Primary Health Care Reform Research Articles

Path Dependence and Health Policy: Intersections between the Past and the Future

On walmgate street in york, england, you can order kebabs or burgers from a restaurant with a storefront that is exactly one perch long, a property boundary and unit of measurement that survives from Viking times.1 Its persistence hundreds of years and many generations later in the modern streetscape is a classic example of path dependence. While path dependence is perhaps most obvious in the case of physical structures, they are by no means the only context in which current decisions or situations are shaped by past circumstances. Examples in economic, cultural and other contexts abound. Indeed, one could argue that embedding effective practice and healthy behaviours – or uprooting well-established practices that no longer serve us well – is one of the key challenges of health management and policy. At the core is the fundamental question: how can we make the right thing to do the easy thing to do? This applies to thousands of micro-level decisions made every day, such as how best to organize a surgical cart, and to broad challenges in health promotion, such as which features of urban design are most likely to encourage physical activity at the population level. This issue of Healthcare Policy / Politiques de Sante features a number of papers that address aspects of this challenge, from documenting gaps and their causes to exploring policy options to address them. Brian Hutchison focuses on primary healthcare reform. This is an area of enduring policy focus around the world, reflecting its complexity and importance to health and healthcare systems. Hutchison's paper takes a fresh look at what has changed, what has not and why. In contrast, Sisira Sarma and his colleagues examine a very specific aspect of family practice: whether use of health information technology in primary care is associated with patient visit numbers and visit length. Pharmaceutical policy is another highly complex area where history and context affect decisions and outcomes today. This issue of the journal explores a number of facets of this domain, from cost-control mechanisms in private or public drug plans (Jillian Kratzer et al.) to potential conflict of interest in reimbursement decisions (David Hughes and Bryn Williams-Jones). The policy choices that we make in these and other areas are likely to influence costs and outcomes for years to come. Likewise, Jason Sutherland and Trafford Crump address the mismatch between patient needs and resources used represented by alternative level of care in hospitals. Future decisions about the policy alternatives that they discuss may well be informed by the analysis of Saad Rais and colleagues on high-cost users of healthcare services. Many of the home care clients studied by Diane Doran and her co-authors from across the country would fall into this category. Their research provides important insight into the frequency and types of adverse events experienced for those receiving home care. Whichever areas of health policy are your current focus, I hope that you will find new insights and food for thought in the journal's pages. After all, to twist George Santayana's famous quotation somewhat, those who are unaware of how the past influences the present are condemned to repeat it – and to reinforce gaps in quality, access and health that exist today or, alternatively, risk inadvertently disrupting those paths that help us to achieve better health, better care and better value.

Parents' decision making and access to preventive healthcare for young children: applying Andersen's Model.

Implementing preventive health care for young children provides the best chance of improving health and changing a child's life course. In Australia, despite government support for preventive health care, uptake of preventive services for young children is low. Using Andersen's behavioural model of health-care utilization, we aimed to understand how parents conceptualized their children's preventive health care and how this impacted on access to preventive health-care services. Semi-structured telephone interviews conducted between May and July 2011. Twenty-eight parents of children aged 3-5 years from three diverse socio-economic areas of Melbourne, Australia. Thematic analysis showed parents' access to child preventive health care was determined by birth order of their child, cultural health beliefs, personal health practices, relationship with the health provider and the costs associated with health services. Parents with more than one child placed their own experience ahead of professional expertise, and their younger children were less likely to complete routine preventive health checks. Concerns around developmental delays required validation through family, friends and childcare organizations before presentation to health services. To improve child preventive health requires increased flexibility of services, strengthening of inter-professional relationships and enhancement of parents' knowledge about the importance of preventive health in early childhood. Policies that encourage continuity of care and remove point of service costs will further reduce barriers to preventive care for young children. Recent reforms in Australia's primary health care and the expansion of child preventive health checks into general practice present a timely opportunity for this to occur.

Physicians as Advocates Oral Abstracts

Physicians as Advocates Oral Abstracts

Primary Health Care: Comparing Public Health Nursing Models in Ireland and Norway

Health of populations is determined by a multitude of contextual factors. Primary Health Care Reform endeavors to meet the broad health needs of populations and remains on international health agendas. Public health nurses are key professionals in the delivery of primary health care, and it is important for them to learn from global experiences. International collaboration is often facilitated by academic exchanges. As a result of one such exchange, an international PHN collaboration took place. The aim of this paper is to analyse the similarities and differences in public health nursing in Ireland and Norway within the context of primary care.

Commentary on ‘‘Primary Care Physician Shortage, Healthcare Reform, and Convenient Care

Commentary on ‘‘Primary Care Physician Shortage, Healthcare Reform, and Convenient Care

Commentary on “Primary Care Physician Shortage, Healthcare Reform, and Convenient Care

Commentary on “Primary Care Physician Shortage, Healthcare Reform, and Convenient Care

Emerging organisational models of primary healthcare and unmet needs for care: insights from a population-based survey in Quebec province.

BackgroundReform of primary healthcare (PHC) organisations is underway in Canada. The capacity of various types of PHC organizations to respond to populations’ needs remains to be assessed. The main objective of this study was to evaluate the association of PHC affiliation with unmet needs for care.MethodsPopulation-based survey of 9205 randomly selected adults in two regions of Quebec, Canada. Outcomes Self-reported unmet needs for care and identification of the usual source of PHC.ResultsAmong eligible adults, 18 % reported unmet needs for care in the last six months. Reasons reported for unmet needs were: waiting times (59 % of cases); unavailability of usual doctor (42 %); impossibility to obtain an appointment (36 %); doctors not accepting new patients (31 %). Regression models showed that unmet needs were decreasing with age and was lower among males, the least educated, and unemployed or retired. Controlling for other factors, unmet needs were higher among the poor and those with worse health status. Having a family doctor was associated with fewer unmet needs. People reporting a usual source of care in the last two-years were more likely to report unmet need for care. There were no differences in unmet needs for care across types of PHC organisations when controlling for affiliation with a family physician.ConclusionReform models of primary healthcare consistent with the medical home concept did not differ from other types of organisations in our study. Further research looking at primary healthcare reform models at other levels of implementation should be done.

Uso de cenários estratégicos para planeamento de recursos humanos em saúde: o caso dos farmacêuticos comunitários em Portugal 2010-2020

IntroductionThe planning of Human Resources for Health is especially important in an environment of political and economic uncertainty as it is today. For community pharmacists practice, an environment characterized by constant technological innovation and increasing empowerment of patients concerning health issues, as well as a shortage of primary care physicians and a Primary Health Care Reform that is currently taking place, may represent an opportunity to rethink the role that community pharmacists may play in the Portuguese Health System, accomplishing the paradigm shift from a product-centered to a service-centered model of practice, that these professionals are experiencing since the 90s. MethodAs a tool of strategic thinking, prospective scenario analysis allows us to imagine and analyze different alternatives for community pharmacist's future. The design of the scenarios took place in three stages: the first two stages were scenario building workshops, for which we invited experts from practice and academic settings where the main tool for collecting information was the brainstorming technique. In the final stage, we built the final scenarios with the information obtained in the workshops and with the information collected in the scientific literature on community pharmacists’ role and factors influencing it. ResultsThis analysis allowed us to identify the critical uncertainties that will have more influence in the future for Portuguese community pharmacists, the «Legislative Environment» and «Ability to innovate and develop services». Resolving these uncertainties in a 2x2 matrix, we built our final scenarios that we named «Pharmacy-Mall», «e-Pharmacist», and «Reorganize or die». ConclusionsIn these scenarios is clear that the future role of community pharmacists is dependent of pharmaceutical services provision, beyond the dispensing of medicines. These future community pharmacists will also have to gain new competencies in areas traditionally out of their scope such as management, leadership, marketing, information technologies, teamwork abilities and behavioral and communication techniques.

Unfulfilled expectations to services offered at primary health care facilities: Experiences of caretakers of underfive children in rural Tanzania

BackgroundThere is growing evidence that patients frequently bypass primary health care (PHC) facilities in favour of higher level hospitals regardless of substantial additional time and costs. Among the reasons given for bypassing are poor services (including lack of drugs and diagnostic facilities) and lack of trust in health workers. The World Health Report 2008 “PHC now more than ever” pointed to the importance of organizing health services around people’s needs and expectations as one of the four main issues of PHC reforms. There is limited documentation of user’s expectations to services offered at PHC facilities. The current study is a community extension of a hospital-based survey that showed a high bypassing frequency of PHC facilities among caretakers seeking care for their underfive children at two district hospitals. We aimed to explore caretakers’ perceptions and expectations to services offered at PHC facilities in their area with reference to their experiences seeking care at such facilities.MethodsWe conducted four community-based focus group discussions (FGD’s) with 47 caretakers of underfive children in Muheza district of Tanga region, Tanzania in October 2009.ResultsLack of clinical examinations and laboratory tests, combined with shortage of drugs and health workers, were common experiences. Across all the focus group discussions, unpleasant health workers’ behaviors, lack of urgency and unnecessary delays were major complaints. In some places, unauthorized fees reduced access to services.ConclusionThe study revealed significant disappointments among caretakers with regard to the quality of services offered at PHC facilities in their areas, with implications for their utilization and proper functioning of the referral system. Practices regarding partial drugs administrations, skipping of injections, unofficial payments and consultations by unskilled health care providers need urgent action. There is also a need for proper accountability mechanisms to govern appropriate allocation and monitoring of health care resources and services in Tanzania.

From policy to reality: clinical managers' views of the organizational challenges of primary care reform in Portugal

The primary healthcare reform in Portugal is based on the development of a new management model and clinical governance framework. The objective is to strengthen primary healthcare services to reduce the inappropriate utilization of secondary and emergency services and to make efficiency gains and to better control costs. New interventions include the introduction of a system of production-based incentives for family health units. This paper presents an initial assessment of the implementation of the new policies and tries to explain the gap between its expected results and what was observed in the field 5 years later. We used a Strengths, Weaknesses, Opportunities, and Threats analysis conducted in 12 regions, to collect the perceptions of members of Clinical Councils of Health Centers Groups, responsible for the implementation of the reform. The analysis looked at the dimensions of coverage, productivity, technical quality, and service quality. It identifies weaknesses in human resources management (shortages, incentives, team management) and lack of support from central and regional management. There is a perceived gap between the framework for reform as defined by law and the support made available for its implementation, leading to tensions between decision makers, managers, and health professionals.

Organizational changes in the course of the PHC reform in Lithuania from 1994 to 2010

ObjectivesTo assess the organizational changes in Lithuanian Primary Health Care (PHC) in the period from 1994 to 2010, and to highlight the differences with respect to the background of family physicians, the level of urbanization and the type of PHC centers. MethodsThree cross-sectional, comparative questionnaire surveys were conducted before the start of the PHC reform (in 1994) and in the course of the PHC reform (in 2004 and 2010) in Lithuania. The anonymous questionnaires were sent by mail to district physicians (i.e. internists, who provided health care for adults, and pediatricians, who provided care for children younger than 18 years old) in 1994, and to family physicians (i.e. retrained district physicians and family physicians-graduates from residency in family medicine) in 2004 and 2010. ResultsThe differences observed in 1994 between former district physicians and those who had completed residency in family medicine, private and public PHC centers and different level of urbanization dissolved in the years of the PHC reform. Physicians’ age tended to be higher in the course of the PHC reform. Numbers of patients’ consultations were increasing in the period after 1994 till 2010, though numbers of CME hours and home visits were decreasing. ConclusionsThe idea to retrain district physicians into family physicians was a valuable decision. In the years of the PHC reform the workload of family physicians in Lithuania approached the level existing in the EU. The aging of workforce, high workload and reduction of CME hours are the major concerns for future PHC policy.

Cuidados de saúde primários: as regras do jogo

Background – Primary Health Care (PHC) reform is a fact in several countries and is happening also in Portugal demanding a reflection on the process. Aim – To describe the PHC reform and to identify the factors of success or potential failure in PHC public services. Methods – Critical appraisal of the literature. Results and Conclusions – The efficiency, efficacy and access to health care are insufficient. Organizational changes are taking place altering inter‑professional and inter‑organizational cooperation and relationship. Tension among the parts involved is evident. New organizational models are being created to secure the sustainability of the reforms and the systems. The new models should provide a balanced management of the available resources, in a strategy of health for all that doesn’t mean health for everything.

Review of Handbook of cognitive-behavioural approaches in primary care.

Handbook of Cognitive-Behavioural Approaches in Primary Care, by Robert A. DiTomasso, Barbara A. Golden, & Harry J. Morris (Eds.). New York, NY: Springer Publishing Company, 2011, 753 pages (ISBN 978-082610383-3, US $95.00 Hardcover) Reviewed by JEAN GRENIER DOI: 10.1037/O.0027784 Primary health care reform has been a major point of interest from various perspectives (clinical, healtii care, health policies, etc.) in many countries over the past 12 years. One of the premises of primary health care reforms across the world is the recognition that physical and mental healtii problems are more often than not intertwined and interact in complex and sometimes unknown ways. Left ignored, or addressed in silos, this complex mind- body connection or interaction often leads to physical and mental health problems that increasingly need to be addressed bodi from a physical as well as a mental health perspective. For this reason, there has been rising awareness that primary care physicians can benefit from collaborating with other health professionals such as psychologists, psychotherapists, mental health counsellors, and behavioural educators, and share the burden of healtii problems seen in primary care. Interprofessional collaboration and clinical best practices are two other major points of interest in primary care reforms. Interprofessional collaboration has been generally shown to improve some clinical outcomes and increase satisfaction with care for both patients and providers. It is hoped that the longer term impact of such collaboration amongst various health professionals with different expertise and scopes of practice will include not only better healtii outcomes for patients but also reduce costs to the healdi care system and society as a whole. As for best practices, one aim of reform is to increase population access to empirically supported treatments in primary care. This being said, early career as well as seasoned clinicians and scholars are not always sure as to how all of these knowledge bases get transferred and articulated efficiently in day-to-day practice. The Handbook of Cognitive-Behavioural Approaches in Primary Care takes these theoretical concepts, empirically supported knowledge bases, experiences in clinical healdi psychology and behavioural medicine, and the realities of primary care medical settings, and uses the solid judgment and accumulated wisdom of various author-contributors to help readers understand just how all of those elements can be efficiently integrated and articulated not only in day-to-day practice, but as part of a healdi practitioner's practice philosophy and professional identity. This volume is impressively comprehensive and covers a broad spectrum of theory, research, and practice issues related to the growing awareness of the mind-body connection in primary care. Its broad micro-to-macro spectrum spans from the individual patient level all the way up to professional and health care systems level, and up again to the level of societal access to empirically supported interventions in primary care and primary mental health care. As a psychologist and clinician-investigator, I teach and conduct research in a university-affiliated hospital and also provide psychological services in a Family Health Team in primary care. I wish to underline to potential readers that this book is very well written and comprehensive enough to stand on its own as an invaluable volume to health care practitioners who wish to develop a combination of broad as well as in-depth understanding of all of the pertinent issues related to the integration of medical and mental healdi care services and, more specifically, how empirically supported cognitive-behavioural approaches can be applied and tailored to a variety of presenting problems in the primary care setting. …

Economic crisis and primary care reform in Greece: driving the wrong way?

The economic crisis in Greece1 may offer an opportunity for the reorganisation of the health system,2 and although primary healthcare reform is high on the political agenda, questions remain about the direction of restructuring. Weaknesses in the Greek health system include poor continuity of care, excessive use of curative services, lack of preventive measures, low levels of satisfaction, high rates of out-of pocket payments, and significant inequalities in the range and quality of health services.3,4 In the past a plethora of occupational funds had offered different packages of primary healthcare coverage. In some cases they used their own infrastructure (GP-led health clinics) and/or contracted private physicians and laboratories, situated mainly in urban and semi-urban areas.5 In 1953 the state established the first public medical posts in rural areas a few years later, obliging medical graduates to offer their services to local populations as fully employed civil servants. In 1983 the Greek National Health System (Ethniko Systima Ygeias [ESY]) was founded following the Alma Ata Declaration's emphasis on primary care.6 It foresaw the replacement of the existing primary healthcare infrastructure with ESY urban and rural health centres and the unification of social health insurance schemes. In the next decade 176 health centres and 19 small hospitals4 were established in rural areas offering health services accessible to all, comprehensive and free at the point of use. Unfortunately, the 220 urban health centres envisaged by the ESY implementation plan,4 were never established. The sickness funds' primary care infrastructure and variable benefits remained untouched, due to opposition from physicians engaged in private practice, and social groups …

Pharmacist provision of primary health care: a modified Delphi validation of pharmacists' competencies

BackgroundPharmacists have expanded their roles and responsibilities as a result of primary health care reform. There is currently no consensus on the core competencies for pharmacists working in these evolving practices. The aim of this study was to develop and validate competencies for pharmacists' effective performance in these roles, and in so doing, document the perceived contribution of pharmacists providing collaborative primary health care services.MethodsUsing a modified Delphi process including assessing perception of the frequency and criticality of performing tasks, we validated competencies important to primary health care pharmacists practising across Canada.ResultsTen key informants contributed to competency drafting; thirty-three expert pharmacists replied to a second round survey. The final primary health care pharmacist competencies consisted of 34 elements and 153 sub-elements organized in seven CanMeds-based domains. Highest importance rankings were allocated to the domains of care provider and professional, followed by communicator and collaborator, with the lower importance rankings relatively equally distributed across the manager, advocate and scholar domains.ConclusionsExpert pharmacists working in primary health care estimated their most important responsibilities to be related to direct patient care. Competencies that underlie and are required for successful fulfillment of these patient care responsibilities, such as those related to communication, collaboration and professionalism were also highly ranked. These ranked competencies can be used to help pharmacists understand their potential roles in these evolving practices, to help other health care professionals learn about pharmacists' contributions to primary health care, to establish standards and performance indicators, and to prioritize supports and education to maximize effectiveness in this role.

Innovative and Diverse Strategies Toward Primary Health Care Reform: Lessons Learned from the Canadian Experience

In the last decade, Canadian provincial and territorial health systems have taken diverse approaches to strengthening primary care delivery. Although the Canadian and US systems differ in significant ways, important commonalities include the organization of care delivery, core principles guiding primary care reform, and some degree of provincial/state autonomy. This suggests that Canadian experiences, which employed a variety of tools, strategies, and policies, may be informative for US efforts to improve primary care. The range of primary care reform initiatives implemented across Canada target organizational infrastructure, provider payment, health care workforce, and quality and safety. Primary care teams and networks in which multiple physicians work in concert with other providers have become widespread in some provinces; they vary on a number of dimensions, including physician payment, incorporation of other providers, and formal enrolment of patients. Family medicine is attracting more recent medical school graduates, a trend likely affected by new physician payment models, increases in the number of primary care providers, and efforts to better integrate nonphysician providers into clinical practice. Efforts to integrate electronic medical records into practice and pursue quality improvement strategies are gaining ground in some provinces. Canadian primary care reform initiatives rely on voluntary participation, incremental change, and diverse models, encouraging engagement and collaboration from a range of stakeholders including patients, providers, and policymakers. Cross-country collaboration in evaluating and translating Canada's primary care reform efforts are likely to yield important lessons for the US experience.

The World Health Report 2008 – Primary Healthcare: How Wide Is the Gap between Its Agenda and Implementation in 12 High-Income Health Systems?

The World Health Organization's 2008 report asserted that the focus on primary healthcare (PHC) within health systems should increase, with four sets of reforms required. The WHO's PHC advocacy is well founded, yet its report is a policy document that fails to address adoption and implementation questions within WHO member countries. This paper examines the prospects for the WHO PHC agenda in 12 high-income health systems from Asia, Australasia, Europe and North America, comparing performances against the WHO agenda. A health policy specialist on each of the 12 systems sketched policy activities in each of the four areas of concern to the WHO: (a) whether there is universal coverage, (b) service delivery reforms to build a PHC-oriented system, (c) reforms integrating public health initiatives into PHC settings and (d) leadership promoting dialogue among stakeholders. All 12 systems demonstrate considerable gaps between the actual status of PHC and the WHO vision when assessed in terms of the four WHO reform dimensions, although many initiatives to enhance PHC have been implemented. Institutional arrangements pose significant barriers to PHC reform as envisioned by the WHO. PHC reform requires more attention from policy makers. Meanwhile, the WHO PHC report is perhaps too idealistic and fails to address the fundamentals for successful policy adoption and implementation within member countries.

German GPs' willingness to expand roles of physician assistants: a regional survey of perceptions and informal practices influencing uptake of health reforms in primary health care

Many countries with shortages in health personnel are introducing task shifting in primary health care. GPs' attitudes and practices strongly affect task shifting and the expansion of the roles of physician assistants (PAs). To assess, in a German state with shortages of health personnel, the overall willingness of GPs to delegate home visit tasks to PAs and to elicit their perceptions of barriers to and benefits of such delegation and the current practice of informal delegation. Postal self-administered anonymous survey of all practicing GPs in the rural state of Mecklenburg-Vorpommern. Main outcomes were GPs' willingness to delegate in home visit tasks to a properly trained PA, perceived barriers to and benefits of home visit delegation and current practice of informal delegation. Using multinomial logistic regression, associations were identified among outcome variables, and characteristics of the GPs and of their practices. Response rate was 47%. Responders (500) were comparable to all GPs in the state (1096); 48% of practitioners are willing to delegate home visits tasks to PAs. The main barrier to delegation was the related costs of PAs' training (34%), and the main benefit that it 'saves the GP's time' (67%). The 46% of practitioners who are informally delegating home visit tasks were significantly more likely be younger [odds ratio (OR) and 95% confidence interval (CI)] [OR = 0.96 (0.93-0.99)] and female [OR = 1.70 (1.12-2.58)]. The increasing proportion of women in family medicine might favor task shifting in General Practice.

The Impact of Primary Care: A Focused Review

Primary care serves as the cornerstone in a strong healthcare system. However, it has long been overlooked in the United States (USA), and an imbalance between specialty and primary care exists. The objective of this focused review paper is to identify research evidence on the value of primary care both in the USA and internationally, focusing on the importance of effective primary care services in delivering quality healthcare, improving health outcomes, and reducing disparities. Literature searches were performed in PubMed as well as “snowballing” based on the bibliographies of the retrieved articles. The areas reviewed included primary care definitions, primary care measurement, primary care practice, primary care and health, primary care and quality, primary care and cost, primary care and equity, primary care and health centers, and primary care and healthcare reform. In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health.

Primary Care Physician Shortage, Healthcare Reform, and Convenient Care

Primary Care Physician Shortage, Healthcare Reform, and Convenient Care