Inappropriate use of emergency ambulance services and the implications for primary health care in Japan

The number and per-capita emergency transports by public ambulancesand the percentage of transports of patients with non-emergencyconditions has been increasing in Japan, especially in urbanareas. Public ambulance services are, of course, essential fortransporting patients with crucial health problems. However,inappropriate ambulance use by patients who do not need emergencytreatment, but who need primary health care, means that thesepatients cannot get suitable health care, and diminishes theeffectiveness and efficiency of emergency medical-care servicesystems. The purposes of this study were to identify the factorsrelating to usage of public ambulance services in urban areas,to determine how to make these services more effective and moreefficient, and to discuss how to provide primary health-careservices so as to reduce the inappropriate use of public ambulanceservices. We investigated the accessibility of primary health-careservices, the characteristics of public ambulance service utilization,and the potential needs of the elderly for emergency-care servicesin two Tokyo wards: Edogawa andSetagaya. There were less healthresources, such as clinics, hospital beds and physicians, percapita in Edogawa than in Setagaya. Both the percentage of ambulancetransports of patients suffering from mild problems and thepercentage of ambulance transports on Sundays were higher inEdogawa than in Setagaya. Our survey showed that the percentagesof the elderly who would call for ambulances for each of threespecific health problems (fever, chest pain and ankle sprain)were all higher in Edogawa than in Setagaya. In both wards,elderly people living with their children and/or grandchildrenwere more likely to choose different health resources accordingto the specific problem being experienced than were elderlypeople living with other aged persons but without young people.The insufficient development of primary healthcare resourcesand systems increased the inappropriate use of high-cost emergencyambulance services by the elderly living in urban areas, wherefamily support is weakening. Health systems therefore need tobe reoriented so as to enhance accessibility to primary healthcareservices.     

Determinants of health status and the influence of primary health care services in Latin America, 1990-98

Primary health care (PHC) services have been advocated as a means by which less developed countries may improve the health of their populations even in the face of poverty, low levels of literacy, poor nutrition and other factors that negatively influence health status. Using aggregated data from the World Bank and UNICEF this study examined which factors, both within the health care system and outside of it, are associated with under-5 mortality rates in 22 countries of Latin America and the Caribbean during the 1990s. In a multivariate analysis using generalized estimating equations for repeated measures, five factors were found to be independent predictors of lower under-5 mortality rates (U5MRs). These were vaccination levels, female literacy, the use of oral rehydration therapy, access to safe water and GNP per capita. When the magnitude of these associations were assessed, higher levels of GNP per capita was found to be very weakly associated with lower U5MRs, compared with female literacy and vaccination rates. These findings suggest that government policies which focus only on promoting economic growth, while not making important investments in PHC services, female education and access to safe water are unlikely to see large improvements in health status.     

基本医疗卫生与公共卫生服务整合的国际经验及启示

探索基本医疗卫生与公共卫生服务的整合是创新医疗卫生服务模式和完善公共卫生服务项目的重要课题之一。本文介绍了近年来国际上关于基本医疗卫生与公共卫生服务整合代表性的理论框架,对世界卫生组织、欧洲和美国整合的原则、模式和典型案例进行了总结和分析。结合目前我国对于医防融合的发展需求,为促进我国基本医疗卫生与公共卫生服务的整合提出以下建议:(1)加强基本医疗卫生服务人员公共卫生能力的建设;(2)加快基本医疗卫生与公共卫生信息化的建设;(3)促进社区参与基本医疗卫生与公共卫生服务的整合。     

Assessing health status and service utilization in Athens: the implications for policy and planning

Morbidity, subjective health and health care utilization werestudied in two populations, living in two municipalities inthe major area of Athens, characterized by different socio-economicand educational levels. In each area studied, a random householdsample was selected. All subjects in the selected householdsaged 15 and over were included in the study. A total of 248individuals in area I and 303 individuals in area II respondedto the survey. Data were collected through personal interviewsarranged for each respondent. The results of the study suggestthat there exist similar trends as well as some differencesbetween the two populations studied, concerning mainly subjectivehealth and the use of drugs. These findings indicate that amorbidity and health care utilization survey carried out ina large and representative sample of inhabitants of the majorAthens area could be a sufficient basis for rational healthplanning in every municipality of the metropolitan area.     

Health care, public policy and the courts: black health status as a civil rights issue.

In the U.S.A. serious differences in the health status between black and white citizens continue to exist. Black Americans are less healthy and receive less health care than while Americans. The discrimination is examined as a civil rights issue with focus on both the policy and judicial perspectives of the application of Title VI of the Civil Rights Act of 1964 and the implementative effects of the Hill-Burton Act of 1946. The application, and compliance and enforcement, of civil rights to health care is complicated by a captivity process involving Federal agencies, by corporate medical rights emphasizing a business approach to health care, and by a liberal pluralistic political arena in which certain influential groups prevail over others. In order for black health status and care to improve in the U.S.A., blacks must continue to utilize the judicial system to seek redress of health care inequities. Second, they must utilize their demonstrated political power to demand better treatment from the medical establishment.     

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.     

社区卫生服务中心特定人群保健现状分析

目的 了解中国城市社区卫生服务中心特定人群保健功能的开展情况,发现制约功能任务发挥的主要障碍,为完善我国基层卫生组织功能提供科学的政策依据。方法 在全国31个省市进行大样本量的机构抽样调查,共调查社区卫生服务中心116家,并随机抽取50名相关人员进行关键知情者访谈。结果 社区卫生服务中心平均开展12.0项特定人群保健服务,占应开展项目数的46.3%;一、二、三级项目的开展比例分别为62.4%,39.9%和25.2%。结论 制定有效的激励机制,提高基层卫生人员数量和能力,并加大政府的财力、物力支持,以完善我国城市基层卫生机构的特定人群保健功能。     

The primary care physician workforce: ethical and policy implications

PURPOSE We undertook a study to examine the characteristics of countries exporting physicians to the United States according to their relative contribution to the primary care supply in the United States.METHODS We used data from the World Health Organization and from the American Medical Association Physician Masterfile to gather sociodemographic, health system, and health characteristics of countries and the number of international medical graduates (IMGs) for the countries, according to the specialty of their practice in the United States.RESULTS Countries whose medical school graduates added a relatively greater percentage of the primary care physicians than the overall percentage of primary care physicians in the United States (31%) were poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates than countries contributing relatively more specialists to the US physician workforce.CONCLUSION The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply. The ethical aspects of depending on foreign medical graduates is an important issue, especially when it deprives disadvantaged countries of their graduates to buttress a declining US primary care physician supply.     

城乡基层医疗卫生机构基本公共卫生服务居民满意度研究:以湖北省为例

目的:分析湖北省城乡居民对基本公共卫生服务的满意度及影响因素,为改善我国基本公共卫生服务质量提供政策依据。方法:根据经济发展情况选取湖北省武汉、黄冈、荆州地区共12家基层医疗卫生机构,对就诊居民进行满意度问卷调查,测量居民对基本公共卫生服务的可及性、舒适性、安全性和有效性的满意状况。结果:城乡居民对基本公共卫生服务的满意度得分为71.62分,总满意率为73.44%。城乡居民对基本公共卫生服务具体指标满意度最高的为就诊方便性(83.03%)和隐私保护(80.25%),满意度最低的指标为医疗技术(61.61%)和设备设施(64.53%)。Logistic回归分析结果显示,基本公共卫生服务的可及性、舒适性、安全性对社区居民满意度影响较大,性别及年医疗支出对居民满意度也有一定的影响。结论:城乡居民对基本公共卫生服务总体满意度处于一般水平,有待提升;城市平均满意度高于农村,农村地区存在较大的提升空间;基本公共卫生服务应进一步强化质量建设,促进城乡基本公共卫生服务均等化发展。     

How primary care reforms influenced health indicators in Manisa district in Turkey: Lessons for general practitioners

Background: Turkish health reforms began in 2003 and brought some significant changes in primary care services. Few studies in Turkey compare the shift from health centres (HC) to family physicians (FP) approach, which was initiated by reforms.

Objectives: This study compares health status indicators during the HC period before reforms (2003–2007) and the FP period after reforms (2008–2012) in Turkey.

Methods: This study encompasses time series data consisting of the results of a 10-year assessment (2003–2012) in Manisa district. All the data were obtained electronically and by month. The intersection points of the regression curves of these two periods and the beta coefficients were compared using segmented linear regression analysis.

Results: The mean number of follow-up per person/year during the HC period in infants (10.5), pregnant women (6.6) and women (1.8) was significantly higher than the mean number of follow-up during the FP period in infants (6.7), pregnant women (5.6) and women (0.9). Rates of BCG and measles vaccinations were significantly higher during the FP period; however, rates of HBV and DPT were same. The mean number of outpatient services per person/year during the FP period (3.3) was significantly higher than HC period (2.8). Within non-communicable diseases, no difference was detected for hypertension prevalence. Within communicable diseases, there was no difference for rabies suspected bites but acute haemorrhagic gastroenteritis significantly decreased. The infant mortality rate and under five-year child mortality rate significantly increased during the FP period.

Conclusion: Primary care services should be reorganized and integrated with public health services.     

广西卫生事业发展现状分析

从健康水平、妇幼保健、卫生机构、卫生人力、卫生床位、医疗服务、传染病疫情、卫生经费等多角度分析广西卫生事业发展现状,并与全国平均水平进行比较。结果表明,近年来广西卫生事业发展水平不断提升,居民主要健康指标总体优于全国平均水平;卫生资源总量持续增加;社会资本办医成效显著,民营医院发展迅速;卫生筹资结构在不断优化,个人卫生负担有所减轻。但也面临妇幼保健体系有待完善、卫生人均量不足、基层医疗卫生资源利用不足、医疗费用持续上涨、法定传染病报告发病率上升、社会卫生筹资不足以及农村居民人均医疗保健支出增长过快等问题。因此,广西卫生事业发展综合水平还有待进一步提升。     

Optimising Hepatitis C care in an urban Aboriginal and Torres Strait Islander primary health care clinic

Objective: Describe the sociodemographic and clinical characteristics of patients with Hepatitis C Virus (HCV) attending an urban Indigenous primary health clinic (IPHC) in Brisbane, Australia. Methods: A retrospective chart review of sociodemographic characteristics, presence of liver disease and treatments, lifestyle behaviours and comorbidities in patients with a HCV infection was conducted between October 2015 and March 2016. Results: One hundred and thirteen patients with confirmed HCV infection were aged between seven and 63 years; 66% were male, and 84% were Indigenous. Sixty‐nine per cent had been incarcerated; 41% had experienced conflict or domestic violence; 47% were injecting drugs; 72% had depression; and 61% had anxiety. Cirrhosis was present in 7/95 patients with adequate data and associated with age (p=0.02). Eleven patients had commenced direct acting antiviral (DAA) therapy in the 18 months that it had been available. Conclusions: The study highlights the opportunities for enhancing treatment of patients with HCV infection. Opportunities to improve treatment rates in an Indigenous primary healthcare include optimising diagnostic pathways, improving patient engagement, and general practitioner and peer worker participation. Implications for public health: HCV poses a serious threat to public health in Australia and IPHCs are key sites to addressing this for Indigenous people. Optimising care of patients with HCV attending IPHC requires recognition of the complex health needs and social context, to reduce the incidence and consequences of HCV infection.     

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

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

Advancing Indigenous primary health care policy in Alberta,Canada

For Indigenous people worldwide, accessing Primary Health Care (PHC) services responsive to socio-cultural realities is challenging, with institutional inequities in healthcare and jurisdictional barriers encumbering patients, providers, and decision-makers. In the Canadian province of Alberta, appropriate Indigenous health promotion, disease prevention, and primary care health services are needed, though policy reform is hindered by complex networks and competing interests between: federal/provincial funders; reserve/urban contexts; medical/allied health professional priorities; and three Treaty territories each structuring fiduciary responsibilities of the Canadian government.In 2015, the Truth and Reconciliation Commission (TRC) of Canada released a final report from over six years spent considering impacts of the country's history of Indian residential schools, which for more than a century forcibly removed thousands of children from their families and communities. The TRC directed 94 calls to action to all levels of society, including health systems, to address an historical legacy of cultural assimilationism against Indigenous peoples. To address TRC calls that Indigenous health disparities be recognized as resulting from previous government policies, and to integrate Indigenous leadership and perspectives into health systems, PHC decision-makers, practitioners, and scholars in the province of Alberta brought together stakeholders from across Canada. The gathering detailed here explored Indigenous PHC models from other Canadian provinces to collaboratively build relationships for policy reform and identify opportunities for PHC innovations within Alberta.     

Association between perceived health status and satisfaction with quality of care: evidence from users of primary health care in Oman

OBJECTIVE: Our aim was to assess the influence of perceived health status, as measured by SF-12, on the client's views of service quality. METHODS: A structured interview of patients was carried out in six primary health care centres in Adh Dhahira region health authority in the Sultanate of Oman. A total of 1226 patients aged 15 and over attending the different health care services within the health centres took part in the study. The main outcome measures were patients' satisfaction with the different aspects of health care and their perceived physical and mental health status. RESULTS: When adjusted for the relevant background factors such as age and gender, poor perceived health status has been found to predict less positive judgements of various aspects of health care quality. Poor mental health status, for example, predicts less positive judgements of aspects that are linked to the accessibility of the service and interpersonal aspects of care such as the working hours of the centre, GP's attitude and time spent with the GP (P < 0.05, <0.05 and <0.01, respectively). Poor physical health status, on the other hand, predicts less positive judgements of aspects such as cleanliness of the building, confidentiality of consultation with the GP, explanation about the visit to the antenatal clinic and standard of antenatal clinic in general (P < 0.05, <0.05, <0.05 and <0.05, respectively). CONCLUSION: Users' perceived health status has to be evaluated concurrently with assessing satisfaction with the quality of health care services. This would provide more valid results with regard to the patients' views on their level of satisfaction with health care quality.     

A gendered users′ perspective on decentralized primary health services in rural Tanzania

Since the 1990s, Tanzania has been implementing health sector reforms including decentralization of primary healthcare services to districts and users. The impact of the reforms on the access, quality and appropriateness of primary healthcare services from the viewpoint of users is, however, not clearly documented. This article draws on a gendered users' perspective to address the question of whether the delivery of gender‐sensitive primary health services has improved after the reforms. The article is based on empirical data collected through a household survey, interviews, focus group discussions, case studies and analysis of secondary data in two rural districts in Tanzania. The analysis shows that the reforms have generated mixed effects: they have contributed to improving the availability of health facilities in some villages but have also reinforced inter‐village inequalities. Men and women hold similar views on the perceived changes and appropriateness to women on a number of services. Gender inequalities are, however, reflected in the significantly low membership of female‐headed households in the community health fund and their inability to pay the user fees and in the fact that women's reproductive and maternal health needs are as yet insufficiently addressed. Although over half of users are satisfied with the services, more women than men are dissatisfied. The reforms appear to have put much emphasis on building health infrastructure and less on quality issues as perceived by users. Copyright © 2013 John Wiley & Sons, Ltd.     

Retinal photography for diabetic retinopathy screening in Indigenous primary health care: the Inala experience

Objective: We aimed to determine the impact of clinic based retinal photography on access to appropriate screening for diabetic retinopathy (DR). Design, setting and participants: We opportunistically recruited patients undergoing their annual diabetic cycle of care over a two year period in the urban Indigenous primary health care clinic. Data were collected on retinal outcomes, health variables and referral patterns. Main outcome measures: Access to appropriate screening and ophthalmic follow up, prevalence of DR, acceptability and feasibility of clinic‐based retinal photography were the main outcome measures of this study. Results: One hundred and thirty‐two of a possible 147 patients consented to participate. 30% of participants had DR. Appropriate screening and ophthalmic follow up increased six fold, from 20 to 124 participants, following the introduction of the retinal camera. Most participants felt very positive about DR screening. Conclusions: Primary care DR screening using retinal photography can improve access to DR screening for indigenous patients, reduce the burden on busy outpatient departments and should reduce visual loss. Policy‐makers could contribute to screening sustainability by funding a medicare item‐number for primary care based DR screening associated with the annual diabetic cycle of care. An upfront Practice Incentive Program (PIP) payment could offset set up costs.     

The comparison of health status and health services utilisation between Indigenous and non-Indigenous infants in Australia

Objective: To examine the differences in health services utilisation and the associated risk factors between Indigenous and non-Indigenous infants at a national level in Australia.
Methods: We analysed data from a national representative longitudinal study, the Longitudinal Study for Australian Children (LSAC) starting in 2004. We used survey logistic regression and survey multiple linear regression to examine the factors associated with health services utilisation.
Results: Health status of Indigenous infants was poorer than that of non-Indigenous. In comparison to non-Indigenous infants, in the previous 12-month period, the Indigenous infants were significantly less likely to use the following health services: maternal and child health centre or help lines (OR=0.35, 95%CI: 0.24-0.49); maternal and child health nurse visits (OR=0.45, 95%CI: 0.32-0.63); general practitioners (GPs) (OR=0.45, 95%CI: 0.31-0.64); and paediatrician (OR=0.52, 95%CI: 0.35-0.77). In contrast, they were more likely to visit a hospital outpatient clinic (OR=1.82, 95%CI: 1.16-2.85). Mothers' age, education and marital status were associated with certain health services use. Financial status and residential location were the important predictors of the use of health services.
Conclusion: The rates of health services utilisation by Indigenous infants were lower and were associated with mothers' characteristics and socio-economic status.
Implications: The gaps in health services utilisation between Indigenous and non-Indigenous infant requires immediate policy initiatives. Further research is needed to explore the causal pathways between health status, health services utilisation and multiple risk factors at different levels.