Strong Primary Care Research Articles

Implementation as the acid test: International lessons from Universal Health Coverage reforms around the world

Abstract Introduction Health systems around the world are moving towards Universal Health Coverage, which is included in the Sustainable Development Goals. However, the journey towards UHC began decades ago, with countries in Europe introducing national health services following World War II. This was mirrored in Canada and, more recently, countries in Latin America introduced health reforms as part of broader social movements. Since the millennium, reforms have also taken place in Low and Middle Income Countries as well as High Incomes Countries. However, because the introduction of UHC often necessitates far-reaching reforms, countries face significant challenges along the path of policy implementation. Methods A realist review explored international experiences of introducing and implementing UHC. Embase, Medline and Web of Science were searched. Descriptive, inductive and deductive realist analysis aided the development of Context, Mechanism, Outcome Configurations, alongside stakeholder engagement. Findings How countries go about establishing UHC depends on their social, political, cultural and economic contexts. For reforms to be facilitated, there must be cohesion and commitment across all systems, as well as the functions of financing, governance and service delivery. This includes political support, often underpinned by legislation framing healthcare as a human right, as well as communication between stakeholders and the development of a strong primary care sector. Conversely, fragmentation across these systems and functions pose significant barriers to reform. Conclusions Examining international experiences of UHC reforms supports learning around the factors that facilitate or challenge implementation. These learnings empower policy makers and health system leaders by providing roadmaps for reform implementation. Finally, this research provides insights into health inequities that are rebalanced through the implementation of UHC reforms.

Organizational innovations related to Primary Care Access Points (GAP) for unattached patients in Quebec: a multi-case qualitative study

BackgroundBeing attached to a primary care (PC) provider is at the core of a strong primary health care system. Centralized waiting lists (CWL) for unattached patients have been implemented in eight provinces of Canada to support the attachment process. In Quebec, the Ministry of Health mandated the implementation of Primary Care Access Points (GAP) across the province to help unattached patients navigate the health system while awaiting attachment through the CWL. Several local health territories developed complementary innovations to the GAP to respond to local population needs. This paper aims to describe five organizational innovations implemented locally.MethodsThis multi-case qualitative study was conducted in four local health territories in the province of Quebec. Fifty-two semi-structured interviews with healthcare managers, nurses, physicians, other health professionals and administrative staff were conducted between April 2023 and April 2024. An interview guide was developed based on existing frameworks on the implementation of innovations and the evaluation of the GAP. Thematic analysis was conducted using NVivo software. Inductive and deductive approaches were used to develop relevant codes and themes. Logic models were built to describe the organizational innovations.ResultsFive organizational innovations are described. First, a multidisciplinary clinic aimed at responding to patients with mental health issues was implemented. Second, a nurse clinic was implemented to provide temporary care for patients with unstable chronic illnesses. The third innovation is a mobile proximity clinic where unattached GAP patients are first evaluated by a paramedic before receiving care from a nurse. Fourth, a pharmacist trajectory was implemented to increase engagement of community pharmacists to respond to GAP patients. The last innovation is a decentralized GAP offering in-person nursing care to unattached GAP patients.ConclusionsDescriptions of these five innovations are key to inform other territories and provinces on ways to improve access for unattached patients while they are waiting to be attached. The introduction of the GAP and the organizational innovations, suggests a transition where access to PC services does not rely solely on attachment status.

The role of primary healthcare amid the COVID-19 pandemic: Evidence from the Family Health Strategy in Brazil

This paper investigates the role of primary healthcare in mitigating the consequences of the COVID-19 pandemic, focusing on the Brazilian Family Health Strategy (ESF) as a case study. ESF is Brazil’s major primary care initiative, with prior evidence indicating its effectiveness in improving various health outcomes. The COVID-19 pandemic submitted the Brazilian healthcare system to a rigorous and unprecedented stress test, whose repercussions are still under study. Using comprehensive administrative microdata from 2016 to 2022 encompassing dimensions related to mortality, healthcare service, supply of family health teams, and vaccination coverage, our empirical strategy accounts for heterogeneous effects based on program intensity and pandemic evolution of the 5570 Brazilian municipalities. Our findings reveal that municipalities with high-intensity of ESF coverage (i.e. stronger primary care) experienced 347.93 (95% CI: 289.04, 406.81) fewer COVID-19 and cardiorespiratory deaths per million inhabitants throughout the pandemic period, compared to those in low-intensity ESF areas, despite sharing similar profiles of deaths from respiratory and cardiovascular causes. Among the channels contributing to this relative performance, high-intensity ESF municipalities were found to engage in more home-based primary care visits and health promotion activities while maintaining a similar supply of community health workers. Additionally, they achieved higher vaccination coverage, and these effects were more pronounced in areas with greater ESF presence, emphasising the importance of primary care coverage. In conclusion, our findings underscore the relevance of strong primary care in mitigating the consequences of the pandemic and addressing post-pandemic health challenges.

Evaluation of the McGill-Tongji Blended Education Program for Teacher Leaders in General Practice: The importance of partnership and contextualization in International Primary Care Training Initiatives.

Strong primary health care (PHC) systems require well-established PHC education systems to enhance the skills of general practitioners (GPs). However, the literature on the experiences of international collaboration in primary care education in low- and middle-income countries remains limited. The purpose of this study was to evaluate the implementation and perceived impact of the McGill-Tongji Blended Education Program for Teacher Leaders in General Practice (referred to as the "Tongji Program"). In 2020-2021, the McGill Department of Family Medicine (Montreal, Canada) and Tongji University School of Medicine (TUSM,Shanghai, China) jointly implemented the Tongji Program in Shanghai, China to improve the teaching capacity of PHC teachers. We conducted an exploratory longitudinal case study with a mixed methods design for the evaluation. Quantitative (QUAN) data was collected through questionnaire surveys and qualitative (QUAL) data was collected through focus group discussions. The evaluation showed that learners in Tongji Program were primarily female GPs (21/22，95%) with less than 4 years of experience in teaching (16/22，73%). This program was considered a successful learning experience by most participants (19/22, 86%) with higher order learning tasks such as critical thinking and problem-solving. They also agreed that this program helped them feel more prepared to teach (21/22，95%), and developed a positive attitude toward primary care (21/22，95%). The QUAL interview revealed that both the Tongji and McGill organizers noted that TUSM showed strong leadership in organization, education, and coordination. Both students and teachers agreed that by adapting training content into contextualized delivery formats and settings, the Tongji Program successfully overcame language and technology barriers. Committed partnerships and contextualization were key to the success of the Tongji Program. Future research should focus on how international primary care education programs affect learners' behavior in their practice settings, and explore barriers and facilitators to change.

Learning From Countries on Measuring and Defining Community-Based Resilience in Health Systems: Voices From Nepal, Sierra Leone, Liberia, and Ethiopia

Background: The best approach for defining and measuring community health care resilience in times of crisis remains elusive. We aimed to synthesise definitions and indicators of resilience from countries who had recently undergone shocks (i.e., outbreaks and natural disasters). Methods: We purposively selected four countries that had recently or were currently experiencing a shock: Nepal, Ethiopia, Sierra Leone, and Liberia. Focus group discussions and key informant interviews were conducted with participants at the community, facility, district, sub-national, national, and international levels. Interviews and discussions were translated and transcribed verbatim. Data were open coded in ATLAS.ti using a grounded theory approach and were thematically collated to a pre-specified framework. Results: A total of 486 people participated in the study (n=378 community members, n=108 non-community members). Emergent themes defining community-based health system resilience included: the importance of communities, health system characteristics, learning from shocks, preventing and preparing for shocks, and considerations for sustainability and intersectoral engagement. Participants identified 193 potential indicators for measuring resilience, which fell into the domains of: 1) preparedness, 2) response and recovery, 3) communities, 4) health systems, and 5) intersectoral engagement. Conclusion: Despite varying definitions and understanding of the concept of resilience, community-centred responses to shocks were key in building resilience. Further insight is needed into how the definitions and indicators identified in this study compare to other shocks and contexts and can be used to further our understanding of health system resilience. Metrics and definitions could assist policy makers, researchers, and practitioners in evaluating the readiness of systems to respond to shocks and to allow comparability across health systems. We must build health systems that can continue to function and ensure quality, equity, community-focused care, and engagement, regardless of the pressures put upon them and ensure they are linked to strong primary health care.

Cancer Care Disparities: Overcoming Barriers to Cancer Control in Low- and Middle-Income Countries.

The rising global burden of cancer disproportionately affects low- and middle-income countries (LMICs), which account for over half of new patients and cancer deaths worldwide. However, LMIC health systems face profound challenges in implementing comprehensive cancer control programs because of limited health care resources and infrastructure. This analytical review explores contemporary evidence on barriers undermining cancer control efforts in resource-constrained LMIC settings. We conducted a comprehensive literature review of peer-reviewed evidence on cancer control challenges and solutions tailored to resource-limited settings. We provide a conceptual framework categorizing these barriers across the cancer care continuum, from raising public awareness to palliative care. We also appraise evidence-based strategies proposed to overcome identified obstacles to cancer control in the published literature, including task-shifting to nonspecialist health workers, strategic prioritization of high-impact interventions, regional collaborations, patient navigation systems, and novel financing mechanisms. Developing strong primary care delivery platforms integrated with specialized oncology care, alongside flexible and resilient health system models tailored to local contexts, will be critical to curb the rising tide of cancer in resource-limited settings. Urgent global commitments and investments are needed to dismantle barriers and expand access to prevention, early detection, diagnosis, treatment, and palliation services for all patients with cancer residing in LMICs as an ethical imperative. The review elucidates priority areas for policy actions, health systems strengthening, and future research to guide international efforts toward more equitable cancer control globally.

Citizens’ perspectives on relocating care: a scoping review

BackgroundHealthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients’ homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens’ attitudes towards relocating care.MethodA scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens’ perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained.ResultsFactors positively influencing citizens’ attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home.ConclusionSeveral factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens’ preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens’ perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

A 360<sup>0</sup> scan of primary care in Flanders: what is needed and how to address challenges to build a strong primary care.

The primary care (PC) in Flanders is going through a transition to realize integrated care (IC).
 Artevelde University of Applied Sciences (AUAS), as knowledge institution, wants to contribute to a strong PC and undertook a needs analysis incorporating the problems PC-actors are facing and the support AUAS could offer.
 A stakeholder mapping (e.g. care, welfare actors at micro-, meso- and macrolevel) was executed. 44 in dept interviews were conducted. After data-analyze, a member check (n=17) took place, followed by validation by the Flemish Patient Organization representing the person with care and support need, the Flemish Institute for PC, and the King Baudouin Foundation, a philanthropy organization.
 Key is the paradigm shift from supply-led care to person-centered care. Transformation towards IC encompasses various dimensions of integration: clinical, service, functional and organizational (Lewis et al.). Our findings showed obstacles on those dimensions. At the clinical level, care professionals and providers stressed the need for shared guidelines and protocols. At the service level, implementation of IC-services through interdisciplinary teams is hampered. Professionals do not know each other or what to expect, since they are mainly organized in ad hoc or fluid teams, hampering good collaboration. Participants indicated at the functional level the lacking of an integrated, patient-centered electronic record.Integration of organizations is still ongoing. Different obstacles within and without the sphere of influence of an organization were brought up, e.g., the current legal and financial framework.
 The participants indicated that both the PC- sector as well as education, research and policy hold a piece of the puzzle to facilitate the different forms of cooperation. 
 They reached out to educational institutions to coordinate their educational and lifelong learning programs more co-creatively and flexible. Basic courses should work on interdisciplinary courses to promote cooperation later in the field. There is a need for further development of the so-called t-shaped professional, a professional with skills and expertise in a single field, but the ability to collaborate across disciplines with experts in other areas and to apply knowledge in areas of expertise other than one's own.
 Lifelong learning should work out multidisciplinary education courses targeting broad topics and develop a tailor-made offer, including coaching of PC actors, organizations, and networks. 
 They also called for more cooperation between PC and research. Research must be tailor-mode and needs to speed-up. Support in all forms and phases of research is wanted. A willingness to work together as equal partners from scratch is formulated. Co-creation and transfer of research competence are key. In addition, mandate is given to researchers to report results to policy.
 Based on those findings AUAS is working together with PC to develop an ""academic collaborative center (ACC)"" a sustainably funded collaboration between end users, science, care practice and education with complete equality between partners. Central is co-creation with intensive and equal collaboration between various stakeholders, creating scientific knowledge in which the perspectives of the end users are central (f.i. implementation of IC in PC) and creating societal impact (improve quality of care) are ambitions that are intertwined.
 
 

The role of primary care during the pandemic: shared experiences from providers in five European countries

BackgroundThe COVID-19 pandemic necessitated wide-ranging adaptations to the organisation of health systems, and primary care is no exception. This article aims to collate insights on the role of primary care during the pandemic. The gained knowledge helps to increase pandemic preparedness and resilience.MethodsThe role of primary care during the pandemic in five European countries (Austria, Denmark, France, Hungary, Italy) was investigated using a qualitative approach, namely case study, based on document analysis and semi-structured interviews. In total, 31 interviews were conducted with primary care providers between June and August 2022. The five country case studies were subjected to an overarching analysis focusing on successful strategies as well as gaps and failures regarding pandemic management in primary care.ResultsPrimary care providers identified disruptions to service delivery as a major challenge emerging from the pandemic which led to a widespread adoption of telehealth. Despite the rapid increase in telehealth usage and efforts of primary care providers to organise face-to-face care delivery in a safe way, some patient groups were particularly affected by disruptions in service delivery. Moreover, primary care providers perceived a substantial propagation of misinformation about COVID-19 and vaccines among the population, which also threatened patient-physician relationships. At the same time, primary care providers faced an increased workload, had to work with insufficient personal protective equipment and were provided incongruous guidelines from public authorities. There was a consensus among primary care providers that they were mostly sidelined by public health policy in the context of pandemic management. Primary care providers tackled these problems through a diverse set of measures including home visits, implementing infection control measures, refurbishing used masks, holding internal meetings and relying on their own experiences as well as information shared by colleagues.ConclusionPrimary care providers were neither well prepared nor the focus of initial policy making. However, they implemented creative solutions to the problems they faced and applying the learnings from the pandemic could help in increasing the resilience of primary care. Attributes of an integrated health system with a strong primary care component proved beneficial in addressing immediate effects of the pandemic.

The quality of prison primary care: cross-sectional cluster-level analyses of prison healthcare data in the North of England

Prisoners have significant health needs, are relatively high users of healthcare, and often die prematurely. Strong primary care systems are associated with better population health outcomes. We investigated the quality of primary care delivered to prisoners. We assessed achievement against 30 quality indicators spanning different domains of care in 13 prisons in the North of England. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records over 2017-20. Multi-level mixed effects logistic regression models explored associations between indicator achievement and prison and prisoner characteristics. Achievement varied markedly between indicators, prisons and over time. Achieved processes of care ranged from 1% for annual epilepsy reviews to 94% for blood pressure checks in diabetes. Intermediate outcomes of care ranged from only 0.2% of people with epilepsy being seizure-free in the preceding year to 34% with diabetes having sufficient blood pressure control. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, e.g., 1.93-fold for gabapentinoid prescribing without coded neuropathic pain (odds ratio [OR] range 0.67-1.29) and 169-fold for dried blood spot testing (OR range 0.05-8.45). Shorter lengths of stay were frequently associated with lower achievement. Ethnicity was associated with some indicators achievement, although the associations differed (both positive and negative) with indicators. We found substantial scope for improvement and marked variations in quality, which were largely unaltered after adjustment for prison and prisoner characteristics. National Institute for Health and Care Research Health and Social Care and Delivery Research Programme: 17/05/26.

Triaging of patients by general practitioners (GPs) in primary health care settings: a neglected aspect in the health policy & practice in Nepal

General Practitioners are the backbones of the primary health care and whole health system around the world. United nation declaration in Alma Ata about primary health care and WHO reinforcement regarding the importance of robust primary health care for universal health coverage are major catalysts to sensitize the government to implement triaging of patients through primary care by general practitioners. Nepal lacks strong primary health care system utilizing general practitioners as frontline health service providers in the community level. This has made people travel a long distance risking high expenses to get basic healthcare. The overcrowding in tertiary care hospitals is a result of improper triaging and referral system. General practitioners in Nepal work in emergency departments of hospitals and medical colleges, do private practices and a small number of GPs work in health departments of Ministry of Health and Population. Proper mobilization of GPs and establishing primary health care system is paramount to achieve equity, efficiency and effectiveness in health services. Current health policies and program must be reviewed and updated based on the evidences from the studies. CME (Continuous Medical Education) was organized in Chitwan for General Practitioners as a regular program of GPEMAN(General Practice and Emergency Medicine Association of Nepal). Participants were asked about primary health care system in Nepal and its opportunities and barriers. Majority of participants 84% (32 out of 38) pointed out that poor health policy and lack of recognition of General Practice for primary health care as first contact physicians by the government are the major challenges and barriers. Evidences will guide government and concerned stakeholders to establish robust primary healthcare system to increase access, efficiency, effectiveness of health service and to reduce out-of-pocket expenditure and disease burden in the community.

Barriers to and enablers of the promotion of patient and family participation in primary healthcare nursing in Brazil, Germany and Spain: A qualitative study.

Most health systems are insufficiently prepared to promote the participation of chronically ill patients in their care. Strong primary health care (PHC) strengthens patients' resources and thus promotes their participation. The tasks of providing continuous care to people with chronic diseases and promoting self-management are the responsibility of PHC nurses. Recent research assessing enablers of or barriers to nurses'efforts to support patients'participation has mostly not considered the special situation of patients with chronic diseases or focused on the PHC setting. To investigate enablers of and barriers to PHC nurses' efforts to promote the participation of chronically ill patients in their care. We interviewed 34 practicing PHC nurses and 23 key informants with advanced knowledge of PHC nursing practice in Brazil, Germanyand Spain. The data was analyzed using thematic coding. We identified four categories of barriers and enablers. (1) Establishing bonds with patients: Interviewees emphasized that understanding patients' views and behaviours is important for PHC nurses. (2) Cooperation with relatives and families: Good relationships with families are fundamental, however conflicts within families could challenge PHC nurses efforts to strengthen participation. (3) Communication and cooperation within PHC teams: PHC nurses see Cooperative team structures as a potential enabler, while the dominance of a 'biomedical' approach to patient care is seen as a barrier. (4) Work environment: Interviewees agreed that increased workload is a barrier to patient participation. Supporting patient participation should be acknowledged as an important responsibility for nurses by general practitionersand PHC planners. PHC nurses should be trained in communicative competencewhen discussing participation with chronically ill patients. Interprofessional education could strengthen other professionals' understanding of patient participation as a nursing task. This study is part of a research project associated with the research network 'forges: User-oriented care: Promotion of health in the context of chronic diseases and care dependency'. The study's focus and provisional results were discussed continuously with partners in health and social care practice and presented to and discussed with the public at two conferences in which patient representatives, professionals and researchers participated.

Enabling System Functionalities of Primary Care Practices for Team Dynamics in Transformation to Team-Based Care: A Qualitative Comparative Analysis (QCA).

Team-based primary care has been shown to be an important initiative for transforming primary care to achieve whole-person care, enhance health equity, and reduce provider burnout. Organizational approaches have been explored to better implement team-based care but a thorough understanding of the role of system functions is lacking. We aimed to identify the combinations of system functionalities in primary care practices that most enable effective teamwork. We used a novel method, qualitative comparative analysis (QCA), to identify cross-case patterns in 19 primary care practices in the Harvard Academic Innovations Collaborative (AIC), an initiative for transforming primary care practices by establishing teams and implementing team-based care. QCA findings identified that primary care practices with strong team dynamics exhibited strengths in three operational care process functionalities, including management of abnormal test results, cancer screening and medication management for high-priority patients, care transitions, and in health information technology (HIT) functionality. HIT functionality alone was not sufficient to achieve the desired outcomes. System functionalities in a primary care practice that support physicians and their teams in identifying patients with urgent and complex acute illnesses requiring immediate response and care and overcoming barriers to collaboration within and across institutional settings, may be essential for sustaining strong team-based primary care.

The quality of prison primary care: cross-sectional analyses of prison healthcare data in Northern England.

Prisoners have considerable health needs, are relatively high users of health care and often die prematurely. Prison healthcare research has typically focused on specific problems such as substance misuse, but 'routine' primary care has received less attention. Strong primary care systems are associated with better population outcomes. Identifying inappropriate variations in care will inform strategies to close gaps in health care and reduce preventable deaths. To explore variations in the quality of primary care for prisoners. We assessed achievement against 30 quality indicators examining different aspects of care in 13 prisons. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records across 2017-2020. Multi-level logistic regression models explored associations between indicator achievement and prison and prisoner characteristics. We found marked variations in achievement between different indicators and different prisons. Achievement ranged from 0·2% of people with epilepsy coded as seizure-free, to 93·8% of people with diabetes having blood pressure checks, in the preceding year. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, from 1·93-fold for prescribing of gabapentinoids with no coded diagnosis of neuropathic pain (Odds Ratio (OR) range 0·67 to 1·29) to 21,610-fold for medicine reconciliation (OR range 0·45 to 9724·5). Shorter lengths of stay were frequently associated with lower achievement. Some associations between ethnicity and achievement were identified. We found substantial scope for improvement and marked variations in quality which were largely unaltered after adjustment for prison and prisoner characteristics.

HSD92 Relationship between Patient Experience of Primary Care and Their Utilization of Hospital Care: A Cross-Sectional Study in China

Strong primary care in a healthcare system, with a greater focus on prevention and early management of health problems, is considered to provide better quality care and expected to reduce unnecessary hospital utilization. This study aimed to explore the relationship between patient experience of primary care and their utilization of hospital care in China.

Team-Based Diabetes Care in Ontario and Hong Kong: a Comparative Review.

There are gaps in implementing and accessing team-based diabetes care. We reviewed and compared how team-based diabetes care was implemented in the primary care contexts of Ontario and Hong Kong. Ontario's Diabetes Education Programs (DEPs) were scaled-up incrementally. Hong Kong's Multidisciplinary Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) evolved from a research-driven quality improvement program. Each jurisdiction had a mixture of non-team and team-based primary care with variable accessibility. Referral procedures, follow-up processes, and financing models varied. DEPs used a flexible approach, while the RAMP-DM used structured assessment for quality assurance. Each approach depended on adequate infrastructure, processes, and staff. Diabetes care is most accessible and functional when integrated team-based services are automatically initiated upon diabetes diagnosis within a strong primary care system, ideally linked to a register with supports including specialist care. Structured assessment and risk stratification are the basis of a well-studied, evidence-based approach for achieving the standards of team-based diabetes care, although flexibility in care delivery may be needed to meet the unique needs of some individuals. Policymakers and funders should ensure investment in skilled health professionals, infrastructure, and processes to improve care quality.

Exploring medical students’ perceptions of family medicine in Kyrgyzstan: a mixed method study

BackgroundDespite knowing that health systems with strong primary care improve overall health outcomes within a population, many countries are facing a global trend of declining interest and shortage of family doctors. This is the case of the Kyrgyz Republic, in which rural areas are struggling to attract and retain family medicine (FM) doctors. This study aims to explore how Kyrgyz medical students perceive FM and the factors that influence their specialty choice.MethodsThis study used a cross-sectional explanatory sequential design, including quantitative survey and focus group discussions that were carried out at the Kyrgyz State Medical Academy (KSMA) in Bishkek in 2017. Overall, 66% (953 out of 1449) of medical undergraduate students registered in year 1, 4 and 6 completed the survey, and 42 participated in the focus groups. The results were organized around 7 factors influencing perceptions and attitudes towards FM identified through a qualitative systematic review.ResultsThe interest of Kyrgyz students for FM was the lowest of all specialties. Access to high medical technologies, career opportunities, salary, patient interaction and possibility to work abroad were the five most important factors influencing specialty choice. FM was perceived as a difficult profession, yet with poor prestige, insufficient remuneration, limited career possibilities and poor working conditions, especially in rural areas. The academic discourse, which disregards FM specialty had a negative influence on student’s perceptions and prevented students’ ability to identify with the practice of family medicine. However, students’ awareness of their social accountability arose as a positive leverage to increase the choice of FM, provided other problems were solved.ConclusionThis study highlighted key factors responsible for the low number of students choosing to become FM in Kyrgyzstan. The first major factor, presumably specific to many low- and lower-middle- income countries was the poor working conditions in remote areas. The second factor, common to many countries, was the distorted image of FM and its specialty transmitted through the medical schools’ institutional culture which does not value FM through positive role models. This study served as a basis to establish a strategy to promote FM within the KSMA and potentially at National level.

Harnessing fast and slow thinking to ensure sustainability of general practice and functional universal health coverage in Australia.

Harnessing fast and slow thinking to ensure sustainability of general practice and functional universal health coverage in Australia.

Effectiveness of hierarchical medical system policy: an interrupted time series analysis of a pilot scheme in China.

The Chinese healthcare system faces a dilemma between its hospital-centric approach to healthcare delivery and a rapidly ageing population that requires strong primary care. To improve system efficiency and continuity of care, the Hierarchical Medical System (HMS) policy package was issued in November 2014 and fully implemented in 2015 in Ningbo, Zhejiang province, China. This study aimed to investigate the impact of the HMS on the local healthcare system. We conducted a repeated cross-sectional study with quarterly data collected between 2010 and 2018 from Yinzhou district, Ningbo. The data were analysed with an interrupted time series design to assess the impact of HMS on the changes in levels and trends of three outcome variables: primary care physicians' (PCPs') patient encounter ratio (i.e.the mean quarterly number of patient encounters of PCPs divided by that of all other physicians), PCP degree ratio (i.e.the mean degree of PCPs divided by the mean degree of all other physicians, with the mean degree revealing the mean activity and popularity of physicians, which reflected the extent to which he/she coordinated with others in delivering health services), and PCP betweenness centrality ratio (i.e.the mean betweenness centrality of PCPs divided by the mean betweenness centrality of all other physicians; the mean betweenness centrality was interpreted as the mean relative importance of physicians within the network, indicating the centrality of the network). Observed results were compared with counterfactual scenarios computed based on pre-HMS trends. Between January 2010 and December 2018, 272 267 patients visited doctors for hypertension, a representative non-communicable disease with a high prevalence of 44.7% among adults aged 35-75 years, amounting to a total of 9 270 974 patient encounters. We analysed quarterly data of 45 464 observations over 36 time points. Compared to the counterfactual, by the fourth quarter of 2018, the PCP patient encounter ratio rose by 42.7% [95% confidence interval (CI): 27.1-58.2, P < 0.001], the PCP degree ratio increased by 23.6% (95%CI: 8.6-38.5, P < 0.01) and the PCP betweenness centrality ratio grew by 129.4% (95%CI: 87.1-171.7, P < 0.001). The HMS policy can incentivize patients to visit primary care facilities and enhance the centrality of PCPs within their professional network.

Training community health workers to limit the transmission of monkeypox virus in India: an urgent need for action.

Training community health workers to limit the transmission of monkeypox virus in India: an urgent need for action.