Primary Health Care System Research Articles

Стратегии новых моделей медицинских организаций в системе первичной медико-санитарной помощи.

At present, primary health care is improved by the new models of organisation’s work. All elements of the transformational change process are based on a patient-centered system of medical care that is sustainable in the long term. The urgent problem for outpatient clinics to become improve effectively using a patient-centered approach. The aim of this study was to describe the strategies on patient-centred outcomes used in primary care in Russian regions. Materials and methods. A systematic literature review was conducted in Google Scholar and Elibrary databases using keywords. According to the inclusion criteria, the studies described the experience of implementing new strategies in the Russian primary health care system between 2017 and 2023, resulted in a total of 2874 articles being found. After reviewing the abstracts of the retrieved articles, 211 were retained for further analysis. Another 175 articles were excluded after reading the full text. Results. In this article, we describe a set of priorities strategies related with a new models in primary health care: expanded role of nurses in primary health care, improvement of Ambulatory complementary technologies, use of new organizational structures of medical care, using remote technologies. Findings. The strategies of new organizational models in primary health care are based on the successful experience of reforms. Factors affecting the expansion of strategies to other health care organizations include: teamwork of medical and non-medical professionals, low level of interprofessional collaboration to ensure effective implementation and delivery of patient-centered care, lack of incentives to improve the Ambulatory complementary technologies, patient routing problem for primary health care services, systematization of experience of telemedicine technologies in outpatient practice.

СРАВНИТЕЛЬНЫЙ АНАЛИЗ ОРГАНИЗАЦИИ И ОПЛАТЫ МОДЕЛИ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ С МУЛЬТИДИСЦИПЛИНАРНЫМ ПОДХОДОМ В РЕСПУБЛИКЕ КАЗАХСТАН И РОССИЙСКОЙ ФЕДЕРАЦИИ

Significance. The need for practical implementation of new models of organization of the primary health care system is due to demographic, social, epidemiological, technological and economic factors. Promising practices of medical care delivery have been formed in the world, both on the basis of interdepartmental interaction of medical and social workers, and in the form of a teamwork of specialists, including general practitioners, as well as specialists providing social and psychological assistance. The experience of Kazakhstan in organizing multidisciplinary teams has shown high efficiency, including decreased hospitalization rates, increased involvement and patient satisfaction. The purpose of the study is to conduct a comparative analysis of current models of organization of primary care delivery based on a multidisciplinary approach in the Republic of Kazakhstan and the Russian Federation. Material and methods. The authors analyzed results of domestic and foreign scientific research confirming effectiveness of the organization model of primary health care delivery based on a multidisciplinary approach in the Republic of Kazakhstan, as well as normative legal documents of the Republic of Kazakhstan and the Russian Federation regulating primary care organization and reimbursement. Results. The comparative analysis of the normative-legal base in health care system of the Republic of Kazakhstan and the Russian Federation shows common for both countries approaches to the primary care organization and reimbursement, while in the Russian Federation the provision of social and psychological assistance within the framework of the multidisciplinary approach is regulated only for individual categories of patients (children, elderly citizens, pregnant women). Conclusion. The introduction of multidisciplinary teams increases medical and social efficiency of primary care delivery and quality of life of the population attached to medical organizations on the district-based principle. In order to substantiate feasibility of a large-scale implementation of the multidisciplinary approach to primary care organization and reimbursement in the Russian Federation, it is necessary to test it in individual constituent entities of the Russian Federation in medical organizations with adult and pediatric polyclinics, as well as women's consultation.

Health System Resilience in a PHC Setting in India—A study of Assam and MP

Context: To bolster the ambitious Program of Government of India (GOI), to build a strong and resilient healthcare system plans to establish 1,50,000 Health and Wellness Centres (HWCs) across the country by 2024, the GOI gave a clear to its partners to explore options. Aim: Therefore, LEHS | WISH, initiated a baseline study to assess the service availability and service readiness (SARA) status of 18 Sub-centres (SCs) and Primary Health Centres (PHCs) to be upgraded as HWCs to deliver the twelve package of services as envisaged in HWC guidelines to strengthen the primary healthcare system. Settings and Design: Health system resilience, was assessed against the 10 Areas of Concern, elaborated in National Quality Assurance Standards (NQAS) for all the 12 thematic areas of service delivery of HWCs. Methods and Material: A sequential mixed method of design was adopted, which included both quantitative and qualitative components of assessment. The major focus of the study was quantitative in nature to assess HWC facility level gaps across key areas. Qualitative study with stakeholders including that of the community was undertaken to elicit reasons for such gaps and awareness of the community to respond/ engage with health systems better. Statistical Analysis Used: STATA was used a quantitative analysis tool undertake the analysis. Results: on average, both the last mile healthcare delivery system (PHC and SC) and the community are less than 25% resilient, even for disasters. Conclusion: It is not possible to make the system resilient unless focused effort is made. Therefore, there’s a need to clearly define the essential services and its resource requirement to be made available 24X7 for 365 days without fail, offer regular training to the staff to ensure process resilience, create awareness within the community to engage with the health system optimally, strengthen local governance to assure provision of essential services.

Ten years of the Citizen's Electronic Health Record e-SUS Primary Healthcare: in search of an electronic Unified Health System.

Contextualize the adherence to the Prontuário Eletrônico do Cidadão (PEC - Citizen's Electronic Health Record) by Brazilian municipalities and the evolution of the electronic strategy of the Unified Health System (e-SUS) for Primary Healthcare (PHC) during its 10 years. This descriptive study added information on adherence to the use of medical records extracted from the database of the Secretaria de Atenção Primária à Saúde (SAPS- Primary Healthcare Secretary) of the Federal Government between 2017 and 2022. We analized the number of computerized basic healthcare units that used some electronic medical records, the number of those that used simplified data collection (SDC), and those that implemented the citizen's electronic health record (PEC) in the same period. A descriptive synthesis of the functionalities and modules implemented in the system during its 10 years of development was also carried out. The adherence of Brazilian municipalities to the PEC has grown exponentially in the last five years, going from 8,930 healthcare units in 2017 to 26,091 in 2022. As expected, while the main functionalities and improvements developed in this decade sought to implement new flows and modules of administrative, clinical care, and care management processes and health service administration, improving aspects of usability and technological infrastructure of the application architecture was also crucial for the success of the system. In 2023, the milestone of a decade will be celebrated since the beginning of health records implementation by Brazilian municipalities, marked by technological and infrastructure challenges and improvements and new functionalities that highlight the technological evolution of the e-SUS PHC system and strategy. Despite many other tools, the PEC is arguably Brazil's leading electronic medical record today, as it has always invested in evolution, updating itself in technological and usability opportunities.

The current state of primary healthcare in Pakistan: a way forward for low-to-middle income countries.

Primary healthcare (PHC) plays a crucial role in improving health outcomes and reducing healthcare burden, especially in low-to-middle-income countries (LMICs). However, PHC has not received adequate attention in Pakistan despite its recognized importance. This study aims to examine the current state of PHC in Pakistan, identifying factors compromising its quality and effectiveness. To find relevant data, the authors conducted a thorough literature search on PubMed, Google Scholar, and Cochrane Library from inception till 2 July 2022, without any language restriction. The following keywords were employed during the literature search, separated by Boolean operators AND, OR: "Primary Healthcare", "PHC", "Healthcare primary", "Primary Health", and "Pakistan". Pakistan's PHC infrastructure shows promise, with a considerable number of healthcare facilities in place. However, various factors hinder its effectiveness and compromise the quality of care provided. Insufficient investment, resource constraints, inadequate training of healthcare providers, lack of oversight, and limited access to essential medicines and equipment are some of the key challenges observed. Improving PHC in Pakistan is vital for addressing the population's healthcare needs, particularly in rural areas. Adequate investment, enhanced training programs, improved oversight mechanisms, and increased availability of essential resources are necessary to strengthen the PHC system. By prioritizing PHC and addressing the identified challenges, Pakistan can enhance healthcare access, reduce healthcare burden, and improve overall health outcomes for its population. It is high time LMICs like Pakistan recognize PHC as the most economically feasible pathway toward accomplishing healthcare targets and adopt adequate measures to elevate its standards.

Community health practice: the Nigerian model

The Nigerian model of community health practice is a unique approach to healthcare delivery that emphasizes the involvement of community members in the planning and implementation of healthcare services. This model is based on the principle that healthcare should be accessible, affordable, and equitable for all members of the community. This review focused on the Nigerian model of community health practice yesterday, today, and in the future. Findings indicated that the Nigerian model of community health practice was established in 1978 and is characterized by the use of community health practitioners who have acquired National Diplomas, Higher National Diploma, Bachelor, Master and Ph.D. degrees in Community Health. They are licensed by the Community Health Practitioners Registration Board of Nigeria to provide basic healthcare services such as health education, preventive care, treatment of common illnesses, maternal and child health services, and family planning at primary health centers and community levels. While the model of community health practice has faced significant challenges, including inadequate funding, lack of infrastructure, and a shortage of trained personnel, it has demonstrated promising results in improving healthcare access and outcomes in rural communities. The Nigerian Model of community health practice holds important lessons for other countries seeking to strengthen their primary healthcare systems.

Lessons on chronic care organisation during the COVID-19 pandemic in Cambodia, Slovenia, and Belgium. COVID as a magnifying glass on primary health care.

Introduction: Primary health care (PHC) systems worldwide have been challenged by the COVID-19 pandemic. Some patients couldn’t access care or services were not available.
 Background: Fuelled by different health systems, the impact on NCD care has been different in the three countries under research: Cambodia (a developing health system in a middle-income country), Slovenia (a centrally-steered health system in a high-income country), and Belgium (a publicly-funded privatised health system in a high-income country). As crises can uncover both the strengths and weaknesses of a PHC system, we can use them as an opportunity to pinpoint weak and strong areas and translate this knowledge into recommendations to strengthen the PHC system. This study aims to answer two research questions: ‘How has COVID-19 influenced NCD care within PHC?’ and ‘Under which circumstances does a crisis lead to health system strengthening in which types of countries?’.
 Methods: Interviews were conducted with 58 key stakeholders including policy makers or influencers, patient and provider representatives, researchers and primary care providers. These interviews were supplemented with document reviews. A qualitative thematic analysis was performed and results were discussed with the international research team. This study is part of the SCUBY project, funded by the EU Horizon 2020 programme.
 Results: COVID-19 had different impacts on key organizations in the three countries. In Belgium, general practitioners got overburdened with COVID-19 testing and accompanying administration, highlighting the chronic lack of auxiliary staff such as nurses or assistants. In Cambodia, some private PHC facilities, serving the majority of the patients with NCDS were closed by the owners to prevent transmission. This led to the increased burden of NCD on the public sector which has a duty to maintain essential services in the crisis circumstance. However, it pointed to the importance of strengthening the public sector for NCD care to cope with future crises. In Slovenia, the high COVID-19 burden in nursing homes revealed vulnerabilities in the long-term care system, such as lack of staff and fragmented service provision.
 
 In relation to health system strengthening opportunities, the current crisis also provides a unique chance to move forward in the three countries. In Cambodia, the successful vaccination campaign renewed trust in the public health sector, whereas in Slovenia new investments in the health care sector were announced. In Belgium, the Minister of Health planned to reform the financing system and to strengthen primary care.
 Conclusions: The COVID pandemic caused disruption of care in all three countries. However, it also creates important chances to accelerate the scale-up of high-quality care for all patients with NCDs. When taking the time to analyse how COVID-19 impacted the health care system we can boost it faster than before.

Hypertension cascade across three healthcare systems and in relation to the level of implementation of the integrated care package of hypertension

Introduction: Primary health care (PHC) systems across the globe are struggling to produce an effective response to the rising burden of disease related to Type 2 Diabetes (T2D). However, effective T2D care at the PHC level – the ‘Integrated Care Package (ICP)’– exists and is cost-effective. Further, there is evidence that this integrated care package ((1) structure) leads to improved care processes (2), to health care responsive to people’s needs and eventually to better health outcomes (3). There is however a clear need for an assessment framework to enable countries to evaluate their progress towards integrated care for T2D.
 We aim to test an assessment framework incorporating these 3 elements: (1) a tool to assess the degree to which the T2D care provided corresponds to the ICP for T2D (structure); (2) cascades-of-care to visualize and detect the ‘leakages’ at each separate step of the care continuum (process and outcomes of T2D care); and (3) a contextualization of (1) and (2) in order to explain why the implementation of specific ICP elements has or has not led to the expected outcomes. This framework will be tested in 3 countries with different PHC approaches, namely Slovenia, Belgium and Cambodia.
 Methods: A mixed methods design is used. First, information about the level of ICP implementation is collected using the ICP Grid at the health care facility level. Secondly, patient level data is used to build de T2D cascades-of-care: we rely on representative survey data (5000 individuals) in Cambodia, on health insurance (+ laboratory) data in Belgium and routine data in Slovenia. Where feasible, we used ICP scores as explanatory variables explaining the drops in the cascade. Thirdly, expert consultations and stakeholder interviews were used to contextualize the findings.
 Results: The ICP grid scores showed considerable variations in the implementation of the ICP for patients with T2D between Belgium, Slovenia, and Cambodia – with Slovenia consistently reporting the highest scores. However, important in-country variations were observed for Belgium and Cambodia indicating that specific initiatives have resulted in higher levels of integrated care. In terms of T2D care process and outcomes, the country cascades-of-care display similar profiles with the biggest drops at the ‘diagnosis’ and ‘under control’-bars. The qualitative data on the health system clearly demonstrate that the context can hamper (1) the construction of the cascades (i.e. in Belgium and Cambodia due an absence of a routine monitoring system) and (2) the linking of the ICP grid data with the cascade-of-care data (i.e. in Cambodia where the private sector takes up a large proportion of T2D care).
 Conclusions: The developed framework offers a promising strategy to assess (1) the progress made in ICP implementation in PHC for T2D as well as (2) its impact on the T2D care process and outcomes. As such, the framework offers policy makers and stakeholders a tool to monitor T2D care and adapt specific elements where required. The study, however, also indicated severe challenges in collecting the required data which also limited the cross-country comparability of the produced outcomes.

Does rural India need a new primary healthcare delivery model?

There has been a continuous downfall in equipping the Primary Health Centres (PHCs) with infrastructure, facilities, and workforce to provide basic minimum primary healthcare services to the underserved population in the Indian context. The main goal of this research is to look at the infrastructure and manpower in a sample of PHCs in the Kanpur district of Uttar Pradesh, India. The interview template exclusively for Product-Service System (PSS) by Singapore University of Technology and Design-Massachusetts Institute of Technology (SUTD-MIT) was used to study randomly selected samples of 51 PHCs. The data were examined using the Indian Public Health Standards (IPHS) of the Indian government. Some of the key findings included the lack of workforce and their commitment, shortage of space, electricity, and water supply. To find a solution for the found lacunae, this article also discusses about the functioning of Mobile Hospitals (MHs) depending upon the contexts and thus extracting lessons for a new intervention in the primary health care system delivery model. Finally, a new healthcare delivery model in the form of a mobile Primary Health Centre (mPHC) is proposed based on the field study and the synthesis of historical literature on MH.

Change management on the meso-level: Primary mental health care in Pallieterland, supported by Emergo/PANGG 0-18 (Flanders, Belgium)

Introduction: One of the main current challenges for the Belgian primary health care system is the integration of primary mental health care.
 Belgium is known to have a shortage of mental health professionals. Public mental health services are understaffed, resulting in long waiting lists. Private mental health professionals are too expensive for many people in psychological distress.
 Since 2019, a limited number of primary mental health consultations is reimbursed, to lower the financial threshold to access the private mental health sector. Since 2021, the primary mental health convention changed, towards higher renumeration for psychologists working in the convention, and starting more from a public mental health vision.
 This is a Belgian federal action. In Pallieterland and four other primary care zones, this action is coordinated by two mental health networks: Emergo (for adults) and PANNG 0-18 (for minors).
 In this article the focus is on the change management on the meso-level: how did and still does primary care zone Pallieterland help to implement this policy change?
 What we did: The first step was to have a representative of the mental health sector in the board of the primary care zone, a necessary navigator and go-between, facilitating communication efforts of the primary care zone towards the mental health sector.
 The second step was to help founding a local psychologists’ association. After some previous attempts, the start of the new convention showed to be a good momentum for the start of the local psychologists’ association. Their founders are good communicators, representing the local primary mental health professionals in the boards of both the primary care zone, and of the local implementation group of the new primary mental health care convention.
 The third step is to keep monitoring the implementation progress, making sure that all localities in the primary care zone are well served with reimbursed primary health care consultations.
 
 The primary care zone facilitated and still facilitates these processes, by using a diversity of communication platforms:
 - A monthly electronic newsletter, reaching local healthcare and social care professionals;
 - Siilo Connect, a “medical Whatsapp” respecting GDPR legislation and able to send messages both to the whole contact list and to specific professional groups. Sometimes we sent a targeted request to fill a survey related to this topic, whenever we needed input for local policy decisions;
 - Six-monthly platform meetings on relevant interdisciplinary topics, reaching local healthcare and social care professionals: we both gave dedicated time for this project on one platform meeting and gave short follow-up notices on other platform meetings;
 - Six-weekly board meetings and annual general meeting: short notices on the progress of implementation, allowing questions from diverse stakeholders.
 Conclusion: Summarizing the efforts of primary care zone Pallieterland towards the implementation of the new primary mental health convention through the lens of Donabedian’s theory (Structure – Process – Outcome), we found that we spent most energy and time in modelling the structures, and monitoring processes of communication/collaboration. At the moment, primary care zones don’t have access to any outcome indicator.
 

30 by 2030 campaign

Primary Health Care (PHC) is a cornerstone of universal health coverage (UHC). To prevent diseases and holistically treat people, community-based primary healthcare systems need to be strengthened. PHC is an approach that aims to address physical, mental, and social health and well-being, and to provide comprehensive care for a person's health needs throughout life rather than focus on treating a specific set of diseases. To achieve this approach, we must strengthen horizontal PHC systems and encourage vertical programmes, including disease-specific programmes, to be developed, integrated, and implemented in the context of integrated Primary Health Care.
 In early 2020 the WHO Collaborating Centre on Family Medicine and Primary Health Care launched the 30by2030 campaign (https://www.30by2030.net), whereby signatories are asking donors of vertical disease-oriented projects to invest at least 30% of their budgets for vertical programs in strengthening coordinated and integrated primary health care. The initiative is a pull of efforts of different organizations such as Wonca: World Organisation of Family Doctors, The Network: Towards Unity for Health (TUFH), African Forum for Primary Health Care, European Forum for Primary Care, PRIMAFAMED network, among others.
 The 30 by 2030 has two aims: the first one is to inform and raise awareness of the impact of vertical programs on health systems. Most of the private and external funds, which represent one-third of the total spending of PHC, are channelled through programmes that focus on the health problems of specific population subgroups (e.g., HIV, tuberculosis, malaria) which also leads to inequity by disease. The second aim is to call for international donors to assign 30% of their vertical top-down, disease-oriented budgets to strengthen primary healthcare services through coordination, increased human resources and improved infrastructure.

COVID-19 Vaccination Integration: Efforts in 11 African Countries to Strengthen the Primary Health Care System.

COVID-19 Vaccination Integration: Efforts in 11 African Countries to Strengthen the Primary Health Care System.

Mental Health Awareness and Promotion during the First 1000 Days of Life: An Expert Consensus.

The first 1000 days of life constitute a critical phase that will determine the optimum growth and development of a child. An important factor in this phase of life is the perinatal mental health of mothers and children. Mental health awareness is an important public health issue with significant impacts on mothers, spouses, and families, as well as the long-term emotional and cognitive development of children as well. However, the awareness and promotion of mental health within the realms of reproductive health, maternal health, and infant health, i.e., the first 1000 days of life, do not receive high prioritization in Indonesia. Nonetheless, Indonesia, with its existing primary healthcare system, has the potential to raise awareness of and promote the importance of perinatal mental health for its citizens. This experts' consensus proposes several strategies to maximize the usefulness of primary healthcare facilities in Indonesia, including Community Health Centers and Integrated Healthcare Posts, to support perinatal mental health awareness and promotion during the first 1000 days of life. The success of this program, in return, will improve the health status of women and children in Indonesia.

Experience in implementing a new model of a medical organization providing primary health care in The North Caucasus Federal Scientific and Clinical Center of the Federal Medical and Biological Agency

The article presents the experience of introducing a new model of a medical organization that provides primary health care in the Federal State Budgetary Institution of the SKFNCC of the FMBA of Russia as part of the implementation of the federal project «Development of a system of primary health care.

Exploring Factors Shaping Primary Health Care Readiness to Respond to Family Violence: Findings from a Rapid Evidence Assessment

Abstract Purpose Family violence (FV) is defined as any situation where an individual employs abusive behaviour to control and/or harm a former or current spouse, non-marital partner, or a member of their family. The health consequences of FV are vast, including a wide range of physical and mental health conditions for individuals experiencing violence or survivors, perpetrators, and their children. Primary health care (PHC) is recognized as a setting uniquely positioned to identify the risk and protective factors for FV, being an entry point into the health care system and a first, or only, point of contact for families with professionals who can facilitate access to specialist care and support. Methods A rapid evidence assessment of empirical studies on FV interventions in PHC was conducted to examine outcomes of effective FV interventions that promote identification, assessment, and care delivery within diverse PHC settings, factors shaping PHC provider and system readiness, and key intervention components that are important for sustaining PHC responses to FV. After completing data extraction, quality appraisal, and a hand search, a total of 49 articles were included in data synthesis and analysis. Results Several FV interventions that include multiple components such as, screening and identification of FV, training of PHC providers, advocacy, and referrals to supports, have been rigorously tested and evaluated in diverse PHC settings in rural and urban areas including primary care/family medicine practice clinics and community PHC centers. These interventions have demonstrated to be effective in identifying and responding to violence primarily experienced by women. There is a dearth of FV interventions or programs from empirical studies focused on men, children, and perpetrators. Additionally, provider and system readiness measurement tools and models have been implemented and evaluated in PHC specifically to assess physician or the health care team’s readiness to manage FV in terms of knowledge and awareness of FV. The findings highlight that there is no clear or standardized definition of provider or system “readiness” in the literature related to FV responses in PHC. Further, the findings revealed four key intervention components to facilitate PHC provider and organization readiness to address FV: (1) multidisciplinary teamwork and collaboration, (2) improving provider knowledge on the social and cultural determinants impacting FV, and (3) embedding system-level supports within PHC. Conclusions FV is a serious public health concern and PHC providers have a vital role in early detection of FV and the poor health outcomes associated with violence A focus on comprehensive or multi-component FV interventions are more likely to change provider behavior, and would allow for safe, confident, and professional identification and assessment of FV within PHC.

PRAGMATIC IMPLEMENTATION OF AN ADVANCE CARE PLANNING INTERVENTION: FINDINGS FROM SHARING CHOICES

Abstract Advance care planning (ACP) is defined as a key task in ambulatory care for patients to share values, goals, and preferences for future medical care. Ideally ACP is revisited throughout the course of serious illness and engages family in discussions with clinicians. Most interventions, however, have not targeted primary care as a setting for ACP but have instead targeted a specific illness, conversation or setting such as the inpatient hospital or nursing home. Additionally, family is often not included in ACP discussions. This symposium will discuss critical components of the SHARING Choices cluster-randomized pragmatic trial, including the setup, monitoring, and analysis of this intervention within two primary care health systems located in the Baltimore-Washington DC metropolitan corridor. Each presenter will discuss key efforts conducted during the trial that highlight challenges, lessons learned, and novel approaches of embedding an evidence-based intervention within usual care settings targeting older adults 65 years of age and older. Preliminary analyses indicate that the ACP intervention was highly effective for increasing the likelihood of having advance directives in the patients’ electronic health records within 1-year of intervention initiation (odds ratio = 2.88, p < 0.001). Attendees of this symposium will take away relevant insights for implementing effective ACP and communication interventions within primary care settings as well as supporting outcome data. Our discussant will provide thoughts on the implications of these results for current primary care organizations and in the field of ACP and communication for older adults including those with dementia.

Health literacy and cultural responsiveness of primary health care systems and services in Australia: reflections from service providers, stakeholders, and people from refugee backgrounds

BackgroundPrimary health care [PHC] services with general practitioners (GPs) as the first point of access to health care services for people from refugee backgrounds in Australia can play a crucial role in building health literacy and promoting access to culturally appropriate services. To achieve equitable access and engagement, services and systems must be responsive to diverse health literacy and cultural needs. This study aims to explore how primary health services respond as a system and organisation to the health literacy and cultural needs of people from refugee backgrounds in Australia.MethodsThis exploratory qualitative study involved 52 semi-structured interviews among 19 Africans from refugee backgrounds, 14 service providers, including GPs and nurses, and 19 other stakeholders, such as service managers/directors. Participants resided in New South Wales, Victoria, and Queensland. Interviews were audio-recorded, transcribed, and coded into QSR NVivo 12. Data analysis was guided by reflexive thematic analysis.FindingsThree interrelated themes were identified from the data relating to the health literacy and cultural responsiveness of PHC systems and services. The first theme, ‘variable and ad hoc organisational response to health literacy and culturally responsive care,’ demonstrated that some organisations did not systematically address the inherent complexity of navigating the health system nor the capacity of services and providers to respond to the cultural needs of people from refugee backgrounds. The second theme, ‘individual provider responsibility,’ captured the individual providers’ interpersonal and relational efforts in supporting the health literacy and cultural needs of people from refugee backgrounds based on their motivation and adaptation. The third theme, ‘refugee patient responsibility,’ encapsulated people from refugee backgrounds’ adaptations to and learning of the health system to navigate and access services.ConclusionHealth literacy and culturally responsive practices need to be systematised by PHC organisations to be implemented and sustained over time. There is a need for diversity in the organisational leadership and health care workforce, organisational commitment, health literacy and culturally responsive care policies, provider training, and auditing practice as essential components of the change process. Engaging with refugee communities would allow services to focus on people from refugee backgrounds’ needs by design.

Usefulness of a Multicomponent Group Intervention Program for Fibromyalgia Patients in Primary Care: A Qualitative Study of Health Professionals.

To explore the perceptions and experiences of health professionals who participated in a multicomponent program for fibromyalgia (FM) patients based on health education, physical exercise and cognitive-behavioral therapy. In this qualitative, descriptive study that was based on a pragmatic and utilitarian approach, we conducted two focus groups (FGs) with 12 professionals (nurses and general practitioners) from the primary healthcare system of Spain who had been trained as FM experts. A thematic content analysis was carried out. The findings were organized into four key domains, each with explanatory emerging themes. Overall, the professionals positively valued the program for the knowledge gain it offered, its integrated approach, the group effect and other benefits to patients. Work overload and peers' lack of acknowledgement of the program's value were identified as barriers. A reduction in the amount of content in each session, the creation of quality-of-care indicators and the promotion of the new professional role (FM expert) were proposed. The FM experts supported the program and recognized its usefulness. To implement the program within the primary healthcare system, the program needs to be adjusted to accommodate professionals' and patients' reality, and institutional health policies must be improved by providing training on FM to the healthcare community.

Alone yet accountable, the unseen buffers: A qualitative study of nurses' experiences working in home care during the COVID-19 pandemic.

Norwegian society's resilience during the COVID-19 pandemic resulted in low mortality rates and moderate economic decline. The accessible primary healthcare system played a vital role in this, especially in the care of elderly and chronically ill patients. However, nurses in home care experienced emotional burdens, ethical dilemmas and limited access to protective equipment. These challenges were overshadowed by media coverage of hospital struggles, and municipal home care services were oddly absent from post-pandemic reports. This research therefore aimed to explore and describe how nurses experienced working in home care during the pandemic. We designed a qualitative study and conducted semi-structured interviews with nine home care nurses from different municipalities in Southeast Norway. Systematic text condensation inspired by Malterud was employed for data analysis. Nurses' experiences were described through two categories: 'adapting approaches' and 'adapting work practices'. The results showed how nurses often felt alone while simultaneously shouldering a significant responsibility for patients facing a novel and unfamiliar illness. The pandemic necessitated treating patients in their own homes to minimise infection risks, intensifying the nurses' treatment responsibilities. Furthermore, limited access to medical expertise and physical separation from management due to remote work accentuated feelings of isolation and amplified the nurses' responsibility for patient care. Additionally, the nurses encountered frequent changes in work routines, demanding adaptability. This study underscores the significant role of home care nurses, who, despite feeling professionally isolated and unsupported, demonstrated impressive adaptability. They served as a crucial buffer in the healthcare system, ensuring vulnerable individuals received essential care. This highlights the importance of a robust primary healthcare system with a skilled nursing workforce that can work autonomously, shoulder responsibility, and make clinical decisions, even when medical expertise is less readily available. It also reminds us that healthcare preparedness depends on collaborative efforts across all sectors.

An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria.

The availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states. We collected primary data from 50 health facilities (25 per state), including PHC facilities-health posts, health clinics, health centers-and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider's perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state. We found that average actual PHC costs per capita at PHC facilities-where most PHC services should be provided according to government guidelines-ranged from US$ 18.9 to US$ 28 in Kaduna and US$ 15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals-where approximately a third of PHC services are delivered in both states-the actual per capita costs of PHC services ranged from US$ 20 to US$ 30.6 in Kaduna and US$ 17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$ 44.9 in Kaduna and US$ 49.5 in Kano. Bridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services.