Attaining health for all through community partnerships: principles of the census-based, impact-oriented (CBIO) approach to primary health care developed in Bolivia, South America.

This article describes a flexible primary health care methodology which was developed by Andean Rural Health Care and its colleagues in Bolivia, South America. This methodology, the census-based, impact-oriented (CBIO) approach to primary health care, involves determining local health priorities as defined both by locally acquired epidemiologic information and by the local people themselves. The CBIO approach to primary health care is now functioning successfully at seven program sites in Bolivia, which together serve 75,000 people in urban and rural communities in three distinct cultural and ecological regions of the country. High levels of coverage of basic health services can be achieved through a system of 'epidemographic' surveillance of all families and through home delivery, when needed, of priority services to those at risk. When the services provided are based on local health priorities, when they are provided in a technically effective manner, and when the community has a strong partnership in planning, implementation and evaluation, then the CBIO approach to primary health care will lead to measurable health improvements as defined by changes in population-based rates of mortality and illness in the community. On the basis of our experience, we believe that the CBIO approach offers great potential for strengthening the effectiveness of local health programs in impoverished communities around the world in a way which fosters community ownership and, hence, long-term sustainability.     

Federal primary health care projects in texas

The rural health strategy of the Bureau of Community Health Services has focused on the integrative mechanism of the Rural Health Initiative (RHI) to combine resources in the best manner to meet local community health needs. An essential component is the National Health Service Corps which provides physicians and other health service personnel both to the RHIs and to free-standing sites.Whether this strategy succeeds or not depends in large measure on the location of the limited health care resources available. In this study, the researchers examined the Bureau's efforts in Texas, a rural conservative state, to place RHIs, NHSC personnel, and other health care projects in areas by priority of need. The basic underlying hypothesis in examining the availability of primary health care services is that the projects would go predominantly into areas with at least three of four need designations defined by the Bureau under positive programming. The baseline used was 1975, just prior to the initiation of the RHI, and 1980 a period sufficiently later to assess progress of the program.The data show the number of federal primary health care projects increased in Texas and the number of projects in areas of highest need also increased. Further, analysis of the data by rural versus urban setting showed the rural areas had increased both in numbers of projects and as a percentage of the total number of projects in the State, suggesting the effectiveness of positive programming.Accessibility to primary health care and physicians for the rural population of more than 2,000,000 people in Texas declined for many years. More recently, however, a number of programs were established to reverse this trend. One of the most important of these, the Rural Health Initiative (RHI), was established by the Bureau of Community Health Services in 1975 to assist in developing the primary health care capacity of underserved rural areas. This article describes the RHI in Texas. It compares the placement of primary health care projects in 1975 and 1980, highlights the growth of selected RHIs, and considers the effect of the private sector of medicine in increasing the number of physicians for rural practice.Research support provided under Personal Service Contract from the Director of the Bureau of Community Health Services, Department of Health and Human Services, 1980.     

The community-oriented primary care experience in the United kingdom

The UK National Health Service has long delivered public health programs through primary care. However, attempts to promote Sidney Kark's model of community-oriented primary care (COPC), based on general practice populations, have made only limited headway. Recent policy developments give COPC new resonance. Currently, primary care trusts are assuming responsibility for improving the health of the populations they serve, and personal medical service pilots are tailoring primary care to local needs under local contracts. COPC has yielded training packages and frameworks that can assist these new organizations in developing public health skills and understanding among a wide range of primary care professionals.     

The provision of accessible, acceptable health care in rural remote areas and the right to health: Bedouin in the North East region of Jordan

Provision of accessible acceptable health care in remote rural areas poses a challenge to health care providers. This case study of formal and informal health care provision for Bedouin in North East Jordan is based on interviews conducted in 2007-2008 involving clinic providers, policymakers and Bedouin as part of an EC funded study from 2006 to 2010. The paper explores to what extent the right to health as set out in UN General Comment 14 (on Article 12 and 12.2 of the International Covenant on Social Economic and Cultural Rights on the right to health) can provide a framework for considering the availability, accessibility and acceptability of current provision in a rural setting in Jordan. Health care is provided in the public sector by the Ministry of Health and the Royal Medical Services to a dispersed population living in encampments and villages over a large rural area. There are issues of accessibility in terms of distance, and of acceptability in relation to the lack of local and female staff, lack of cultural competencies and poor communication. We found that these providers of health care have a developing partnership that could potentially address the challenge of provision to this rural area. The policymakers have an overview that is in line with applying the concept of health care justice for a more equitable distribution of resources and adjustment of differential access and availability. The health providers are less aware of the right to accessible acceptable health care in their day to day provision whilst the Bedouin population are quite aware of this. This case study of Bedouin in North East Jordan has particular relevance to the needs of populations - both pastoralists and non pastoralists living in remote and rural areas.     

广东省农村10年初保成果经济层次分析

文章对１９９４－２０００年广东省２１个地级市１１５个县级单位的“２０００年人人享有卫生保健”规划目标审评结果与经济因素的关系进行了分析。结果表明：经济水平类型和审评合格构成比关系无显著性,但审评总分与经济水平有关;各指标及各分指标得分中,与经济水平有明显关联的指标有指标２、指标、３．１、３．４、指标５、指标７、指标９．２,提示有关部门在进行卫生事业财政拨款、集资医疗保健制度、改而和健康教育等工作时,要考虑经济因素对农村初级卫生保健效果的影响。     

Challenges in Evaluating Rural Health Programs

Complex community-based prevention programs are being held to scientific evidence of their effectiveness and rural public health departments that implement such programs often are not equipped to evaluate them. Rural public health departments are fettered by small budgets, small staffs, and less access to evaluation experts and similar resources. Community-based health promotion programs can include complex designs that may work differently in rural areas and evaluation of rural programs can be hampered by lack of control groups and the instability of results from small populations. The University of Kentucky has entered into a contract with the state Department for Public Health to implement an internal, participatory model of evaluation. In this model, the university evaluation expert trains local public health department staff in technical skills for program evaluation and acts as mentor and technical consultant to local public health departments on an ongoing basis. Through training and site visits, this model is one approach to addressing the challenges of evaluating rural health promotion programs.     

Commentary: in search of innovative approaches to international health.

The community health program of the Aga Khan University in Pakistan is reviewed from the perspective of historic and present-day developments in primary health care based in and focused on the community. The approach commonly referred to as community-oriented primary health care involves the complementary functions of clinical practice and epidemiology in partnership with the community. Encouragement and support by governments and other organizations for teaching and research in this field would ensure more adequate preparation of future practitioners and health scientists for community-oriented primary health care and would lead to improved health. Continuity of support for community health programs is important.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

A Rural Health Education, Training and Research Network for Queensland

ABSTRACT: The purpose of the Rural Health Education, Training and Research Network is to support the education and training of rural health practitioners and research in rural health through the optimum use of appropriate information and communication technologies to link and inform all individuals and organisation involved in the teaching, planning and delivery of health care in rural and remote Queensland. The health care of people in rural areas has the potential to be enhanced, through providing the rural and remote health professionals in Queensland with the same access to educational and training opportunities as their metropolitan colleagues. This consultative, coordinated approach should be cost-effective through both increasing awareness and utilisation of existing and developing networks, and through more efficient and rational use of both the basic and sophisticated technologies which support them. Technological hardware, expertise and infrastructure are already in place in Queensland to support a Rural Health Education, Training and Research Network, but are not being used to their potential, more often due to a lack of awareness of their existence and utility than to their perceived costs. Development of the network has commenced through seeding funds provided by Queensland Health. Future expansion will ensure access by health professionals to existing networks within Queensland. This paper explores the issues and implications of a network for rural health professionals in Queensland and potentially throughout Australia, with a specific focus on the implications for rural and isolated health professional.     

Rural Primary Care Program Survival: An Analysis of Financial Variables

This study examines the effect of financial characteristics of rural primary care programs on the probability of their continuing as federally funded entities. A randomly selected national cohort of rural primary care programs (n = 162) was used to compare financial measures of programs that were continuing and those that were noncontinuing. Financial data were obtained from 1978-1987 Bureau Common Reporting Requirements (BCRR) forms submitted to the Bureau of Health Care Delivery and Assistance of the Department of Health and Human Services as part of the requirement to receive federal grant support for the programs. The results emphasize the importance of both outside funding and increased level of self-sufficiency in the continuation of rural primary care programs. Noncontinuing programs often suffer from both a lack of self-sufficiency and a lack of outside funding, mostly from federal sources. To a lesser extent, the number of patients also affects the program's chance of continuation. From a policy perspective, government intervention is both necessary and likely if rural primary care programs are to succeed and fulfill their mission of providing primary care for the medically underserved who are primarily poor, uninsured, and unable to pay.     

Public, decentralized and community health networks in Bolivia]

Health sector reform in Bolivia is based primarily on the principles of decentralization and equity, and with the objectives of improving quality and of expanding health services coverage in rural and low-income areas of the country. As an experiment in reform, the Bolivian Ministry of Health and Social Welfare, the department of La Paz, and the municipality of El Alto signed an agreement with a nongovernmental organization (NGO), transferring to the NGO the overall management of one of the health services networks in El Alto. The transfer was based on a management contract that had process and outcome indicators for the network. A year after implementation began, the preliminary results suggest that through the agreement the quality of management and services has improved, health services coverage has expanded, and the network's primary care services have been strengthened. Bed occupancy rates are generally very low in secondary hospitals in Bolivia, with that figure being just 43% in the department of La Paz in 1999. However, in the second 6 months of operation of the El Alto network the occupancy rate for the network's hospital reached 84%. Between the first 6 months of 1999 and the same period in 2000, outpatient consultations increased by 55% in the network (83% in the hospital and 18% in the network's primary care centers). Over that same period, institutional deliveries increased by 41% and the percentage of deliveries in the primary care centers grew from 5% of the total to 9%. A recent user survey found that 87% of the people receiving care in the network felt highly satisfied with the service they had received, and 75% of the persons surveyed said they would recommend the service to others. These are not typical data for health services in Bolivia. This pilot effort suggests that a change in the organization and management of a health services network, with a separation of the roles of purchaser and provider, combined with management based on results and with community participation in the process, can improve the quality and efficiency of those health services, stimulate demand for them, and increase user satisfaction.     

Impact of federal primary health care policy in rural areas: empirical evidence from the literature.

This review examines the equity, efficiency and effectiveness of federal rural primary care policy as documented by the existing literature. The focus is on the Community Health Center and National Health Service Corps programs which have constituted the major components of the policy. The literature relating to the policy is limited in the number of studies available and in the quality of the research. The available evidence indicates that the policy is associated with an improvement in the distribution of health resources between rural and urban areas,and among rural areas.There is also partial evidence that the policy has been cost-efficient. For federally subsidized practices,the cost of delivering a similar quality of health care is shown to be up to 50 percent less in rural than in urban areas. Rural private practitioners, though, may be more cost-efficient than federally subsidized rural practitioners, at least under certain conditions which have yet to be fully delineated. Program effectiveness is the least well documented, but the literature does suggest that the policy has had a positive effect on the health status of rural populations. Substantially more research on the efficiency, and particular the effectiveness, of federal rural primary care policy is required for the development of a rational basis for the policy.     

The March to Accountable Care Organizations—How Will Rural Fare?

Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. Findings: Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. Conclusions: Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural‐relevant ACO‐performance measures and provide necessary technical assistance to rural providers and organizations.     

Managing rural health care reform

Rural health care requires a response system that is unique and substantially different from other, more traditional systems of health care delivery. Any reform of the present rural health care system must offer services that include the public health sector as well as other aspects of the social "safety net." The authors present a vivid picture of the multiple realities operating in the rural environment, and they explore the opportunity for the creation of Accountable Health Plans suitable for the rural health care delivery mechanism.     

Physicians for Rural America: The Role of Institutional Commitment Within Academic Medical Centers

CONTEXT: Prior study suggests that contextual characteristics of medical schools (e.g., state demographics, public vs private, NIH research effort) predict output of rural physicians without also considering the effects of the medical schools' own policies and programs. PURPOSE: This study examines medical school commitment to rural policies and programs and its relationship to contextual characteristics and rural physician output. METHODS: A survey of 122 U.S. allopathic medical schools provided data to construct a 32-item Rural Commitment Index for each medical school. Data for other characteristics were linked from published sources. Correlations, t tests, and multiple regression analysis were used to study the association between variables and percentage of medical school graduates (1988-1996) who were in rural primary care practice in 2000. FINDINGS: Among 90 medical schools (response rate, 73.8%), the Rural Commitment Index correlated with the percentage of the state population that is rural and whether the school is public or private, and it joined percentage state population rural, public vs private, and National Institutes of Health support in correlating with percentage of graduates in rural primary care. In a regression model that explained 48.4% of variation in the percentage of graduates in rural primary care, the Rural Commitment Index explained most variation, followed by percentage state population rural, public vs private, National Institutes of Health support, and the interaction between the Rural Commitment Index and public vs private. CONCLUSIONS: The findings support the proposition that observable institutional commitment affects rural physician output and provide justification for a definitive study to verify that a change in medical school commitment to rural medicine produces a change in rural physician output.     

Challenges to equity in health and health care: a Zimbabwean case study

The current economic crisis in Africa has posed a serious challenge to policies of comprehensive and equitable health care. This paper examines the extent to which the Zimbabwe government has achieved the policy of "Equity in Health" it adopted at independence in 1980, that is provision of health care according to need. The paper identifies groups with the highest level of health needs in terms of both health status and economic factors which increase the risk of ill health. It describes a series of changes within the health sector in support of resource redistribution towards health needs, including a shift in the budget allocation towards preventive care, expansion of rural infrastructures, increased coverage of primary health care, introduction of free health services for those earning below Z$150 a month in 1980, increased manpower deployment in the public sector and the reorientation of medical training towards the health needs of the majority. The implementation of equity policies in health have however been challenged by several trends and features of the health care system, these becoming more pronounced in the economic stagnation period after 1983. These include the reduction in allocations to local authorities, increasing the pressure for fees, the static nominal level of the free health care limit despite inflation, the continued concentration of financial, higher cost manpower and other resources within urban, central and private sector health care and the lack of effective functioning of the referral system, with high cost central quaternary facilities being used as primary or secondary level care by nearby urban residents. While primary health care expansion has clearly been one of the success stories of Zimbabwe's health care post 1980, the paper notes plateauing coverage, with evidence of lack of coverage in more high risk, socio-economically marginal communities. Measures to address these continuing inequalities are discussed. Their implementation is seen to be dependent on increasing the capacity and organisation of the poor to more strongly influence policy and resource distribution in the health sector.     

Illinois RMED: a comprehensive program to improve the supply of rural family physicians

BACKGROUND: Rural areas of the United States are perennially medically underserved, and the state of Illinois is no exception. A recent survey showed that 75 of Illinois' 84 rural counties are primary care physician shortage areas. In response to this chronic physician shortage, the Illinois Rural Medical Education (RMED) Program was developed by the University of Illinois College of Medicine at Rockford. The RMED program is a comprehensive, multifaceted program that combines recruitment, admissions, curriculum, support, and evaluation components and is longitudinal across all 4 years of the medical school experience. The admissions process seeks to select students who possess traits indicative of success in eventual rural family practice. These traits are fostered and developed by the 4-year rural curriculum, which emphasizes family medicine, community-oriented primary care, the physician functioning in the context of community, relevant aspects of the "hidden" curriculum, and service learning. After 6 years, RMED has graduated 39 physicians; 69% have gone into family practice, and a total of 82% have selected primary care residencies.     

中国农村基本卫生保健工作发展与思考

目的：了解我国农村地区基本卫生保健工作的现状,以及在新世纪第一个十年中取得的成绩和存在的问题,为进一步推进农村基本卫生保健工作提出有针对性的政策建议。方法：按照分层抽样的方法,在全国选择400个县级行政单位,收集当地农村基本卫生保健工作的相关数据。结果与发现：（1）农村基本卫生保健工作得到政府重视,但财政保障仍不足;（2）乡村两级医疗卫生服务体系建设仍需不断完善;（3）基本公共卫生服务在医改政策推动下进展明显,后续要加大力度推进;（4）新型农村合作医疗制度不断完善;（5）基本药物制度实施使基层医疗卫生机构面临发展困境。     

The Southern Rural Access Program and Alabama's Rural Health leaders Pipeline: A Partnership to Develop Needed Minority Health Care Professionals

ABSTRACT: Rural Health Leaders Pipeline programs are intended to increase the number of youth interested in and pursuing health professions in rural communities. This paper presents 2 complementary approaches to Rural Health Leaders Pipeline programs. Two different organizations in Alabama recruit students from 18 specified counties. One organization is a rural, community-based program with college freshmen and upperclassmen from rural communities. Students shadow health professionals for 6 weeks, attend classes, visit medical schools, complete and present health projects, and receive support from online tutors. The second organization is a university based program that supplements an existing 11th grade-medical school rural medicine pipeline with 10 minority students from rural communities who have graduated from high school and plan to enter college as premedical students in the following academic year. Students participate in classes, tutorials, seminars, and other activities, Students earn college credits during the 7-week program, maintain contact with program staff during the school year, and by performance and interest can continue in this pipeline program for a total of 4 consecutive summers, culminating in application to medical school. Each organization provides stipends for students. Early experiences have been positive, although Rural Health Leaders Pipeline programs are expensive and require long-term commitments.     

The availability of drugs: what does it mean in Ugandan primary care

Availability of drugs is often considered the most important element in quality of health care in rural African settings. Using material collected through mainly qualitative methods, this article examines drug availability in six primary health care units in southeastern Uganda. Emphasis is on the differing perspectives of three categories of actors: health planners/managers; health workers; and users of health services. The main concern is the availability of chloroquine and penicillin, especially injectable forms, and the needles and syringes for administering them. Health sector reforms have changed the conditions for managing, supplying, and using drugs through decentralization, user fees, and privatization. Patients were dissatisfied when they were not able to obtain all drugs prescribed at the health unit. Government health units both compete with, and use, local commercial sources of drugs. They need to attract patients and, with user fees, they are more able to supplement the drug kit supplies provided through the Ministry of Health. There is a need to revise policy in light of the new situation. Dialogue and realism are needed in order to create policies that respect both good medical treatment standards and the concerns of front line workers and their patients. The exercise of rethinking the meaning of drug availability in primary health care calls for methodologies examining the changing context of health care and the positions of different categories of actors, at national and district setting, to appreciate gaps existing between drug policy and practice.