Weak Primary Health Care Research Articles

Challenges and opportunities in strengthening primary mental healthcare for older people in India: a qualitative stakeholder analysis

BackgroundPrimary mental healthcare (PMHC) allows for complex mental health issues in old age to be addressed. India has sought to improve PMHC through legislation, strategies and programmes. This study analyses the challenges and opportunities involved in strengthening PMHC for older persons in India from the perspectives of key stakeholders.MethodsSemistructured interviews were conducted with 14 stakeholders selected from the PMHC system in India and analysed using thematic analysis. First, the analysis was organizationally structured in accordance with the six WHO mental health system domains: (1) policy and legislative framework, (2) mental health services, (3) mental health in primary care, (4) human resources, (5) public information and links to other sectors, and (6) monitoring and research. Second, for each building block, challenges and opportunities were derived using inductive coding.ResultsThis study highlights the numerous challenges that may be encountered when attempting to strengthen age-inclusive PMHC. Among these challenges are poor public governance, a lack of awareness and knowledge among policy-makers and other stakeholders, and existing policies that make unrealistic promises to weak primary healthcare (PHC) structures with an excessive focus on medicalizing mental health problems. Thus, the mental health system often fails to reach vulnerable older people through PHC. Established approaches to comprehensive, family- and community-oriented PHC support attempts to strengthen intersectoral approaches to PMHC that emphasize mental health promotion in old age. Targeting the PHC workforce through age-inclusive mental health education is considered particularly necessary. Experts further argue that adequate monitoring structures and public spending for mental health must be improved.ConclusionsIn this study, we aim to elaborate on the mental healthcare developments that may serve to achieve equity in access to mental healthcare in India. Coordinated and collaborative efforts by public and private stakeholders involved in the care of older persons, both with and without lived mental health experiences, as well as their families and communities, are necessary to bring the vision of those policies for PMHC to fruition. The findings presented in this study can also inform future research, policies and practice in other low- and middle-income countries.

Beyond Scrubs: Understanding the Root Causes of Violence Against Doctors.

Workplace violence (WPV) against doctors is a growing epidemic in India, with at least two-thirds of doctors facing some form of abuse during their careers. Verbal abuse is common, but doctors are also subjected to brutal attacks that endanger their lives. This reviewlists abusive incidents reported by the media since 2021. Despite increased respect for healthcare professionals during the COVID-19 pandemic, doctors in India are under significant stress due to inadequate medical infrastructure, mismanagement of young doctors, increasing mistrust between doctors and patients, a shortage of doctors, and overworked healthcare workers, leading to delays in attention and treatment. Additional factors contributing to the situation include the lack of proper insurance coverage, weak primary healthcare with overburdened tertiary care, the lack of an effective grievance redressal system, and the poor state of medical education. To combat this epidemic, collaborative efforts are needed between doctors, hospitals, the government, and society. Improving communication skills and treating patients with empathy are essential for healthcare workers. Meanwhile, hospitals should implement an efficient security system, a transparent billing system, and an active complaint system to prevent incidents. Unbiased reporting and adequate documentation are required to further investigate this occupational health hazard. The government should focus on building better medical facilities and passing a strict law against violence against doctors to ensure the safety of medical professionals. This review presents some solutions, along with the current legal coverage provided to healthcare professionals regarding WPV.

Investigação sobre Atenção Primária durante a pandemia em territórios vulneráveis de Campinas, São Paulo e Rio de Janeiro, Brasil

Abstract The COVID-19 pandemic found favourable conditions to spread in Brazil. A lack of coordinated action by the federal government, together with already weak Primary Health Care (PHC) had consequences for workers and users. This study examined PHC management and work process in response the COVID-19 pandemic in three municipalities, in view of the history of how PHC was set up, its relationship with the national public health system (SUS), and PHC and social activism in vulnerable territories, from the perceptions of users and workers. The study included a literature search, participant observation and 97 in-depth interviews of PHC workers and users. The results were organised into four areas: PHC implementation and management in the municipalities; the PHC work process; workers’ and users’ perceptions of PHC and the SUS; and territories, organised groups and social activism. Workers faced an environment of fear, overwork and changes in their work process, none of which prevented them from persisting and reinventing their practice. Users encountered barriers to access and difficulties in complying with public health measures, but the study found experiences of organised groups that emerged as means of coping with the pandemic.

Primary health care reforms in Poland: ambitions versus reality

Abstract Poland, like many other former eastern bloc countries, inherited a health system dominated by narrow medical specialties, a large number of hospital beds and relatively weak primary health care (PHC). Since early 1990s, efforts have been made to strengthen the role of PHC, starting with the introduction of specialization training in family medicine. With privatization of PHC practices the standard of PHC care has improved. However, national audits have repeatedly found PHC to still be inadequate, with the key weaknesses including shortages of family medicine specialists, insufficient provision of preventive services, and limited use of diagnostics, which led to inappropriate referrals and long waiting times for specialist consultations. Between mid-2018 and the end of 2021, a new model of PHC organization was piloted in around 40 PHC practices across Poland that met the model's requirements. The pilot, supported by the World Bank, put much emphasis on health promotion and disease prevention by including health educators and dieticians in PHC teams and by introducing periodic check-ups. It also aimed to reduce referrals to specialist care by allowing PHC doctors to order extensive diagnostic and laboratory tests and, if needed, consult with a range of cooperating specialists. It also sought to increase the role of PHC doctors in the management of chronic conditions by introducing disease management programmes (DMPs) for 11 most prevalent conditions. PHC teams were made responsible for coordinating patients’ care pathways, including post-hospital treatment, and a new role of care coordinator was introduced to that end. After the pilot was concluded, all PHC practices were mandated to hire care coordinators. Implementation of other solutions tested in the pilot remains uncertain, mainly due to the lack of financial and human resources, and the dominance of small PHC practices that struggle to meet the ambitious requirements set out in the new model.

Problems and Needs of Georgia’s Primary Health Care

The Paper “Problems and needs of Georgia’s primary health care” discusses generally the role of polyclinics and ambulatory clinics in providing the population with medical service and also the problems that hinder fulfilling this mission. It is underlined in the paper that WHO (World Health Organization) recognized the weakness of primary health care and its inability to solve the problems and to improve the shortcomings as one of the perils of global health. This means that this danger is present not only in the public health domain of Georgia but it is especially severe in low-income countries like Georgia. Moreover, the paper discusses all those programs and initiatives implemented by different international organizations and private funds to improve the unfavorable condition of primary health care. The Research conducted on Georgia is discussed in detail and problems and shortcomings of primary health care are named explicitly: Low qualification of staff (mainly doctors), distrust of patients, lack of right motivation, lack of primary health care strategy, careless, superficial attitude of doctors towards the patients and many more. According to the authors, continuous upgrading skills and qualification of doctors (and nurses) should start immediately, right motivation should be established, income of family and village doctors should be increased, doctors should attend the course in psychology, namely, “psychology of safety with the patients” and many more. Keywords: Public Health; Family doctor; Village doctor; weak primary health care; polyclinics and ambulatory clinics; medical service.

Problems and Needs of Georgia’s Primary Health Care

The Paper “Problems and needs of Georgia’s primary health care” discusses generally the role of polyclinics and ambulatory clinics in providing the population with medical service and also the problems that hinder fulfilling this mission. It is underlined in the paper that WHO (World Health Organization) recognized the weakness of primary health care and its inability to solve the problems and to improve the shortcomings as one of the perils of global health. This means that this danger is present not only in the public health domain of Georgia but it is especially severe in low-income countries like Georgia. Moreover, the paper discusses all those programs and initiatives implemented by different international organizations and private funds to improve the unfavorable condition of primary health care. The Research conducted on Georgia is discussed in detail and problems and shortcomings of primary health care are named explicitly: Low qualification of staff (mainly doctors), distrust of patients, lack of right motivation, lack of primary health care strategy, careless, superficial attitude of doctors towards the patients and many more. According to the authors, continuous upgrading skills and qualification of doctors (and nurses) should start immediately, right motivation should be established, income of family and village doctors should be increased, doctors should attend the course in psychology, namely, “psychology of safety with the patients” and many more. Keywords: Public Health; Family doctor; Village doctor; weak primary health care; polyclinics and ambulatory clinics; medical service.

Antibiotic Stewardship in Retail Pharmacies and the Access-Excess Challenge in China: A Policy Review.

In China, efforts to restrict excessive antibiotic consumption may prevent sufficient access to these life-saving drugs among the most deprived in society because of the weak primary health care system. This makes antibiotic stewardship in the retail pharmacy sector a particular challenge. We conducted an analysis to examinate policies on antibiotic sales in retail pharmacies in China and how tensions between ‘excess’ and ‘access’ are managed. The analysis was guided by the Walt and Gilson health policy analysis triangle to systematically analyse policies based on the content of policies, contexts, governance processes, and actors. Nine research studies and 25 documents identified from national and international sources were extracted, grouped into categories, and examined within and across records and categories. As of 2020, eight key policies have been introduced in China that focus on two areas: dispending prescribed medicines or antimicrobials with a prescription and having a licensed pharmacist present in the retail pharmacies, with approaches having changed over time. Inappropriate sales of antibiotics are still common in retail pharmacies, which can be linked to the lack of consistency and enforcement of published policies, the profit-driven nature of retail pharmacies, and the displacement of the demand for antibiotics from clinical into less regulated settings.

COVID-19 and progress towards achieving universal health coverage in Africa: A case of Nigeria.

Universal Health Coverage (UHC) 2030 is a global health target, and countries are making efforts to convert plans into tangible results. Nigeria, the most populated country in Africa, has made commitments towards UHC2030 target but is underperforming across many building blocks of health and progress has been slow. The arrival of COVID‐19 poses additional pressure on the already feeble health system causing the government to direct focus towards containing the pandemic. However, existing gaps in health workforce density, weak primary health care infrastructure and inadequate budgetary allocation have resulted in inequitable access to basic healthcare services. This situation weighs most heavily on the poor who are mostly part of the informal economy thereby pushing people further into poverty. On the other hand, COVID‐19 has provided valuable insights into Nigeria's current health system status which hopefully can be helpful in strengthening efforts towards building resilient health system and preparing the country towards future pandemic. The pandemic has highlighted the importance of essential health services and the need to strengthen primary healthcare system. It is, therefore, important that stakeholders in Nigeria and other African countries carry out situation analysis of the current health systems towards achieving UHC2030.

Community engagement in COVID-19 responses: Evidence from qualitative interface with community opinion leaders in Enugu, Nigeria

Successful stories of community engagement existed during the Ebola disease outbreak in Liberia, indicating that a combination of government and community efforts are needed in addressing pandemics or epidemics. However, for communities to rise to the challenge of containing and combatting the spread of any disease, they must be communicated most effectively and supported by the government. Therefore, our study investigates how applicable successful community engagement has been in the charge against the Coronavirus disease 2019 (COVID-19) in Nigeria. Through telephone interviews, we sourced data from 12 community opinion leaders in Enugu State, Nigeria. After conducting a thematic analysis of responses, we discovered that the Nigerian government had several gaps in engaging the grassroots in the charge against COVID-19. These gaps comprise the lack of effective inclusion strategies of rural communities and the uneducated, weak accountability, poor database of citizens, weak accountability of security agents, weak primary healthcare system, and the dearth of grassroots-targeted communication. The effects of these gaps majorly manifested in the compromise and disregard of safety measures, which most likely put Nigeria at risk of increased cases of COVID-19 or poor response to disease outbreaks in the future. We concluded that the government must improve its accountability records while effectively interfacing with the grassroots during disease outbreaks and co-producing strategies.

A Qualitative Research Study Which Explores Humanitarian Stakeholders' Views on Healthcare Access for Refugees in Greece.

Introduction: As of January 2020, 115,600 refugees remain in Greece; most are Afghani, Iraqi or Syrian nationals. This qualitative research study explores the views of key stakeholders providing healthcare for refugees in Greece between 2015 and 2018. The focus was on identifying key barriers and facilitators to healthcare access for refugees in Greece. Methods: 16 interviewees from humanitarian and international organisations operating in Greece were identified through purposive and snowball sampling. Semi-structured interviews were conducted between March and April 2018. Data were analysed using the Framework Method. Results: Key themes affecting healthcare access included the influence of socio-cultural factors (healthcare expectations, language, gender) and the ability of the Greek health system to respond to existing and evolving demands; these included Greece’s ongoing economic crisis, human resource shortages, weak primary healthcare system, legal barriers and logistics. The evolution of the humanitarian response from emergency to sustained changes to EU funding, coordination and comprehensiveness of services affected healthcare access for refugees. Conclusion: The most noted barriers cited by humanitarian stakeholders to healthcare access for refugees in Greece were socio-cultural and language differences between refugees and healthcare providers and poor coordination among stakeholders. Policies and interventions which address these could improve healthcare access for refugees in Greece with coordination led by the EU.

Strategies Needed to Ensure Higher Immunization Rates in the Americas.

In their MEDICC Review Perspective, Galindo-Santana and colleagues highlight the challenges presented by anti-vaccination groups, stressing that immunization is an essential cost-effective preventive measure that promotes population health.[1] In 2019, WHO identifi ed vaccine hesitancy, fragile and vulnerable settings and weak primary health care as 3 of 10 main global health threats. Close attention to these threats can detect potential areas of missed opportunities for immunization across populations and mitigate risk of preventable diseases.

Offline: Gender and global health—an inexcusable global failure

WHO has identified “Ten threats to global health in 2019”. Surprisingly—one should say shockingly—gender inequity is not one of them. It is not only WHO that is failing by excluding women and girls from its priority list of dangers. The entire global health community has abdicated its responsibility for achieving gender justice in health. This situation is strange because a vast quantity of evidence linking gender inequity to poor health exists and the mandate is clear, as set out in Sustainable Development Goal 5. The global health community has not, but must, make SDG 5 an indispensable part of its work to achieve healthy lives for all. Ending all forms of discrimination against women and girls. Eliminating all forms of violence against women and girls. Eliminating all harmful practices against women and girls (eg, forced marriage). Recognising and valuing unpaid care and domestic work. Ensuring women's full participation and equal opportunities for leadership in all parts of public life. Ensuring universal access to sexual and reproductive health and rights. Implementing reforms to give women equal rights to economic resources. Enhancing the use of technologies to promote women's empowerment. Finally, adopting policies and laws to promote gender equality. Rarely, if ever, do we hear global health leaders promoting such far-reaching reforms as essential prerequisites for health. We must ask: why not? In May, 2018, The Lancet launched its Commission on Sexual and Reproductive Health and Rights for All, led by Ann Starrs and Alex Ezeh. The health landscape for women is simply appalling. 200 million women who want to avoid pregnancy have no access to modern contraception. 30 million women do not give birth in a health facility. 45 million women have inadequate or no antenatal care. 25 million women have unsafe abortions each year. One in three women experience sexual violence. Over 1 million women die from cancer of the breast, cervix, ovary, and uterus annually. These predicaments exist (and are failing to be resolved anywhere near fast enough) because of gender inequity. Our Commission set out the evidence in support of an essential package of sexual and reproductive rights and health services that should be universally available. I wish I could report otherwise, but this evidence has been comprehensively ignored by global health leaders. But we also need to go beyond SRHR. Ana Langer led a Lancet Commission on Women and Health, published in 2015. She drew attention to the economic, environmental, social, political, and demographic determinants of women's health. The locus for action to advance women's health and rights lay not only with the health system, but also with society. The response to multiple global health threats facing women has largely omitted gender-specific analyses and actions. Women's contributions to health as caregivers are still grossly under-appreciated. Gender-sensitive policies to address deep-rooted inequities are mostly missing. As that Commission concluded, “Sustainable development needs women's social, economic, and environmental contributions, which will increase when women are healthy, valued, enabled, and empowered to reach their potential in all aspects of their lives.” Again, this call to action has been insufficiently heeded. Something has gone wrong in global health. Gender was a more prominent issue during the era of the MDGs, if too narrowly defined through the lens of women's, children's, and adolescent health. It's time to hold men especially accountable for this regression. Given their political prominence and power, they (we) have a special responsibility to speak out for gender equity. Too often we do not. Air pollution and climate change, non-communicable diseases, the risk of a global influenza pandemic, fragile and vulnerable settings, antimicrobial resistance, Ebola and other high-threat pathogens, weak primary health care, vaccine hesitancy, dengue, and HIV. These issues are important, and one can understand why WHO has identified them as particular threats in 2019. But, as Gro Harlem Brundtland (a former Director-General of WHO) once observed, poverty has a woman's face. The whole of health is shaped by our approaches to gender. Men must do more to amplify the importance of gender in global health, to listen, to engage, to advocate, and to create the conditions for women to flourish. The fact that, collectively, we are not doing so is a particularly ugly disfigurement of our community.

Top threats to health worldwide

The World Health Organization’s new strategic plan for 2019–23 envisions “a world in which all people attain the highest possible standard of health and well-being.” To that end, the organization has identified what it sees as top threats to global health in 2019: Air pollution and climate change Noncommunicable diseases such as diabetes, cancer, and heart disease Global influenza pandemic Fragile and vulnerable settings where people live with combinations of drought, famine, conflict, and population displacement Antimicrobial resistance Ebola and other high-threat pathogens Weak primary health care Reluctance to vaccinate Dengue HIV

Systems thinking: A turning point for improving respectful obstetric care in South African health districts.

Poorly functioning health systems and local health systems barriers affect many women giving birth in low- and middle-income countries. The district clinical specialist teams in South Africa are uniquely positioned to provide facilitation and mentoring during interventions for improving the weak primary healthcare system. To ensure success, four key principles should be considered during scale-up of interventions: systems thinking and awareness of contexts and barriers; a focus on sustainability; harnessing factors known to enhance scalability; and respect for human rights and equity. Asking the right questions about the responsibilities of health systems at the micro-, meso- and macro-levels will benefit scale-up processes and sustain innovative pathways to high-quality obstetric care in communities.

Perceived barriers to early detection of breast cancer in Wakiso District, Uganda using a socioecological approach

BackgroundEarly detection of breast cancer is known to improve its prognosis. However, women in most low and middle income countries, including Uganda, do not detect it early hence present at an advanced stage. This study investigated the perceived barriers to early detection of breast cancer in Wakiso district, Uganda using a multilevel approach focused through a socioecological framework.MethodsUsing qualitative methods, participants were purposively selected to take part in the study. 5 semi-structured interviews were conducted among the community members while two focus groups were conducted amongst women’s group and community health workers (CHWs) in Ssisa sub county, Wakiso district. In addition, 7 key informant interviews with health professionals, policy makers and public health researchers were carried out.ResultsFindings from the study revealed that barriers to early detection of breast cancer are multifaceted and complex, cutting across individual, interpersonal, organizational, community and policy barriers. The major themes that emerged from the study included: knowledge, attitudes, beliefs and practices (KABP); health system and policy constraints; and structural barriers. Prominent barriers associated with KABP were low knowledge, apathy, fear and poor health seeking behaviours. Barriers within the health systems and policy arenas were mostly centred around competing health care burdens within the country, lack of a cancer policy and weak primary health care capacity in Wakiso district. Distance, poverty and limited access to media were identified as the most prominent structural barriers.ConclusionBarriers to early detection of breast cancer are complex and go beyond individual behaviours. These barriers interact across multiple levels of influence such as organizational, community and policy. The findings of this study could provide opportunities for investment in multi-level interventions.

Help Seeking Behaviour of Depressive Mothers in the Context of a Weak Primary Health Care System. a Qualitative Study.

Background The need for integration of maternal mental health into primary health care (PHC) is well documented. However, research evidence suggest that maternal depression still remains uderrecognized and untreated. The help seeking bevaviour of mothers with depression remains an insufficiently investigated issue. Objectives The present qualitative study’s objective has been to investigate, identify and interpret the help seeking behavior of mothers of young children experiencing depressive symptoms. Aim Our aim was to inform policies and practices so as to improve the detection and management of maternal depression within the primary health care, in particular in countries of weak PHC systems and limited resources. Methods Thirty semi-structured interviews were conducted to a purposeful sample of thirty mothers living in Athens. The selection of participants’ was based on socioeconomic status and depression severity. Qualitative content analysis was conducted independently by two researchers. Results Two broad themes influencing mothers’ help seeking behavior were identified. Barriers and enablers related to PHC system aspects and psychosocial factors emerged. Barriers were associated to several aspects of the weak PHC system, such as the fragmentation of services, the lack of team based care, but also the perceived low quality and availability of community mental health services. The main psychosocial factors identified were stigma related issues, unfavorable attitudes toward mental health, and perceived social expectations regarding the mothering role. Conclusion Apart from the psychosocial factors, several aspects of the weak primary health care system could mediate the help seeking behavior of mothers experiencing depressive symptoms.

Pediatricians' and health visitors' views towards detection and management of maternal depression in the context of a weak primary health care system: a qualitative study.

BackgroundThe present study’s aim has been to investigate, identify and interpret the views of pediatric primary healthcare providers on the recognition and management of maternal depression in the context of a weak primary healthcare system.MethodsTwenty six pediatricians and health visitors were selected by using purposive sampling. Face to face in-depth interviews of approximately 45 minutes duration were conducted. The data were analyzed by using the framework analysis approach which includes five main steps: familiarization, identifying a thematic framework, indexing, charting, mapping and interpretation.ResultsFear of stigmatization came across as a key barrier for detection and management of maternal depression. Pediatric primary health care providers linked their hesitation to start a conversation about depression with stigma. They highlighted that mothers were not receptive to discussing depression and accepting a referral. It was also revealed that the fragmented primary health care system and the lack of collaboration between health and mental health services have resulted in an unfavorable situation towards maternal mental health.ConclusionsEven though pediatricians and health visitors are aware about maternal depression and the importance of maternal mental health, however they fail to implement detection and management practices successfully. The inefficiently decentralized psychiatric services but also stigmatization and misconceptions about maternal depression have impeded the integration of maternal mental health into primary care and prevent pediatric primary health care providers from implementing detection and management practices.

SP5-9 Geographical distribution of schistosomiasis and its control in Nigeria

IntroductionNigeria is the most populous country in Africa with over 150 million people. Inadequate basic social amenities and weak primary healthcare infrastructure have promoted the transmission of schistosomiasis. Presently, there...

Australian health system restructuring – what problem is being solved?

BackgroundIn recent years, Australian state and territory governments have reviewed and restructured the health systems they lead and regulate. This paper examines the outcomes of the most recent official published reviews of systems and structures; identifies the common themes; and addresses two questions: what problems are being addressed? And how would we know if the changes were successful?ResultsIn all the broad, systemic reviews, the main health system problems identified were money, hospital utilisation and a weak primary health care system. The solutions are various, but there is a common trend towards centralisation of governance, often at state health authority level, and stronger accountability measures. Other common themes are hospital substitution (services to avoid the need for admission); calls for cooperation across the Commonwealth:state divide, or for its abolition; and the expected range of current efficiency and effectiveness measures (eg amalgamate pathology and support services) and ideas in good currency (eg call centres). The top-down nature of the public review process is noted, along with the political nature of the immediate catalysts for calling on a review.ConclusionThe long-standing tension between the pull to centralisation of authority and the need for innovation in care models is heightened by recent changes, which may be counterproductive in an era dominated by the burden of chronic disease. I argue that the current reforms will not succeed in achieving the stated goals unless they make a difference for people with chronic illness. And if this is correct, the most useful focus for evaluation of the success of the reforms may be their impact on the system's ability to develop and deliver better models of care for this growing group of patients.