Comprehensive Primary Health Care Research Articles

Challenges in the implementation of primary health care reforms: a qualitative analysis of stakeholders’ views in Turkey

ObjectivesThis study aims to assess the implementation of the Family Medicine Programme (FMP), which has taken place in Turkey from 2005 to 2010 as a set of comprehensive primary health...

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 feasibility and potential use of case-tracked client journeys in primary healthcare: a pilot study

ObjectivesTo determine the feasibility of case-tracking methods in documenting client journeys at primary healthcare (PHC) services in order to investigate the comprehensiveness of service responses and the experiences of clients.DesignProspective...

The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory.

Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital. This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted. Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost-benefit analysis showed a clear cost saving to the health system as a whole. This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

Análise da realização da cirurgia ambulatorial na perspectiva da qualificação e resolutividade do cuidado prestado pelo médico de família e comunidade na Atenção Primária à Saúde na cidade do Rio de Janeiro

Introdução: A Estratégia de Saúde da Família, a partir de 1998, representa o modelo de organização e de qualificação da Atenção Primária à Saúde no Brasil. No município do Rio de Janeiro, nos últimos anos, ocorreu um incremento rápido na cobertura da população pelas equipes de saúde da família, com a perspectiva de desenvolvimento de uma Atenção Primária à Saúde abrangente. Nesta perspectiva surge a cirurgia ambulatorial, que tem sido incorporada muito timidamente às práticas das Unidades Básicas. Objetivos: Este artigo analisa a incorporação da cirurgia ambulatorial pelas Equipes de Saúde da Família como um dos aspectos envolvidos na ampliação da coordenação do cuidado e da resolutividade da Atenção Primária à Saúde. Métodos: Foi realizado um estudo exploratório descritivo, utilizando-se da análise dos dados da produção dos procedimentos cirúrgicos na rede de atenção básica da cidade. O estudo analisou as informações disponíveis no banco de dados denominado Carteirômetro no período de outubro de 2015 a março de 2017, além de entrevistas online com médicos de família atuantes na Estratégia de Saúde da Família. A expansão das equipes de saúde da família neste período foi acompanhada do aumento percentual dos procedimentos de cirurgia ambulatorial (63,8%). Resultados: Contudo, esta evolução representa, ainda, um tímido quantitativo de cirurgias realizadas pelo número de equipes implantadas, ou seja, cerca de 1,5 procedimento/equipe no último trimestre pesquisado. Conclusão: Entre os fatores limitadores destas intervenções, identificou-se a ausência de capacitação profissional para a execução destes procedimentos, além de estrutura física e processual inadequada das unidades de saúde.

Ayushman Bharat National Health Protection Scheme: an Ethical Analysis.

The Ayushman Bharat (Hindi for "India blessed with a long life") scheme is a government health insurance program that will cover about 100 million poor and vulnerable families in India providing up to INR 0.5 million per family per year for secondary and tertiary care hospitalization services. In addition, it also proposes to establish 150,000 health and wellness centers all over the country providing comprehensive primary health care. The beneficiaries of the hospital insurance scheme can avail health care services from both public and empanelled private health facilities. This scheme is one of the largest government-sponsored health insurance schemes in the world. Previous experience with government-financed health insurance schemes in India has shown that they are inequitable, inefficient, and do not provide financial protection. There is a lack of clarity on the budgetary provisions over the years when the utilization is likely to increase. The Ayushman Bharat scheme in its current form strengthens the "for profit" private health sector, requiring greater emphasis on its regulation. The scheme, which has primary, secondary, and tertiary care components, places a great focus on the secondary and tertiary care services and requires more investment in comprehensive primary health care. The potential problems of "profit-motivated" supplier-induced demand by private health care providers and corrupt practices are possible ethical burdens of the scheme. For the Ayushman Bharat to meet the ethical principle of justice, it should first address universal coverage of comprehensive primary health care and move on to hospital insurance in a progressive manner. The scheme should have provisions to strictly regulate secondary and tertiary care hospitalization in the private health sector to prevent misuse. It is the ethical responsibility of the government to ensure a strong and robust public health system, but the current provisioning of the Ayushman Bharat scheme does not do this and the reasons for this are explained in this paper.

Pradhan Mantri Jan Arogya Yojana: A Paper Tiger

The current budgetary allocation of ₹20 billion under the Pradhan Mantri Jan Arogya Yojana (PMJAY) is grossly inadequate. Our paper estimates that in the current fiscal year, the scheme will require an allocation of at least ₹420.73 billion to be able to give any meaningful coverage to 0.1 billion targetted families. This paper argues that such an expensive tertiary sector- led medical care coverage model is not the correct approach to ensure Universal Health Care (UHC) in India. A majority of illnesses are treatable at the primary level and an unbalanced promotion of the tertiary sector while neglecting primary healthcare will cause a delay in treatments, resulting in more complex and expensive medical interventions. What India urgently needs is to develop a comprehensive primary healthcare system.

India's health and wellness centres: realizing universal health coverage through comprehensive primary health care.

In common with other countries in the World Health Organization South-East Asia Region, disease patterns in India have rapidly transitioned towards an increased burden of noncommunicable diseases. This epidemiological transition has been a major driver impelling a radical rethink of the structure of health care, especially with respect to the role, quality and capacity of primary health care. In addition to the Pradhan Mantri Jan Arogya Yojana insurance scheme, covering 40% of the poorest and most vulnerable individuals in the country for secondary and tertiary care, Ayushman Bharat is based on an ambitious programme of transforming India's 150 000 public peripheral health centres into health and wellness centres (HWCs) delivering universal, free comprehensive primary health care by the end of 2022. This transformation to facilities delivering high-quality, efficient, equitable and comprehensive care will involve paradigm shifts, not least in human resources to include a new cadre of mid-level health providers. The design of HWCs and the delivery of services build on the experiences and lessons learnt from the National Health Mission, India's flagship programme for strengthening health systems. Expanding the scope of these components to address the expanded service delivery package will require reorganization of work processes, including addressing the continuum of care across facility levels; moving from episodic pregnancy and delivery, newborn and immunization services to chronic care services; instituting screening and early treatment programmes; ensuring high-quality clinical services; and using information and communications technology for better reporting, focusing on health promotion and addressing health literacy in communities. Although there are major challenges ahead to meet these ambitious goals, it is important to capitalize on the current high level of political commitment accorded to comprehensive primary health care.

Comprehensive primary health care, not any vertical program needed for UHC.

Comprehensive primary health care, not any vertical program needed for UHC.

Capacity development among academic trainees in community-based primary health care research: The Aging, Community and Health Research Unit Experience.

Health care system capacity and sustainability to address the needs of an aging population are a challenge worldwide. An aging population has brought attention to the limitations associated with existing health systems, specifically the heavy emphasis on costly acute care and insufficient investments in comprehensive primary health care (PHC). Health system reform demands capacity building of academic trainees in PHC research to meet this challenge. The Aging, Community and Health Research Unit at McMaster University has purposefully employed a capacity building model for interdisciplinary trainee development. This paper will describe the processes and outcomes of the model, outlining how the provision of funding, mentorship, and a unique learning environment enables capacity building in networking, collaboration, leadership development, and knowledge mobilization among its trainees. The reciprocal advancement of the research unit through the knowledge and productivity of trainees will also be detailed.

The Role, Relevance, and Potential of Comprehensive Primary Healthcare in the Indonesian Health System

The Indonesian government has significantly improved its health system in the last three decades and has made significant efforts to provide health services to the Indonesian population. However, the health status of the population varies due to different socio-economic circumstances. Disparities in health outcomes exist between urban and rural areas and the western and eastern parts of the country. Implementing a health system based on comprehensive primary healthcare (CPHC) will significantly improve the health of the Indonesian population because this approach includes participation of empowered communities and multisectoral action in addressing the determinants of health.

Engaging with Aboriginal Shire Councils in remote Cape York communities to address smoke-free environments.

The high prevalence and health effect of tobacco smoking and secondhand smoke exposure among Aboriginal and Torres Strait Islander people is well known. Due to its significance, the responsibility of tackling smoking among Aboriginal and Torres Strait Islander people should not remain solely with health service providers. The creation of supportive environments and collaboration beyond the health sector are critical elements of comprehensive primary health care practised by Aboriginal Community Controlled Health Services. This paper discusses how Apunipima Cape York Health Council worked with three Aboriginal Shire Councils to create more smoke-free places, using local working groups, information sessions and community-based health promotion. The flexibility and the time allocated to the engagement process with councils, community leaders, organisations and community members were important. All three communities acknowledged the benefits of role modelling and working together to improve health, with addressing tobacco smoking seen as 'everyone's business' and 'not just service providers'. Aboriginal Shire Councils can play a critical role, in partnership with Aboriginal Community Controlled Health Services, in creating healthy places that enable healthy choices.

Community perspectives on primary health centers in rural Maharashtra: What can we learn for policy?

Introduction:Primary Health Centers (PHCs) are intended to be the “backbone” of the Indian public health system. Yet, these do not get utilized as frontline institutions for basic curative care. As we embark on comprehensive primary health care initiatives, it is important to understand people's perceptions on PHCs; and design services that cater to their felt needs.Aim:In this paper, we examine explanations that communities give for the use or bypass of PHCs. From these perspectives, we derive some policy directions for improving basic curative care services at PHCs.Methods:This qualitative study is based on data from 14 Focus Group Discussions in a rural area in Maharashtra in the catchment area of 8 PHCs (total 91 community participants). The discussions were coded and analyzed thematically with the aid of a qualitative software.Results:PHCs were not viewed as first-access points for health care, though these were valued for specific services. The limited use of PHCs was attributed to the lack of availability of drugs/services of perceived relevance to communities; prevalent healing norms that mismatched with PHC services; doctor-patient interactions that were colored with mistrust; and widespread poor opinions of public-sector services in health.Conclusions:Currently, there seems to be little in the design of PHC services- that appeals to the “felt” needs of communities. Thus, the proposed Health and Wellness Centers (HWC) initiative resonates with people's expectations. In addition, staff at the periphery must provide “attentive” care and be prepared to contend with pre-existing poor expectations of care.

A five-step approach for developing and implementing a Rural Primary Health Care Model for Dementia: a community-academic partnership.

This study is aimed at developing a Rural Primary Health Care (PHC) Model for delivering comprehensive PHC for dementia in rural settings and addressing the gap in knowledge about disseminating and implementing evidence-based dementia care in a rural PHC context. Limited access to specialists and services in rural areas leads to increased responsibility for dementia diagnosis and management in PHC, yet a gap exists in evidence-based best practices for rural dementia care. Elements of the Rural PHC Model for Dementia were based on seven principles of effective PHC for dementia identified from published research and organized into three domains: team-based care, decision support, and specialist-to-provider support. Since 2013 the researchers have collaborated with a rural PHC team in a community of 1000 people in the Canadian province of Saskatchewan to operationalize these elements in ways that were feasible in the local context. The five-step approach included: building relationships; conducting a problem analysis/needs assessment; identifying core and adaptable elements of a decision support tool embedded in the model and resolving applicability issues; implementing and adapting the intervention with local stakeholders; and sustaining the model while incrementally scaling up. Developing and sustaining relationships at regional and PHC team levels was critical. A comprehensive needs assessment identified challenges related to all domains of the Rural PHC Model. An existing decision support tool for dementia diagnosis and management was adapted and embedded in the team's electronic medical record. Strategies for operationalizing other model elements included integrating team-based care co-ordination into the decision support tool and family-centered case conferences. Research team specialists provided educational sessions on topics identified by the PHC team. This paper provides an example of a community-based process for adapting evidence-based practice principles to a real-world setting.

Public health information systems for primary health care in India: A situational analysis study.

Introduction:Information communication technology (ICT) based health information systems (HISs) are expected to transform health system functionality. The present study was aimed to evaluate HISs in India with a focus on primary health care (PHC).Methodology:The study used a qualitative method to evaluate and understand various ICT-based HIS implemented at the state/union territory (UT) level in India. After initial scoping research on HIS through literature search and observation, in-depth interviews of key informants at various levels (programme managers, analysts, co-ordinators, data entry operator and health care providers) was carried out to have an insight on the user experience of these systems. An inductive applied thematic coding of qualitative data was done for analysing the data.Results:Multiple applications have been developed under national health programmes to meet the health information needs, but at present, there is a limited role of these HISs in enhancing the effectiveness of comprehensive PHC. Many of these systems are proprietary-based, and the long-term sustainability and integration of these systems remain a challenge.Conclusion:A change is required in the approach to design a HIS that will cater to the needs of PHC. Moreover, HIS should be people-centred rather than technology-centric with focus on integration and sustainability.

Electronic health and medical records for comprehensive primary healthcare in India.

Electronic health and medical records for comprehensive primary healthcare in India.

Indigenous land management as primary health care: qualitative analysis from the Interplay research project in remote Australia

BackgroundFor Indigenous Australians, health transcends the absence of disease, and includes the health and wellbeing of their community and Country: their whole physical, cultural and spiritual environment. Stronger relationships with Country and greater involvement in cultural practices enhance the wellbeing of Indigenous Australians, and those in more remote regions have greater access to their Country and higher levels of wellbeing. However this does not translate into improvements in clinical indicators, and Indigenous Australians in more remote regions suffer higher levels of morbidity and mortality than Indigenous people in non-remote areas, and other Australians.The Interplay research project aimed to explore how Indigenous Australians in remote regions experience high levels of wellbeing despite poor health statistics, and how services could more effectively enhance both health and wellbeing.MethodsIndigenous Australians in remote regions, together with researchers and government representatives developed a wellbeing framework, comprising government and community priorities: education, employment and health, and community, culture and empowerment respectively. To explore these priorities Indigenous community researchers recruited participants from diverse Indigenous organizations, including Indigenous land management, art, business development, education, employment, health and municipal services. Fourteen focus groups and seven interviews, involving 75 Indigenous and ten non-Indigenous service providers and users were conducted. These were recorded, transcribed and analyzed, using thematic analysis, based on the wellbeing framework.ResultsResearch participants highlighted Indigenous land management as a source of wellbeing, through strengthened identity and empowerment, access to traditional food sources, enjoyable physical activity, and escape from communities where high levels of alcohol are consumed. Participants described how collaboration and partnerships between services, and recognition of Indigenous languages could enhance wellbeing, while competition between services undermines wellbeing. Indigenous land management programs work across different sectors and promote collaboration between services, serving as a source of comprehensive primary health care.ConclusionsDeveloping primary health care to reflect distinctive health needs of Indigenous Australians will enhance their health and wellbeing, which includes their communities and Country. Indigenous land management consolidates aspects of comprehensive primary health care, providing both clinical benefits and wellbeing, and can provide a focus for service collaboration.

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.

Enabling cultural safety in Indigenous primary healthcare.

The Aboriginal Health Access Centre (AHAC) and Aboriginal Community Health Centre Model of Wholistic Health and Wellbeing is critical to addressing inequities and barriers that limit access to comprehensive primary healthcare for Indigenous people. Even with this model in place, there are multiple points of intersection with mainstream healthcare service providers across health sectors. Further, there is considerable cultural diversity among Indigenous healthcare staff and professional groups. These factors place Indigenous people at risk of culturally unsafe experiences causing harm. Given this, it is essential that leaders focus on cultural safety education to address both intercultural frictions within the Indigenous centres and systemic and structural racism widespread within the broader healthcare system. This article explores how one AHAC has undertaken to examine these complex challenges, while offering some direction on leadership within the sector.

Suicide in India: a complex public health tragedy in need of a plan

Suicide in India: a complex public health tragedy in need of a plan