Primary Health Care System Research Articles

Strengthening Primary Healthcare in Jordan for Achieving Universal Health Coverage: A Need for Family Health Team Approach.

Achieving Universal Health Coverage (UHC) is a strategic objective of the Jordanian government and has been prioritized in its strategies and plans. However, there are several challenges affecting primary healthcare in Jordan and the health system in general that prevent Jordan from achieving UHC. This paper highlights the importance of team-based care in the form of Family Health Teams (FHTs) to realize Jordan's goal of achieving UHC. FHTs are a team-based approach that brings together diverse professionals to provide a comprehensive, efficient, patient-centered primary care system that meets the changing needs of Jordan's population and refugees. However, the implementation of FHT may encounter obstacles, including individual, organizational, institutional, and external barriers. To overcome such obstacles, several actions and processes need to be taken, including political commitment and leadership, implementing good governance and policy frameworks, allocating resources and funding, multisectoral collaboration, and engagement of communities and stakeholders. The successful implementation of FHTs requires participation from government officials, parliamentarians, civil society, and influential community, religious, and business leaders. A strategic policy framework, effective oversight, coalition building, regulation, attention to system design, and accountability are also essential. In conclusion, adopting the FHT approach in Jordan's Primary Healthcare system offers a promising path towards achieving UHC, improving healthcare access, quality, and efficiency while addressing the unique challenges faced by the country's healthcare system.

Cumulative Health Vulnerabilities Among Adolescents by Age and Neighborhood Opportunity.

Early detection of health vulnerabilities in adolescents is integral to promoting healthy behaviors into adulthood. Our objective was to quantify the prevalence of health vulnerabilities among adolescents and examine differences by age and neighborhood opportunity. In a cross-sectional analysis of electronic health record data for adolescents aged 13 to 18 years with preventive visits in a large pediatric primary care network between September 2021 and September 2022, we examined 5 health vulnerabilities: Tobacco use, substance use, firearm access, condomless intercourse, and depressive symptoms. Health vulnerabilities were assessed via self-reported adolescent health questionnaire and the validated Patient Health Questionnaire-Modified. Prevalence of health vulnerabilities were calculated alone and in combination, and compared by age and by quintile of neighborhood Child Opportunity Index (COI) score. Multivariable logistic regression estimated associations of neighborhood COI with reporting ≥2 health vulnerabilities. Among 40 197 adolescents (57.7% aged 13-15 years, 66.3% living in "high"/"very high" COI neighborhoods), 29.7% reported at least 1 health vulnerability and 7.9% reported ≥2 vulnerabilities. Cumulative health vulnerabilities were more prevalent among older adolescents and adolescents from lower opportunity neighborhoods. In adjusted models, lower COI was associated with 65% higher odds of having ≥2 vulnerabilities (odds ratio 1.65, 95% confidence interval 1.43-1.91) compared with adolescents from the highest COI quintile. Understanding the relationship between health vulnerabilities and neighborhood opportunities among adolescents may allow pediatric primary care providers and health systems to offer more tailored community support services and transdiagnostic specialized care navigation to address the health needs of teens with multiple vulnerabilities.

Voting with their feet: Primary care provider choice and its implications for public sector primary care services in India

Expanding networks of government primary health centers (PHCs) to bring health services closer to communities is a longstanding policy objective in LMICs. In pluralistic health systems, where public and private providers compete for patients, PHCs are often not the preferred source for care. This study analyzes the market for primary care services in the Indian state of Bihar to understand how choice of primary care provider is influenced by distance, cost and quality of care. This study is based on linked surveys of rural households, PHCs, and private primary care providers conducted in 2019 and 2020. Most rural residents lived in proximity to a primary care provider, though not a qualified one. Within a 5-km distance, 60% of villages had a PHC, 90% had an informal provider, 35% an Indian systems of medicine practitioner, and 10% a private MBBS doctor. Most patients sought care from informal providers irrespective of PHC distance; only 25% of patients living in the PHC's vicinity sought care there. Reducing distance to the PHC by 1 km marginally increased the likehood of the PHC being selected, and reduced the likelihood of private clinics being selected. Reducing patient's costs at PHCs increased the likelihood of the PHC being selected and reduced the likelihood of private clinics and private hospitals being selected. Improved clinical quality at PHCs had no effect on patient selection of PHCs, private clinics, or hospitals. Illness severity reduced the likelihood of PHCs or private clinics being selected, and increased the likelihood of private hospitals selected. Wealthier patients were marginally more likely to use PHCs, substantially more likely to use private hospitals, and less likely to use private clinics. Expanding PHC network coverage or improving their quality of care is not sufficient to make PHCs more relevant to local health needs. An orientation towards essential public health functions, as well as, a community-centered approach to the organization of primary health care system is necessary.

Local knowledge, practices, challenges of ethnopharmacologically used medicinal plants in Benin and implications for brain illnesses.

Traditional medicine (TM) is a significant resource for primary healthcare management all over the world, and principally in Africa. Quality improvement activities that promote evidence-based practices and the integration of traditional medicine into primary healthcare systems can help improve the quality of patient care. In the Republic of Benin (West Africa), traditional medicine practitioners (TMPs) provide different treatments and ways of use, depending on the ailments and the medicinal plants used. The present study aimed at documenting the knowledge, attitudes and practices of Beninese TMPs regarding the use of medicinal plants and the challenges associated with their activities. A focus group survey was conducted using semi-structured interviews with a sample of 91 TMPs in 8 departments of the Republic of Benin. The respondents had an average age of 50years old and belonged to various categories of TMPs. Medicinal plants are harvested depending on the season and time of the day, and are dried in the shade before being used as decoctions or infusions. Nevertheless, the majority of TMPs do not conduct the necessary tests for quality control, efficacy or toxicity of the proposed remedies, which raises several scientific interrogations, particularly for the treatment of mental and brain-related disorders. Among ~ 110 plants used in the treatment of several pathologies, 66 were revealed as threatened species. The challenges faced by TMPs are mainly material, financial and technical difficulties. The present study reports the importance of intervention to modernize TM practices in Benin. Quality improvement could enhance healthcare delivery and provide support for evidence-based interventions aimed at addressing behavioral, social, and environmental determinants of health.

The effects of COVID-19 event strength on job burnout among primary medical staff

BackgroundAs a global pandemic, The Corona Virus Disease 2019 (COVID-19) has brought significant challenges to the primary health care (PHC) system. Health professionals are constantly affected by the pandemic’s harmful impact on their mental health and are at significant risk of job burnout. Therefore, it is essential to gain a comprehensive understanding of how their burnout was affected. The study aimed to examine the relationship between COVID-19 event strength and job burnout among PHC providers and to explore the single mediating effect of job stress and work engagement and the chain mediating effect of these two variables on this relationship.MethodsMultilevel stratified convenience sampling method was used to recruit 1148 primary medical staff from 48 PHC institutions in Jilin Province, China. All participants completed questionnaires regarding sociodemographic characteristics, COVID-19 event strength, job stress, work engagement, and job burnout. The chain mediation model was analyzed using SPSS PROCESS 3.5 Macro Model 6.ResultsCOVID-19 event strength not only positively predicted job burnout, but also indirectly influenced job burnout through the mediation of job stress and work engagement, thereby influencing job burnout through the “job stress → work engagement” chain.ConclusionsThis study extends the application of event systems theory and enriches the literature about how the COVID-19 pandemic impacted PHC medical staff job burnout. The findings derived from our study have critical implications for current and future emergency response and public policy in the long-term COVID-19 disease management period.

MODELING OF MATERNAL MORTALITY (MMR) IN EAST JAVA 2017-2019 USING PANEL REGRESSION APPROACH

Maternal Mortality Rate (MMR), is a country's welfare indicator especially about the women's health. It is included in the development index and the quality of life index. The determinants of maternal mortality are elements that collectively cause maternal mortality. This quantitative research used secondary data on MMR and its influencing factors in East Java Province during the 2017-2019 period and the analysis of the panel data used regression. The trend of Maternal mortality in East Java Province has decreased from year to year; in 2019, it was 89.81 per 100,000 live births. The variable pregnant women using blood-added pills (X1) with a probability value of 0.020 (p<0.05) is found to significantly affected the maternal mortality in the panel regression analysis utilizing the Random Effect Model. The Random Effect Model, which this study found to be the best, contains the model equation Yit = 225.7721 - 1.919457 X1it and the administration of blood-added pills is the variable that significantly affects maternal mortality. The results of this study indicate the need for educational efforts, especially regarding to the benefits of blood-added pills for pregnant women and to correct the misunderstanding about the benefits of blood-added pills in the community, so that the coverage of blood supplement consumption in pregnant women can be increased. Together with the primary health care system and obstetricians, an integrative approach and counseling among pregnant women and their partners will increase awareness of maternity health and birth management.

The role of primary health care in improving health status, financial protection and health equity in the context of China's health system reform.

Stronger primary health care (PHC) is critical to achieving the United Nations' Sustainable Development Goals. However, there is scarce evidence on the impact of PHC on health system performance in developing countries. Since 2009, China has implemented an ambitious health system reform, among which PHC has received unprecedented attention. This study investigates the role of PHC resource in improving health status, financial protection and health equity. We obtained province-level and individual-level data to conduct a longitudinal study across the period of China's health system reform. The dependent variables included health outcomes and financial protection. The independent variables were the number of PHC physicians and share of PHC physicians in all physicians. Mixed-effect models were used for adjusted associations. From 2003 to 2017, the number of PHC physicians slightly increased by 31.75 per 100,000 persons and the share of PHC physicians in all physicians increased by 3.62 percentage points. At the province level, greater PHC physician density was positively associated with life expectancy, negatively associated with age-standardized excess mortality, infectious disease mortality, perinatal mortality low birth weight, as well as the share of health expenses in total consumption expenses. At the individual and household level, greater PHC physician density was positively associated with self-assessed health, and negatively associated with incidence of catastrophic health expenditures. Compared to other quintiles, the poorest quintile benefited more from PHC physician density. In China, an increased PHC physician supply was associated with improved health system performance. While China's PHC system has been strengthened in the context of China's health system reforms, further effective incentives should be developed to attract more qualified PHC workers.

Implementing a patient engagement framework in the primary healthcare system in Qatar

Implementing a patient engagement framework in the primary healthcare system in Qatar

Direct organogenesis, physiochemical evaluation, chemical characterization and genetic uniformity analysis through SCoT marker in Celastrus paniculatus (Willd.): A medicinally important plant

Celastrus paniculatus (Willd.) is a rare woody climbing shrub with high medicinal value used in primary healthcare system and herbal drug formulation as its various parts have immense medicinal properties. The current study focuses to design a refined methodology for the micropropagation of C. paniculatus using young nodal segment explants. A reliable shoot multiplication protocol was attained on Murashige and Skoog (MS) medium augmented with 6-benzylaminopurine (BAP) (5.0 µ M) + meta-Topolin (mT) (2.5 µ M) + gibberellic acid (GA3) (2.5 µ M) + adenine sulphate (ADS) (20.0 µ M) which gave a maximum number of 26.0 ± 0.01 shoots/explant along with 8.5 ± 0.02 cm of shoot length. In vitro regenerated microshoots were accomplished to ex vitro rooting efficiently with a 15 min pulse treatment with two ethylene inhibitors [salicylic acid (SAA) and silver nitrate (AgNO3)] and then transfer to soilrite™. The treatment of SAA (200 μM) proved better for healthy root formation with 10.5 ± 0.017 roots/microshoot and a mean root length of 3.5 ± 0.024 cm under culture condition. The genetic stability of in vitro regenerated plantlets and mother plant was validated by start codon targeted (SCoT) primer based molecular analysis. Healthy adaptation of these plantlets to natural conditions was also revealed by numerous biochemical and photosynthetic parameters along with Scanning Electron Microscopic (SEM) analysis of leaves. Furthermore, a comparison of secondary metabolites from mother and regenerated plants was done by Gas Chromatography and Mass Spectrometry (GC-MS) analysis.

What made primary health care resilient against COVID-19? A mixed-methods positive deviance study in Nigeria

IntroductionThe SARS-CoV-2 (COVID-19) pandemic overwhelmed some primary health care (PHC) systems, while others adapted and recovered. In Nigeria, large, within-state variations existed in the ability to maintain PHC service volumes....

Determinants of government spending on primary healthcare: a global data analysis

In 2018 global leaders renewed their political commitment to primary healthcare (PHC) ratifying the Declaration of Astana emphasising the importance of building a sustainable PHC system based on accessible and...

Strengthening community health worker program in Belize

Community health workers (CHWs) have been identified as effective workforce that can improve access to primary health care particularly for underserved and hard to reach populations. The contributions of CHWs have not been limited to low-income countries. More recently, the use of CHWs has attracted attention in some high-income countries where despite more developed health systems there are large inequities in healthcare access and outcomes amongst different population groups. Belize is an upper middle-income country located in Central America and its health system is based on a primary health care model with community health workers actively involved in health service delivery. A descriptive study through review of grey literature detailing the process for strengthening the community health worker program in the country using the Community Health Worker Assessment and Improvement Matrix (CHW AIM) tool. The results were thematically analysed based on Community Health Worker Assessment and Improvement Matrix (CHW AIM) conceptual framework on factors influencing the performance of community health worker program. Community health workers in Belize are recognized as part of the formal health system with policy and strategy in place that define their roles, tasks, relationship to the health system. They are provided with monthly financial incentives, opportunities for further studies, career advancement and employment opportunities within the health system. The study contributes to the existing literature on strengthening of community health worker program to enhance the primary health care system and build a more resilient health system for better preparedness and response for future pandemics with focus on an upper middle income country.

Self-Reported Accommodation Needs for Patients with Disabilities in Primary Care

People with disabilities experience barriers to engaging with health care due to inaccessible social and physical environments at primary care clinics. Despite legal mandates, identification and provision of necessary accommodations for this population at primary care clinics are poor. The objective of this cross-sectional study was to assess patient-reported disability status and accommodation needs among patients at a primary care clinic. An electronic health record-based Disability and Accommodations Questionnaire assessing disability status, types, and accommodation needs was developed by subject matter experts at Michigan Medicine and the University of Michigan Council for Disability Concerns. The questionnaire underwent multiple rounds of reviews and revisions before its use in clinical settings. A paper-based questionnaire was administered to all patients presenting for a wellness-based visit at an academic health system primary care clinic in southeast Michigan. Data were collected between March 2022 and August 2022. Approximately 13% of the 541 patients self-reported a disability, with 54.2% indicating at least one needed accommodation. The most commonly reported disabilities were mental health and hearing-related disabilities, by 4.8% and 4.6% of patients, respectively. The most frequently requested accommodations were communication- or language-based (for example, presence of an American Sign Language interpreter, assistive listening devices), cognitive-based (for example, inclusion of a support person with care decisions), and mobility-based (for example, assistance with transfers). The Disability and Accommodations Questionnaire helped identify the presence of a disability, its types, and any requested accommodations requested at a primary care health center.

A new Norwegian Injury Registration System as a starting point to assess the burden of injuries in Norway

Abstract Introduction The police register is the main database for monitoring traffic injuries. A study made by Safe Traffic in Norway found that only one of three severe traffic injuries is registered in this register. For giving more complete data, a health-based injury monitoring system was established in 2022 for a period of five years, financed by the traffic safety authorities. Methods An Injury Minimum Data Set (MDS) is collected from all injuries that are treated in ten hospitals and seven municipality AEDs in the primary health care, a representative sample of all medically treated injuries in Norway. By recording the unique birth number of the patient, double registrations are deleted. When fully developed, this system will register about 50 % of all injuries treated in the hospitals as in- and out-patients, and about 10 % of all injuries in the primary health care system in Norway. Max AIS (Abbreviated Injury Scale) and diagnosis (ICD-10 - hospitals, and ICPC-2 - primary health care) are among the registered variables for each injury. Based on the ICD-10 codes, long term disability weights (DW) can be calculated (Gabbe et al 2014). Then the injury burden of injuries in Norway can be shown by: 1) Threat to life: a) minor (AIS 1), b) moderate (AIS 2) and c) serious, (AIS 3+, including AIS 4-6). 2) Threat of disability: a) low, b) medium and c) high probability of long-term disability. Results Data from 2023 seems to be complete enough to enable calculations of the annual injury burden in Norway. Future work There is a need to establish internationally agreed disability weights to enable comparisons across countries. And to establish conversions from ICPC-2 codes to ICD-10 codes for enabling calculations of DWs of injuries treated in the primary health system.

Behavior integration for a sustainable COVID-19 vaccination in Serbia, North Macedonia, and Moldova

Abstract Issue/Problem In Serbia, North Macedonia, and Moldova, USAID's MOMENTUM Routine Immunization Transformation and Equity project is using a behavioral integration approach to increase COVID-19 vaccine uptake in priority populations. This approach is aimed at changing provider and community behaviors to embrace COVID-19 vaccination as part of a healthy lifestyle. This approach may be applicable and replicable in countries around the world. Description In an effort to implement a sustainable model for COVID-19 integration into the primary healthcare system, the project applied a behavioural integration approach to understand barriers and motivators to COVID-19 vaccination. In all three countries, we collected qualitative data through interviews with public health decision-makers, immunization health professionals, and other key partners, and focus group discussions with members of the priority populations. Results The project created profiles for each priority behaviour, detailing barriers and motivators to adopt it, and supporting people and their actions. We conducted participatory workshops with relevant immunization stakeholders that validated and prioritized key behaviors, and conceptualized integrating COVID-19 vaccination into a healthy lifestyles’ framework. We identified effective messages to promote vaccine uptake, and a course curriculum focused on healthy lifestyles, life-course immunization, and person-centred care. Lessons Behavioural insights and the behavioural integration approach helped identify and prioritize critical COVID-related behaviours to increase vaccine uptake amongst key priority populations. For the first time in the region, we proposed the integration of COVID-19 vaccination into a primary healthcare platform, focused on healthy lifestyles and life course immunization, as well as person-centered care, which aligned well with both governments’ and populations’ priorities. Key messages • Behavioral insights and behavioral integration helped identify priority populations and behaviors, and better align the respective priorities of populations and governments for COVID-19 vaccination. • Participatory workshops with relevant stakeholders, together with evidence from qualitative and quantitative research, allowed us to design and adapt public health interventions.

Bridging public health and primary care in an Italian Urban Area. Lessons learnt from pandemic

Abstract COVID-19 pandemic represented a disruptive event for all sectors, especially the healthcare one. It revealed weakness of healthcare systems, often organised in silos, and called for a great coordination among several stakeholders. Different healthcare organizational solutions were implemented in order to address this extraordinary situation. This study investigates the impact of an organizational innovation, District Operation Centres (DOCs), of a Local Health Authority (LHA) in Rome aimed at responding overall to primary care and public health (PH) needs during the first phases of pandemic. In the DOCs health districts professionals supported general physicians (GPs) and family paediatricians (FPs), acting as a bridge with the PH Department, in order to better manage COVID-19 patients and close contacts. To understand the utility and the areas of support to GPs and FPs a survey (21 open questions or on a Likert scale), realised according the Delphi method, was admnistered to them. The sample was calculated using Epi Info, randomization was performed through Excel. A descriptive analysis of the sample and of the answers was carried out. When appropriate, statistical tests were used to understand differences among districts. 215 doctors were interviewed between Dec 2020 and Jan 2021. More than 50% declared to have found DOCs useful, above all for guiding to legislation and to activate medical equipes to deliver swabs at home. The support was evaluated not good regarding COVID-19 cases/contacts and cluster(s) management. Further needs as support in frail patients’ management, involvement of specialists, delivery of telemedicine, more involvement of GPs/FPs in district activities were identified. DOCs were an attempt to support GPs/FPs in improving care to COVID-19 patients/contacts. To provide this new service in the pandemic emergency denotes great leadership in the LHA to yield collaboration among several stakeholeders and vision about patient-centered healthcare. Key messages • Although several limits like need of more integration, DOCs represent an experience aimed at overcoming duality between primary care and public health systems and the fragmentation of the system. • DOCs could be considered an organizational innovation to make the system more resilient and patient-centered.

Is violence a gender issue among community health agents in Northeast Brazil?

Abstract A biopsychosocial phenomenon, violence may be defined as the hurtful outcome of conflicting social forces. Violence affects individual and collective health, creating a demand for targeted public policies and the implementation of services for the prevention and treatment of injury. Community Health Agents (CHAs) are the link between the Brazilian primary health care system and the community. As they live and work in the same neighborhoods, they are involved in what happens in the community, including observants and or potential targets of violence. We aimed to investigate the violence to which CHAs are exposed and if female CHAs experience and or perceive violence the same way as male CHAs. A structured questionnaire applied to CHAs was used to collect information. Two periods (2019 [n = 1402] and 2021 [n = 364]) were compared. The sampled CHAs were found to be highly exposed to violence (>80%), whether as victims in the workplace and at home or as witnesses within the community served. In general, while the occurrence of violence towards CHAs decreased, their perception of community violence increased. Moreover, between 2019 (before the Covid-19 pandemic) and 2021 (a year into the pandemic) the prevalence of perceived urban/community violence (physical aggression, assault, stabbing, lethal and non-lethal gunshots, and gang violence) increased among female CHAs, but remained practically unchanged (with the exception of ‘assault') among male CHAs, indicating a gender-related difference for this variable. In addition to impacting the health and work routines of CHAs, violence is also injurious to the health of the community (directly or indirectly - inability of CHA to deliver care). Given the complexity of violence and its repercussions on the daily routines of CHAs, intersectoral and interdisciplinary partnerships between health workers and other stakeholders are needed to create strategies capable of dealing with expressions of violence in the territories served. Key messages • CHA are highly exposed to violence (> 80%), whether as victims in the workplace and at home or as witnesses within the community served. • There is a gender-related difference for the perception of violence among CHA, which may be due to social inequalities or women's vulnerability to violence.

Long-Term Efficacy of primary care combining a mobile healthcare application with human coaching

Abstract Background Chronic diseases have become a global burden, and digital self-healthcare using mobile devices has gained importance in managing these conditions. However, barriers to implementing mobile self-management healthcare applications in current primary care system, and previous research has focused on short-term effects. This study aims to evaluate the long-lasting effect of combining human coaching with mobile self-management healthcare applications for chronic disease patients in primary healthcare services. Methods The study recruited 178 patients with chronic diseases from participating primary care clinics. The intervention group (N = 128) received a 12-week mobile self-management healthcare application service combined with traditional primary care, while the control group (N = 50) received only traditional healthcare. The Noom application was used, with two weekly human coaching sessions by a nutritionist. A telephone survey on weight changes was conducted one year after the intervention. Results The intervention group showed a greater weight loss compared to the control group during the intervention period (Intervention: -1.29 ± 2.94 vs Control: -0.38 ± 1.72, P-value 0.002). Although there was no statistically significant difference in additional weight change between the two groups during the follow-up period, the difference in weight loss during the intervention period was maintained (Intervention: -2.16 ± 5.54 vs Control: -1.06 ± 3.24, P-value: 0.008). Additionally, among the intervention group continuously for 1 year using the health management application, the average weight loss was higher than the other groups. Conclusions Combining a mobile self-management healthcare application with human coaching has long-lasting effects and can be effective in primary healthcare services. This suggests that such an approach has the potential to be a treatment option in current primary healthcare systems, but further large-scale long-term studies are needed. Key messages • This study suggests that using mobile self-management healthcare apps with human coaching can be an effective long-term treatment option for chronic disease patients in primary healthcare services. • The combination of the two methods may provide better outcomes than traditional healthcare services alone.

Patient experience with primary health care during the COVID-19 pandemic in Bulgaria

Abstract Background The COVID-19 pandemic has had a profound impact on the primary healthcare experience of patients. Restricted access, delays in routine services, postponed checkups owing to safety concerns led to disruptions in care, missed diagnoses, and delays in treatment. This study investigates primary care service obstacles faced by patients during the COVID-19 pandemic in Bulgaria. Methods A national cross-sectional survey was conducted between November and December 2021 by a poll agency using an online self-administered questionnaire with 800 respondents. Binomial logistic regression was used to examine the association between sociodemographic variables and issues related to the availability of primary care services. Results Around 32% (95% CI 28-35%; p < 0.001) of the respondents reported obstacles related to the primary care, and 25% (95% CI 22-38%; p < 0.001) postponed a visit to the general practitioner due to accessibility and availability issues or fear of infection. The most prevalent obstacle cited by patients was a refusal of a referral for specialized care (26%), followed by a refusal of an out-of-hours or weekend consultation in case of urgent need (25%). Home visits and routine examinations were also denied to patients, albeit less frequently. The multivariable analyses found associations between gender, health status, education, and impediments by obtaining primary care services. The odds of facing obstacles rose as self-rated health deteriorated (OR = 6.0, p < 0.001). The likelihood of experiencing availability issues increased with educational level (OR = 6.2, p < 0.001). Women were 1.6 times more likely (p = 0.009) to report difficulties with primary care. Conclusions The COVID-19 pandemic has created significant barriers for many patients to access primary healthcare services. In addition, it has highlighted the need for a primary healthcare system that is resilient and capable of maintaining its essential functions during public health emergencies. Key messages • Primary health care has a crucial role in supporting patients during public health emergencies. • The health system needs resilient primary health care that can adapt to swiftly changing conditions.

“The trip actually opened our eyes to things that we were supposed to do and we were not doing”: developing primary health care system leadership in a low-income country with peer exchanges

BackgroundHealth care systems in low and middle-income countries are decentralizing and devolving power to the periphery. Transferring power without systematic processes to develop and nurture leaders at the district compromises the effectiveness and sustainability of the decentralized health system. To address this problem, we developed an approach to leadership learning by observation and experience that improved the organization and performance of the health care system in a district in Ghana.MethodologyUsing two rounds of a longitudinal qualitative study, the study explores the determinants of implementing the Community-Based Health Planning and Services (CHPS) initiative in a district in Ghana. Insights were gained concerning the leadership regimes of two leaders who administered health services in a common geographic area at different points in time with remarkably contrasting outcomes. Insights of health workers who participated in both periods were elicited to clarify interview contexts. Ten focus group discussions (FGDs) and five expert interviews were conducted for each round of the study. The study was informed by a systems appraisal approach that utilized a thematic analytical framework.ResultsProviding district leaders with a practical observational experience had a significant influence on health care delivery in all aspects of health care provision at the district level. Exposing participants to models of best practices facilitated the replication of processes that improved the conduct of service delivery and CHPS implementation. Upon reflection, district leaders attributed performance constraints to their lack of understanding of practical ways of responding to complex district health system development needs. Observation from community members, volunteers, and health workers who witnessed the system development period corroborated narratives that leaders had expressed.ConclusionEffective leadership is optimally developed with participatory learning that provides leaders with direct access to fully functioning systems. Learning by observation can be structured and used to quicken the spread of managerial excellence.