Implementation Of Primary Health Care Research Articles

Survey-based data describing readiness to adopt an electronic pregnancy registration-monitoring system amongst health workers.

Electronic Health (eHealth) systems show a growing trend in developing countries to enhance their respective healthcare services. However, there is a lack of empirical study regarding readiness during preparation for eHealth implementation in Primary Health Care (PHC) units, specifically for antenatal care health workers who serve not only for personal care but also community services. The survey-based data applied in this research describes the assessment of the pre-implementation of the Electronic Pregnancy Registration and Monitoring System amongst health workers who involved in ANC services in primary health care (PHC) units of South Tangerang district, an urban area of Banten Province, Indonesia. Primary data was collected from 210 ANC health workers who work in 6 PHCs of the district. The data consists of socio-demographic factors of respondents such as age, education, years of experience etc., and captures individual responses to measure their readiness for eHealth adoption. The availability of this data will provide valuable information for researchers, healthcare organisations and government as the policy makers to prepare strategies with regard to readiness for eHealth adoption amongst health workers in PHCs

Implementing primary healthcare-based measurement, advice and treatment for heavy drinking and comorbid depression at the municipal level in three Latin American countries: final protocol for a quasiexperimental study (SCALA study)

This paper outlines the protocol for a quasiexperimental study1 to test the implementation of primary healthcare (PHC)-based measurement, advice and treatment for heavy drinking and comorbid depression at the municipal...

Primary healthcare implementation in practice: Evidence from primary healthcare managers in Ghana.

BackgroundPrimary healthcare (PHC) is a core part of healthcare in developing countries. However, the implementation of PHC since its inception in developing countries has been lethargic, inconsistent and marred by controversies.AimThis study investigates some of the controversies surrounding PHC implementation. It also examines how PHC is being implemented in Ghana as well as how the approaches adopted by PHC implementers influence PHC outcomes in developing countries.SettingThis study is set in Ghana and involves national, regional and district managers of PHC.MethodsA qualitative case study was used to gather information from 19 frontline PHC managers through semi-structured interviews. Interviews were recorded and transcribed. They were then qualitatively analysed using the thematic framework analyses approach.ResultsFindings uncover a lack of clear meaning of what PHC is and how it should be approached amongst key implementers. It also shows discrepancies between official policy documents and directives, and actual PHC practices. Findings also show a gradual shift from Alma Ata’s comprehensive PHC towards a more selective and intervention-specific PHC. Whilst donor and external stakeholders’ influence are the key determinants of PHC policy implementation, their support for vertical and other medicine-based interventions have gradually medicalised PHC.ConclusionThere is a need to pay more attention to understanding and addressing the gaps in PHC implementation and its inconsistencies. Furthermore, the role and control of donors and external development partners in PHC policy formulation and implementation, and their concomitant effects on community participation and empowerment, must be critically examined.

Patients\u2019 experiences of alcohol screening and advice in primary care: a qualitative study

BackgroundDespite evidence supporting the effectiveness of alcohol screening and brief advice to reduce heavy drinking, implementation in primary healthcare remains limited. The challenges that clinicians experience when delivering such interventions are well-known, but we have little understanding of the patient perspective. We used Normalization Process Theory (NPT) informed interviews to explore patients’ views on alcohol screening and brief advice in routine primary healthcare.MethodsSemi-structured qualitative interviews with 22 primary care patients who had been screened for heavy drinking and/or received brief alcohol advice were analysed thematically, informed by Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflexive monitoring).ResultsWe found mixed understanding of the adverse health consequences of heavy drinking, particularly longer-term risks. There was some awareness of current alcohol guidelines but these were viewed flexibly, depending on the individual drinker and drinking context. Most described alcohol screening as routine, with clinicians viewed as trustworthy and objective. Patients enacted a range of self-regulatory techniques to limit their drinking but perceived such strategies as learned through experience rather than based on clinical advice. However, most saw alcohol advice as a valuable component of preventative healthcare, especially those experiencing co-occurring health conditions.ConclusionsDespite strong acceptance of the screening role played by primary care clinicians, patients have less confidence in the effectiveness of alcohol advice. Primary care-based alcohol brief advice needs to reflect how individuals actually drink, and harness strategies that patients already commonly employ, such as self-regulation, to boost its relevance.

What are the key barriers to the implementation of guideline recommendations for breast cancer survivors? Protocol of a mixed methods study

The cancer survival rate has increased and family physicians (FPs) follow cancer survivors who experience long-term problems. Clinical practice guidelines outline best practices in cancer survivor care, but most FPs are unaware of this information. Little is known about specific barriers to survivo rship guideline implementation in primary health care. Thus, our objectives are to identify patterns of FP non-use of survivorship guideline recommendations and describe key use-related barriers. The present paper reports a mixed methods study protocol that is implemented. Participants are FPs providing care to at least one breast cancer survivor. Quantitative component: Recommendations are integrated in a mobile application. Through this app, we deliver a weekly alert to one recommendation. FPs can rate recommendations using the validated Information Assessment Method (IAM) questionnaire. We will identify patterns of non-use of recommendations. Qualitative component: We will interview FPs who do not use a recommendation, identify use-related barriers, and assign them to themes related to information non-use. Integration: We will compare quantitative and qualitative results. We anticipate that results will identify unique barriers to implementation of survivorship information, as well as potential solutions and strategies to improve patient care, for example, information specialists producing and disseminating patient health information. Thus, finding barriers and solutions will contribute to the practice of informationists and FPs.

Evaluation of integrated antenatal care implementation in primary health care

PurposeThis study was aimed to evaluate the implementation of an integrated antenatal care (ANC) scheme through a retrospective document study using a checklist for measuring the adequacy of the cohort ANC register documented by midwives in an urban area and to describe the barriers for the midwives during the ANC record process.Design/methodology/approachAn exploratory descriptive study using a sequential mixed method was utilised where a quantitative method was employed by collecting secondary data of 150 entries of the cohort ANC register and followed by in-depth interviews among midwives and community health workers.FindingsThe results show that the cohort registry indicators for integrated care such as laboratory and management were poorly recorded. Several barriers were found and categorised during the implementation of the integrated ANC, namely (1) governance and strategy, (2) process of care, (3) organisation and management support.Research limitations/implicationsThe contribution of this present research is that it provides empirical data of the integrated ANC implementation in primary health care (PHC) which has the responsibility to deliver an integrated level of care for ANC using a cohort registry for pregnancy registration monitoring which facilitates the continuity and quality of care.Practical implicationsPractical implication of the finding is that functional integration such as the clinical information system to facilitate an efficient and effective approach during the implementation of integrated ANC in primary care should be considered to support the clinical, professional, organisational, system and normative integration.Originality/valueSince only limited studies have been conducted to assess the quality of the cohort ANC registry and to investigate the barriers against integrated ANC implementation in Indonesia, the research findings are valuable information for the national and local governments to improve the ANC service in Indonesia.

Strife of Interests: Constraints on integrated and co-ordinated comprehensive PHC in Australia.

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care.

BackgroundIn 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017.MethodsThis exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed.ResultsNegative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns.ConclusionHealth-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.

Knowledge of Health Personnel Regarding Primary Health Care Implementation and Practice

Primary health care (PHC) is essential care based on practical, scientifically sound, and socially acceptable methods and technologies, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can. Afford to maintain at every step. of their development in a spirit of autonomy and self-determination. It is an integral part of both of the country's health system, of which it is the central function and main axis, and of the general social and economic development of the community. It is the first level of interaction with the national health system of people, families, and communities that takes health care as close as possible to the place of life and work and is the first interaction of care. The health workforce 's awareness of primary health care delivery and procedure is a matter of concern. That is why this IBS research was designed to assess the extent at which primary health care is applied and practiced by health workers. 45 questionnaires on the methods and application of primary health care were analyzed in the report. With the health care workers, a closed questionnaire was exchanged. In the analysis, a descriptive, designed study was used. The findings indicate that 95.56 percent of health staff have knowledge of primary health care. In addition, in primary health care, 89 per cent had good experience. Finally, 88.89 percent had a constructive outlook towards the variables hindering primary health care implementation. The findings indicate that the health workers at the CITE DES PALMIER DISTRICT HOSPITAL had a strong understanding of primary health care delivery and practice. Regarding my research, it is concluded that the health workforce has a good knowledge of the practice and implementation of the primary health workforce and that more than five factors prevent adherence to the implementation and the practice of primary health care due to lack of resources.

Improve education for health professionals to enhance the ability to communicate and work effectively with people living with disability

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Nurses’ attitudes towards the implementation of the Mother-Baby Friendly Initiative in selected primary healthcare facilities at Makhuduthamaga Municipality, Limpopo province

BackgroundThe implementation of the Mother-Baby Friendly Initiative (MBFI) strategy demonstrated its capabilities to improve global children’s health and maternal survival. However, its implementation in primary healthcare (PHC) facilities remains a challenge as many nurses are reluctant to adopt it for the improvement of child and maternal healthcare services in their respective clinics.ObjectivesThe primary objective of this study was to determine the attitudes of nurses towards the implementation of the MBFI in selected PHC facilities in the Makhuduthamaga Municipality, Limpopo province.MethodThis study used a quantitative, descriptive design, and all respondents were conveniently sampled. A self-administered questionnaire was used to collect data. One-hundred and seventy-seven questionnaires were distributed, and 153 nurses responded and completed the questionnaire. The Statistical Package for Social Sciences version 23 was used to analyse data.ResultsResults show that the majority of nurses (professional nurses [PNs] = 65, 78%; enrolled nurses [ENs] = 18, 72%; enrolled nursing auxiliaries [ENAs] = 23, 51%) had a positive attitude towards the MBFI strategy implementation as they agreed that it increased breastfeeding rates. Most PNs (n = 58, 70%) and ENs (n = 15, 60%) showed positive attitudes towards exclusive breastfeeding (EBF) as they agreed that it was the ideal feeding option for any child, and most ENAs (n = 38, 84%) showed a negative attitude as they disagreed that EBF was the ideal feeding option for any child.ConclusionIn this study, most PNs and ENs had a positive attitude in all the aspects that determined their attitudes towards MBFI strategy implementation. A concern is the fact that most ENAs showed negative attitudes in almost all the statements that were in line with the principles of MBFI, as they disagreed in most aspects. Therefore, this study recommends that on-going orientation and trainings should be offered to all nurses including ENAs to equip them with information that can assist in changing their attitudes towards MBFI implementation in PHC facilities.

Nurses' attitudes towards the implementation of the Mother-Baby Friendly Initiative in selected primary healthcare facilities at Makhuduthamaga Municipality, Limpopo province.

The implementation of the Mother-Baby Friendly Initiative (MBFI) strategy demonstrated its capabilities to improve global children's health and maternal survival. However, its implementation in primary healthcare (PHC) facilities remains a challenge as many nurses are reluctant to adopt it for the improvement of child and maternal healthcare services in their respective clinics. The primary objective of this study was to determine the attitudes of nurses towards the implementation of the MBFI in selected PHC facilities in the Makhuduthamaga Municipality, Limpopo province. This study used a quantitative, descriptive design, and all respondents were conveniently sampled. A self-administered questionnaire was used to collect data. One-hundred and seventy-seven questionnaires were distributed, and 153 nurses responded and completed the questionnaire. The Statistical Package for Social Sciences version 23 was used to analyse data. Results show that the majority of nurses (professional nurses [PNs] = 65, 78%; enrolled nurses [ENs] = 18, 72%; enrolled nursing auxiliaries [ENAs] = 23, 51%) had a positive attitude towards the MBFI strategy implementation as they agreed that it increased breastfeeding rates. Most PNs (n= 58, 70%) and ENs (n= 15, 60%) showed positive attitudes towards exclusive breastfeeding (EBF) as they agreed that it was the ideal feeding option for any child, and most ENAs (n= 38, 84%) showed a negative attitude as they disagreed that EBF was the ideal feeding option for any child. In this study, most PNs and ENs had a positive attitude in all the aspects that determined their attitudes towards MBFI strategy implementation. A concern is the fact that most ENAs showed negative attitudes in almost all the statements that were in line with the principles of MBFI, as they disagreed in most aspects. Therefore, this study recommends that on-going orientation and trainings should be offered to all nurses including ENAs to equip them with information that can assist in changing their attitudes towards MBFI implementation in PHC facilities.

Narrative Review for Exploring Barriers to Readiness of Electronic Health Record Implementation in Primary Health Care.

ObjectivesThe aim of this study is to explore the enabling factors associated with readiness in Electronic Health Record (EHR) implementation and to identify the barriers related to readiness regarding the situation of primary health cares in developed and developing countries.MethodsA narrative review of open-source literature was conducted using the ProQuest, ScienceDirect, MEDLINE, and PMC databases to identify the enabling factors and barriers to EHR readiness. The keywords applied were ‘electronic health record’, ‘readiness’, ‘primary health care’, and ‘primary care’.ResultsSome barriers were found that may affect readiness, specifically individual barriers and organizational barriers. In developing countries, organizational barriers such as a lack of skilled manpower, insufficient senior management, and a lack of interaction among team members were the common barriers, while in developed countries individual barriers such as unfamiliarity with new systems and a lack of time to use computers were frequently found as barriers to readiness.ConclusionsThis study summarized the enabling factors and barriers with regard to EHR readiness in developed and developing countries.

Complex diabetes screening guidelines for high-risk adolescent Aboriginal Australians: a barrier to implementation in primary health care.

The aim of this study is to ascertain whether a simplified screening algorithm incorporating glycated haemoglobin (HbA1c) tests increases type 2 diabetes (T2D) screening in 10- to 14-year-old Aboriginal Australians presenting to primary healthcare (PHC) services. The study involved a 6-month pilot of a locally developed evidence-based screening algorithm in a remote Western Australian Kimberley town. A retrospective audit of electronic health records for the pilot period (27 June-26 December 2016) and a 6-month period before the screening algorithm was introduced (1 October 2015-31 March 2016) was conducted. Interviews were held with 30 PHC staff at participating PHC services, an Aboriginal Community Controlled Health Service (ACCHS) and a hospital-based general practice service. During the pilot, significantly more patients received an initial T2D screening test at the ACCHS (28/130 (22%) v. 50/139 (36%), P = 0.011), but there was no change at the hospital (0.02% v. 0.02%, P = 0.615). Staff feedback suggested measures to improve screening; these include simple guidelines, targeted screening, patient and staff education, point-of-care HbA1c tests and a whole-of-clinic approach to implementation. Implementing a screening algorithm for young-onset diabetes in Aboriginal Australians is challenging, but practical measures can be taken to improve screening.

Accountability mechanisms for implementing a health financing option: the case of the basic health care provision fund (BHCPF) in Nigeria

BackgroundThe Nigerian National Health Act proposes a radical shift in health financing in Nigeria through the establishment of a fund – Basic Healthcare Provision Fund, (BHCPF). This Fund is intended to improve the functioning of primary health care in Nigeria. Key stakeholders at national, sub-national and local levels have raised concerns over the management of the BHCPF with respect to the roles of various stakeholders in ensuring accountability for its use, and the readiness of the implementers to manage this fund and achieve its objectives. This study explores the governance and accountability readiness of the different layers of implementation of the Fund; and it contributes to the generation of policy implementation guidelines around governance and accountability for the Fund.MethodsNational, state and LGA level respondents were interviewed using a semi structured tool. Respondents were purposively selected to reflect the different layers of implementation of primary health care and the levels of accountability. Different accountability layers and key stakeholders expected to implement the BHCPF are the Federal government (Federal Ministry of Health, NPHCDA, NHIS, Federal Ministry of Finance); the State government (State Ministry of Health, SPHCB, State Ministry of Finance, Ministry of Local Government); the Local government (Local Government Health Authorities); Health facilities (Health workers, Health facility committees (HFC) and External actors (Development partners and donors, CSOs, Community members).ResultsIn general, the strategies for accountability encompass planning mechanisms, strong and transparent monitoring and supervision systems, and systematic reporting at different levels of the healthcare system. Non-state actors, particularly communities, must be empowered and engaged as instruments for ensuring external accountability at lower levels of implementation. New accountability strategies such as result-based or performance-based financing could be very valuable.ConclusionThe key challenges to accountability identified should be addressed and these included trust, transparency and corruption in the health system, political interference at higher levels of government, poor data management, lack of political commitment from the State in relation to release of funds for health activities, poor motivation, mentorship, monitoring and supervision, weak financial management and accountability systems and weak capacity to implement suggested accountability mechanisms due to political interference with accountability structures.

Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review

BackgroundContinuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation.MethodsSearches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature.Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers.ResultsSixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory.ConclusionInvestigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors.

¡Los modelos preventivos más necesarios hoy!

Gran parte de los Sistemas de Salud en el ámbito mundial se han constituido en fenómenos sociopolíticos que se mueven en la incertidumbre cuando intentan responder a múltiples intereses y necesidades, con respecto a la eficiencia y sostenibilidad financiera de la atención sanitaria o frente a la equidad e igualdad en los resultados de mejores estados de salud. En nuestras sociedades asistimos pasivamente a la confrontación entre un robusto modelo médico industrial y un tímido modelo preventivo, que pretende avanzar hacia una salud universal. En las últimas décadas países de América Latina y el Caribe ha adoptado compromisos de reforma estructural y sectorial de sus sistemas sanitarios, con pocas iniciativas para aumentar su capacidad de respuesta institucional y social frente a necesidades sociales en salud de sus países; han generado un débil escenario para la adopción e implementación de la Atención Primaria en Salud (APS), la cual nos permitiría un fortalecimiento de los niveles de atención haciéndolos más resolutivos, accesibles e insertos en los contextos particulares de nuestras sociedades. Este año, el mundo se reunirá en la Conferencia Mundial sobre APS con el compromiso de posicionar la atención primaria en salud en todas las políticas y alcanzar la cobertura sanitaria universal en el siglo XXI. La Conferencia, se celebrará en Kazajstán los días 25 y 26 de octubre con ocasión del 40º aniversario de la declaración de Alma-Ata. La APS se ha considerado desde los años 20 del siglo pasado un recurso y herramienta de operación que permitiría responder con una atención sanitaria integral a necesidades sociales en salud de la población pobre y vulnerable de países en vía de desarrollo. Los discursos de la OMS, organismos internacionales y gobiernos que ven a la APS como una tecnología de eficiencia de los sistemas de salud, son insuficientes frente a la actual concepción de salud y bienestar de nuestra sociedad, la cual aspira a tener otra lectura más allá del fortalecimiento de la atención curativa y privilegiar otras dimensiones en relación a la APS que ponemos a discusión. Proponemos responder tanto a una necesidad de formación en los programas de pregrado y postgrado, como construir respuestas a las actuales necesidades sociales en salud de toda la sociedad colombiana. También nos interesa explorar otras formas de operar el modelo de atención que el país tiene actualmente. En este mirada amplia, no debemos centrarnos en generar talento humano que responda a una concepción de APS como estrategia de operación del SGSSS, sino que debemos profundizar en la pregunta fundamental, ¿Cuál es el tipo de talento humano que deben formar nuestras Facultades de Salud frente a la situación sanitaria de la sociedad y de nuestro sistema de salud? Aquí la discusión parte de considerar no solamente que la APS es una estrategia de operación de la atención sanitaria, o que la “APS es otro elemento de la Salud Pública”, o considerar que la APS es una forma especial del ejercicio de lo médico, tesis que nos colocan en una postura particular frente a la tendencia actual de un contexto de fortalecimiento de la APS como filosofía, con equipos de salud más allá del saber de las ciencias de la vida. Se requiere un dialogo de saberes y competencias frente al actual escenario sanitario del país. En este ejercicio requerimos conocer una serie de visiones y experiencias frente a la APS, para llegar a consensos, y posibilidades de proponer ajustes en los diferentes programas de ciencias de la salud y ciencias sociales que ofertan nuestras universidades con contenidos relacionados con la APS. Debemos visibilizar diferentes niveles del problema además de reformar el modelo pedagógico para la praxis de la APS: reconocer desde la interculturalidad los cambios en las prácticas sanitarias sustentables, o mejorar las prácticas preventivas insuficientes, para alterar el ejercicio biomédico en relación con la atención primaria. Consideramos que debemos trabajar no solo en fortalecer la capacidad de respuesta social proponiendo modelos de atención más preventivos que incorporen a nuestros ciudadanos en las decisiones de asistencia sanitaria. El fenómeno de la salud debe estar visibilizado en todas las políticas para alcanzar un verdadero fortalecimiento de la APS en el país.

Lessons Learned From a Living Lab on the Broad Adoption of eHealth in Primary Health Care.

BackgroundElectronic health (eHealth) solutions are considered to relieve current and future pressure on the sustainability of primary health care systems. However, evidence of the effectiveness of eHealth in daily practice is missing. Furthermore, eHealth solutions are often not implemented structurally after a pilot phase, even if successful during this phase. Although many studies on barriers and facilitators were published in recent years, eHealth implementation still progresses only slowly. To further unravel the slow implementation process in primary health care and accelerate the implementation of eHealth, a 3-year Living Lab project was set up. In the Living Lab, called eLabEL, patients, health care professionals, small- and medium-sized enterprises (SMEs), and research institutes collaborated to select and integrate fully mature eHealth technologies for implementation in primary health care. Seven primary health care centers, 10 SMEs, and 4 research institutes participated.ObjectiveThis viewpoint paper aims to show the process of adoption of eHealth in primary care from the perspective of different stakeholders in a qualitative way. We provide a real-world view on how such a process occurs, including successes and failures related to the different perspectives.MethodsReflective and process-based notes from all meetings of the project partners, interview data, and data of focus groups were analyzed systematically using four theoretical models to study the adoption of eHealth in primary care.ResultsThe results showed that large-scale implementation of eHealth depends on the efforts of and interaction and collaboration among 4 groups of stakeholders: patients, health care professionals, SMEs, and those responsible for health care policy (health care insurers and policy makers). These stakeholders are all acting within their own contexts and with their own values and expectations. We experienced that patients reported expected benefits regarding the use of eHealth for self-management purposes, and health care professionals stressed the potential benefits of eHealth and were interested in using eHealth to distinguish themselves from other care organizations. In addition, eHealth entrepreneurs valued the collaboration among SMEs as they were not big enough to enter the health care market on their own and valued the collaboration with research institutes. Furthermore, health care insurers and policy makers shared the ambition and need for the development and implementation of an integrated eHealth infrastructure.ConclusionsFor optimal and sustainable use of eHealth, patients should be actively involved, primary health care professionals need to be reinforced in their management, entrepreneurs should work closely with health care professionals and patients, and the government needs to focus on new health care models stimulating innovations. Only when all these parties act together, starting in local communities with a small range of eHealth tools, the potential of eHealth will be enforced.

Ghana's community-based primary health care: Why women and children are ‘disadvantaged’ by its implementation

Policy analysis on why women and children in low- and middle-income settings are still disadvantaged by access to appropriate care despite Primary Health Care (PHC) programmes implementation is limited. Drawing on the street-level bureaucracy theory, we explored how and why frontline providers (FLP) actions on their own and in interaction with health system factors shape Ghana's community-based PHC implementation to the disadvantage of women and children accessing and using health services. This was a qualitative study conducted in 4 communities drawn from rural and urban districts of the Upper West region. Data were collected from 8 focus group discussions with community informants, 73 in-depth interviews with clients, 13 in-depth interviews with district health managers and FLP, and observations. Data were recorded, transcribed and coded deductively and inductively for themes with the aid of Nvivo 11 software. Findings showed that apart from FLP frequent lateness to, and absenteeism from work, that affected care seeking for children, their exercise of discretionary power in determining children who deserve care over others had ripple effects: families experienced financial hardships in seeking alternative care for children, and avoided that by managing symptoms with care provided in non-traditional spaces. FLP adverse behaviours were driven by weak implementation structures embedded in the district health systems. Basic obstetric facilities such as labour room, infusion stand, and beds for deliveries, detention and palpation were lacking prompting FLP to cope by conducting deliveries using a patchwork of improvised delivery methods which worked out to encourage unassisted home deliveries. Perceived poor conditions of service weakened FLP commitment to quality maternal and child care delivery. Findings suggest the need for strategies to induce behaviour change in FLP, strengthen district administrative structures, and improve on the supply chain and logistics system to address gaps in CHPS maternal and child care delivery.

Nepal's Health Facility Operation and Management Committees: exploring community participation and influence in the Dang district's primary care clinics.

Community participation has been recognised as one of the key components for the successful implementation of primary health care (PHC) strategies, following the 1978 Declaration of Alma-Ata. In low- and middle-income countries (LMICs), HFMCs are now widely considered as a mechanism to increase community participation in health through community representation. There is some research examining the implementation process, impact and factors affecting the effectiveness of HFMCs. Despite the documented evidence of the importance of factors such as adequate representation, links with wider community, and decision-making power, there is limited evidence about the nature of community representation and degree of decision making within HFMCs in the PHC setting, particularly in LMICs. Qualitative interviews with 39 key informants were held to explore different aspects of community representation in HFMCs, and the influence of the HFMC on health facility decision-making processes. In addition, a facility audit at 22 facilities and review of HFMC meeting minutes at six health facilities were conducted.FindingsThere were Dalit (a marginalised caste) and Janajati (an ethnic group) representations in 77% and 100% of the committees, respectively. Likewise, there were at least two female members in each committee. However, the HFMC member selection process and decision making within the committees were influenced by powerful elites. The degree of participation through HFMCs appeared to be at the 'Manipulation' and 'Informing' stage of Arnstein's ladder of participation. In conclusion, despite representation of the community on HFMCs, the depth of participation seems low. There is a need to ensure a democratic selection process of committee members; and to expand the depth of participation.