Weaknesses and challenges of primary healthcare system in Iran: a review

While the primary healthcare (PHC) services in Iran were appropriate to the needs of the population in the late 1970s and 1980s, the changing burden of disease and shifting demand patterns have rendered the existing PHC system no longer suitable for meeting current and emergent needs. This has serious implications for the PHC system in Iran, which has clearly succeeded in addressing high levels of communicable diseases, maternal deaths and infant mortality, but appears less well prepared to address the emerging challenges of noncommunicable diseases (NCD). We conducted a systematic review of the available literature in the past 10 years related to the PHC system in Iran to assess its weaknesses and challenges. This paper categorizes PHC system weaknesses from the studied articles into two groups: (i) those related to the key functions of PHC, and (ii) others, which refer to health system weaknesses existing with the current PHC model. Iran can draw on international experience and evidence regarding interventions, which can be used to develop an effective and responsive PHC system designed to address current and emerging needs, in particular the NCD burden.     

The provincial health office as performance manager: change in the local healthcare system after Thailand's universal coverage reforms

This paper examines the implementation of Thailand's universal coverage healthcare reforms in a rural province, using data from field studies undertaken in 2003–2005 and 2008–2011. We focus on the strand of policy that aimed to develop primary care by allocating funds to contracting units for primary care (CUPs) responsible for managing local service networks. The two studies document a striking change in the balance of power in the local healthcare system over the 8‐year period. Initially, the newly formed CUPs gained influence as ‘power followed the money’, and the provincial health offices (PHOs), which had commanded the service units, were left with a weaker co‐ordination role. However, the situation changed as a new insurance purchaser, the National Health Security Office, took financial control and established regional outposts. National Health Security Office outposts worked with PHOs to develop rationalised management tools—strategic plans, targets, KPIs and benchmarking—that installed the PHOs as performance managers of local healthcare systems. New lines of accountability and changed budgetary systems reduced the power of the CUPs to control resource allocation and patterns of services within CUP networks. Whereas some CUPs fought to retain limited autonomy, the PHO has been able to regain much of its former control. We suggest that implementation theory needs to take a long view to capture the complexity of a major reform initiative and argue for an analysis that recognises the key role of policy networks and advocacy coalitions that span national and local levels and realign over time. Copyright © 2012 John Wiley & Sons, Ltd.     

Healthcare professionals’ accounts of challenges in managing motor neurone disease in primary healthcare: a qualitative study

Motor neurone disease (MND) is a progressive neurological disease causing muscle wasting, gradual paralysis and respiratory failure, with a life expectancy of 2–4 years. In order to better understand how MND is managed in the community, we conducted a qualitative study to explore the challenges healthcare professionals encounter when managing MND in primary healthcare. Based on data from 15 semi‐structured interviews with primary healthcare professionals in Norway, we found that MND is viewed as a condition that requires exceptional effort and detailed planning. Healthcare professionals reported five main challenges in managing MND in primary healthcare: (i) building relationships with those giving and receiving care in the home; (ii) preventing caregiver burnout and breakdown; (iii) providing tailored care; (iv) ensuring good working conditions in patients’ homes; and (v) recruiting and retaining qualified nursing assistants. Healthcare professionals reported needing working conditions that allow them to tailor their approach to the personal, emotional and existential nature of care preferences of those living with MND. However, people with MND and their families were sometimes perceived by healthcare professionals to prefer a strictly task‐focused relationship with care providers. Such relationships limited the healthcare professionals’ control over the MND trajectory and their capacity to prevent family caregiver burnout and breakdown. Adequate resources, along with training and support of nursing assistants, may increase the continuity of nursing assistants. Responsiveness to patient and family needs may enhance collaboration and promote tailored primary care and support for patients with MND and their families.     

Upscaling the recruitment and retention of human resources for health at primary healthcare centres in Lebanon: a qualitative study

The sustainability of primary healthcare (PHC) worldwide has been challenged by a global shortage in human resources for health (HRH). This study is a unique attempt at systematically soliciting and synthesising the voice of PHC and community stakeholders on the HRH recruitment and retention strategies at the PHC sector in Lebanon, the obstacles and challenges hindering their optimisation and the recommendations to overcome such obstacles. A qualitative design was utilised, involving 22 semi‐structured interviews with PHC experts in Lebanon conducted in 2013. Nvivo qualitative data analysis software was employed for the thematic analysis of data collected from interviews. Five comprehensive themes emerged: understanding PHC scope, HRH recruitment issues, HRH retention challenges, rural areas' specific challenges and stakeholders' recommendations. Analysis of stakeholders' responses revealed a lack of a unified understanding of the PHC scope impacting the capacity for appropriate HRH planning. Identified impediments to recruitment included the suboptimal supply of HRH, financial constraints and poor management. Retention difficulties were attributed to poor working environments, financial constraints and lack of professional development. There was consensus that HRH challenges faced were aggravated in rural areas, jeopardising the equitable access to PHC services of quality. Equitable access was also jeopardised by the reported shortage of female HRH in a sociocultural context where many females prefer providers of the same gender. The study sets the path towards upscaling recruitment and retention policies and practices through the endorsement of a nationally acknowledged PHC definition and scope, the sustainable development of the PHC workforce and through the implementation of targeted recruitment and retention strategies addressing rural settings and gender equity. Decision‐makers and planners are urged to identify HRH as the most important input for the success of PHC programmes and interventions, especially in the growing fields of mental health and geriatric care.     

Identifying barriers to move to better health coverage: preferences for health insurance benefits among the rural poor population in La Guajira,Colombia

Even though access to health insurance in Colombia has improved since the implementation of the 1993 health reforms (Law 100), universal coverage has not yet been accomplished. There is still a segment of the population under the low‐income (subsidized) health insurance policy or without health insurance altogether. The purpose of this research was to identify preferences and behavior regarding health insurance among the subsidized rural population in La Guajira, Colombia, and to understand why that population remains under the subsidized health insurance policy. The field experiment gathered information from 400 households regarding their socioeconomic situation, health conditions, and preferences for health insurance characteristics. Results suggest that the surveyed population gives priority to expanded family coverage, physician and hospital choice, and access to specialists, rather than to attributes associated with co‐payments or premiums. That indicates that people value healthcare benefits and family coverage more than health insurance expenses, and policy makers could use these preferences to enroll subsidized population into the contributory regime. Copyright © 2014 John Wiley & Sons, Ltd.     

Collaboration and local networks for rural and remote primary mental healthcare in South Australia

This paper draws on a consultation with 200 stakeholders about a mental health plan in the most remote region of South Australia to discuss primary mental healthcare improvement strategies. In rural and remote environments, a lack of services means that it is more difficult to deal with a mental illness or provide assistance for circumstantial life problems. The authors' consultations revealed difficulties with service access, acceptability and teamwork. They also found that the availability of local human service workers leads to their use as first-level mental health contacts, but these workers are neither skilled nor supported for this. These difficulties will require attention to the boundaries between different service providers which can otherwise create inflexibility and service gaps. The regional mental health plan that is being rolled out will develop collaboration through regional interagency task groups, networking groups for local human service workers and the position of a regional mental health coordinator in order to overcome these difficulties and to operationalise service partnerships.     

Primary healthcare personnel challenges and barriers on the management of patients with multimorbidity in Albania

The number of people living with chronic conditions is increasing worldwide with most of these people receiving the needed healthcare services in primary healthcare (PHC) settings. The objective of this study was to explore the main challenges and barriers that PHC providers confront while treating multimorbid patients. This is a qualitative study utilising semi-structured individual in-depth interviews. The study took place in Vlora City, which is the biggest city located in south Albania. Τhe two biggest PHC centres of the city were enrolled. Purposive sampling method was used to recruit PHC practitioners. Main criteria of participation in the study were being fully employed at the enrolled primary care centres, having worked for at least 1 year and to deal with multimorbid patients in daily practice. Data collection took place from September 2019 to January 2020. In total, 36 semi-structured interviews took place with 23 (63.9%) nurses and 12 (33.3%) physicians (general practitioners/family doctors). Communication problems and disputes, lack of materials/equipment and the inappropriate infrastructure, miscommunication and problems in doctor–nurse relationships, coordination problems, lack of protocols and problems in the referral system were reported as the main challenges and barriers that the PHC personnel confront. The findings of this study are critical in understanding challenges that PHC personnel face when dealing with multimorbid patients in PHC settings. The emerged knowledge contributes significantly in a better understanding of the actual situation and to inform health policy makers on how to deal with the existing problems.     

A multidisciplinary primary healthcare clinic for newly arrived humanitarian entrants in regional NSW: model of service delivery and summary of preliminary findings

Objective: To describe a multidisciplinary primary healthcare clinic for newly arrived humanitarian entrants in regional New South Wales and report health problems and issues encountered during the initial period of operation. Methods: A quality assurance study of the Coffs Harbour Refugee Health Clinic (a collaboration between the Area Health Service and general practitioners) was undertaken from February to December 2006. Results: Seventy‐six patients received a comprehensive health assessment: 69 of these within 12 months of arrival. The median time from arrival in Australia to the first clinic visit was five days. Problems detected were categorised according to their management options. GP clinic providers expressed concern about referring patients to GPs in the community for ongoing care. Conclusions: The Coffs Harbour Refugee Health Clinic represents a successful collaboration between relevant stakeholders. It was well utilised by the target community. Implications: The service delivery model used in the clinic could be replicated in other areas in regional Australia, provided financial and human resources are available.     

From policy to reality: clinical managers' views of the organizational challenges of primary care reform in Portugal

The primary healthcare reform in Portugal is based on the development of a new management model and clinical governance framework. The objective is to strengthen primary healthcare services to reduce the inappropriate utilization of secondary and emergency services and to make efficiency gains and to better control costs. New interventions include the introduction of a system of production‐based incentives for family health units. This paper presents an initial assessment of the implementation of the new policies and tries to explain the gap between its expected results and what was observed in the field 5 years later. We used a Strengths, Weaknesses, Opportunities, and Threats analysis conducted in 12 regions, to collect the perceptions of members of Clinical Councils of Health Centers Groups, responsible for the implementation of the reform. The analysis looked at the dimensions of coverage, productivity, technical quality, and service quality. It identifies weaknesses in human resources management (shortages, incentives, team management) and lack of support from central and regional management. There is a perceived gap between the framework for reform as defined by law and the support made available for its implementation, leading to tensions between decision makers, managers, and health professionals. Copyright © 2012 John Wiley & Sons, Ltd.     

Assessing the quality of preschool child health surveillance in primary care: a pilot study in one health district

OBJECTIVE: To develop a framework for measuring the quality of preschool child health surveillance acceptable to primary health care teams and measurable at individual primary health care team level. DESIGN: Published research evidence was identified and criteria developed by a local multidisciplinary expert group. The criteria were discussed with primary health care teams. How well they were achieved was assessed. SETTING: Twenty-eight general practices in one health authority area. METHODS: Data collection included observation of baby clinics, interviews with health visitors and general practitioners (GPs), questionnaires to parents, collation of child health surveillance reviews recorded in personal child health records and immunization rates. RESULTS: The criteria for assessing preschool child health surveillance were thought to be acceptable and achievable by primary health care teams. Fifteen of the 22 criteria used to assess baby clinics were met by over 90 of practices. Almost all practices completed child health surveillance reviews within a standard time and achieved 90 coverage for primary immunizations. At many practices, less than 90 of parents felt welcome at the baby clinic, usually had enough time to talk to their health visitor or had the purpose or results of the 6 to 8 week child health surveillance review explained to them. GPs were less likely than health visitors to discuss health promotion at child health surveillance reviews (chi(2) 11.52, P = 0.0007). Few practices had a call-up and recall system for all reviews. CONCLUSION: The framework that we developed for assessing preschool child health surveillance was acceptable and achievable by primary health care teams.     

Associations of Nutritional Status with Full Immunization Coverage and Safe Hygiene Practices among Thai Children Aged 12–59 Months

Prevailing prevention measures against morbidity, such as vaccination and safe hygiene practices, vary among local cultural contexts, and little is known about the extent to which these behaviors mitigate poor nutritional status in young children in Southeast Asia. We examined the associations between nutrition status with full immunization coverage, and water, sanitation and hygiene status among children aged 12–59 months in the 2015–2016 Thailand Multiple Indicator Cluster Survey (n = 9060). When adjusted for confounding factors, children with incomplete immunization status were more likely to be stunted (adjusted odds ratio (aOR) 1.47; 95% confidence interval (CI): 1.24–1.75, p < 0.001), wasted (aOR 1.67, 95% CI: 1.31–2.12, p < 0.001), and overweight (aOR 1.24, 95% CI: 1.01–1.51, p < 0.05), whereas children who used unimproved water sources were more likely to be overweight (aOR 2.43, 95% CI: 1.27–4.64, p < 0.01). The further implementation of simple and cost-effective health promotion activities and practices at the household level may be important interventions for healthy child growth and development, particularly under restricted living conditions due to COVID-19.     

Prevalence and predictors of psychological distress among primary healthcare service users in Mansoura district,Egypt

The current study is a health facility‐based cross‐sectional study that aims to measure the prevalence of psychological distress and to determine its associated factors among primary healthcare (PHC) service users in Mansoura district, Egypt. The study included service users aged ≥18 years. A predesigned structured interviewer‐administered questionnaire was used to collect data from participants during the period from January 2018 to November 2018. The questionnaire included four sections; sociodemographic characteristics, recent history of stressful life events, history of relevant health conditions and a validated Arabic version of General Health Questionnaire, that was used to screen for psychological distress. The total calculated sample size was 573. Data was analysed using SPSS V. 16. Results indicated that the prevalence of psychological distress among PHC service users was 72.2% (95% CI: 68.6%–75.9%). Being a female, non‐working, or married increased the risk of high psychological distress [OR (95%CI): 1.6 (1.2–2.4), 1.8(1.2–2.8) and 1.7 (1.1–2.8) respectively], but these factors were insignificant in multiple regression. Exposure to domestic violence (DV) and being current smokers were the only independent significant predictors of psychological distress [adjusted OR (95%CI): 3.8 (1.7–8.1) and 0.7 (0.4–0.9) respectively]. Findings indicate that psychological distress is common among PHC service users. Exposure to DV significantly predicts psychological distress, while smoking is associated with lower stress. Screening of PHC service users for mental health problems should be integrated within the PHC system.     

Investigating the job satisfaction of healthcare providers at primary healthcare centres in Lebanon: A national cross‐sectional study

Low job satisfaction is linked to higher staff turnover and intensified shortages in healthcare providers (HCP). This study investigates the level of, and factors associated with, HCP job satisfaction in the national primary healthcare (PHC) network in Lebanon. The study adopts a cross‐sectional design to survey HCP at 99 PHC centres distributed across the country between October 2013 and May 2014. The study questionnaire consisted of four sections: socio‐demographics/professional background, employment characteristics, level of job satisfaction (Measure of Job Satisfaction scale) and level of professional burnout (Maslach Burnout Inventory‐HSS scale). A total of 1,000 providers completed the questionnaire (75.8% response rate). Bivariate and multivariate regression analyses were used to identify factors significantly associated with job satisfaction. Findings of the study highlight an overall mean job satisfaction score of 3.59 (SD 0.54) indicating that HCP are partially satisfied. Upon further examination, HCP were least satisfied with pay, training and job prospects. Gender, age, career plans, salary, exposure to violence, and level of burnout were significantly associated with the overall level of job satisfaction which was also associated with increased likelihood to quit. Overall, the study highlights how compensation, development and protection of PHC HCP can influence their job satisfaction. Recommendations include the necessity of developing a nationally representative committee, led by the Ministry of Public Health, to examine the policies and remuneration scales within the PHC sector and suggest mechanisms to bridge the pay differential with other sectors. The effective engagement of key stakeholders with the development, organisation and evaluation of professional development programmes offered to HCP in the PHC sector remains crucial. Concerned stakeholders should assess and formulate initiatives and programmes that enrich the physical, psychological and professional well‐being of their HCP. The aforementioned suggestions are necessary to strengthen and sustain PHC HCP and support the provision of universal health coverage to the Lebanese population.     

浙江省基层医疗卫生机构补偿机制改革试点评估

目的了解浙江省基层医疗卫生机构补偿机制在改革试点地区的公平性、实施绩效、激励性与可持续性情况。方法以利益相关者理论、公平理论、期望理论、可持续发展理论为基础,构建补偿机制改革试点评估指标体系。采用焦点小组访谈法,对各改革利益主体进行访谈。同时,收集4个试点地区基层医疗卫生机构的财政补偿情况、收支情况、工作当量等内容。对定量资料进行描述性统计。结果共开展了12场访谈,访谈了92人。研究发现,改革采取了合理的资金分配比例(保基本人员经费比例低于50%)及不同医疗机构的差异调节系数(1.0~1.8)等措施,保障了改革的公平性;机构和职工工作当量的提升(4个试点地区在岗人员工作当量数的平均值由前一年的3843.5万工作当量增至4259.0万工作当量)体现了改革的绩效成果。而政策的激励性和可持续性是当前改革的薄弱环节,主要原因是机构内部的分配制度未开展相应的改革。结论以当量法为基础的补偿机制改革改变了医务人员以往对资金分配的认知。其倡导的"多劳多得,优绩优酬"的理念与信息化管理,有效提高了基层医务人员的积极性和基层医疗卫生机构的运行效率。     

The economics of primary healthcare reform in Australia - towards single fundholding through development of primary care organisations

Objective: A strong primary care sector is widely acknowledged as a fundamental component of a well functioning health system and thus has been the focus of strategic reforms in a number of countries. This paper provides an economic analysis of primary healthcare reform, with the aim of identifying the key structural elements that are necessary to support enhanced models of primary health in the Australian context. Approach: This paper utilises economic theory, and draws upon empirical evidence and international experience to analyse primary healthcare reform to identify the structural elements necessary for an enhanced primary care sector. The aim of which is to improve health system performance. These structural elements are then critically examined in the Australian health system setting. Conclusion: For enhanced models of primary healthcare to promote efficiency, they must incorporate a number of key structural elements; notably: governance and purchasing responsibilities for primary care devolved to a meso‐level organisational structure through capitated single fundholding arrangements; blended payment methods for reimbursing providers; the establishment of a national quality and performance framework; and the development of primary care infrastructure. Implications: As the Federal government attempts to address recommendations of the National Health and Hospital Reform Commission, a window of opportunity now exists to pursue long overdue structural reforms to deal with the challenges facing the Australian health system. The paper advances the important structural features to primary healthcare that need to be embraced as the government attempts to pursue its health reform agenda.     

安徽省深化基层卫生综合改革的进展与挑战

安徽省为深化基层卫生综合改革,于2011年8月颁布了《关于巩固完善基层卫生综合改革的意见》。本文主要分析了该项政策实施以来的主要进展与挑战。政策实施以后,提高了乡镇卫生院服务效率和农村居民就医受益程度,促进了村卫生室落实基本药物制度等;但财政补助政策落实、乡镇卫生院服务提供、卫生技术人才队伍建设和药品配送等方面还存在一些问题。针对这些问题,提出了如下政策建议：落实财政保障制度,建立统分结合的人员聘用制度,完善基本药物采购及配送制度,加强村医及村卫生室管理,建立县域基层卫生服务能力评估制度等。