Primary Health Care Performance Research Articles

The Ethiopian Health Extension Program and Variation in Health Systems Performance: What Matters?

BackgroundPrimary health care services are fundamental to improving health and health equity, particularly in the context of low and middle-income settings where resources are scarce. During the past decade, Ethiopia undertook an ambitious investment in primary health care known as the Ethiopian Health Extension Program that recorded impressive gains in several health outcomes. Despite this progress, substantial disparities in health outcomes persist across the country. The objective of this study was to understand how variation in the implementation of the primary health care efforts may explain differences in key health outcomes.Methods and FindingsWe conducted a qualitative study of higher-performing and lower-performing woredas using site visits and in-depth interviews undertaken in 7 woredas. We classified woredas as higher-performing or lower-performing based on data on 5 indicators. We conducted a total of 94 open-ended interviews; 12–15 from each woreda. The data were analyzed using the constant comparative method of qualitative data analysis. Substantial contrasts were apparent between higher-performing and lower-performing woredas in use of data for problem solving and performance improvement; collaboration and respectful relationships among health extension workers, community members, and health center staff; and coordination between the woreda health office and higher-level regulatory and financing bodies at the zonal and regional levels. We found similarities in what was reported to motivate or demotivate health extension workers and other staff. Additionally, higher-performing and lower-performing woredas shared concerns about hospitals being isolated from health centers and health posts. Participants from both woredas also highlighted a mismatch between the urban health extension program design and the urban-dwelling communities’ expectations for primary health care.ConclusionsData-informed problem solving, respectful and supportive relationships with the community, and strong support from zonal and regional health bureaus contributed to woreda performance, suggesting avenues for achieving higher performance in primary health care.

Western Cape Primary Care Assessment Tool (PCAT) study: Measuring primary care organisation and performance in the Western Cape Province, South Africa (2013).

BackgroundMajor health sector reform and the need for baseline measures of performance to determine impact.AimBaseline audit of primary healthcare (PHC) performance.SettingCape Town and Cape Winelands (rural) PHC facilities (PCFs) in Western Cape Province, South Africa.MethodThe South African cross-culturally validated ZA PCAT to audit PHC performance on 11 subdomains associated with improved health and reduced costs. Adult PCF users systematically sampled. All full-time doctors and nurse practitioners in PCFs sampled and all PCF managers in sub-districts sampled invited into the study.ResultsData from 1432 users, 100 clinicians and 64 managers from 13 PCFs in 10 sub-districts analysed (figures show stakeholder percentages scoring subdomain performance ‘acceptable to good’). 11.5% users scored access ‘acceptable to good’; community orientation and comprehensive services provided 20.8% and 39.9%, respectively. Total PHC score for users 50.2%; for managers and practitioners 82.8% and 88.0%, respectively. Among practitioners access was lowest (33.3%); PHC team (98.0%) and comprehensive services available (100.0%) highest. Among managers, access (13.5%) and family centredness (45.6%) are lowest; PHC team (85.9%) and comprehensive services available (90.6%) highest. Managers scored access, family centredness and cultural competence significantly lower than practitioners. Users scored comprehensive services available, comprehensive services provided and community orientation significantly lower than practitioners and managers.ConclusionGaps between users’ experience and providers’ assessments of PHC performance are identified. Features that need strengthening and alignment with best practice, provincial and national, and health policies are highlighted with implications for practitioner and manager training, health policy, and research.

Trial of the Primary Care Practice Improvement Tool: building organisational performance in Australian general practice and primary health care.

To nationally trial the Primary Care Practice Improvement Tool (PC-PIT), an organisational performance improvement tool previously co-created with Australian primary care practices to increase their focus on relevant quality improvement (QI) activities. The study was conducted from March to December 2015 with volunteer general practices from a range of Australian primary care settings. We used a mixed-methods approach in two parts. Part 1 involved staff in Australian primary care practices assessing how they perceived their practice met (or did not meet) each of the 13 PC-PIT elements of high-performing practices, using a 1-5 Likert scale. In Part 2, two external raters conducted an independent practice visit to independently and objectively assess the subjective practice assessment from Part 1 against objective indicators for the 13 elements, using the same 1-5 Likert scale. Concordance between the raters was determined by comparing their ratings. In-depth interviews conducted during the independent practice visits explored practice managers' experiences and perceived support and resource needs to undertake organisational improvement in practice. Data were available for 34 general practices participating in Part 1. For Part 2, independent practice visits and the inter-rater comparison were conducted for a purposeful sample of 19 of the 34 practices. Overall concordance between the two raters for each of the assessed elements was excellent. Three practice types across a continuum of higher- to lower-scoring practices were identified, with each using the PC-PIT in a unique way. During the in-depth interviews, practice managers identified benefits of having additional QI tools that relate to the PC-PIT elements. The PC-PIT is an organisational performance tool that is acceptable, valid and relevant to our range of partners and the end users (general practices). Work is continuing with our partners and end users to embed the PC-PIT in existing organisational improvement programs.

Measures of Quality of Care for People with HIV: A Scoping Review of Performance Indicators for Primary Care.

The healthcare of people with HIV is transitioning from specialty care to the primary healthcare (PHC) system. However, many of the performance indicators used to measure the quality of HIV care pre-date this transition. The goal of this work was to examine how existing HIV care performance indicators measure the comprehensive and longitudinal care offered in a PHC setting. A scoping review consisting of peer-reviewed and grey literature searches was performed. Two reviewers evaluated study eligibility and indicators in documents meeting inclusion criteria were extracted into a database. Indicators were matched to a PHC performance measurement framework to determine their applicability for evaluating quality of care in the PHC setting. The literature search identified 221 publications, of which 47 met inclusion criteria. 1184 indicators were extracted and removal of duplicates left 558 unique indicators. A majority of the 558 indicators fell under the ‘secondary prevention’ (12%) and ‘care of chronic conditions’ (33%) domains when indicators were matched to the PHC performance framework. Despite the imbalance, nearly all performance domains in the PHC framework were populated by at least one indicator with significant concentrations in domains such as patient-provider relationship, patient satisfaction, population and community characteristics, and access to care. Existing performance frameworks for the care of people with HIV provide a comprehensive set of indicators that align well with a PHC performance framework. Nonetheless, some important elements of care, such as patient-reported outcomes, are poorly covered by existing indicators. Advancing our understanding of how the experience of care for people with HIV is impacted by changes in health services delivery, specifically more care within the PHC system, will require performance indicators to capture this aspect of HIV care.

On evaluating health centers groups in Lisbon and Tagus Valley: efficiency, equity and quality

BackgroundBearing in mind the increasing health expenses and their weight in the Portuguese gross domestic product, it is of the utmost importance to evaluate the performance of Primary Health Care providers taking into account both efficiency, quality and equity. This paper aims to contribute to a better understanding of the performance of Primary Health Care by measuring it in a Portuguese region (Lisbon and Tagus Valley) and identifying best practices. It also intends to evaluate the quality and equity provided.MethodsFor the purpose of measuring the efficiency of the health care centers (ACES) the non-parametric full frontier technique of data envelopment analysis (DEA) was adopted. The recent partial frontier method of order-m was also used to estimate the influence of exogenous variables on the efficiency of the ACES. The horizontal equity was investigated by applying the non-parametric Kruskal-Wallis test with multiple comparisons. Moreover, the quality of service was analyzed by using the ratio between the complaints and the total activity of the ACES.ResultsOn the whole, a significant level of inefficiency was observed, although there was a general improvement in efficiency between 2009 and 2010. It was found that nursing was the service with the lowest scores. Concerning the horizontal equity, the analysis showed that there is no evidence of relevant disparities between the different subregions(NUTS III). Concerning the exogenous variables, the purchasing power, the percentage of patients aged 65 years old or older and the population size affect the efficiency negatively.ConclusionsThis research shows that better usage of the available resources and the creation of a learning network and dissemination of best practices will contribute to improvements in the efficiency of the ACES while maintaining or even improving quality and equity. It was also proved that the market structure does matter when efficiency measurement is addressed.

Tuberculosis diagnosis: primary health care or emergency medical services?

OBJECTIVETo assess primary health care and emergency medical services performance for tuberculosis diagnosis.METHODSCross-sectional study were conducted with 90 health professionals from primary health care and 68 from emergency medical services, in Ribeirao Preto, SP, Southeastern Brazil, in 2009. A structured questionnaire based on an instrument of tuberculosis care assessment was used. The association between health service and the variables of structure and process for tuberculosis diagnosis was assessed by Chi-square test, Fisher's exact test (both with 5% of statistical significance) and multiple correspondence analysis.RESULTSPrimary health care was associated with the adequate provision of inputs and human resources, as well as with the sputum test request. Emergencial medical services were associated with the availability of X-ray equipment, work overload, human resources turnover, insufficient availability of health professionals, unavailability of sputum collection pots and do not request sputum test. In both services, tuberculosis diagnosis remained as a physician's responsibility.CONCLUSIONSEmergencial medical services presented weaknesses in its structure to identify tuberculosis suspects. Gaps on the process were identified in both primary health care and emergencial medical services. This situation highlights the need for qualification of health services that are the main gateway to health system to meet sector reforms that prioritize the timely diagnosis of tuberculosis and its control.

Acceptability of Quality Reporting and Pay for Performance among Primary Health Centers in Lebanon

Primary health care (PHC) is emphasized as the cornerstone of any health care system. Enhancing PHC performance is considered a strategy to enhance effective and equitable access to care. This study assesses the acceptability of and factors associated with quality reporting among PHC centers (PHCCs) in Lebanon. The managers of 132 Lebanese Ministry of Health PHCCs were surveyed using a cross-sectional design. Managers' willingness to report quality, participate in comparative quality assessments, and endorse pay-for-performance schemes was evaluated. Collected data were matched to the infrastructural characteristics and services database. Seventy-six percent of managers responded to the questionnaire, 93 percent of whom were willing to report clinical performance. Most expressed strong support for peer-performance comparison and pay-for-performance schemes. Willingness to report was negatively associated with the religious affiliation of centers and presence of health care facilities in the catchment area and favorably associated with use of information systems and the size of population served. The great willingness of PHCC managers to employ quality-enhancing initiatives flags a policy priority for PHC stakeholders to strengthen PHCC infrastructure and to enable reporting in an easy, standardized, and systematic way. Enhancing equity necessitates education and empowerment of managers in remote areas and those managing religiously affiliated centers.

Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota–Colombia: a cross-sectional study

BackgroundThe high segmentation and fragmentation in the provision of services are some of the main problems of the Colombian health system. In 2004 the district government of Bogota decided to implement a Primary Health Care (PHC) strategy through the Home Health program. PHC was conceived as a model for transforming health care delivery within the network of the first-level public health care facilities. This study aims to evaluate the performance of the essential dimensions of the PHC strategy in six localities geographically distributed throughout Bogotá city.MethodsThe rapid assessment tool to measure PHC performance, validated in Brazil, was applied. The perception of participants (users, professionals, health managers) in public health facilities where the Home Health program was implemented was compared with the perception of participants in private health facilities not implementing the program. A global performance index and specific indices for each primary care dimension were calculated. A multivariate logistic regression analysis was conducted to determine possible associations between the performance of the PHC dimensions and the self-perceived health status of users.ResultsThe global performance index was rated as good for all participants interviewed. In general, with the exception of professionals, the differences in most of the essential dimensions seemed to favor public health care facilities where the Home Health program was implemented. The weakest dimensions were the family focus and community orientation—rated as critical by users; the distribution of financial resources—rated as critical by health managers; and, accessibility—rated as intermediate by users.ConclusionsThe overall findings suggest that the Home Health program could be improving the performance of the network of the first-level public health care facilities in some PHC essential dimensions, but significant efforts to achieve its objectives and raise its visibility in the community are required.

Public health services provided in the framework of general practitioners' clusters

ARTICLE ARTICLE The public health focused operation of primary health care (PHC) is impeded by its reactive approach and old fashioned treatment-oriented organization in many countries, including Hungary. Our general practitioners’ (GPs’) cluster model, to solve the presently existing organizational problems, builds a new structure described by Adany et al. 1 The lack of adequate education in public health of the current PHC staff2 represents another crucial obstacle of the improvement of PHC performance, which is also handled by the Programme.3 An additional obstacle is that guidelines for PHC preventive services are generally lacking. Although certain countries have developed such kind of guidelines, their proposals are adopted by other countries to a limited extent. The Decree No. 51/1997 of the Minister of Welfare (on the compulsory health insurance-based health services, aimed to prevent and timely detect the diseases and the certification of screenings) defines the preventive tasks of GPs and health visitors. Although, the listed tasks are almost entirely in harmony with the international recommendations, due to the lack of organizational base, financing incentives, relevant training, detailed protocols and auditing, the interventions/screenings prescribed by the decree are hardly implemented. The performance indicators obtained in the preliminary studies in connection with the Swiss Contribution Programme are unacceptably low: 1. Assessment of family history, 36.2% 2. Assessment of dietary habit, 24.7% 3. Screening for alcohol misuse, 16.3% 4. Assessment of smoking …

Variabilidad en Vizcaya del registro de las actividades preventivas en la mujer

Several studies have reported that there is a lack of preventive activities performance in Primary Health Care, however in Vizcaya, the situation is not known, so, we decided determine the percentage of preventive activities carried out on women by primary care physicians which are recorded in the Electronic Health Record (Osabide), and analyze the characteristics which determine differences in registration between regions and physicians.We conducted a cross-sectional study involving 425 women aged between 26 and 51 years who were to the general practitioners' consult at least twice, and who were again on April 28, 29 or 30, 2011. We colleted as primary variable the registries of contraceptives practices (group aged between 26 and 51 years), the registries of cervical cytologies during the last five years, as well as the registries of mammograms performed during the two last years, and compared the medical record between men and women practitioners, health regions and between areas with and without centers for women, using the chi-square statistic.In 139 (34.1%) of all women and in 99 (48.3%) of women aged between 26 and 51 years there was registry of cytologies and contraceptives practices respectively. The mammography performance was registered in 22 (10.7%) of women aged between 52 and 65 years.The registry of preventive activities on women is low. We have observed differences by practitioners' gender.

The relationship between avoidable hospitalization and accessibility to primary care: a systematic review

Avoidable hospitalization (AH) has been widely studied as a possible measure of the performance of primary health care (PHC). However, studies examining the relationship between the efficiency and quality of PHC and AH have found mixed results. Our study aims at highlighting those factors related to the relationship between AH and accessibility to PHC in different countries. We conducted a systematic search for peer-reviewed studies published between 1990 and October 2010 in English, German, French, Italian or Spanish and indexed primary electronic databases. The final analysis was conducted on the basis of 51 papers. Of them, 72.5% revealed a significant inverse association between the indicator of PHC accessibility and rates of AH. Indicators of PHC calculated at individual level are more likely to reveal contradictory aspects of the relationship between rates of AH and indicators of quality and PHC accessibility. Most studies confirmed the expected relationship between indicators of PHC accessibility and hospitalization for ambulatory care sensitive conditions (ACSCs), showing lower hospitalization rates for ACSC in areas with greater access to PHC. The findings support the use of ACSC hospitalization as an indicator of primary care quality, with the precaution of applying appropriate adjustment factors.

Health services performance for TB treatment in Brazil: a cross-sectional study.

BackgroundResearches to evaluate Primary Health Care performance in TB control in Brazil show that different cities aggregate local specificities in the dynamics of coping with the disease. This study aims to evaluate health services' performance in TB treatment in cities across different Brazilian regions.MethodsThis cross-sectional study was conducted in five cities that are considered priorities for TB control in Brazil: Itaboraí (ITA), Ribeirão Preto (RP) and São José do Rio Preto (SJRP) in the Southeast; Campina Grande (CG) and Feira de Santana (FS) in the Northeast. Data were collected through interviews with 514 TB patients under treatment in 2007, using the Primary Care Assessment Tool adapted for TB care in Brazil. Indicators were constructed based on the mean response scores (Likert scale) and compared among the study sites.Results"Access to treatment" was evaluated as satisfactory in the Southeast and regular in the Northeast, which displayed poor results on 'home visits' and 'distance between treatment site and patient's house'. "Bond" was assessed as satisfactory in all cities, with a slightly better performance in RP and SJRP. "Range of services" was rated as regular, with better performance of southeastern cities. 'Health education', 'DOT' and 'food vouchers' were less offered in the Northeast. "Coordination" was evaluated as satisfactory in all cities. "Family focus" was evaluated as satisfactory in RP and SJRP, and regular in the others. 'Professional asking patient's family about other health problems' was evaluated as unsatisfactory, except in RP.ConclusionsTwo types of obstacles are faced for health service performance in TB treatment in the cities under analysis, mainly in the Northeast. The first is structural and derives from difficulties to access health services and actions. The second is organizational and derives from the way health technologies and services are distributed and integrated. Incentives to improve care organization and management practices, aimed at the integration of primary, secondary and tertiary services, can contribute towards a better performance of health services in TB treatment.

Innovation in rural health: Sound the trumpet!

The first three articles of this edition of the Australian Journal of Rural Health address important innovations in rural health. Gardner et al.1 review what is known about the challenges of implementing quality improvement programs and draws on data from a systematic continuous quality improvement project in remote communities in Australia and Fiji, known as Audit and Best practice for Chronic Disease (ABCD), to synthesise lessons and discuss the potential for broader application in low and middle income countries, including Pacific Island countries and territories. They argue that the participatory action research approach supports innovation and broad-based change and the evidence it has produced extends the current knowledge base and facilitates the translation of knowledge into action, both for policy and practice. Reddy and colleagues2 describe two real world diabetes prevention programs, one in Montana based on US Diabetes Prevention Program, the other in Australia based on the Finnish Diabetes Prevention Study – the two landmark randomised control trials. Using qualitative research, they sought to determine whether there were specific rural context issues involved in implementation in Montana and Victoria Australia. They conclude that there were some rural issues but overall diabetes prevention programs can be implemented in any setting urban or rural without major adaptation. Humphreys and Wakerman3 review what factors seem to contribute to successful and sustainable health systems in rural and remote communities drawing on evidence from Australia, Canada and the USA. They identify good governance, leadership and management, adequate funding infrastructure and service linkages as crucial for optimal workforce recruitment. Needs must – workforce shortages and other factors frequently lead to innovation in rural health simply because necessity is the mother of invention.4 These papers cover the two great questions of rural health – how much can we explain the disparity by understanding risk factors for chronic diseases and how much of the disparity is the result of poor access to services?5 The authors of these papers have made a substantial contribution to our understanding of how we can improve rural health. The Australian government has policies to reduce rural and remote health disparities. Medical Schools are funded to ensure that 25% of students complete 50% of their clinical training in rural areas. Eleven University Departments of Rural Health around the country have been established by the Government to improve the health, health services and workforce of rural and remote Australia. Disparities in health due to rurality are well recognised internationally but the causes and consequences are incompletely understood.5 What is it about rurality that explains increased morbidity and mortality? We still need to see a comparative study of risk factors that takes into account socioeconomic circumstances such as education, income and occupation to separate out the explanation for rural excess morbidity and mortality. We are fortunate to have the publicly funded infrastructure to be able to undertake research into rural health, health services and workforce. We have also come of age. In the first round of Centres for Research Excellence in Primary Health Care funded by the Australian Primary Health Care Research Institute, rural and remote researchers performed outstandingly.6 One centre is looking at accountable and equitable primary health care provision in rural and remote Australia, a second is looking at building quality, governance, performance and sustainability in primary health care, and the third looks at indigenous primary care interventions in chronic disease. Two of the centres are rurally or remotely based and the third has a large rural component. By comparison with University Departments of General Practice, University Departments of Rural Health are well represented including Broken Hill, Centre for Remote Health, Greater Green Triangle and the School of Rural Health Bendigo. Rural health research in Australia has come of age. A new model of rural research is emerging. Each of the Centres is a multisite collaboration frequently involving metropolitan colleagues with distinguished track records in research. The next five years will see a flourishing of rural and remote research particularly since the centres have a role in building capacity at the postdoctoral level. Sound the trumpet!

Developing a Performance Measurement Framework and Indicators for Community Health Service Facilities in Urban China

BackgroundChina has had no effective and systematic information system to provide guidance for strengthening PHC (Primary Health Care) or account to citizens on progress. We report on the development of the China results-based Logic Model for Community Health Facilities and Stations (CHS) and a set of relevant PHC indicators intended to measure CHS priorities.MethodsWe adapted the PHC Results Based Logic Model developed in Canada and current work conducted in the community health system in China to create the China CHS Logic Model framework. We used a staged approach by first constructing the framework and indicators and then validating their content through an interactive process involving policy analysis, critical review of relevant literature and multiple stakeholder consultation.ResultsThe China CHS Logic Model includes inputs, activities, outputs and outcomes with a total of 287 detailed performance indicators. In these indicators, 31 indicators measure inputs, 64 measure activities, 105 measure outputs, and 87 measure immediate (n = 65), intermediate (n = 15), or final (n = 7) outcomes.ConclusionA Logic Model framework can be useful in planning, implementation, analysis and evaluation of PHC at a system and service level. The development and content validation of the China CHS Logic Model and subsequent indicators provides a means for stronger accountability and a clearer sense of overall direction and purpose needed to renew and strengthen the PHC system in China. Moreover, this work will be useful in moving towards developing a PHC information system and performance measurement across districts in urban China, and guiding the pursuit of quality in PHC.

Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples

BackgroundStrengthening primary health care is critical to reducing health inequity between Indigenous and non-Indigenous Australians. The Audit and Best practice for Chronic Disease Extension (ABCDE) project has facilitated the implementation of modern Continuous Quality Improvement (CQI) approaches in Indigenous community health care centres across Australia. The project demonstrated improvements in health centre systems, delivery of primary care services and in patient intermediate outcomes. It has also highlighted substantial variation in quality of care. Through a partnership between academic researchers, service providers and policy makers, we are now implementing a study which aims to 1) explore the factors associated with variation in clinical performance; 2) examine specific strategies that have been effective in improving primary care clinical performance; and 3) work with health service staff, management and policy makers to enhance the effective implementation of successful strategies.Methods/DesignThe study will be conducted in Indigenous community health centres from at least six States/Territories (Northern Territory, Western Australia, New South Wales, South Australia, Queensland and Victoria) over a five year period. A research hub will be established in each region to support collection and reporting of quantitative and qualitative clinical and health centre system performance data, to investigate factors affecting variation in quality of care and to facilitate effective translation of research evidence into policy and practice. The project is supported by a web-based information system, providing automated analysis and reporting of clinical care performance to health centre staff and management.DiscussionBy linking researchers directly to users of research (service providers, managers and policy makers), the partnership is well placed to generate new knowledge on effective strategies for improving the quality of primary health care and fostering effective and efficient exchange and use of data and information among service providers and policy makers to achieve evidence-based resource allocation, service planning, system development, and improvements of service delivery and Indigenous health outcomes.

CIHR pledges to tackle primary health care

The Canadian Institutes of Health Research (CIHR) will bolster support for research that tackles Canada’s lacklustre primary health care performance, federal officials told a gathering of almost 500 primary health care practitioners and researchers in Toronto, Ontario, in January. “Primary

Notas para el estudio de la Atención Primaria en contextos de sistemas de salud segmentados

This paper discusses the contribution of the concept of governance, combined with traditional approaches to primary health care (PHC) analysis, in a multicentre study covering Argentina, Brazil, Paraguay and Uruguay. Considering health systems’ variety of configurations and their segmented context, it aims to compare PHC implementation and performance characteristics in each country so as to explain them according to different determinants and compare them to governance models. Each country’s segmented context is presented, identifying public, private and social insurance sub-sectors’ arrangements. The PHC concept and its potential role in reorganizing equity- and access-based health systems are discussed. Five dimensions for PHC study are then defined: stewardship, financing, resources, comprehensiveness and intersectorality. Governance analysis revealed state-society relationships and is thus proposed as a tool for understanding such dimensions’ dynamic relationships.

The Development of a Primary Healthcare Information System to Support Performance Measurement and Research in British Columbia

In 2003, the British Columbia Ministry of Health Services contracted with the Centre for Health Services and Policy Research at the University of British Columbia to conduct three years of work to establish a population-based information system to describe the primary healthcare (PHC) sector from temporal, geographic, population and provider perspectives. In this special issue of Healthcare Policy/Politiques de Sante, we share lessons from that experience for those interested in conducting similar work, and point readers to other reports that have emerged from these undertakings. This information will be of interest to healthcare policy makers and managers, as we describe key challenges and opportunities in developing information systems designed to support performance management and research in this sector. The topic is timely, given the importance that Canadians attribute to PHC and the magnitude of public investments over the past decade to improve PHC performance.

State Mental Health Policy: Mending Missouri's Safety Net: Transforming Systems of Care by Integrating Primary and Behavioral Health Care

State Mental Health Policy: Mending Missouri's Safety Net: Transforming Systems of Care by Integrating Primary and Behavioral Health Care

Exploring health stakeholders' perceptions on moving towards comprehensive primary health care to address childhood malnutrition in Iran: a qualitative study

BackgroundDue to the multifaceted aspect of child malnutrition, a comprehensive approach, taking social factors into account, has been frequently recommended in health literature. The Alma-Ata declaration explicitly outlined comprehensive primary health care as an approach that addresses the social, economic and political causes of poor health and nutrition.Iran as a signatory country to the Alma Ata Declaration has established primary health care since 1979 with significant progress on many health indicators during the last three decades. However, the primary health care system is still challenged to reduce inequity in conditions such as child malnutrition which trace back to social factors. This study aimed to explore the perceptions of the Iranian health stakeholders with respect to the Iranian primary health care performance and actions to move towards a comprehensive approach in addressing childhood malnutrition. Health stakeholders are defined as those who affect or can be affected by health system, for example health policy-makers, health providers or health service recipients.MethodsStakeholder analysis approach was undertaken using a qualitative research method. Different levels of stakeholders, including health policy-makers, health providers and community members were interviewed as either individuals or focus groups. Qualitative content analysis was used to interpret and compare/contrast the viewpoints of the study participants.ResultsThe results demonstrated that fundamental differences exist in the perceptions of different health stakeholders in the understanding of comprehensive notion and action. Health policy-makers mainly believed in the need for a secure health management environment and the necessity for a whole of the government approach to enhance collaborative action. Community health workers, on the other hand, indicated that staff motivation, advocacy and involvement are the main challenges need to be addressed. Turning to community stakeholders, greater emphasis has been placed on community capabilities, informal link with other social sectors based on trust and local initiatives.ConclusionThis research provided a picture of the differences in the perceptions and values of different stakeholders with respect to primary health care concepts. The study suggests that a top-down approach, which still exists among health policy-makers, is a key obstacle that delays, and possibly worse, undermines the implementation of the comprehensive strategy codified by the Alma-Ata Declaration. A need to revitalise primary health care to use its full potential and to combine top-down and bottom-up approaches by narrowing the gap between perceptions of policy makers and those who provide and receive health-related services is crucial.