Patterns of health service utilization and perceptions of needs and services in rural Orissa

Despite emphasis on strengthening local health care provision, concern remains regarding the rates of utilization of state-provided services within Orissa. The reported study examined patterns of service utilization across the rural population of four districts of Orissa, with special reference to perceptions of the availability and quality of state services at the primary care level. Within the selected districts, 219 interviews were conducted across 66 villages. Households reported utilizing a wide range of health care providers, although hospitals constituted the most frequently--and primary health care centres (PHCs) the least frequently--accessed services. Private practitioners (qualified and unqualified) represented a major sector of provision. This included high rates of access by scheduled tribes and castes (running at approximately twice the rate of access to both local and PHC provision). Key factors guiding patterns of utilization were reputation of the provider, cost and physical accessibility. Local health provision through assistant nurse midwives and male health workers was generally perceived of poor quality, with the lowest rates of resolution of health problems of all service providers. The location of a sub-centre base for assistant nurse midwives within a village had no demonstrable impact on access to services. Acknowledging constraints on broader generalization, the implications of the findings for informing health policy and programming within Orissa are noted. This includes support for current efforts to strengthen the capacity of PHC and sub-centre level provision within the state, and acknowledgement of the potentially growing role of effectively regulated private provision in meeting the needs of the rural poor.     

Imbalances in the health labour force: an assessment using data from three national health facility surveys

Accurate knowledge of the characteristics of the health labour force that can affect health care production is of critical importance to health planners and policymakers. This study uses health facility survey data to examine characteristics of the primary health care labour force in Nicaragua, Tanzania and Bangladesh. The characteristics examined are those that are likely to affect service provision, including urban/rural distribution, demographic characteristics, and experience and in-service training, for three types of providers (physicians, nurses and auxiliary nurses). The profiles suggest a pattern of urban/rural imbalances in Nicaragua and Tanzania. The Bangladesh facility survey did not include hospitals, thereby making concrete conclusions on the supply and distribution of providers difficult to make. Multivariate logistic regressions are used to assess the relationship between the urban/rural placement of providers by health need, population demand and facility characteristics. Health need, as measured by child mortality rates, does not have a significant association with the placement of providers in either country, unlike population size and annual growth rates. The mean number of years providers have worked at a facility is significantly associated with a decreased likelihood of rural placement for the three types of providers in Nicaragua. The mean age and percentage of female providers at each facility has a negative association with the placement of rural providers in Tanzania. The use of health facility data to profile the health care labour force is also discussed.     

Providers’ perceptions of Aboriginal palliative care in British Columbia’s rural interior

Aboriginal Canadians experience a disproportionate burden of ill‐health and have endured a history of racism in accessing and using health care. Meanwhile, this population is rapidly growing, resulting in an urgent need to facilitate better quality of living and dying in many ways, including through enhancing (cultural) access to palliative care. In this article, we report the findings from a qualitative case study undertaken in rural British Columbia, Canada through exploring the perceptions of Aboriginal palliative care in a region identified as lacking in formal palliative care services and having only a limited Aboriginal population. Using interview data collected from 31 formal and informal palliative care providers (May–September 2008), we thematically explore not only the existing challenges and contradictions associated with the prioritisation and provision of Aboriginal palliative care in the region in terms of (in)visibility but also identify the elements necessary to enhance such care in the future. The implications for service providers in rural regions are such that consideration of the presence of small, and not always ‘visible’, populations is necessary; while rural care providers are known for their resilience and resourcefulness, increased opportunities for meaningful two‐way knowledge exchange with peers and consultation with experts cannot be overlooked. Doing so will serve to enhance culturally accessible palliative care in the region in general and for Aboriginal peoples specifically. This analysis thus contributes to a substantial gap in the palliative care literature concerning service providers’ perceptions surrounding Aboriginal palliative care as well as Aboriginal peoples’ experiences with receiving such care. Given the growing Aboriginal population and continued health inequities, this study serves to not only increase awareness but also create better living and dying conditions in small but incremental ways.     

Key considerations in delivering appropriate and accessible health care for rural and remote populations: Discussant overview

Objective:  To provide an overview of papers discussing optimal service delivery models for rural and remote Australia.
Design:  A synthesis of overarching considerations guiding rural and remote health service policies.
Setting:  Small rural and remote communities in Australia.
Participants:  Invited delegates attending the Inaugural Rural and Remote Health Scientific Symposium in Brisbane 2008.
Main outcome measures:  Key issues underpinning health service provision for small rural and remote communities.
Results:  The formulation and implementation of effective health service provision policies must be underpinned by overarching health goals, agreed health service requirements, recognition of how rural and remote health contexts impact upon health service provision and the constraints limiting health service responses.
Conclusion:  Systemic change is required in order to ensure equitable access to health care services in small rural and remote communities.     

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.     

Responding to the health needs of women from migrant and refugee backgrounds—Models of maternity and postpartum care in high‐income countries: A systematic scoping review

Pregnant women from migrant and refugee backgrounds living in high‐income countries (HIC) are at increased risk of adverse perinatal outcomes compared with women born in the host country. Women from migrant and refugee background have perinatal healthcare needs that are recognised internationally as a public health priority. The aim of this study was to identify, appraise and synthesise available evidence on the effectiveness of models of care in pregnancy or first 12 months postpartum for women from migrant and refugee backgrounds living in HIC. Care models were mapped in terms of (a) effectiveness at improving service access, (b) effectiveness at improving maternal and infant health outcomes, (c) acceptability and appropriateness from the perspective of women and (d) acceptability and appropriateness from the perspective of service providers. Using systematic scoping review methodology, qualitative, quantitative, and mixed methods research published in English 2008–2019 were included. The databases MEDLINE, Embase, Emcare, PubMed, Scopus, CINAHL, PsycINFO, Web of Science, Google Scholar, Cochrane Database of Systematic Reviews and Joanna Briggs Institute were searched between 27 February 2019 and updated 27 December 2019. Qualitative and quantitative data were analysed narratively. Seventeen studies, involving 1,499 women and 203 service providers, were included. A diverse range of interventions were identified, including bilingual/bicultural workers, group antenatal care and specialised clinics. All identified interventions were acceptable to women, and improved access, however, few provided evidence of improved perinatal outcomes. Gaps identified for future research include the use of qualitative and quantitative approaches to ascertain the experiences of women, their families, service providers and impact on perinatal outcomes. Synthesis of the included studies indicates the key elements of acceptable and accessible models, which were as follows: culturally responsive care, continuity of care, effective communication, psychosocial and practical support, support to navigate systems, flexible and accessible services.     

农村孕产期保健服务可及性的定性研究

目的:了解安徽省农村孕产期保健服务可及性,为制定干预方案及改善我国农村孕产期保健服务提供科学依据。方法:选取服务提供者及地方不同级别的关键知情人采用焦点小组访谈和个人深入访谈进行定性调查。结果:产前检查、住院分娩、产后访视和健康教育在乡镇卫生院都已开展,但是数量和质量达不到要求;计划生育部门协助开展了部分孕产期保健服务。近几年,服务提供者提高重视程度、加大经费投入、加强人员培训、加大宣传力度、改变行政管理,提高了孕产期保健服务的可及性。但是也存在资金投入不足、资金分配不平衡、"重临床轻保健"思想、健康教育不足、妇幼保健网络建设不完善、人力制约因素、私人门诊增加等问题,制约了孕产期保健的发展。结论:农村孕产期保健服务取得了一定的成绩,同时也存在着制约服务可及性的问题,应该采取因地制宜的措施,探索新的政府投入方式、乡镇和农村结合的孕产期保健模式,制定统一的孕产期保健服务规范等。     

Helping policy‐makers address rural health access problems

This paper provides a comprehensive review of the key dimensions of access and their significance for the provision of primary health care and a framework that assists policy‐makers to evaluate how well policy targets the dimensions of access. Access to health care can be conceptualised as the potential ease with which consumers can obtain health care at times of need. Disaggregation of the concept of access into the dimensions of availability, geography, affordability, accommodation, timeliness, acceptability and awareness allows policy‐makers to identify key questions which must be addressed to ensure reasonable primary health care access for rural and remote Australians. Evaluating how well national primary health care policies target these dimensions of access helps identify policy gaps and potential inequities in ensuring access to primary health care. Effective policies must incorporate the multiple dimensions of access if they are to comprehensively and effectively address unacceptable inequities in health status and access to basic health services experienced by rural and remote Australians.     

我国基层卫生机构服务功能分析

基层卫生机构功能决定着基本卫生服务的供给。本文利用国家第四次卫生服务总调查以及专题调查资料,对城乡基层卫生机构服务开展情况进行了分析。根据经济社会发展水平、基层卫生机构服务能力和城乡居民需要解决的主要健康问题,本研究将基本卫生服务项目按照优先程度分为三个等级。约三分之一的城乡基层卫生机构尚不能提供最应优先开展的基本卫生服务;农村基层卫生机构服务能力与城市基层卫生机构相比更为薄弱,特别是村级卫生机构基本卫生服务能力需要加强;乡镇卫生院和社区卫生服务中心开展最优先项目的比例均不足70%;村卫生室和社区服务站开展最优先项目比例分别为62%和77%。影响基层卫生机构功能的主要因素为人员数量不足、人员能力不够、缺乏运转资金等。需要以基层卫生机构功能建设为核心,创新我国基本医疗卫生保健体系。     

HIV Testing and HIV/AIDS Treatment Services in Rural Counties in 10 Southern States: Service Provider Perspectives

Context: Forty percent of AIDS cases are reported in the southern United States, the region with the largest proportion of HIV/AIDS cases from rural areas. Data are limited regarding provider perspectives of the accessibility and availability of HIV testing and treatment services in southern rural counties. Purpose: We surveyed providers in the rural south to better understand: (1) the accessibility and availability, and (2) the facilitators and barriers of HIV testing and treatment services. Methods: All county health departments (N = 326) serving populations of <50,000 persons, within 10 southern states, were mailed surveys. Responding health departments identified up to 3 HIV testing sites and up to 3 HIV treatment sites to which they refer clients. Findings: Overall, 243 of 326 (75%) health departments, 133 of 250 (53%) HIV testing sites, and 73 of 152 (48%) HIV treatment sites responded to the surveys. The number of testing sites per county ranged from 0 to 20; the number of treatment sites ranged from 0 to 4. An average distance of 50 miles for clients to travel for HIV treatment was reported by health department respondents as a barrier. Facilitators of HIV testing were (1) integrating HIV testing into other health services; (2) using rapid HIV testing; and (3) establishing easily accessible HIV testing locations and free testing services. Conclusion: Providers perceive that distance from local health departments to HIV treatment sites presents a barrier to HIV care for their clients. Future studies should ascertain clients’ perspectives to ensure appropriate service provisions.     

The excess health care costs of KardioPro,an integrated care program for coronary heart disease prevention

Coronary heart disease (CHD) is a major cause of death and important driver of health care costs. Recent German health care reforms have promoted integrated care contracts allowing statutory health insurance providers more room to organize health care provision. One provider offers KardioPro, an integrated primary care-based CHD prevention program. As insurance providers should be aware of the financial consequences when developing optional programs, this study aims to analyze the costs associated with KardioPro participation. 13,264 KardioPro participants were compared with a propensity score-matched control group. Post-enrollment health care costs were calculated based on routine data over a follow-up period of up to 4 years. For those people who incurred costs, KardioPro participation was significantly associated with increased physician costs (by 33%), reduced hospital costs (by 19%), and reduced pharmaceutical costs (by 16%). Overall costs were increased by 4%, but this was not significant. Total excess costs per observation year were €131 per person (95% confidence interval: [€−36.5; €296]). Overall, KardioPro likely affected treatment as the program increased costs of physician services and reduced costs of hospital services. Further effects of substituting potential inpatient care with increased outpatient care might become fully apparent only over a longer time horizon.     

Policy barriers for advanced practice nurses in rural health care

ObjectivesThe objective of this paper was to examine rural health access to care, barriers to practice for Advanced Practice Nurses (APNs) in rural health, explore solutions, and arrive at a policy change that would improve rural citizens′ access to health care. This policy change should improve access to care, be cost-efficient, and have ease of implementation.MethodsMethods used for research included online health care journals, original research, and government statistics and websites. Sources were PubMed, Google Scholar, state Boards of Nursing publications including Scope of Practice statutes, and Rural Health Associations′ publications.ResultsBackground information and evidence was gathered, and 3 alternatives were explored: (1) Increasing incentives to practitioners to practice in rural areas, (2) Removing regulatory barriers to practice for APNs in rural health, and (3) Funding original research to determine optimal provider mix in rural health care. Advantages and disadvantages to these alternatives were examined with respect to population benefit, cost-effectiveness, administrative feasibility, and resource allocation equity. The 2nd alternative was determined to be the most effective.ConclusionAccess to health care for rural citizens is significantly worse than for urban dwellers, and the current methods of improving it are inadequate. The situation will be worsened by the projected shortage of primary care providers in the future, and therefore action to improve this is imperative. This situation can be greatly improved by removing barriers to practice for APNs to enable them to better provide care in rural areas, thus increasing rural citizens′ access to health care.     

“If Only Someone Had Told Me …”: Lessons From Rural Providers

Purpose: Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers’ knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains. Methods: Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, “What are the 3 things you wish someone would have told you about delivering health care in rural areas?” were thematically coded. Findings: Emergent themes coalesced into 3 overarching themes addressing practice‐related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner. Conclusion: Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.     

公共卫生保障体系的建立与农村卫生改革

SARS的肆虐,使我们看到了建立公共卫生保障体系的迫切性;“三农”问题的日益突出,使农村卫生改革变得更加刻不容缓。把公共卫生保障体系的建立与农村卫生的改革有机地融合在一起,是一个新的思路,也是一个新的课题。本文试图对此作初步的探讨。     

Organizing health care within political turmoil: the Palestinian case

Palestinians were given control over their own health services in late 1994. Since then they have been facing the challenge of reorganizing disordered health services into a cohesive, regulated and sustainable health care system. This paper focuses on the experience of organizing health care during political instability. It considers the ways that health care is currently provided and funded in the Palestinian Territories. The patterns of accessibility to health care services in terms of insurance coverage and provision (physical allocation) of services are discussed. Finally, the major health care policy changes in this transitional period are examined.     

The tradeoff between centralized and decentralized health services: Evidence from rural areas in Mexico

This study investigates the effectiveness of centralized and decentralized health care providers in rural Mexico. It compares provider performance since both centralized and decentralized providers co-exist in rural areas of the country. The data are drawn from the 2003 household survey of Oportunidades, a comprehensive study of rural families from seven states in Mexico. The analyses compare out-of-pocket health care expenditures and utilization of preventive care among rural households with access to either centralized or decentralized health care providers. This study benefits from differences in timing of health care decentralization and from a quasi-random distribution of providers. Results show that overall centralized providers perform better. Households served by this organization report less regressive out-of-pocket health care expenditures (32% lower), and observe higher utilization of preventive services (3.6% more). Decentralized providers that were devolved to state governments in the early 1980s observe a slightly better performance than providers that were decentralized in the mid-1990s. These findings are robust to decentralization timing, heterogeneity in per capita government health expenditures, state and health infrastructure effects, and other confounders.     

On a European collaboration to identify organizational models,potential shortcomings and improvement options in out-of-hours primary health care

Background: Out-of-hours care (OOHC) provision is an increasingly challenging aspect in the delivery of primary health care services. Although many European countries have implemented organizational models for out-of-hours primary care, which has been traditionally delivered by general practitioners, health care providers throughout Europe are still looking to resolve current challenges in OOHC. It is within this context that the European Research Network for Out-of-Hours Primary Health Care (EurOOHnet) was established in 2010 to investigate the provision of out-of-hours care across European countries, which have diverse political and health care systems. In this paper, we report on the EurOOHnet work related to OOHC organizational models, potential shortcomings and improvement options in out-of-hours primary health care.

Needs assessment: The EurOOHnet expert working party proposed that models for OOHC should be reviewed to evaluate the availability and accessibility of OOHC for patients while also seeking ways to make the delivery of care more satisfying for service providers.

Outcomes: To move towards resolution of OOHC challenges in primary care, as the first stage, the EurOOHnet expert working party identified the following key needs: clear and uniform definitions of the different OOHC models between different countries; adequate—ideally transnational—definitions of urgency levels and corresponding data; and educational programmes for nurses and doctors (e.g. in the use of a standardized triage system for OOHC). Finally, the need for a modern system of data transfer between different health care providers in regular care and providers in OOHC to prevent information loss was identified.     

Service provision and quality outcomes in home health for rural Medicare beneficiaries at high risk for unplanned care

Multiple barriers exist to providing home health care in rural areas. This study examined relationships between service provision and quality outcomes among rural, fee-for-service Medicare beneficiaries who received home health care between 2011 and 2013 for conditions associated with high-risk for unplanned care. More skilled nursing visits, visits by more types of providers, more timely care, and shorter lengths of stay were associated with significantly higher odds of hospital readmission and emergency department use and significantly lower odds of community discharge. Results may indicate unmeasured clinical severity and care needs among this population. Additional research regarding the accuracy of current severity measures and adequacy of case-mix adjustment for quality metrics is warranted, especially given the continued focus on value-based payment policies.     

They aren't all first cousins: Bedouin marriage and health policies in Lebanon

Objective. Fertility and consanguineous marriages among the Bedouin tribes of the Middle East have long generated interest particularly around health outcomes and social relations. In particular, Bedouin in Lebanon have increasingly embraced the Lebanese national bio-medical health system in the past two decades, while Lebanese policy-makers' responses continue to be minimal and ill-informed. This paper investigates the mismatch between policy-makers' formulations of Bedouin consanguineous marriages and the Bedouins's actual reproductive practices and discusses the implications of these formulations on the Bedouins's access to health services.

Design. The findings are drawn from the data collected as part of the Bedouin Health Project, an EU-funded five-year study (2005–2010), aiming at assessing access to reproductive and child health care among the Bedouin in Lebanon. The data was collected from 6 clusters representing the main Bedouin informal and unrecognized settlements in the Bekaa Valley of Lebanon. The data consists of 111 socioeconomic questionnaires with Bedouin women users of local public, private, and nongovernmental reproductive and child health-focused clinics, in addition to 40 in-depth interviews with Bedouin women across the clusters and 17 semi-structured interviews with policy-makers.

Results. The findings suggest a gap between the perceptions of policy-makers and the incidence of consanguineous marriages and reproductive practices among the Bedouin. While there was no national data available for the Bedouin populations, policy-makers relied on a constructed ‘Bedouin reproductive profile’ that portrayed them as ‘a problematic health group’. The national policy formulation of the Bedouin reproductive profile has an exclusionary impact on the Bedouin population as they are ignored from any targeted health policies or provided with politically motivated palliative care provision.

Conclusion. These findings highlight the importance of addressing stereotyping and discrimination among health practitioners and policy-makers, as a crucial part of improving the overall marriage and reproductive health practices of the Bedouin.