Comprehensive Primary Health Care Research Articles

The Future of Health Insurance in India: A Case of Ayushman Bharat

Introduction: In 2017, the National Health Policy recommended the introduction of Ayushman Bharat to promote Universal Health Coverage (UHC), with the aim of providing comprehensive, need-based, and equitable healthcare services to the Indian population. The scheme comprises two primary components: the creation of 1,50,000 Health and Wellness Centres (HWCs) and the implementation of the Pradhan Mantri Jan Arogya Yojana (PM-JAY). These initiatives aim to enhance infrastructure related to comprehensive primary healthcare, maternal and child healthcare, non-communicable diseases, and improved drug delivery and diagnostic services. Out of 28 states and 8 Union territories in India, Delhi, Odisha, and West Bengal have not implemented the AB-PMJAY scheme. Telangana joined the scheme in May 2021, and each state has adopted different models to accommodate their healthcare requirements. Objective: The study elicits the various aspects of Ayushman Bharat, the scheme’s evolution throughout different timelines and its future prospects. Conclusion: The Ayushman Bharat scheme has played an enormous role in achieving comprehensive healthcare system by leveraging various technologies and digital health methods. During the pandemic, the rates of utilization have changed, and Ayushman Bharat is anticipated to contribute significantly to achieve UHC in the future.

Enhancing Primary Health Care through Interprofessional education: Insights from a Training Workshop.

Strengthening primary care services with a focus on comprehensive Primary Health Care principles necessitates collaborative work practices within interprofessional teams. In Italy, the Local Health District of Florence embodies a comprehensive Primary Health Care -inspired model of primary care, prominently featuring the House of Community concept. This work presents findings and insights from a multidisciplinary, interprofessional education activity tailored for healthcare professionals, researchers, and students actively participating in the primary care reorganization. The activity was structured using a four-phase learning model (imaginative, analytical, common sense, and dynamic), aligning with four distinct activities (brainstorming, lecture, case study, and group project). Key themes that emerged encompassed the significance of nurturing relationships among team members, the aspiration for an inclusive work environment, the vital role of community engagement and collaboration across various services, disciplines, and sectors beyond healthcare. These themes highlight the essential attributes of successful primary care practices built on the principles of comprehensive comprehensive Primary Health Care. Throughout the innovation process of primary care services, interprofessional education training events emerged as indispensable components for bolstering implementation and ensuring sustainability. This study underscores the crucial role of interprofessional education in bridging the gap between theoretical constructs and practical application, emphasizing that comprehensive Primary Healthcare principles find tangible manifestation in real-world scenarios.

IJCM_252A: An Assessment of Functioning of Health and Wellness Centres - Sub Health Centres (HWC-SHC) in Raipur District.

Background: The National Health Policy 2017 has envisioned the integration of Health and Wellness Centers (HWCs) into India’s healthcare system as part of Ayushman Bharat. In February 2018, the Indian Government declared the transformation of 1,50,000 existing Sub Health Centers and Primary Health Centers into Health and Wellness Centers (HWCs) to provide Comprehensive Primary Health Care (CPHC). Health and Wellness Centres have an important role in the prevention of several diseases and health promotion and in undertaking public health functions in the community to strengthen the frontline workers and community platforms. Objective: To assess the availability of Infrastructure and 12 comprehensive primary health care services in study centres (HWC-SHC) in Raipur district Methodology: This is a cross-sectional observational study conducted in the 32 Health and wellness centre-sub centres of Raipur district, Chhattisgarh. In the Raipur district, there are 4 blocks and from each block, 25% of the study centres (HWC-SHC) are selected by simple random sampling. Semi- structured assessment tool with the reference of Government of India Operational Guidelines was used which consisted of checklist regarding Physical Infrastructure, Human Resource, Medicine, Diagnostic, IT component and 12 comprehensive primary health care services. The data was collected and analysis is being done by using SPSS software. Results: Out of 32 HWC-SHCs, 6 (18.75% ) were catering the services for the population as per the norms i.e. 3000- 5000. In the present study, 19 (59.4%) boundary wall, and 21 (65.6%) of SCs had wellness space. There were 31 (96.9%) of SCs had labor room, and 14 (43.8 %) had newborn care corner (NBCC). In this study, 21.9% Grievance board and 100% of IEC were present at the studied subcentres. It was observed that 31(96.9%) SCs had water, 27 (84.4%) had electricity supply and 1 (3.1%) of SCs had power backup. Separate public utilities for males and females were available in 2(6.3%) of the study centres. Out of the study sub-centre, 28 (87.5%) residential facilities were available, out of which 24 (85%) were occupied. For diagnostic services, 53.1 % of study centres have sickle- cell rapid tests and none of the centres have VIA for Screening of cervical cancer. Conclusion: The finding of the study shows that there is a scarcity in the physical infrastructure, Human resource and lab-diagnostic services at the studied centres. The major factor contributing to the non-utilization of health services at the SCs was the lack of adequate infrastructure, and logistics available at these centres.

Developing a Dynamic Conceptual Model of a Home-Based Palliative Care Plan Using the Comprehensive Primary Health Care (PHC) Approach

Background: Palliative Care (PC) was a core component of Primary Health Care services during the World Health Assembly Resolution, 2014. The study aims to develop a Comprehensive Palliative Care Model (CPCM) for patients with life-threatening conditions compliant with the local context and unmet needs. Materials and Methods: A mixed-methods approach will be adopted for the three-phased study in two districts of Telangana. Phase I, a literature review, will be performed to explore globally available PC models, followed by an on-ground observational study. Phase II will address the gaps in existing models while identifying the unmet needs of the patients and caregivers. The outcome of the above phases will help develop a CPCM in Phase III. The developed model will be validated using the Delphi technique. Results: The expected outcomes of the study are a) Phase-I: Details of the PC models available globally and locally, b) Phase-II: Availability of essential resources in the Health and Wellness Centers (HWCs), Knowledge and Attitude of the PC team, Barriers to provide PC, Unmet needs, and c) Phase-III: CPCM model Conclusion: The study attempts to provide a holistic PC model, considering the health system, patients, and caregivers and offering policy suggestions to the state.

Challenges and opportunities in strengthening primary mental healthcare for older people in India: a qualitative stakeholder analysis

BackgroundPrimary mental healthcare (PMHC) allows for complex mental health issues in old age to be addressed. India has sought to improve PMHC through legislation, strategies and programmes. This study analyses the challenges and opportunities involved in strengthening PMHC for older persons in India from the perspectives of key stakeholders.MethodsSemistructured interviews were conducted with 14 stakeholders selected from the PMHC system in India and analysed using thematic analysis. First, the analysis was organizationally structured in accordance with the six WHO mental health system domains: (1) policy and legislative framework, (2) mental health services, (3) mental health in primary care, (4) human resources, (5) public information and links to other sectors, and (6) monitoring and research. Second, for each building block, challenges and opportunities were derived using inductive coding.ResultsThis study highlights the numerous challenges that may be encountered when attempting to strengthen age-inclusive PMHC. Among these challenges are poor public governance, a lack of awareness and knowledge among policy-makers and other stakeholders, and existing policies that make unrealistic promises to weak primary healthcare (PHC) structures with an excessive focus on medicalizing mental health problems. Thus, the mental health system often fails to reach vulnerable older people through PHC. Established approaches to comprehensive, family- and community-oriented PHC support attempts to strengthen intersectoral approaches to PMHC that emphasize mental health promotion in old age. Targeting the PHC workforce through age-inclusive mental health education is considered particularly necessary. Experts further argue that adequate monitoring structures and public spending for mental health must be improved.ConclusionsIn this study, we aim to elaborate on the mental healthcare developments that may serve to achieve equity in access to mental healthcare in India. Coordinated and collaborative efforts by public and private stakeholders involved in the care of older persons, both with and without lived mental health experiences, as well as their families and communities, are necessary to bring the vision of those policies for PMHC to fruition. The findings presented in this study can also inform future research, policies and practice in other low- and middle-income countries.

Mapping and analysing community health worker programmes in the Eastern Mediterranean region.

Community health worker (CHW) programmes are increasingly being recognized as an important strategy that can help to strengthen comprehensive primary health care (PHC), as the foundation of work towards achieving universal health care (UHC) and meeting the Sustainable Development Goals (SDGs). The WHO Regional Office for the Eastern Mediterranean undertook a situational analysis of CHW programmes in the Region to better understand the current situation and the issues involved. A two-step process was employed: a review of available literature on CHWs in the Region was conducted, followed by a survey of CHW programmes in the region, focussing on programmes that were country-led and country-wide. Thirteen countries were found to have community health worker programmes with varying governance and programmatic structures. Broadly, two categories can be distinguished: (a) several countries have well established and mature national CHW programmes that are in most cases supported by external donors but driven and coordinated by national governments; (b) a greater number of countries that have smaller, emerging government or partner led projects and programmes. A few countries have deliberately opted for other models to strengthen primary care and community outreach, for example, through community nursing. CHW programmes play an increasingly important role in primary health care in the Eastern Mediterranean Region, providing promotive, preventive, and emergency services. This bodes well for efforts to strengthen and embed comprehensive primary health care as the foundation of national health systems, to improve health emergency preparedness, achieve UHC and meet the SDGs. Nonetheless, all but a few programmes face challenges of weak governance, fragmentation and unreliable support, similar to those in other countries. However, the main finding of the analysis was that the role of CHWs in countries' health service delivery is woefully under-researched in almost all countries in the region, and more research to better understand and support programmes in the context of local health system contexts is urgently needed.

Integrating nurse practitioners into primary healthcare to advance health equity through a social justice lens: An integrative review.

To develop a framework to guide the successful integration of nurse practitioners (NPs) into practice settings and, working from a social justice lens, deliver comprehensive primary healthcare which advances health equity. Integrative review. The integrative review was informed by the Whittemore and Knafl's framework and followed the Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines. Quality was assessed using the Johns Hopkins Research Evidence Appraisal Tool. Findings were extracted and thematically analysed using NVivo. A social justice lens informed all phases. Databases, including CINAHL, PubMed, Scopus and Web of Science, were searched for peer-reviewed literature published in English between 2005 and April 2022. Twenty-eight articles were included. Six themes were identified at the individual (micro), local health provider (meso), and national systems and structures (macro) levels of the health sector: (1) autonomy and agency; (2) awareness and visibility; (3) shared vision; (4) leadership; (5) funding and infrastructure; and (6) intentional support and self-care. The evidence-based framework is explicitly focused on the components required to successfully integrate NPs into primary healthcare to advance health equity. Integrating NPs into primary healthcare is complex and requires a multilevel approach at macro, meso and micro levels. NPs offer the potential to transform primary healthcare delivery to meet the health needs of local communities. Health workforce and integration policies and strategies are essential if the contribution of NPs is to be realized. The proposed framework offers an opportunity for further research to inform NP integration. Nurse practitioners (NPs) offer the potential to transform primary healthcare services to meet local community health needs and advance health equity. Globally, there is a lack of guidance and health policy to support the integration of the NP workforce. The developed framework provides guidance to successfully integrate NPs to deliver comprehensive primary healthcare grounded in social justice. Integrating NPs into PHC is complex and requires a multilevel approach at macro, meso and micro levels. The framework offers an opportunity for further research to inform NP integration, education and policy. What problem did the study address: The challenges of integrating nurse practitioners (NPs) into primary healthcare (PHC) are internationally recognized. Attempts to establish NP roles in New Zealand have been ad hoc with limited research, evidence-informed frameworks or policy to guide integration initiatives. Our review builds on existing international literature to understand how NPs are successfully integrated into PHC to advance health equity and provide a guiding framework. What were the main findings: Six themes were identified across individual (micro), local health provider (meso) and national systems and structures (macro) levels as fundamental to NP integration: autonomy and agency; awareness and visibility of the NP and their role; a shared vision for the direction of primary healthcare utilizing NP scope of practice; leadership in all spaces; necessary funding and infrastructure; and intentional support and self-care. Where and on whom will the research have an impact: Given extant health workforce challenges together with persisting health inequities, NPs provide a solution to delivering comprehensive primary healthcare from a social justice lens to promote healthcare access and health equity. The proposed evidence-informed framework provides guidance for successful integration across the health sector, training providers, as well as the NP profession, and is a platform for future research. This integrative review adhered to the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) method. No patient or public contribution.

Primary health care organization in municipalities of São Paulo, Brazil: a model of care aligned with the Brazilian Unified National Health System's guidelines.

This study analyzes the main organization patterns used by primary health care (PHC) services in municipal networks and evaluates them according to indicators of local management-administration interface. Evaluative research analyzed 461 municipalities in São Paulo, Brazil, that participated in the Primary Care Services Quality Assessment Survey (QualiAB) in 2017/2018, classified according to the organizational arrangements composition of 2,472 PHC services. Eight indicators of local management and administration were selected to evaluate the identified patterns. Results indicate two groups of municipalities: homogeneous, with services presenting the same arrangement (43.6%); and heterogeneous, with different arrangements (56.4%). These were subdivided into seven patterns that ranged from homogeneous-traditional, homogeneous-Family Health Strategy, homogeneous-mixed, and different combinations in the heterogeneous group. All indicators showed significant differences between groups (p < 0.001), especially the homogeneous-traditional group, which presented an organizational pattern far from the desired model of a comprehensive and problem-solving PHC. Those integrated with family health units (FHU) and basic health units with community health workers and/or family health teams (BHU/FHU) showed a pattern closer to a comprehensive model - with planning and evaluation actions committed to the local reality and qualification of care. Implementation of federal and state policies are essential for defining the PHC health care model adopted by municipalities.

Organização da atenção primária à saúde de municípios de São Paulo, Brasil: modelo de atenção e coerência com as diretrizes do Sistema Único de Saúde

Abstract: This study analyzes the main organization patterns used by primary health care (PHC) services in municipal networks and evaluates them according to indicators of local management-administration interface. Evaluative research analyzed 461 municipalities in São Paulo, Brazil, that participated in the Primary Care Services Quality Assessment Survey (QualiAB) in 2017/2018, classified according to the organizational arrangements composition of 2,472 PHC services. Eight indicators of local management and administration were selected to evaluate the identified patterns. Results indicate two groups of municipalities: homogeneous, with services presenting the same arrangement (43.6%); and heterogeneous, with different arrangements (56.4%). These were subdivided into seven patterns that ranged from homogeneous-traditional, homogeneous-Family Health Strategy, homogeneous-mixed, and different combinations in the heterogeneous group. All indicators showed significant differences between groups (p &lt; 0.001), especially the homogeneous-traditional group, which presented an organizational pattern far from the desired model of a comprehensive and problem-solving PHC. Those integrated with family health units (FHU) and basic health units with community health workers and/or family health teams (BHU/FHU) showed a pattern closer to a comprehensive model - with planning and evaluation actions committed to the local reality and qualification of care. Implementation of federal and state policies are essential for defining the PHC health care model adopted by municipalities.

Children and youth in street situations in Nairobi. A study for a comprehensive model of care

We investigated the profiles of children and youth in street situations in Mlango Kubwa slum in Nairobi. Through a quanti-qualitative questionnaire, we collected the responses of 300 children and youth, starting from the social determinants of health as indicators of vulnerability. The foremost objective is to understand their social and health conditions as vulnerable/at-risk street groups. The secondary goal is to identify the populations' strengths, inspecting protection mechanisms, survival strategies and dreams. The data show a complex situation: experiences of trauma, violence, conflict and abandonment; ambivalent family ties, school drop-out, lack of legal and physical protection, homelessness, living below the limit of extreme poverty. The street has activated survival strategies, mostly on an individual level, but functioning as a "base system" the street seems to act as a protective system and a possible scenario in which to create a different future together with youth workers: reconnecting with the family, liaising with expert figures in order to return to school or look for suitable training. Working with children and youth in street situations highlights the complexity of their vulnerability. This could be addressed through an integrated approach and a comprehensive primary health care model.

Mother, child and adolescent health outcomes in two long-term refugee camp settings at the Thai-Myanmar border 2000-2018: a retrospective analysis.

The study assessed mothers, children and adolescents' health (MCAH) outcomes in the context of a Primary Health Care (PHC) project and associated costs in two protracted long-term refugee camps, along the Thai-Myanmar border. Myanmar refugees settled in Thailand nearly 40 years ago, in a string of camps along the border, where they fully depend on external support for health and social services. Between 2000 and 2018, a single international NGO has been implementing an integrated PHC project. This retrospective study looked at the trends of MCAH indicators of mortality and morbidity and compared them to the sustainable development goals (SDGs) indicators. A review of programme documents explored and triangulated the evolution and changing context of the PHC services, and associated project costs were analysed. To verify changes over time, interviews with 12 key informants were conducted. While maternal mortality (SDG3.1) remained high at 126.5/100,000 live births, child mortality (SDG 3.2) and infectious diseases in children under 5 (SDG 3.3) fell by 69% and by up to 92%, respectively. Maternal anaemia decreased by 30%; and more than 90% of pregnant women attended four or more antenatal care visits, whereas 80% delivered by a skilled birth attendant; caesarean section rates rose but remained low at an average of 3.7%; the adolescent (15-19 years) birth rate peaked at 188 per 1000 in 2015 but declined to 89/1000 in 2018 (SDG 3.7). Comprehensive PHC delivery, with improved health provider competence in MCAH care, together with secured funding is an appropriate strategy to bring MCAH indicators to acceptable levels. However, inequities due to confinement in camps, fragmentation of specific health services, prevent fulfilment of the 2030 SDG Agenda to 'Leave no one behind'. Costs per birth was 115 EURO in 2018; however, MCAH expenditure requires further exploration over a longer period.

Strengthening Public Financing of Primary Healthcare in India: A Perspective.

Resilient and high-performing health systems that can respond to the global polycrisis hinge upon the effectiveness of their primary healthcare (PHC) system. This requires adequate and sustainable financing for PHC, which should be predominantly government financed. The recent Ayushman Bharat health reforms in India aim to ensure comprehensive PHC services and enhance financial risk protection through increased government financing. The government has augmented investments to fortify the PHC system by establishing Health and Wellness Centers (HWCs), equipped with an expanded benefit package for PHC services & human resource capacity. Aligned with the National Health Mission's targeted and flexible financial mechanisms, this offers States the opportunity to contextualize solutions and offer incentives to healthcare workers. However, aligning public financing arrangements to service delivery complexities and health outcomes pose intricate challenges in shaping the required reforms. The economic growth and room for increased taxation on health products provide an avenue for increased funding. Smart and efficient payment mechanism with improved accountability should complement increased investment.

The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality

Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

Evaluating local primary health care actions to address health inequities: analysis of Australia’s Primary Health Networks

BackgroundMeso-level, regional primary health care organisations such as Australia’s Primary Health Networks (PHNs) are well placed to address health inequities through comprehensive primary health care approaches. This study aimed to examine the equity actions of PHNs and identify factors that hinder or enable the equity-orientation of PHNs’ activities.MethodsAnalysis of all 31 PHNs’ public planning documents. Case studies with a sample of five PHNs, drawing on 29 original interviews with key stakeholders, secondary analysis of 38 prior interviews, and analysis of 30 internal planning guidance documents. This study employed an existing framework to examine equity actions.ResultsPHNs displayed clear intentions and goals for health equity and collected considerable evidence of health inequities. However, their planned activities were largely restricted to individualistic clinical and behavioural approaches, with little to facilitate access to other health and social services, or act on the broader social determinants of health. PHNs’ equity-oriented planning was enabled by organisational values for equity, evidence of local health inequities, and engagement with local stakeholders. Equity-oriented planning was hindered by federal government constraints and lack of equity-oriented prompts in the planning process.ConclusionsPHNs’ equity actions were limited. To optimise regional planning for health equity, primary health care organisations need autonomy and scope to act on the ‘upstream’ factors that contribute to local health issues. They also need sufficient time and resources for robust, systematic planning processes that incorporate mechanisms such as procedure guides and tools/templates, to capitalise on their local evidence to address health inequities. Organisations should engage meaningfully with local communities and service providers, to ensure approaches are equity sensitive and appropriately targeted.

Building communities of health: the experience of European social clinics

Abstract Social clinics are grassroots health initiatives characterized by the development of mutualist practices of healthcare provision and the articulation of their action at territorial and community level. The present paper explores the development and implementation of community participation practices across three social clinics in Europe: social clinic of solidarity KIA in Greece, Village2Santé in France, and Microclinica Fatih in Italy. Drawing on findings collected through qualitative methods, our paper reflects on three overlapping themes of community participation highlighting its collective and eminently political character. Inspired by the frameworks of health promotion, comprehensive Primary Health Care and community development, we analyze three levels of community participation in the social clinics: participatory medical practices, the co-creation of health services, and the connection with broader social movements. Our paper contributes to the literature on community development by stressing the urge to reimagine the principles and practices of community participation through the creation of alternative forms of organizing and of radical empowerment. At the same time, it can inspire practitioners in experimenting with community participation initiatives from a more critical perspective, resisting the worst elements of neoliberalism.

Drivers of the Australian Health System towards Health Care for All: A Scoping Review and Qualitative Synthesis.

Australia has made significant progress towards universal access to primary health care (PHC) services. However, disparities in the utilisation of health services and health status remain challenges in achieving the global target of universal health coverage (UHC). This scoping review aimed at synthesizing the drivers of PHC services towards UHC in Australia. We conducted a scoping review of the literature published from 1 January 2010 to 30 July 2021 in three databases: PubMed, Scopus, and Embase. Search terms were identified under four themes: health services, Australia, UHC, and successes or challenges. Data were analysed using an inductive thematic analysis approach. Drivers (facilitators and barriers) of PHC services were explained by employing a multilevel framework that included the proximal level (at the level of users and providers), intermediate level (organisational and community level), and distal level (macrosystem or distal/structural level). A total of 114 studies were included in the review. Australia has recorded several successes in increased utilisation of PHC services, resulting in an overall improvement in health status. However, challenges remain in poor access and high unmet needs of health services among disadvantaged/priority populations (e.g., immigrants and Indigenous groups), those with chronic illnesses (multiple chronic conditions), and those living in rural and remote areas. Several drivers have contributed in access to and utilisation of health services (especially among priority populations)operating at multilevel health systems, such as proximal level drivers (health literacy, users' language, access to health facilities, providers' behaviours, quantity and competency of health workforce, and service provision at health facilities), intermediate drivers (community engagement, health programs, planning and monitoring, and funding), and distal (structural) drivers (socioeconomic disparities and discriminations). Australia has had several successes towards UHC. However, access to health services poses significant challenges among specific priority populations and rural residents. To achieve universality and equity of health services, health system efforts (supply- and demand-side policies, programs and service interventions) are required to be implemented in multilevel health systems. Implementation of targeted health policy and program approaches are needed to provide comprehensive PHC and address the effects of structural disparities.

Connecting Health and Social Services for Patients with Complex Care Needs: A Pan-Canadian Comparative Policy Research Program.

Comprehensive primary healthcare for patients with complex care needs requires connections to other health services, social services and community supports. This descriptive comparative policy research program used publicly available documents and informant interviews to examine progress toward integrated comprehensive care through the lens of services needed by children and youth (0-25 years) and community-dwelling older adults (≥ 65 years) with high functional health needs. This article describes five projects. The following three findings emerged across all the projects: Canada indeed has multiple health systems; numerous integrated service delivery solutions are being trialled and most focus on medical services; and it is an ongoing challenge for ministries of health to engage physicians and physician associations in integration.

Logic modelling as hermeneutic praxis: Bringing knowledge systems into view during comprehensive primary health care planning for homelessness in Australia.

Logic modelling is used widely in health promotion planning for complex health and social problems. It is often undertaken collaboratively with stakeholders across sectors that hold and enact different institutional approaches. We use hermeneutic philosophy to explore how knowledge is 'lived' by - and unfolds differently for - cross-sectoral stakeholders during comprehensive primary healthcare service planning. An Organisational Action Research partnership was established with a non-government organisation designing comprehensive primary health care for individuals experiencing homelessness in Adelaide, Australia. Grey literature, stakeholder input, academic feedback, a targeted literature review and evidence synthesis were integrated in iterative cycles to inform and refine the logic model. Diverse knowledge systems are active when cross-sectoral stakeholders collaborate on logic models for comprehensive primary health care planning. Considering logic modelling as a hermeneutic praxis helps to foreground and explore these differences. In our case, divergent ideas emerged in how health/wellbeing and trust were conceptualised; language had different meanings across sectors; and the outcomes and data sought were nuanced for various collaborators. We explicate these methodological insights and also contribute our evidence-informed, collaboratively-derived model for design of a comprehensive primary health care service with populations experiencing homelessness. We outline the value of considering cross-sectoral logic modelling as hermeneutic praxis. Engaging with points of difference in cross-sectoral knowledge systems can strengthen logic modelling processes, partnerships and potential outcomes for complex and comprehensive primary health care services.

How to promote changes in primary care? The Florentine experience of the House of Community.

Primary care (PC) has a central role in promoting health and preventing diseases, even during health emergencies. The COVID-19 pandemic has shown how strengthening comprehensive primary healthcare (c-PHC) services is key to ensuring community health. The Italian government decided to support PHC by investing resources from the Next Generation EU (NextGenEu) plan in the development of local health districts (LHDs) and local PC centers called "Houses of Community (HoC)". The Florence LHD (Tuscany)-in direct collaboration with the University of Florence-has represented the experimental context in which a c-PHC-inspired organizational model has been proposed and included the HoC as the nearest access point to PC services. Through multiprofessional collaboration practices, HoCs provide continuity of care as well as health and social integration. Different levels of action must coexist to initiate, implement, and sustain this new PC model: the organizational and managerial level, the experimentation of a new model of care, and the research level, which includes universities and LHD through participatory research and action approaches. This process benefits from health professionals' (HPs) participation and continuous assessment, the care for working relationships between HPs and services, an appropriate research methodology together with a "permeable" multidisciplinary research group, and educational programs. In this context, the HoC assumes the role of a permanent laboratory of experimentation in PC, supporting the effectiveness of care and answering what the Next Gen EU plan has been foreseeing for the rethinking of Italian territorial services.

Understanding Dalit equity: a critical analysis of primary health care policy discourse of Kerala in the context of 'Aardram' mission.

The Government of Kerala in 2017 launched the Aardram Mission with the aim to revamp public health delivery in the State. A key strategy under the mission was its focus on comprehensive primary health care to achieve equitable health care delivery through the Family Health Centre (FHC) initiative. Given this, the current study aims to examine the primary health care policy discourse for their perspectives on caste-driven inequities. The study undertook a Critical Discourse Analysis (CDA) of the primary health care policy discoursein Kerala. This included CDA of spoken words by senior health policy actors and policy texts on Aardram Mission and FHC. Though equity was a major aspirational goal of the Mission, related policy discourse around equity failed to acknowledge caste as a potential axis of health marginalisation in the State. The dismissal of caste manifested in three major ways within the policy discourse. One, the 'invisibilisation' of caste-driven inequities through strategies of (un)conscious exclusion of Dalit issues and 'obliteration' of caste differences through the construction of abstract and homogenous groups that invisibilise Dalits. Secondly, locating caste as a barrier to primary health care initiatives and health equity in the state, and finally through the maintenance of an 'apoliticised' social determinants discourse that fails to recognize the role of caste in shaping health disparities, specifically among Dalits in Kerala. Given Kerala's renewed commitment to strengthening its public health provisioning, the acknowledgment of caste-driven inequities is invariable in its path toward health equity and social justice.