughout. Reassessment occurs at six months by the educator, with the intervention offered to the control group. Both are followed for an additional six months.Results:Anticipated findings will validate pilot results that respiratory education conducted by a respiratory educator in the PCPs office, improves asthma control/management. Pilot showed: improvements in symptom severity, activity limitation, shortness of breath, wheeze, night waking, and rescue medication used; Reduced Beta 2 agonist (0.875 to 0.5 puffs/day); Increase in FEV1 (0.15 litres).Conclusions:This study will empower patients to better manage their disease, optimizing control; minimizing unscheduled physician visits, emergency room visits and hospital stays. The health evidence and cost benefits obtained will be useful for policy makers to support implementation. Conflict of interest and funding Project funded by: Alberta Heritage Foundation for Medical Researh (AHFMR), The Alberta Strategy to Help Manage Asthma (ASTHMA), Astra Zeneca, GlaxoSmithKline.

Social and Environmental Influences Affecting the Risk of Development of Meningococcal Disease: Considerations for Prehospital Care

After briefly reviewing the clinical features, major sequelae and initial treatment of invasive meningococcal disease, and reviewing the international and domestic incidence of meningococcal disease, the epidemiological risk factors for meningococcal disease found in the literature are summarised. These findings and the heterogeneity of sub-population risk, especially in relation to indigenous populations, are then discussed. The implications of these discussions are then applied to paramedic practice as a component of primary health care. The author argues that consideration of such data is important in developing recommendations for the development of system planning and clinical practice guidelines.

Partnerships, primary health care and health inequalities: problems and possibilities

Partnerships have become a widespread tool for coordinating the disconnected components of primary health care. They are based on network modes of governing which are seen as less susceptible to power disparities and as being more democratic than hierarchies, and more inclusive and egalitarian than markets. This paper examines whether government mandated partnerships, which mix network characteristics with aspects of hierarchies and markets, can contribute to ameliorating the effects of inequities and their impacts on health. Partnerships have benefits but are complicated and time consuming. They have theoretical appeal in addressing health problems which require solutions that reach beyond traditional health boundaries to be more interconnected and inclusive. Evaluations of partnerships in the UK indicate their substantial coordination benefits. But reducing the impact of inequities also requires shifting to a conception of health that emphasises the social and environmental context. This is the case even where partnerships have political support and health inequalities are on the agenda. Partnerships are not a quick fix, but they are a necessary component of tackling the impacts of inequities on health. They create possibilities for reducing the impacts of inequities on health by providing a platform on which additional measures can be built.

Citizens advice in primary care for families with young children.

Citizens advice can help clients avoid the worst consequences of poverty and hence has the potential to reduce inequalities in health. Previous studies of providing citizens advice from primary care have concentrated largely on older clients. To measure the benefits obtained by families with young children from a citizens advice service in primary care. An advice worker was placed in three practices. Eligible families had a child less than 1 year of age. Quantitative analysis of data on benefits obtained by all families using the service was performed. Qualitative analysis of interviews with five users and five non-users of the service was undertaken. Out of 107 families recruited, 23 used the CAB service, seeking advice on 49 different problems and obtaining benefit on 32 of these, most frequently on welfare benefits, debt management and housing. One-off financial benefits totalled pound sterlings 17 857 with annual recurring payments of pound sterlings 6480. The interviews raised five general themes: (1) the stresses surrounding the birth of a child; (2) factors associated with uptake of the service; (3) the content and value of the advice received; (4) the benefits to their health of the advice; and (5) their perception of the links between health and financial adversity. Citizens advice offers considerable benefits to families with young children. It may have positive effects on maternal and child health. An advice service is a useful component of primary health care for young families.

Determinants of users' satisfaction with primary health care settings and services in Saudi Arabia.

To identify the components of primary health care that cause most concern to service users and to identify socio-demographic and other factors associated with satisfaction among the users of primary health care centres. Interviews conducted by well-trained interviewers with a random sample of heads of households. The questionnaires were composed of questions that measure the extent of satisfaction with settings and services in the primary health care centres using a 5-point rating scale from very satisfied to very dissatisfied. The community of Qateef, eastern Saudi Arabia. A sample of 802 households representing 838 families was chosen randomly from the housing lists of the primary health care centres in Qateef. There were 40 vacant houses and nine refusals. Thus the number of heads of households actually interviewed was 789. Waiting area structure, confidentiality measures and environmental structure were the areas that caused most concern to service users. The factors that showed the greatest association with satisfaction were the type of the primary health care centre building (purpose-built or rented), literacy status of the household head (literate or illiterate), the extent of the primary health care centre utilization (regular or infrequent). Surprisingly, age showed no association when other characteristics of the respondents were adjusted for, and sex was less important than in other studies. How regular the respondent was in using his or her primary health care centre was more predictive in deciding the extent of satisfaction with the various components in the study than the other variables. Socio-demographic factors played minor roles in deciding the extent of satisfaction, although each had a deciding role with one or more, but not all, components.

Primary care for persons with disabilities. The physiatrist's perspective.

It is difficult for many persons with physical disabilities to find and access primary health care. This article discusses this problem from the perspective of a physiatrist. It discusses the components of primary health care and then compares and contrasts the current status of the training, skills, and interest levels of generalist physicians and physiatrists in providing primary medical care for disabled persons. It includes a discussion of the artificiality of the specialist/generalist dichotomy and the concept of specialists providing true primary care to certain patient populations. General and personal strategies are suggested to influence and to change the health care system so disabled persons can find and have improved access to good primary health care.

Country report. Kenya.

Kenya has an estimated population of 27 million GNP per capita of US$300 and life expectancy of 54 years. Levels of mortality have declined in the country since it became independent in 1963 but Kenya still claims one of the highest rates of population growth in the world. The high population growth rate has affected the general socioeconomic status of the country. Malaria acute respiratory infections diarrhea and AIDS are the most important causes of morbidity and mortality. An inequitable and partial distribution of health services lack of adequate public information and education about health underfunding in key areas of promotive and preventive health services mismanagement of public health services public sector budgetary constraints in the financing of health facility and service expansion shortages of drugs and vaccines and a high infant mortality rate are other factors which affect the populations health status. National health policy is to increase the emphasis upon maternal and child health and family planning services increase health service coverage and accessibility in rural areas further consolidate urban and rural curative and preventive/promotive services and reduce the population growth rate to 3.0% by 1994. Central strategy is to strengthen community-based health care as a basic component of primary health care in which community participation in environmental health activities and the prevention of disease are the major foci as contained in national policies and goals. Nongovernmental organizations (NGO) will launch health initiatives and there will be AIDS programs. Closer collaboration with NGOs has also strengthened the foci with health promotion programs targeted at specific community groups. Networks such as Kenyas Health Education Network bring together professionals involved in health promotion to share experiences and expertise.

Implications of access, utilization and need for oral health care by the non‐institutionalized and institutionalized elderly on the dental delivery system

Oral health is integral to an older adult's general health and quality of life, and basic oral health services are an essential component of primary health care. The elderly should receive special consideration in terms of their oral health care needs since they: 1) may have unique problems accessing the health care delivery system; 2) experience different patterns and prevalence rates of oral diseases; and 3) may have characteristics that affect the amount and types of dental treatment and the method by which it is performed. Older adults are maintaining their natural teeth into their later years, and epidemiologic trends suggest the increasing need for dental services by older adults. Yet dental utilization rates are lower for older adults than for younger age groups, and barriers to care include the cost of dental care, the lack of perceived need for care, transportation problems, and fear. Oral diseases and impairments are most commonly experienced by those segments of society least able to obtain dental care. Economically and socially disadvantaged older adults and the physically impaired are more likely to experience tooth loss and edentulism, untreated dental decay and periodontal diseases. Adults over the age of 65 years have the lowest proportion of dental expenses reimbursed by private dental insurance (10 percent), and the highest percentage of out-of-pocket dental expenses (79 percent), as compared to all other age groups. Of the two largest public programs, Medicare does not pay for most dental services, and Medicaid (Title XIX), does not offer dental benefits for adults in most states. Although the majority of older adults live independently in the community, there is a growing number of elders with special needs that require long term care either at home or in an institution. These frail and functionally dependent elders have significant dental needs, and experience greater barriers to receiving dental care as compared to the independent elderly. Additional research is needed to accurately characterize the oral health status and needs of the growing number of homebound and institutionalized elders. This will be of growing importance with the emergence of the vast array of home health care services available to older adults, and the changing emphasis on home care often seen as the preferred and lower cost alternative to nursing home care.

A health district as the operational unit for primary health care.

Commentary is provided on the usefulness of the health district as the organizational hub for implementation of primary health care (PHC) objectives. The recommendation is based on experiences in developing countries, and the awareness that PHC has been constrained by political, economic, social, and bureaucratic factors. A district government area is defined as a clearly defined administrative unit under the aegis of the central government and is responsible for local management. At the district level, the geographic and demographic area is small enough for managing problems and solutions and large enough to have professionally qualified staff. Community participation, intersectoral action, affordable appropriate technology, equity and social justice, and major components of PHC can all be implemented at the district level. Community initiatives can be incorporated into district programs. District health teams have access to District Health Officers, who encourage and support directly and indirectly health-related community initiatives. External cooperation agencies have been active in developing and strengthening local and district government. The 8 basic components of the Alma Ata Declaration on PHC can be realized at the district level. The district level also provides the ideal opportunity to encourage cooperation between people, their governments, and external agencies and to develop a strong national health system.

Informed choice

The subjects of family planning and reproductive health, essential components of primary health care, are extensive and this supplement is only an introduction, focusing on the impact the Pill has had on millions of women.

ACCESSIBILITY TO PRIMARY HEALTH CARE CENTERS: EXPERIENCE AND EVALUATION OF AN APPOINTMENT SYSTEM PROGRAM

Appropriate access to health care is one of the components of Primary Health Care (PHC) and it can be a good quality indicator. We present in this paper the results of 1 year of follow-up of an appointment system applied in 29 PHC centers in the Balearic Islands, Spain; the program was set up by the National Institute of Health. Telephonic appointment proportion increased from the first weeks, stabilizing at about 70%. The number of calls that it is necessary to make in order to get an appointment at peak time is now 1.5 and only 1 throughout the rest of the day. To determine changes in the waiting time and visit time, and the user opinion of the system, an enquiry was made to a sample of patients 1 month before, and 1 month, 6 months and 1 year after the program started. The waiting time is now less than 15 min for most of the people interviewed, in contrast with the previous situation when the waiting time was more than 30 min. The visit time is longer now and more than two thirds of the people think that care is better or much better than prior to the start of the program. These results have been verified in the waiting room (11.2 min mean waiting time and 7.2 min mean visit time). We conclude that we have achieved the goals of the appointment system program in all the centers covered by our department.