Primary Health Care Reform Research Articles

The Continuing Quest for Primary Healthcare Reform: Measuring Performance

The Continuing Quest for Primary Healthcare Reform: Measuring Performance

Health Reforms in an Interdependent Environment: Dealing with the Laggards

Resource dependency theory holds that organizations dependent on single funders have a strong motivation to behave in a manner which reduces funders‟ power over them. Dependent organizations are required to meet funders‟ accountability demands at the expense of other stakeholders. However, it has also been suggested that, if the funder contracts with a provider for a specialised product (for example health care) the funder-provider relationship may become interdependent instead. By inference this may allow the provider to behave in a manner which is outside funders‟ expectations.This research considers primary health care reforms and the interplay between state funders and General Practitioner associations established as nonprofit providers. Four case studies are analysed, two of which appear to behave in a manner conducive to the reforms and funders and two of which do not. We hypothesize that the strength of the GP profession is instrumental in these laggards‟ behaviour.The analysis finds that, while the state funders act in a way that emphasises interdependence with agreeable providers, they act differently towards the laggards. State funders penalise laggards by making increasingly stringent accountability demands and publicly questioning their reputation. These tactics were used, notwithstanding standard contractual arrangements and the specialised product these associations deliver. Therefore, while health contracting can bring interdependent relationships, resource dependent providers will continue to be subject to powerful funders pushing for change through direct and indirect means. Additionally, the specialization of the GPs enabled them to manage their resource dependence without wholesale changes to organizational structures.

A perspectiva da enfermagem comunitária na atenção básica em Portugal

Portugal, em 2005, iniciou uma reconfiguração dos centros de saúde que nomeou como reforma da atenção básica, com os objectivos de melhorar a acessibilidade, a eficiência, a qualidade e a continuidade dos cuidados e aumentar a satisfação dos profissionais e cidadãos. Foram reorganizados os agrupamentos de centros de saúde e criadas novas tipologias de unidades de cuidados. Paralelamente foi desenvolvido o processo de continuidade de cuidados e a rede nacional de cuidados continuados integrados. As intervenções de enfermagem nos cuidados a pessoas, famílias, grupos e comunidades, na atual reforma, são fundamentais para o seu êxito. Os primeiros relatórios apresentam ainda algumas ineficiências que a actual reforma se propõe melhorar de forma sistemática incidindo na qualidade das boas práticas, no bem estar dos usuarios e a satisfação dos profissionais.

Optimal Positioning of Occupational Therapy

Occupation is central to occupational therapy. Although occupation is a universal experience, occupational therapists need to consider the risks and opportunities of exploring new roles and maintaining existing services. I propose three questions to guide the optimal positioning of occupational therapy services. First, how proximal is occupation in the role? Second, how strong is the evidence to support occupational therapy in the role? Third, is the timing right for change? These questions are applied to the role of occupational therapy in primary health care. Occupation is proximal and the evidence is emerging to support an occupational therapy role in primary health care. Reforms make timing ideal. If we focus on the underlying principles of primary health care reform, the potential for an emerging role in primary health care is optimal. The same three questions can be used to transform and optimally position occupational therapy.

Reforma da Atenção Primária em Portugal em duplo movimento: unidades assistenciais autónomas de saúde familiar e gestão em agrupamentos de Centros de Saúde

In 2005, Portugal began a reform of Primary Health Care. This reform process through to April 2010 is described and analyzed. During this period the Mission for Primary Health Care was responsible for conducting a profound reconfiguration. The main objectives for this reform were to improve accessibility, efficiency, quality and continuity of care and increase the satisfaction of professionals and citizens. The main features are voluntary adhesion, teamwork, mandatory information system, performance-sensitive payment, contracting and evaluation. The reconfiguration of health centers was two pronged. First, there was the formation of small autonomous functional units, known as Family Health Units (USF) providing services with proximity and quality. The second measure involved the aggregation of resources and management structures, groups of health centers (ACES), seeking to achieve efficiency and economies of scale. The FHU proved to offer simultaneously more efficiency, accessibility, better working environment, greater citizen satisfaction, namely better quality. The importance of strong political support, the creation of a structure responsible for the design and implementation of reform and good liaison with the media are stressed.

Future models of general practice training in Australia

Current proposals for significant primary health care reform in Australia create a timely opportunity to reflect on the education and training requirements of future general practitioners. Australian general practice will become increasingly team-based, with growing emphasis on coordinated care, chronic disease management, and disease prevention and self-management, while maintaining its focus on delivering high-quality, patient-centred care. This will require cost-effective application of new technologies and information management systems within new models of delivering health care. Future models of general practice training must respond to these new ways of working to ensure general practice remains an attractive career choice and training programs graduate doctors who are equipped to meet the health needs of Australians. This article discusses potential development of new general practice vocational training models in Australia. This includes hospital rotations that are more directly integrated with general practice placements and have greater emphasis on the needs of the future general practice workforce; and an extension of the training program to 4 years with a final year tailored to future career plans including development of expertise in practice management, specific clinical disciplines or academic skills.

Primary health care in Canada: systems in motion.

During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert.

Sustainable primary health care services in rural and remote areas: Innovation and evidence

To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to 'difficult-to-service' communities. The paper synthesises evidence from remote and rural PHC health service innovations in Australia. There is a strong history of PHC innovation in Australia. Successful health service models are 'contextualised' to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.

China's primary health-care reform

China's primary health-care reform

The WHO and primary healthcare reform: mind the implementation gap

Policy makers are well known for producing grand plans. However, they routinely overlook the fact that their big idea for the way forward may account for perhaps only 5% or 10% of the healthcare policy process. The rest sits in the practical undertakings of policy adoption and implementation (1,2). The literature points to various conditions that need to be taken into account if policy is to achieve its goals in implementation (3,4). These include whether pre-existing institutional arrangements (the regulatory, financing and organisational forms as well as the traditions that govern how healthcare is delivered in a country) will be conductive to adopting and promoting new policy directions. Issues such as the scope of change required will influence potential for change, as will support from among those affected (e.g. healthcare providers and interest groups). Routinely, policy makers avoid analysing these conditions and simply hand responsibility for implementation to someone else. This is why the grandest of policies often falter in execution (5).

Shifting Focus of Primary Health Care in the Context of Health Systems Reform in Resource Poor Settings

Purpose:To review the concepts of Primary Health Care (PHC) and provide evidence for a shift in its focus and implementation in the resource poor setting. Sources of data:Desk and internet based review of relevant articles and official documents. Data extraction:Search themes were ‘concepts and models of PHC’, contextual issues in PHC and health care reforms aimed at achieving the universally accepted core social values of health care delivery. Results:Four main concepts and approaches to PHC include selective PHC, primary care; Alma-Ata comprehensive PHC and health and human rights approach. The concept of PHC in resource poor settings is oversimplified and restrictive. This is in contrast with the situation in well-resourced contexts where primary care concept is practiced.The World Health Organisation recommends a shift in focus of PHC through four sets of reforms in the health system, universal coverage reforms, service delivery reforms, public policy reforms and leadership reforms. This shift should bridge the gap between citizens’ expectations and performance of the health care system. Conclusion:Inability of health services to deliver levels of national coverage that meet stated demands and changing needs has been a source of worry. The health systems need to respond better and faster to the challenges of a changing world.

Primary health care and equity: the case of lesbian, gay, bisexual, trans and intersex Australians

The current period of health reform in Australia offers an opportunity for positive actions to be taken to address the significant challenges that lesbian, gay, bisexual, trans, intersex and other sexuality, sex and gender diverse (LGBTI) people face in the health system. This paper provides analysis of why this group should be considered a priority health group using a social determinants of health framework, which has, to date, largely been ignored within primary health care policy reform in Australia. Several key areas of the primary health care reform package are considered in relation to LGBTI health and well-being. Practical suggestions are provided as to how the primary health care sector could contribute to reducing the health inequities affecting LGBTI people. It is argued that care needs to be taken to ensure the reform process does not further marginalise this group.

The Brazilian health system: highlighting the primary health care reform

This paper aims to describe the health system reform in Brazil, highlight the primary health care reform and the development of the Family Health Program, as well as explore future directions based on the current situation. The paper’s first section provides an overview of the Brazilian Health System and a brief historical perspective of the health system reform. It sets out the principles of the health system based on its legal framework and analyses how these principles have been implemented. At the end of the first section, an overview of financial issues is provided. The second section focuses on the primary care reform and the Family Health Program. It describes the program’s structural and innovative process characteristics. It further describes some of the outcomes and impacts already documented in the literature. Finally, the paper explores challenges to the health system and the program’s sustainability

Assessing the evolution of primary healthcare organizations and their performance (2005-2010) in two regions of Québec province: Montréal and Montérégie.

BackgroundThe Canadian healthcare system is currently experiencing important organizational transformations through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of proposing the transformation of PHC organizations by implementing new models of PHC organization. These models vary in their performance with respect to client affiliation, utilization of services, experience of care and perceived outcomes of care.ObjectivesIn early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and population-level experience of care. The goal of the present research project is to track the evolution of PHC organizational models and their relative performance through the reform process (from 2005 until 2010) and to assess factors at the organizational and contextual levels that are associated with the transformation of PHC organizations and their performance.Methods/DesignThis study will consist of three interrelated surveys, hierarchically nested. The first survey is a population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This survey will assess the current affiliation of people with PHC organizations, their level of utilization of healthcare services, attributes of their experience of care, reception of preventive and curative services and perception of unmet needs for care. The second survey is an organizational survey of PHC organizations assessing aspects related to their vision, organizational structure, level of resources, and clinical practice characteristics. This information will serve to develop a taxonomy of organizations using a mixed methods approach of factorial analysis and principal component analysis. The third survey is an assessment of the organizational context in which PHC organizations are evolving. The five year prospective period will serve as a natural experiment to assess contextual and organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models (in 2010) and assess the impact of this evolution on the performance of PHC.DiscussionThe results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes.

An interprofessional collaborative practice model: Primary-care clinical associates at the family practice setting

A persistent physician shortage challenges the ability of our healthcare system to meet the growing health needs of our aging population. Health system redesign must maximize the efficient use of available human resources. The Alberta Westview Primary Care Network (WPCN) introduced the Primary Care Clinical Associate (CA) program in 2005. This interprofessional collaborative practice model recruits nonphysician health professionals from various disciplines as autonomous, independent practitioners. They are associates of the family physician and use their full scope of practice to jointly care for a panel of patients in family practice settings. Three years after its inception, the CA program has grown steadily from two initial participating family practices to its current implementation in six of seven WPCN clinics. The present direction of Canadian primary healthcare reform is towards team approaches. Accordingly, the CA program has wide applicability provincially across Canada. The objective of this article is to describe in detail the design of the WPCN CA program including its conceptual framework and operational strategies and to share program implementation learning. This knowledge transfer will enable replication of the WPCN CA model, where appropriate, in other jurisdictions.

The economics of primary healthcare reform in Australia – towards single fundholding through development of primary care organisations

A strong primary care sector is widely acknowledged as a fundamental component of a well functioning health system and thus has been the focus of strategic reforms in a number of countries. This paper provides an economic analysis of primary healthcare reform, with the aim of identifying the key structural elements that are necessary to support enhanced models of primary health in the Australian context. This paper utilises economic theory, and draws upon empirical evidence and international experience to analyse primary healthcare reform to identify the structural elements necessary for an enhanced primary care sector. The aim of which is to improve health system performance. These structural elements are then critically examined in the Australian health system setting. For enhanced models of primary healthcare to promote efficiency, they must incorporate a number of key structural elements; notably: governance and purchasing responsibilities for primary care devolved to a meso-level organisational structure through capitated single fundholding arrangements; blended payment methods for reimbursing providers; the establishment of a national quality and performance framework; and the development of primary care infrastructure. As the Federal government attempts to address recommendations of the National Health and Hospital Reform Commission, a window of opportunity now exists to pursue long overdue structural reforms to deal with the challenges facing the Australian health system. The paper advances the important structural features to primary healthcare that need to be embraced as the government attempts to pursue its health reform agenda.

Bringing it all back home: can Europeans learn from recent moves toward the medical home in US primary health care reform?

As its health care system undergoes reform, most observers would agree that US primary care is fragmented and uncoordinated. Instead of being provided by a medical generalist in a context of continuity, it has traditionally been provided by specialists, particularly from internal medicine or paediatrics. This has been considered a major driver of rising costs in the US system. Minor conditions are seen through the lens of specialty-focused care, which can lead to over-testing and over-treatment by anxious specialists, untrained in the arts of laid-back watchful waiting, gate keeping and continuity of care. These shortcomings of US primary care have recently been documented by Schoen and colleagues1 in a survey of primary care in 11 countries. We quote: ‘although the United States spends far more than the other countries do, US primary care physicians continue to lag well behind in health IT capacity, are the least likely to have arrangements for after-hours care, and report few incentives or targeted support for improving primary care’. However, … Correspondence: Aileen Clarke, Professor of Public Health & Health Services Research, Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK. tel: +44 (0) 24 761 51060, fax: +44(0) 24765 28375, e-mail: aileen.clarke{at}warwick.ac.uk

Primary healthcare reform in Momtenegro and its influence on rights of patients suffering from mental disorders

The aim of the study is to determine the influence of current reforms in Montenegro on the level of protection of patients suffering from mental disorders. Currently two reforms of...

Journal of Diabetes News

<i>Journal of Diabetes</i> News

Health information systems, decentralisation and democratic accountability

AbstractWhile decentralisation is a much‐used term in development discourse, there is lack of clarity about how much autonomy should be granted to local agencies in programme implementation. This is particularly the case in the health sector in developing countries where decentralisation has resulted in the primary health centre (PHC) being identified as the focal point for the delivery of basic health services to rural citizens. An important element of primary healthcare reform has been the implementation of health information systems (HIS). These systems primarily account for monies spent to higher levels of administration and funding bodies rather than account for primary healthcare provision to citizens. In this article, we focus on various emergent processes of change that are occurring under the auspices of the National Rural Health Mission (NRHM) in India to strengthen the interface between the PHC and the community. We present a case study of Gumballi PHC in Karnataka, South India. Our findings reveal ways in which these new processes can be supported by conceptualising the HIS as more than a mere reporting tool. Copyright © 2010 John Wiley &amp; Sons, Ltd.