Comprehensive Primary Health Care System Research Articles

Universal health care - A matter of design and agency?

Universal health care (UHC) is primarily a financing concern, whereas primary health care (PHC) is primarily concerned with providing the right care at the right time to achieve the best possible health outcomes for individuals and communities. A recent call for contributions by the WHO emphasized that UHC can only be achieved through PHC, and that to achieve this goal will require the strengthening of the three pillars of PHC - (a) enabling primary care and public health to integrate health services, (b) empowering people and communities to create healthy living conditions, and (c) integrating multisectoral policy decisions to ensure UHC that achieves the goal of "health for all." "Pillars" - as a static metaphor - sends the wrong signal to the research and policy-making community. It, in fact, contradicts the WHO's own view, namely that there is "the need to strengthen comprehensive primary health care systems based on local priorities, needs and contexts … [that are] co-developed by people who are engaged in their own health." What we really need to develop PHC as the basis to achieve the goal of UHC is a dynamic agency to drive a "system-as-a-whole framework" that simultaneously takes into account finance, individual, and local needs. Health systems are socially constructed organizational systems that are "functionally layered" in a hierarchical fashion - governments and/or funders at the top-level not only promote the goals of the system (policies) but also constrain the system (rules, regulations, resources) in its ability to deliver. Hence, there is a need to focus on two key system features - political leadership and dynamic bottom-up agency that maintains everyone's focus on the goal to be achieved, and a limitation of system constraints so that communities can shape best adapted primary care services that truly meet the needs of their individuals, families, and community.

‘Ayushman Bharat is a Boon for the Country’: For the Motion

Ayushman Bharat approved by the Indian government in March 2018, is an ambitious reform to the Indian health system to provide Comprehensive Primary Health Care (CPHC) and to achieve Universal Health Coverage. The Ayushman Bharat with two components intends to provide a continuum of care services across the three-level of care, expanded service delivery through population enumeration and empanelment of Families at HWC and also expanded the range of preventive, promotive, curative, diagnostic, rehabilitative and palliative care services. There is sufficient evidence available that strengthening of primary healthcare is the most appropriate approach to achieve UHC. Investment on comprehensive primary healthcare system is a practical and affordable solution for India. The concept of Mid-Level Health Provider (MLHP) is newly introduced to improve Sub center and PHC resource utilization. Health and wellness centers with referral services provide preventive, promotive, curative, rehabilitative and palliative aspects with the inclusion of non-communicable disease and other important component will make the programme to deliver Comprehensive health care. With the availability of extensive potentially trainable human resources at comparatively low cost, the Health services of the programme are provided with the Human resource incentives. Ayushman Bharat National Health Protection Scheme will be implanted in conjunctions with the existing state insurance scheme, will provide a cashless benefit for identified secondary/ tertiary treatments, in public/ empaneled private facilities all over India without any cap on family size and age, beneficiaries being identified on the basis of Socio-Economic Caste Survey (SECC) 2011. The Utilization of manpower under Ayushman Bharat is proved by successful engagement and potential usage of nearly 1 million ASHA under the National Health Mission (NHM). The programme provides an innovative initiative of building a highly impactful health model with low cost with the utilization of skilledworkforce. This review describes why Ayushman Bharat is a boon for the country.

What are the Experiences and Needs of Primary Care Nurses in Caring for Patients With Type 2 Diabetes in a Rural Village in South Africa? An Exploratory Study

Since 1994, the emphasis in the provision of health services in South Africa has shifted from hospital-based care to a community-based comprehensive primary health care system, especially important in the management of chronic diseases. However, primary health care professional nurses are not well trained to manage chronic conditions like type 2 diabetes. Therefore, this study aimed to explore the experiences and needs of primary care nurses as a basis for the development of a training programme for professional nurses who care for T2D patients. A qualitative descriptive approach was employed, using individual interviews with primary health care nurses caring for T2D patients in the Ga-Dikgale village clinics. Ethical considerations were observed throughout the study and quality supportive measures were employed. Three main themes emerged from the study findings which address the current practices and knowledge of professional nurses related to care provided to diabetes patients, the challenges experienced by professional nurses during the provision of care to diabetes patients on treatment and their training experiences, gaps and needs. A need for continuing education for professional nurses related to the care of patients with diabetes was identified. The results of this study will be used to develop a training programme to improve the knowledge and skills of professional nurses and to improve the quality of care of patients with type 2 diabetes.

The influence of quality of primary care on productive interactions among community-living frail older persons and their general practitioners and practice nurses

Introduction: The Chronic Care Model CCM identifies important elements of primary healthcare systems that promote high-quality care, foster productive patient-professional interactions and improve patient outcomes. We lack evidence regarding the influence of quality of care on productivity of patient-professional interactions in a population of community-dwelling frail older adults. Exactly these productive interactions are at the heart of patient-centered care and considered essential in improving patient outcomes. The aim of our study was to investigate whether community-living frail older persons’ perspectives on quality of primary care delivery according to elements of the CCM are associated with perceived productivity of interactions with general practitioners GPs and practice nurses. Methods: A longitudinal study was conducted in the Netherlands between 2014 and 2017. The study included 4 GP practices providing usual primary care and 11 GP practices that implemented the proactive, integrated care approach ‘Finding and Follow-up of Frail older persons’ FFF. Interrelated components of the FFF approach e.g. multidisciplinary consultations, proactive case finding are presumed to promote high-quality care delivery and foster productive patient-professional interactions. Our study included 464 independently living frail older adults ≥ 75 years. Perceptions of quality of primary care Patient Assessment of Chronic Illness Care Short version; PACIC-S and productive interactions with the GP and practice nurse relational coproduction instrument were assessed at baseline and 12 months after. Data were analyzed using chi-square tests, t-tests, and multilevel methods. Results: Perceived quality of primary care, productive interaction with the GP and productive interaction with the practice nurse improved over time in both the intervention group and control group. Productive interactions with the GP and practice nurse were significantly influenced by the perceived productive interaction at baseline, the perceived quality of primary care at baseline, and the change in perceived quality of primary care over time. We found no significant differences between the intervention group and control group. Discussion and conclusion: Our study showed that perceived productive patient-professional interactions are associated with the perceived quality of primary care delivery in a sample of frail independently living older persons. Based on the relatively robust and comprehensive primary healthcare system in the Netherlands, the contrast between the FFF approach and care as usual may be too small to detect substantial differences between the groups. Lessons learned: Our study stresses the need to invest in high-quality primary care and interactions among frail older persons and their healthcare professionals. Especially in the care for older persons with often long-term complex healthcare needs and multimorbidity, productive patient-professional interactions seem to be important. Limitations: We limited the selection of professionals to GPs and practice nurses. These professionals are most frequently contacted in general practice in the Netherlands. Moreover, we did not examine whether improvements in quality of care and productive patient-professional interactions resulted in improved patient outcomes, like well-being. Suggestions for future research: Research to examine productive interactions with other professionals, like elderly care physicians, is necessary. Furthermore, the influence of improvements in quality of care and productive patient-professional interactions on patient outcomes should be investigated.

Millennium Development Goal Four; Child and Infant Mortality, Achievements in Economic Cooperation Organization Countries: An Ecological Study

Background: It has been shown that trend of achieving to Millennium Development Goal 4 (MDG 4), varies by region and between countries, indicating the possibility of existing different barriers and/or facilitators. Objectives: This study aimed to evaluate the trend of Under Five Mortality Rate (U5MR), and Infant Mortality Rate (IMR) and explore the main challenges to reach MDG 4 by 2015. Patients and Methods: In 2009, we have reviewed the latest countries’ MDG reports. The key stakeholders, from both governmental and international organizations in the country have been visited, and interviewed by the research team as a part of the data triangulation process. The last data on U5MR and IMR has been explored, and the achievements were tracked. Results: The U5MR and IMR varied from 257 and 165 deaths per 1000 live births in Afghanistan, to 24 and 17 in Turkey, respectively. Turkey has already reached the U5MR and IMR goals. Afghanistan, Uzbekistan, and Pakistan were at risk of not reaching the goals, and Iran and Tajikistan were a little beyond the time schedule. Turkmenistan, Kirghizstan and Azerbaijan were on the track on MDG on U5MR. Regarding IMR, Afghanistan, Uzbekistan, Pakistan and Iran were at the risk of not reaching the MDGs in 2015, and Turkmenistan, Kyrgyzstan and Azerbaijan were on the track. Adult literacy, Expenditure on Health and Out-of-Pocket Expenditure on Heath had a strong association with both U5MR and IMR. Conclusions: it is optimistically expected that few of ECO countries would reach the target millennium goals. More focus on the basic needs of communities through a comprehensive primary health care system, and improving health financing are experiences worked in the region, and could help the ECO countries to improve more in MDGs health related achievements.

Millennium Development Goal Four; Child and Infant Mortality, Achievements in Economic Cooperation Organization Countries: An Ecological Study

Background: It has been shown that trend of achieving to Millennium Development Goal 4 (MDG 4), varies by region and between countries, indicating the possibility of existing different barriers and/or facilitators. Objectives: This study aimed to evaluate the trend of Under Five Mortality Rate (U5MR), and Infant Mortality Rate (IMR) and explore the main challenges to reach MDG 4 by 2015. Patients and Methods: In 2009, we have reviewed the latest countries’ MDG reports. The key stakeholders, from both governmental and international organizations in the country have been visited, and interviewed by the research team as a part of the data triangulation process. The last data on U5MR and IMR has been explored, and the achievements were tracked. Results: The U5MR and IMR varied from 257 and 165 deaths per 1000 live births in Afghanistan, to 24 and 17 in Turkey, respectively. Turkey has already reached the U5MR and IMR goals. Afghanistan, Uzbekistan, and Pakistan were at risk of not reaching the goals, and Iran and Tajikistan were a little beyond the time schedule. Turkmenistan, Kirghizstan and Azerbaijan were on the track on MDG on U5MR. Regarding IMR, Afghanistan, Uzbekistan, Pakistan and Iran were at the risk of not reaching the MDGs in 2015, and Turkmenistan, Kyrgyzstan and Azerbaijan were on the track. Adult literacy, Expenditure on Health and Out-of-Pocket Expenditure on Heath had a strong association with both U5MR and IMR. Conclusions: it is optimistically expected that few of ECO countries would reach the target millennium goals. More focus on the basic needs of communities through a comprehensive primary health care system, and improving health financing are experiences worked in the region, and could help the ECO countries to improve more in MDGs health related achievements.

Equity of Access to Quality of Care in Family Medicine

Accessibility is an important characteristic of primary health care contributing in large part to its success in making health care more efficient and equitable. Countries which have comprehensive primary health care systems have lower costs and generally healthier populations [1, 2]. To get the benefits of PHC services, people need to be able to access and use them. Access to primary health care has also been proposed as a strategy to address health inequities [3].

Improving health and building human capital through an effective primary care system.

To improve population health, one must put emphasis on reducing health inequities and enhancing health protection and disease prevention, and early diagnosis and treatment of diseases by tackling the determinants of health at the downstream, midstream, and upstream levels. There is strong theoretical and empirical evidence for the association between strong national primary care systems and improved health indicators. The setting approach to promote health such as healthy schools, healthy cities also aims to address the determinants of health and build the capacity of individuals, families, and communities to create strong human and social capitals. The notion of human and social capitals begins to offer explanations why certain communities are unable to achieve better health than other communities with similar demography. In this paper, a review of studies conducted in different countries illustrate how a well-developed primary health care system would reduce all causes of mortalities, improve health status, reduce hospitalization, and be cost saving despite a disparity in socioeconomic conditions. The intervention strategy recommended in this paper is developing a model of comprehensive primary health care system by joining up different settings integrating the efforts of different parties within and outside the health sector. Different components of primary health care team would then work more closely with individuals and families and different healthy settings. This synergistic effect would help to strengthen human and social capital development. The model can then combine the efforts of upstream, midstream, and downstream approaches to improve population health and reduce health inequity. Otherwise, health would easily be jeopardized as a result of rapid urbanization.

Developments in Australian general practice 2000-2002: what did these contribute to a well functioning and comprehensive Primary Health Care System?

BackgroundIn recent years, national and state/territory governments have undertaken an increasing number of initiatives to strengthen general practice and improve its links with the rest of the primary health care sector. This paper reviews how far these initiatives were contributing to a well functioning and comprehensive primary health care system during the period 2000–2002, using a normative model of primary health care and data from a descriptive study to evaluate progress.ResultsThere was a significant number of programs, at both state/territory and national level. Most focused on individual care, particularly for chronic disease, rather than population health approaches. There was little evidence of integration across programs: each tended to be based in and focus on a single jurisdiction, and build capacity chiefly within the services funded through that jurisdiction. As a result, the overall effect was patchy, with similar difficulties being noted across all jurisdictions and little gain in overall system capacity for effective primary health care.ConclusionEfforts to develop more effective primary health care need a more balanced approach to reform, with a better balance across the different elements of primary health care and greater integration across programs and jurisdictions. One way ahead is to form a single funding agency, as in the UK and New Zealand, and so remove the need to work across jurisdictions and manage their competing interests. A second, perhaps less politically challenging starting point, is to create an agreed framework for primary health care within which a collective vision for primary health care can be developed, based on population health needs, and the responsibilities of different sectors services can be negotiated. Either of these approaches would be assisted by a more systematic and comprehensive program of research and evaluation for primary health care.

The role of empowerment through life skills development in building comprehensive primary health care systems in Indigenous Australia

This paper examines the potential contribution of empowerment through life skills development in building effective primary health Care (PHC) systems in Indigenous Australia. More specifically, it assesses the effectiveness of a Family Wellbeing (FWB) empowerment program as a tool for "engaging" Aboriginal people of Cape York to take greater control and responsibility for their health and wellbeing as part of a broader Cape York Partnerships Initiative. Preliminary findings from the pilot study demonstrated the acceptability of the program to both adults and school children. Challenges and opportunities involved in introducing and sustaining such programs in remote Indigenous settings were also highlighted. This follow-up study presents information which demonstrates the critical role that empowerment programs such as FWB may play in achieving the "hardest parts" of the PHC ideal; namely, enhancing the capacity of people to be their own change agents. The key features of the FWB approach that make it effective are that it starts small and focuses on people, it puts people before structures, and it works from personal empowerment or the micro before broadening out to tackling structural issues. This paper highlights the importance of empowerment through life skills development as critical components of PHC systems. The paper also highlights the need for health professionals to work towards creating comprehensive PHC environments through policies and programs that address crucial parts of the PHC ideal - parts which, until now, have been left in the "too hard basket". They include equity, self-determination, world peace and reductions in spending on armaments in order to increase resources to the PHC sector. The aim is to ensure healthy policy environments that support local Indigenous health development initiatives such as those currently being pursued by Cape York leaders.

Comprehensive integrated primary mental health care for South Africa. Pipedream or possibility?

While the vision for restructuring health care in South Africa is based on a comprehensive primary health care system, care at the primary level remains largely biomedical in orientation. Given this, I argue that whilst adding mental health care to primary level care may increase accessibility of psychiatric care, it will not, however, provide for comprehensive integrated primary mental health care as planned. This would require a paradigm shift towards a comprehensive discourse of care which includes mental health care. While efforts towards reorienting health care personnel in South Africa towards the primary health care approach have been initiated, an examination of the primary health care system in one sub-district in South Africa, reveals that the delivery of biomedical care is sustained by a number of factors within the primary health care system as well as within the macro-context. A shift in the paradigm of care provided would therefore require the transformation of the system on many fronts. Of central importance would be the restructuring of the primary health care system to be supportive of emotional labour, health promotion, empowerment of service users and of care which takes the subjectivity of the illness experience for the patient into account.

Family practice development around the world

Haq C, Ventres W, Hunt V, Mull D, Thompson R, Rivo M and Johnson P. Family practice development around the world. Family Practice 1996; 13: 351-356. There is a global need for family physicians to serve as cornerstones of comprehensive primary health care systems. In order to meet this need, it is necessary for each country to provide these physicians with a thorough education focused on the relevant health care problems of the population being served.

The Role of Pharmacists in AIDS Care Delivery

The delivery of a national quality comprehensive primary health care system for the HIV/AIDS epidemic in the year 2000 requires major alteration in the attitudes of all health care professionals worldwide. HIV infection and related illnesses continue to cause high rates of morbidity and mortality, and therapeutic management of these patients requires a wide array of drugs and medications. Such drug treatments include physician-prescribed drugs, investigational drugs, alternative and complementary therapies, and drugs acquired as a result of information obtained through the AIDS underground networks. As the number of infected people continues to rise, we see more polytherapy among patients. This necessitates the involvement of clinical pharmacists who have the expertise to provide high quality pharmaceutical care to these patients. Although widespread effort is being devoted to the management of HIV/AIDS patients through formation of national comprehensive health care delivery teams, pharmacists have generally been excluded from such teams. This paper outlines the specific capabilities of pharmacists that highlight their significant contributions to the successful management of these patients. Also, these capabilities put pharmacists in a position to be included as members of these health care delivery teams. The pharmacy profession therefore needs to be included in the U.S. Public Health Services sponsored AIDS Education and Training Center (ETC) programs. By using the pharmacist's role and services, quality of life and the morbidity and mortality rates will improve in these patients.

Health practices and indices of a poor urban population in Indonesia. Part II: Immunization, nutrition, and incidence of diarrhea.

This second section in a two-part study of health indices and practices among a poor urban population in Indonesia focuses on problems related to immunization, nutrition, and incidence of diarrhea. Through a survey of 690 mothers and 593 children in two slum communities in Jakarta, we found that 1) 65% of the children were mildly to severely malnourished according to Gomez criteria, with malnutrition most prevalent among the poorest; 2) 75% of the mothers reported exclusive breastfeeding of their infants during the first four months after birth, but breastfeeding decreased sharply with increasing socioeconomic status; 3) of the 19% of one- to three-year-old children who were incompletely immunized, most were likely to be missing their measles and DPT3 immunizations; and 4) 28% of the mothers reported that at least one of their under-three-year-old children had diarrhea in the last month, with frequency of reporting highest among poor mothers and those using water from vendors. We concluded that selective interventions should be accompanied by development of a comprehensive health infrastructure that permits uninterrupted service delivery and follow up of those identified as high risk. Such a comprehensive primary health care system should be part of a multisectoral development strategy.