The process of social participation in primary health care: the case of Palencia,Guatemala

Background In 2008, the World Health Organization issued a callback to the principles of primary health care, which renewed interests in social participation in health. In Guatemala, social participation has been the main policy for the decentralization process since the late 1990s and the social development council scheme has been the main means for participation for the country’s population since 2002. Aim The aim of this study was to explore the process of social participation at a municipal‐level health commission in the municipality of Palencia, Guatemala. Methods Analysis of legal and policy documents and in‐depth interviews with institutional and community‐level stakeholders of the commission. Results The lack of clear guidelines and regulations means that the stakeholders own motivations, agendas and power resources play an important part in defining the roles of the participants. Institutional stakeholders have the human and financial power to make policies. The community‐level stakeholders are token participants with little power resources. Their main role is to identify the needs of their communities and seek help from the authorities. Satisfaction and the perceived benefits that the stakeholders obtain from the process play an important part in maintaining the commission’s dynamic, which is unlikely to change unless the stakeholders perceive that the benefit they obtain does not outweigh the effort their role entails. Conclusion Without more uniformed mechanisms and incentives for municipalities to work towards the national goal of equitable involvement in the development process, the achievements will be fragmented and will depend on the individual stakeholder’s good will.     

‘Fruit of the accords’: Healthcare reform and civil participation in Highland Guatemala

Governmental-contracting of non-governmental organizations (NGOs) is a central strategy of neoliberal health reforms in Central America. More than improving the equity, efficiency, and quality of health services, contracting presents a potential mechanism to redefine antagonistic relationships between the state and civil society, particularly in countries ravaged by political violence. In this paper I examine the process of heath reform in Guatemala through the implementation of the Sistema Integral de Atención en Salud (SIAS) in the municipality of San Martín Jilotepeque. Mandated in the 1996 Peace Accords, SIAS potentially facilitates decentralization and civil participation through governmental-contracting of NGOs to provide health services to underserved populations. Drawing on ethnographic interviews with NGO representatives, Ministry of Health (MOH) workers, and community health workers and midwives, I examine the contracting process and then address issues of equity, efficiency, and quality of services, as well as the process of decentralization. I argue that contracted NGOs are largely restricted to serve as administrators, removed from the delivery of services, and are heavily dependent upon the traditional MOH structure, which limits the ability of SIAS to improve health services or foster the processes of decentralization and democratization.     

Palliative care in public health: a formal and content-related analysis of European journals

Public health and health care science take on an important role in the further development of palliative care. This study examines to what degree palliative care is represented in the pertinent academic journals of public health and health care science and what the major subjects are. We analysed the European journals that were listed in the Journal Citation Reports in the categories health care science and services, public, environmental and occupational health, as well as health policy and services. The literature search was conducted in the journals identified for the years 1996 through 2005, using the terms palliative care*, palliative medicine*, terminal care* and hospice care*. The analyses were based on the quantity of publications in the journals, the publication years, the impact factors and the subjects focused on. There were 82 journals included. Altogether, 57,737 publications appeared during the analysis period; 166 papers were on palliative care (0.3% of all papers). The majority of palliative care articles (55%, n = 91) were concentrated in a very small circle of journals (4%, n = 3). The absolute quantity of palliative publications and their percentage among all publications have continuously increased from 0.1% in 1996/1997 to 0.4% in 2004/2005. The largest group of papers on the subject (42%, n = 70) appeared in journals with impact factors less than 1, whereas the largest group of all papers was found in journals with impact factors of 1–1.999 (51%, n = 15,732). Most papers focus on patient orientation and health professionals’ perspective and education; subjects such as health care utilization and barriers are less frequently covered. There is need for more research on palliative care relevant for public health and health care science in terms of reach and top-level impact. For example, the research questions should deal with health care utilization and potential social and cultural barriers. The interdisciplinary community of public health sets the stage for the required collaborative research activities.     

Provision of surgical care in Ethiopia: Challenges and solutions

With the lowest measured rate of surgery in the world, Ethiopia is faced with a number of challenges in providing surgical care. The aim of this study was to elucidate challenges in providing safe surgical care in Ethiopia, and solutions providers have created to overcome them. Semi-structured interviews were conducted with 10 practicing surgeons in Ethiopia. Following de-identification and immersion into field notes, topical coding was completed with an existing coding manual. Codes were adapted and expanded as necessary, and the primary data analyst confirmed reproducibility with a secondary analyst. Qualitative analysis revealed topics in access to care, in-hospital care delivery, and health policy. Patient financial constraints were identified as a challenge to accessing care. Surgeons were overwhelmed by patient volume and frustrated by lack of material resources and equipment. Numerous surgeons commented on the inadequacy of training and felt that medical education is not a government priority. They reported an insufficient number of anaesthesiologists, nurses, and support staff. Perceived inadequate financial compensation and high workload led to low morale among surgeons. Our study describes specific challenges surgeons encounter in Ethiopia and demonstrates the need for prioritisation of surgical care in the Ethiopian health agenda.

Abbreviations: LCoGS: The Lancet Commission on Global Surgery; LMIC: low- and middle-income country     

Thinking teams thinking clients: issues of discourse and representation in the work of health care teams

Abstract The use of multi-disciplinary health care teams is an increasingly common aspect of service delivery in health care in Western countries. While the literature rehearses the putative benefits to practitioners and clients of such teams, there appears to be an absence of extensive evidence-based research on team practices to substantiate such claims. What evidence there is suggests that team work is in different ways problematic. This article is a progress report on a qualitative research project into the operation of health teams with responsibility for clients in hospitals and the community in New Zealand. The first part of the article presents some of the main themes in current research on health care teams. The second part argues that effective teamwork requires giving attention to a hitherto marginalised dimension of teamwork - the team's reflexive and representational practices. Attention to these practices appears to be particularly important in complex cases or when the team believes that its work with the client is not progressing as well as it might. The article concludes by highlighting the sociological significance of representational issues in team work and by drawing some inferences about factors affecting effective teamwork.     

La Revolución Ciudadana and social medicine: Undermining community in the state provision of health care in Ecuador

ABSTRACT

Under President Rafael Correa (2007–2017), Ecuador’s Ministry of Health established a state-centred health care regime that incorporates elements of Latin American social medicine into post-neoliberalism. These initiatives – which are part of ‘The National Plan for Good Living (Buen Vivir)’ – include free healthcare, greater attention to social determinants of health, a focus on equity and inclusion, and increased coordination across welfare, health, and development sectors. However, the reforms also use health services to build a sense of inclusive, participatory citizenship, with the Ecuadorean state as the central figure in service provision. In this paper, we demonstrate that state-centred health care reforms have paradoxically weakened community organising for collective health. Drawing on seventeen years of ethnographic research and health solidarity work in rural Northwest Ecuador, we illustrate how Ecuador’s health reforms have reconfigured relations among local civil society, transnational NGOs, and the state. Established modes of community participation and international collaboration have been undermined largely because these reforms ignore community sovereignty and self-organisation and overemphasise the threat of neoliberalism. The lessons about balancing the state-based fulfilment of rights with community power are relevant to social medicine advocates, particularly those working in rural communities that are already organising creatively for their own health and well-being.     

基层卫生服务医防融合：概念框架及指标体系构建

目的本研究致力于构建医疗服务和预防服务融合的概念框架, 设计医防融合水平测量的指标体系,并用实证数据测试指标体系的信度和适用性。方法结合现有整合型卫生服务体系的概念框架和我国卫生体系的特征,构建基层卫生服务提供中医防融合的概念框架;利用德尔菲专家咨询法构建医防融合水平测量的指标体系;测试指标体系的调查数据来自广西两县中6个乡镇的医疗机构、医务人员、重点疾病患者以及常住居民。结果我国基层卫生服务提供机构在“基本公共卫生服务”和“基本医疗服务”上的融合表现在个人、机构和体系三个层次上,融合的实现需要在筹资激励、组织、信息系统和人才培养等方面的支持环境,供方融合行为可促进需方预防性服务利用和健康行为的改善。基于此框架开发了包括5个维度、共28个指标的测量指标体系。在广西两县测试指标体系,显示测量结果与两县整合导向改革阶段相符合,并识别出医防融合支持环境中需要加强“激励”和“组织”维度。结论本研究指标体系整体信度较好,能识别需要加强的支持政策,在整合型卫生体系改革背景下,有在全国不同卫生体系发展水平地区测试和应用的价值。     

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study

BackgroundWidespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team‐based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care.ObjectiveThe main study objective was to understand patients’ perspectives on the quality of care that they received for anxiety and depression in primary care teams.MethodsThis was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data.ResultsForty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs.ConclusionGreater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.     

Effectiveness of an NGO primary health care programme in rural Bangladesh: evidence from the management information system

This paper considers evidence of the effectiveness of a non-governmental organization (NGO) primary health care programme in rural Bangladesh. It is based on data from the programme's management information system reported by 27 partner NGOs from 1996-2002. The data indicate relatively high coverage has been achieved for reproductive and child health services, as well as lower infant and child mortality. On the basis of a crude indicator of socio-economic status, the programme is poverty-focused. There is good service coverage among the poorest one-third and others, and the infant and child mortality differential has been eliminated over recent years. A rapid decline in infant mortality among the poorest from 1999-2002 reflects a reduction in neonatal mortality of about 50%. Allowing for some under-reporting and possible misclassification of deaths to the stillbirths category, neonatal mortality is relatively low in the NGO areas. The lower child and maternal mortality for the NGO areas combined, compared with estimates for Bangladesh in recent years, may at least in part be due to high coverage of reproductive and child health services. Other development programmes implemented by many of the NGOs could also have contributed. Despite the limited resources available, and the lower infant and child mortality already achieved, there appears to be scope for further prevention of deaths, particularly those due to birth asphyxia, acute respiratory infection, diarrhoeal disease and accidents. Maternal mortality in the NGO areas was lower in 2000-02 than the most recent estimate for Bangladesh. Further reduction is likely to depend on improved access to qualified community midwives and essential obstetric care at government referral facilities.     

Clinical research and global health: Mentoring the next generation of health care students

Abstract

Interest in global health and opportunities to conduct clinical research at international sites have increased markedly for health profession trainees. With this increase in demand comes an increase in the need for mentors at international and home institutions to provide guidance with designing, implementing and analysing clinical research projects that benefit both the trainees and the research site. In this article, we provide an overview of our insights gained through mentoring in the international setting and suggest a series of key points to help ensure an enjoyable and productive international clinical research experience for both trainees and mentors.     

Informal and formal care for elderly persons: how adult children's characteristics affect the use of formal care in Japan

Informal care by adult children remains the most common source of caregiving for elderly parents in Japan, even after the introduction of long-term care insurance in 2000. We estimate how the potential supply of child caregivers affects the use of formal care of elderly parents, focusing on the differences across children. We find that the effects of children's presence vary substantially with gender, marital status, and opportunity costs of children. The potential supply of daughters-in-law, as the traditional source of informal care, is less important in providing care than that of unmarried children. The opportunity costs of children make a difference in the use of formal long-term care.     

Rebuilding a health care system: war, reconstruction and health care reforms in Kosovo

This article explores the complexity of a health care system reforms in a post-conflict situation. It describes how the health care system was revamped immediately after the war, and then reorganized with Primary Health Care (PHC) as the fulcrum for change. It highlights the coordination problems, typical of a post-war situation when un-coordinated humanitarian assistance pours in. From the vantage points of Ministry of Health officials, the article details how the change process has gone over the years, the directions it has taken and the lessons learnt. It notes that reforms are often so fast that they outstrip the absorption capacity of the potential change agents because of their inadequate preparation for the new roles and responsibilities. This in turn threatens to undermine and weaken the very system that the reforms seek to strengthen. Several options adopted for change in Kosovo's health care system are at varying levels of implementation today. Some commentators have questioned if the policy for the new health care system has failed. We contend that there have been major organizational successes. But there are also shortcomings. There is also a potential danger that the health care system could partly revert to the old system. While some of the successes and shortcomings may be specific to Kosovo, many lessons learnt from Kosovo apply to health care reforms elsewhere.     

Evaluating health care programs by combining cost with quality of life measures: a case study comparing capitation and fee for service

Objective. To demonstrate cost-effectiveness analysis (CEA) for evaluating different reimbursement models.
Data Sources/Study Setting. The CEA used an observational study comparing fee for service (FFS) versus capitation for Medicaid cases with severe mental illness ( n =522). Under capitation, services were provided either directly (direct capitation [DC]) by not-for-profit community mental health centers (CMHC), or in a joint venture between CMHCs and a for-profit managed behavioral health organization (MBHO).
Study Design. A nonparametric matching method (genetic matching) was used to identify those cases that minimized baseline differences across the groups. Quality-adjusted life years (QALYs) were reported for each group. Incremental QALYs were valued at different thresholds for a QALY gained, and combined with cost estimates to plot cost-effectiveness acceptability curves.
Principal Findings. QALYs were similar across reimbursement models. Compared with FFS, the MBHO model had incremental costs of −$1,991 and the probability that this model was cost-effective exceeded 0.90. The DC model had incremental costs of $4,694; the probability that this model was cost-effective compared with FFS was <0.10.
Conclusions. A capitation model with a for-profit element was more cost-effective for Medicaid patients with severe mental illness than not-for-profit capitation or FFS models.     

从对“看病贵”问题看我国医疗保障制度的变革及其存在的问题

我国卫生总费用占GDP的5.6%,没有理由说我国卫生总费用超过了其社会平均支付能力。但为何看病贵问题成为当前我国全社会普遍关心的问题呢?笔者认为,在卫生总费用没有超过社会平均支付能力前提下,看病贵问题凸现的是不健全的医疗保障制度带来的费用风险机制的缺失。医疗保障制度改革中,处理好政府宏观调控和市场机制的关系,增加政府筹资职能从而确保筹资体系的稳定性和公平性,扩大医疗保障制度的覆盖面,提高现有保障制度的风险分担机制,完善保障制度的费用控制措施,应成为改革关键点。     

Knowledge and expertise in care practices: the role of the peer worker in mental health teams

Our research examines how different forms of knowledge and expertise are increasingly important in caring for people experiencing mental illness. We build on theoretical developments regarding multiple ontologies of knowing about illness. We examine how experiential knowledge of mental health problems, learned by being subject to illness rather than through objective study, is enacted in mental healthcare teams. We focus on Peer Workers (PW), individuals who have lived experience of mental health problems, and who contribute knowledge and expertise to mental health care within multidisciplinary healthcare teams. Our longitudinal study was undertaken over 2 years by a multidisciplinary team who conducted 91 interviews with PW and other stakeholders to peer support within a comparative case study design. We show how workers with tacit, experiential knowledge of mental ill health engaged in care practice. First, we show how subjective knowing is underpinned by unique socialisation that enables the development of shared interactional spaces. Second, we point to how the situated nature of subjective knowing is uniquely embedded in time and space and allows for the alignment of embodied knowledge with trajectories of care. Third, we provide insight into how subjective forms of expertise might be incorporated into multidisciplinary care.     

Evaluating the impact of integrated health and social care teams on older people living in the community

Although it is perceived wisdom that joint working must be beneficial, there is, even at this stage, little evidence to support that notion. The present study is an evaluation of two integrated co-located health and social care teams which were established in a rural county to meet the needs of older people and their carers. This study does identify that patients from the 'integrated teams' may self-refer more and are assessed more quickly. This might indicate that the 'one-stop shop' approach is having an impact on the process of service delivery. The findings also suggest that, in the integrated teams, the initial stages of the process of seeking help and being assessed for a service may have improved through better communication, understanding and exchange of information amongst different professional groups. However, the degree of 'integration' seen within these co-located health and social care teams does not appear to be sufficiently well developed to have had an impact upon the clinical outcomes for the patients/service users. It appears unlikely from the available evidence that measures such as co-location go far enough to produce changes in outcomes for older people. If the Department of Health wishes to see benefits in process progress to benefits to service users, then more major structural changes will be required. The process of changing organisational structures can be enhanced where there is evidence that such changes will produce better outcomes. At present, this evidence does not exist, although the present study does suggest that benefits might be forthcoming if greater integration can be achieved. Nevertheless, until the social services and National Health Service trusts develop more efficient and compatible information systems, it will be impossible to evaluate what impact any further steps towards integration might have on older people without significant external resources.     

社会医疗保险配套医药卫生政策存在的问题及对策探讨

目前我国医疗保险、医疗卫生和医药行业未能同步协调发展影响了我国社会医疗保险制度的顺利实施。文章分析了我国社会医疗保险制度的相关配套医药卫生政策方面存在的问题及改进对策。     

Typical electronic health record use in primary care practices and the quality of diabetes care

PURPOSE

Recent efforts to encourage meaningful use of electronic health records (EHRs) assume that widespread adoption will improve the quality of ambulatory care, especially for complex clinical conditions such as diabetes. Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care, and effects of longer-term EHR use in community-based primary care settings on the quality of care are not well understood.

METHODS

We analyzed data from 16 EHR-using and 26 non–EHR-using practices in 2 northeastern states participating in a group-randomized quality improvement trial. Measures of care were assessed for 798 patients with diabetes. We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence-based diabetes care guidelines, and hierarchical logistic models to compare rates of improvement over 3 years.

RESULTS

EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A_1c, low-density lipoprotein cholesterol, and blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI, 1.12–2.51). Although the quality of care improved across all practices, rates of improvement did not differ between the 2 groups.

CONCLUSIONS

Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care. Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care. These efforts will need to include provision of assistance to longer-term EHR users.