Primary Care Policy Research Articles

Changes in the primary care policy and the (un)sustainability of the Family Health Strategy

RESUMO A Atenção Primária à Saúde é um nível de atenção estratégico para a conformação de um sistema de saúde sustentável e capaz de responder a necessidades diversas. Este artigo teve como objetivo analisar a normatização federal e suas implicações para a organização das equipes de atenção primária no Brasil. Pesquisa exploratória de métodos mistos, envolvendo a análise de 25 portarias federais e de dados secundários de abrangência nacional referentes às equipes homologadas no Cadastro Nacional de Estabelecimentos de Saúde, no período de 2017 a 2021. Os resultados indicam mudanças na direcionalidade da política quanto à configuração, ao financiamento e ao credenciamento das equipes. Verificaram-se expansão das equipes de atenção primária, redução de Agentes Comunitários de Saúde e enfraquecimento do Núcleo de Apoio à Saúde da Família. Os resultados sugerem que os estímulos a outros arranjos de equipes e a flexibilização da cobertura do agente comunitário e da atuação multiprofissional comprometem a sustentabilidade do modelo de Saúde da Família no Sistema Único Saúde.

Diverse and vulnerable: experiences of private allied health practices managing through the coronavirus (COVID-19) pandemic. Implications for the financial viability of Australian primary care.

Background The majority of allied health services are delivered by small, private practices in the primary care setting with limited government funding. During the coronavirus disease 2019 (COVID-19) lockdowns these practices were subject to the same health orders as any other private business with only 'essential services' permitted to remain open. Research aim We set out to understand the impact of the COVID-19 pandemic, and associated public health measures, on the financial viability of private allied health practices. Methods Thirteen semi-structured interviews were conducted with primary care allied health practice owners and managers in Sydney. Data were analysed thematically. Findings All of the interviewees reported experiencing the stress of balancing precarious finances caused by reduced and/or fluctuating patient demand. Patients' reluctance to seek care was compounded by ambiguity around whether allied health services were 'essential'. Manual therapies were particularly vulnerable to financial stress because their capacity to transition to telehealth and access to government funding were limited. Conversely, psychologists reported demand for their services exceeded what they could provide. Study implications The findings are indicative of primary care allied health's peripheral status in Australia's primary care landscape. Greater priority to the funding and integration of primary care allied health is needed in primary care policy.

EFFECTIVENESS OF THE FAMILY HEALTH STRATEGY IN BAHIA

Objective: to know the evolution of effective programs and actions in primary care through public health policies for the family health strategy (FHS) and point out which are the programs and actions in primary care in preventive health for the Baiana population. Methodology: A systematic review was conducted with the objective of answering “Which are the health policies in primary care that were effective in the incorporation of the ESF in Bahia?” in the SciELO, LILACS and MEDLINE bases using the descriptors “Estratégia Saúde da Família”; “Atenção Primária”; “Bahia” in the Portuguese language, in national journals such as Cadernos de Saúde Pública CPS, Brazilian Journal of Health Review, Ciência & Saúde Coletiva, Revista Brasileira de Enfermagem. Results and Discussion: In view of the analysis of the articles and according to the authors, the Public Policies effective in primary care that were most consolidated were: the Popular Pharmacy, Integrative and Complementary Health Practices (PICS), Community Health Agents (ACS), Smiling Brazil, Municipal Health Councilors (CMS), HiperDia Program, More Doctors Program (PMM), Hospitalizations for Conditions Sensitive to Primary Care (ICSAP), Pact for Life and Health at School Program (PSE). Concluding remarks: Therefore, added to the historical facts and the improvements in programs and actions developed in Bahia it is possible to conclude that primary health mediated by the ESF allowed the pathological diagnosis to any Baiano, to be made early and with that his sexual, emotional, nutritional and physical life could be oriented and assisted in its integrality.

Are Medicare Funded Multidisciplinary Care Policies Being Claimed in accordance to Rehabilitation Needs in Patients with Stroke?

Australian Primary Care Practitioners are incentivised through Medicare funded policies to provide chronic disease management and facilitate multidisciplinary care. Little is known about how these policies are claimed in the long-term management of stroke. The objective of this study was to describe the use of funded primary care policies for people with stroke by impairment status. Linked Australian Stroke Clinical Registry (2010-2014) and Medicare data from adults with 90-180 days post-stroke EQ-5D health status survey data and admitted to one of 26 participating Australian hospitals were analysed. Medicare item claims for Primary Care Practitioner led chronic disease management and multidisciplinary care coordination policies, during the 18 months following stroke are described. Registrants were classified into impairment groups using their EQ-5D dimension responses through Latent Class Analysis. Associations between impairment and use of relevant primary care policies were explored using multivariable regression. 5432 registrants were included (median age 74 years, 44% female, 86% ischaemic), 39% had a chronic disease management claim and 39% a multidisciplinary care coordination claim. Three latent classes emerged representing minimal, moderate and severe impairment. Compared to minimal, those with severe impairment were least likely to receive chronic disease management (adjusted Odds Ratio (aOR): 0.61, 95% Confidence Interval (CI): 0.49, 0.75) but were most likely to receive multidisciplinary care coordination. Podiatry was the commonest allied health service prescribed, regardless of impairment. Less than half of people living with stroke had a claim for primary care initiated chronic disease management, with mixed access for those with severe impairments.

Quality indicator framework for primary care of patients with dementia.

To develop a framework of population-based primary care quality indicators adapted to patients with dementia and to identify a subset of stakeholder-driven priority indicators. Framework development was carried out through the selection of an initial framework based on a rapid review and identification of relevant indicators and enrichment based on existing dementia indicators and guidelines. Prioritization of indicators was carried out through a stakeholder survey. Ontario, Quebec, New Brunswick, and Saskatchewan. Stakeholders in community dementia care (N=109) including clinicians, patients, caregivers, decision makers, and managers. Primary care quality indicators. The framework comprised 34 indicators across 8 domains of quality (access, integration, effective care, efficient care, equity, safety, population health, and patient-centred care). Access to a regular primary care provider, continuity of care, early-stage diagnosis, and access to home care were consistently rated as priorities. Equitable care was a specific priority among patients and caregivers; clinicians reported avoidable hospitalizations as among their priorities. A framework of indicators was established for persons with dementia that adds an important dimension to existing primary care and dementia quality indicators by providing primary care and population-based perspectives. This framework could set a foundation for the ongoing monitoring of primary care practices and policies for persons with dementia at a population level.

ATIPIAS INDETERMINADAS NO DIAGNÓSTICO CITOPATOLÓGICO: UMA REVISÃO DE LITERATURA

Cervical cancer (CC) is one of the most common cancers among women in Brazil. Prevention and early diagnosis are considered the ideal methods to reduce morbidity and mortality rates due to cancer. Diagnosis of CC is performed by Pap smear and the current description of cervical cytology is based on the Bethesda system which results in atypical squamous intraepithelial (ASC), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL). ), squamous cell carcinoma, atypical glandular cells (AGC) and adenocarcinoma. The ASC nomenclature is used to define atypias of indeterminate meaning, however, this generates great concern because it can be used as a way out in situations due to the limitations of the analyst who interprets cervicovaginal cytology. The objective of this paper is to review the existing literature on ASC injuries, describing their clinical importance, such as follow-up procedures and the proposed follow-up protocols. The term ASC requires epithelial changes that are not qualitatively and quantitatively sufficient for a definitive interpretation. The management of patients diagnosed with ASC is not well defined and the most explored option is follow-up with cytopathological examination for 4 to 6 months, immediate colposcopy with biopsy and screening with research for HPV. Defined as the high incidence and mortality of CC, the need to develop studies on indeterminate atypias and the improvement of public policies in primary care, with emphasis on women's health, is evidenced.

Post-Pandemic Telehealth Policy for Primary Care: An Equity Perspective.

National telehealth policy thus far has focused on broadening access to service, specialties, and originating sites. Yet telehealth policy can further equity by providing system-level change needed to reduce structural determinants that hamper telehealth access in historically marginalized, low income, and limited English-speaking populations. The authors propose policy solutions for states and CMS to help address these structural determinants of telehealth care. A telehealth "ecosystem" grounded in the following core components would ensure equitable access to care: use of technology inclusive of economically marginalized patients, access to the technology and broadband for completing virtual visits, and concrete support for patients as they develop their digital and telehealth skills.

Factors influencing primary care organization commitment to technical assistance for pharmacist clinical services integration

BackgroundWhile technical assistance (TA) has been utilized by primary care organizations (PCOs) for electronic health record installation and medical home recognition, little is known about PCOs’ use of TA to optimize pharmacist clinical services and integration in team-based care or population health programs. In 2019, the Connecticut Office of Health Strategy’s State Innovation Model Program funded a no-cost TA initiative for 9 PCOs to initiate and/or advance pharmacist clinical services. ObjectiveTo assess organizational, operational, and pharmacist factors that influenced PCO commitment to the TA program. MethodsDuring the TA program, data were collected from multiple sources including PCO demographic data; discussions and meetings with PCO medical, pharmacy, and administrative leaders; on-site workflow observations; and pharmacist coaching sessions.Configurational comparative methods were applied using the data collected during the TA program. Candidate factors were identified and calibrated on the basis of the researchers’ knowledge of the TA program, organizational readiness for change models, implementation science frameworks, and published literature. Each candidate factor was iteratively assessed until 13 factors were selected and calibrated by independently assigning each factor a dichotomous value across PCOs. Calibration differences between the researchers were discussed until consensus was reached. Solutions were modeled using the Coincidence Analysis (cna) package in R and RStudio (RStudio, PBC). ResultsOf the 9 PCOs, 4 committed to participating in the TA program. Only 1 factor, the presence of a hired pharmacist, consistently distinguished PCOs that committed from those that did not, with 100% coverage and 80% consistency. ConclusionPCO commitment to participate in the TA program was best explained by the factor of already having hired a pharmacist. These results can inform future efforts to engage PCOs in TA, primary care policy initiatives, and future research to understand factors influencing PCO success with pharmacist clinical services integration.

Effects of Healthcare Policies and Reforms at the Primary Level in China: From the Evidence of Shenzhen Primary Care Reforms from 2018 to 2019.

Countries worldwide are making efforts to achieve health equity. China focuses on the implementation of the policy goal of “improving the primary level” to eliminate the health equity gap. The main purpose of this study is to examine the effects of the healthcare reforms at the primary level in China and to analyze the key factors that can help to improve their effectiveness. From the perspectives of the policy attention mechanism and public policy analysis, this study will explore primary care reforms from policy formulation to policy implementation on the basis of grounded theory and empirical research on primary care reforms in Shenzhen, China, that was conducted from 2018 to 2019. The present study found that the government pays close attention to the medical level and service level of primary care services at the policy formulation phase but less attention to talent level and information sharing. At the same time, this study combined with empirical data from primary care centers in Shenzhen for the period covering 2018 to 2019 evaluates policy implementation and its effect. Multiple regression analysis revealed that the medical level, talent level, service level, and information sharing helped to develop primary care services and improved health equity. Nevertheless, this study reflects a deviation between policy formulation and policy implementation for the development of primary care policies. Empirical experience shows that the development of talent level and information sharing can significantly promote primary care services and health management. Therefore, this study implies that in the process of promoting the health equity at the primary level, more attention should be paid to the consistency between policy formulation and policy implementation. Additionally, the policy promotion and influence mechanism can be improved, particularly in terms of talent development and information sharing, in order to effectively promote the development of health equity at the primary level.

Impacts of the 2017 Brazilian National Primary Care Policy on public primary health care in Rio de Janeiro, Brazil.

In 2017, in a scenario of financial restrictions caused by an economic crisis in Brazil, a new primary health care policy promoted changes in the way different primary health care models were prioritized and implemented, with possible negative effects on the access to primary health care. This study aims to investigate if the 2017 Brazilian National Primary Care Policy (PNAB) negatively affected the primary care organization based on the Family Health Strategy (FHS) model and on the access to public primary care services in the city of Rio de Janeiro. The annual averages and the pre- and post-2017 averages of 15 variables were analyzed to identify possible trend breaks in 2017. A Bayesian structural time series model was used to determine the differences between actual and predicted post-2017 averages of each variable. The data were obtained via the Brazilian Health Informatics Department (DATASUS), the Department of Informatics of the Brazilian Unified National Health System. The annual average of family health teams was 1,179.9 teams, in 2017, and 788.8 teams in 2020, while the annual average of equivalent family health teams was 163.6, in 2017, and 125.4, in 2020. The actual post-2017 average of 989.3 family health teams (p = 0.004) was 16.7% lower than the predicted post-2017 average of 1,187.4 teams. In total, 62.6% and 40.5% of the population in Rio de Janeiro were covered by the FHS in 2017, and 2020, respectively. The provision of public primary care services decreased after 2017. Results show a deterioration of the FHS in Rio de Janeiro after 2017 and no increase in the traditional primary care model. Access to public primary care services reduced in the same period.

Informing Equity & Diversity in Primary Care Policy and Practice: Introducing a New Series of Policy Briefs, Commentaries, and Voices in JABFM.

Recent events remind us that deeply embedded inequities in health care access and health outcomes are rooted in historically white, and male, systems of power.[1][1],[2][2] Authors have documented how, in the United States, medicine was built on racist and patriarchal foundations that excluded and

Cuidados paliativos: percurso na atenção básica no Brasil

In 2022, an important international report was published on the “value of death” not only in the field of health, but in relation to human societies in general. This report proposed to reimagine systems related to end of life in which death is understood not only as a physiological event but also as a relational and spiritual phenomenon with a value of its own and inseparable from life. It identifies the low priority given by most governments worldwide to the issue of alleviating suffering and supporting bereavement, evidenced by the low investment in palliative care. At the same time, we are witnessing in Brazil changes that threaten the feasibility of palliative care policies in primary health care. The denial of finitude within health systems is reflected in global indicators such as the quality of death index of The Economist magazine, in which Brazil ranks 42nd, the global atlas of palliative care of the World Hospice and Palliative Care Alliance, where Brazil is in level 3b, and the global trends in opioid consumption of International Narcotics Control Board of the World Health Organization, in which opioid consumption in Brazil is in the hundreds of doses per million inhabitants per day. Despite notable advances in the legislative and executive fields with regard to palliative care, the Brazilian Unified National Health System (SUS) and primary health care have suffered important structural setbacks that will impact the design of public policy for palliative care. The goal of this article is to undertake an initial analysis of the impacts of current policies within this context and their repercussions in the construction of a solid policy for palliative care.

Palliative care: pathway in primary health care in Brazil.

In 2022, an important international report was published on the "value of death" not only in the field of health, but in relation to human societies in general. This report proposed to reimagine systems related to end of life in which death is understood not only as a physiological event but also as a relational and spiritual phenomenon with a value of its own and inseparable from life. It identifies the low priority given by most governments worldwide to the issue of alleviating suffering and supporting bereavement, evidenced by the low investment in palliative care. At the same time, we are witnessing in Brazil changes that threaten the feasibility of palliative care policies in primary health care. The denial of finitude within health systems is reflected in global indicators such as the quality of death index of The Economist magazine, in which Brazil ranks 42nd, the global atlas of palliative care of the World Hospice and Palliative Care Alliance, where Brazil is in level 3b, and the global trends in opioid consumption of International Narcotics Control Board of the World Health Organization, in which opioid consumption in Brazil is in the hundreds of doses per million inhabitants per day. Despite notable advances in the legislative and executive fields with regard to palliative care, the Brazilian Unified National Health System (SUS) and primary health care have suffered important structural setbacks that will impact the design of public policy for palliative care. The goal of this article is to undertake an initial analysis of the impacts of current policies within this context and their repercussions in the construction of a solid policy for palliative care.

Priority setting and cross-country learning: the relevance of TO-REACH for primary care.

To inform the primary care community about priorities for research in primary care as came up from the European project TO-REACH and to discuss transferability of service and policy innovations between countries. TO-REACH stands for Transfer of Organizational innovations for Resilient, Effective, equitable, Accessible, sustainable and Comprehensive Health services and systems. This EU-funded project has put health systems and services research higher on the European agenda and has led to the current development of a European 'Partnership Transforming Health and Care Systems'. To identify research priorities, both qualitative and quantitative approaches were used. Policy documents and strategic roadmaps were searched, and priorities were mapped. Stakeholders were involved through national roundtable consultations and online consultations. Regarding transferability, we carried out a review of the literature, guided by a conceptual framework, and using a snowballing approach. Primary care emerged as an important priority from the inventory, as are areas that are conducive to strengthening primary care, such as workforce policies. The large variation in service organisation and policy around primary care in Europe is a huge potential for cross-country learning. However, the simple transfer of primary care service and policy arrangements from one health system to another has a big chance to fail, unless known conditions for successful transfer are taken into account and gaps in our knowledge about transfer are resolved.

Longitudinal treatment of smoking in Primary Health Care: an evaluation research.

to evaluate the coordination of the attention for continuing treatment for smoking cessation in the Primary Health Care, from the perspective of users. the conceptual base was longitudinal care, which is an attribute of the National Policy of Primary Care. The methodological framework was that of an evaluative research, as informed by theory-based evaluation. Data collection used observation with moderate participation in the groups to abandon smoking, intensive interviews with 22 users, and analysis of medical records. The interviews used initial and focused coding, which are analytical stages of the Grounded Theory, with the aid of the MaxQDA® software. the interviewees had a positive evaluation of their treatment for smoking, although they mentioned limitations for medium- and long-term continuity. the smoking treatment sessions, even if infrequent, were found to be a successful experience for smoking cessation.

Fundamentos da assistência de enfermagem na atenção primária às gestantes ribeirinhas afetadas pelo despejo de mercúrio em corpos d’agua

The aim was to present a proposal for a protocol for nursing care for the health of pregnant women living in riverside communities exposed to the risk of mercury poisoning irregularly dumped in water bodies where fish is the primary food source of the local population. To achieve the proposed objective, it was decided to collect the data that guided the elaboration of the proposed research protocol through a bibliographic survey on the platforms and virtual databases of the Virtual Health Library, LILACS and SciELO, with a period between 2013 and 2020. Mercury has a cumulative effect on the body, therefore, exposure can cause changes at systemic levels, and affect gestational development. The role of nursing in this context is important because such educational-prophylactic measures constitute care based on the principles of the National Primary Care Policy, focused on the individualities of a population (social, economic and cultural activities) and on the risks to which the health of this population can be exposed. It is concluded that the adequate orientation of the community in relation to the risks of contamination of the body by mercury is a competence of nursing and that a protocol for nursing care is important to guide primary health care.

Primary health care facility readiness to implement primary eye care in Nigeria: equipment, infrastructure, service delivery and health management information systems

BackgroundOver two-thirds of Africans have no access to eye care services. To increase access, the World Health Organization (WHO) recommends integrating eye care into primary health care, and the WHO Africa region recently developed a package for primary eye care. However, there are limited data on the capacities needed for delivery, to guide policymakers and implementers on the feasibility of integration. The overall purpose of this study was to assess the technical capacity of the health system at primary level to deliver the WHO primary eye care package. Findings with respect to service delivery, equipment and health management information systems (HMIS) are presented in this paper.MethodsThis was a mixed-methods, cross sectional feasibility study in Anambra State, Nigeria. Methods included a desk review of relevant Nigerian policies; a survey of 48 primary health facilities in six districts randomly selected using two stage sampling, and semi-structured interviews with six supervisors and nine purposively selected facility heads. Quantitative study tools included observational checklists and questionnaires. Survey data were analysed descriptively using STATA V.15.1 (Statcorp, Texas). Differences between health centres and health posts were analysed using the z-test statistic. Interview data were analysed using thematic analysis assisted by Open Code Software V.4.02.ResultsThere are enabling national health policies for eye care, but no policy specifically for primary eye care. 85% of facilities had no medication for eye conditions and one in eight had no vitamin A in stock. Eyecare was available in < 10% of the facilities. The services delivered focussed on maternal and child health, with low attendance by adults aged over 50 years with over 50% of facilities reporting ≤10 attendances per year per 1000 catchment population. No facility reported data on patients with eye conditions in their patient registers.ConclusionA policy for primary eye care is needed which aligns with existing eye health policies. There are currently substantial capacity gaps in service delivery, equipment and data management which will need to be addressed if eye care is to be successfully integrated into primary care in Nigeria.

PNAB 2017 and the number of community health agents in primary care in Brazil.

ABSTRACTOBJECTIVE:To analyze the effect of the 2017 Basic Primary Care Policy (PNAB) on the number of community health agents per primary health care team.METHODS:This is a cross-sectional, descriptive and analytical study using data available on the Ministry of Health platform called e-Gestor da Atenção Básica, about Brazil's 5,570 towns between October 2017 and December 2019. The survival of the number of towns that did not reduce the number of community health agents was analyzed according to region of the country, the Human Development Index (HDI), the Gini Inequality Index and population size. Cox regression was used to analyze the factors associated with a reduction in the number of CHAs after one month and, from then on, every three months until two years had passed since the publication of the 2017 PNAB Ordinance, considering p < 0.05.CONCLUSIONS:After two years, the greatest reduction was observed in towns in the Midwest and South regions, which presented a high HDI, lower inequality and larger populations. Towns in the Midwest (HR = 1.256) had a higher chance of reducing the number of CHAs compared to the North region. Towns with a higher HDI (HR = 1.053) and larger population size (HR = 1.186) were also more likely to reduc the number of community health agents. Therefore, after the 2017 PNA, the number of towns reducing the amount of community health workers in primary health care increased over the months

The effect of primary care policy changes on hospitalisation for ambulatory care sensitive conditions: notes from Brazil

Objectives: The aim of this study was to assess the effect of the Primary Health Care Reform and the impact of recent national policy changes on the trend in hospitalisation rates for Ambulatory Conditions Sensitive to Primary Care (ACSC) in the city of Rio de Janeiro, Brazil.Study design: Ecological study with data from the Brazilian National Health Information System.Methods: This study performed an interrupted time-series analysis, comparing three different time periods related to important changes in primary care policies in Brazil: Baseline (2008–2009); Primary Health Care Reform (RCAPS) (2010–2017); and National Primary Health Care Policy (PNAB) (2018–2019). Data included total monthly admissions for ACSC and rates for 19 groups of causes for hospitalisation.Results: There was a non-significant increasing trend in ACSC hospital admissions between January 2008 and December 2009 (β = 4.01, 95% confidence interval [CI] −12.14 to 20.15). The Primary Health Care Reform (RCAPS), which commenced in January 2010, resulted in a significant reduction in ACSC hospital admission trends during this time period (β = −7.97, 95% CI –9.78 to −6.16). Change in the PNAB did not change the declining ACSC hospital admission trend but it did reduce the rate of decline. In addition, the coefficient was no longer significant (β = −1.93, 95% CI –2.46 to 0.59), suggesting that monitoring of the historical series for a long time may show a reversal of the downward trend in some months. The most consistent change in ACSC hospital admission trend occurred between baseline and the RCAPS (β slope = −0.143, P < 0.001) and the level between the RCAPS period and the new PNAB (β step = 7.00, P = 0.008). Trends and differences in the time periods vary in the different ACSC hospitalisation-cause groups.Conclusion: Changes in public health policies impact ACSC hospitalisation rates, which can thus be used as an indicator for monitoring primary health care. We also recommend analysing admission rates by the individual ACSC hospitalisation-cause groups.

The door is open, but not everyone may enter: racial inequities in healthcare access across three Brazilian surveys.

Health policies in Brazil have sought to expand healthcare access and mitigate inequities, but recent revisions of their content have weakened the Brazilian Unified Health System. This study estimates three healthcare indicators across three national surveys conducted in 2008, 2013, and 2019 to assess the impact of changes to the National Primary Care Policy on racial inequities in healthcare. Considering the survey design and sampling weights, we estimated the prevalence of each outcome among both whites and Blacks for the whole country, and according to the Brazilian regions. We test the following hypotheses: compared to whites, Blacks showed higher frequency of coverage by the Family Health Strategy, lower frequency of health insurance coverage, and higher frequency of perceived difficulty accessing health services (H1); Racial inequities decreased in the ten-year period but remained constant between 2013-2019 (H2); Racial gaps have widened among regions with lower proportions of Blacks (H3). Our findings fully support H1, but not H2 and H3. Racial inequities either remained constant or decreased in the 2013-2019 period. By downplaying the importance of the universality and equity principles, the latest revision of the National Primary Care Policy has contributed to the persistence of racial inequities in healthcare.