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Background: Primary care is a central element of healthcare and addresses the main health problems of the population. While primary care gains in importance due to an aging population, there is an ongoing debate on physician shortages in German rural regions. The study aims on analyzing the population's preferences on primary healthcare and, therefore, on helping policy makers to make care delivery more responsive to patients' needs when planning political reforms of primary care., Methods: A paper-based discrete choice experiment (DCE) was used to assess preferences of the population of eight rural regions in Germany. Based on literature search and qualitative research, six attributes were selected and included in the choice experiment. The survey presented participants with eight choice sets in which they had to choose between two possible scenarios of care. A conditional logistic regression as well as a latent class model (LCM) were used to analyze preferences for primary healthcare., Results: Nine hundred four participants completed the survey (response rate 46.1%). The conditional logistic regression showed significant impact of the attributes "home visits", "distance to practice", "number of healthcare providers", "opening hours of the practice", and "diagnostic facilities" on the respondents' choices of primary healthcare alternatives. Moreover, the LCM identified four classes that can be characterized by preference homogeneity within and heterogeneity between the classes., Conclusion: Although the study revealed heterogeneous preferences among the latent classes, several similarities in preferences for primary care could be detected. The knowledge on these public preferences may help policy makers when implementing new models of primary care and, thus, raise the populations' acceptance of future primary care provision and innovative care models.

Background: Governments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented., Methods: We used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically., Results: The institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania's long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements., Conclusions: Tanzania's central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.

Background: Non-government, not-for-profit community health centres (CHCs) play a crucial role within healthcare systems in fostering equity, acting both as direct providers of services and as sentinels of health and social inequity. In a study of an intervention to promote equity-oriented health care, we enlisted four diverse primary healthcare clinics with mandates to serve highly marginalized populations. All of these CHCs operate as not-for-profit, non-government organizations (NGOs), and have a marginal relationship financially and socially to other parts of the system. The purpose of this paper is to provide an analysis of the factors that shape how CHCs are able to carry out an equity mandate and, from this, to identify what is required at the level of policy to enhance capacity to provide equity-oriented health care., Methods: We systematically examined the clinics' policy and funding contexts, and identified influences on the clinics' capacities to promote equity-oriented health care., Results: We identified three key mechanisms of influence, each playing out against the backdrop of a contested and marginal position of CHCs within the health care system: a) accountability and performance frameworks; b) patterns of funding and allocation of resources, and c) pathways for emergent priorities. We examine these mechanisms, considering how each influenced the pursuit of equity, and propose policy directions to optimize the primary health care sectors' capacity to support equity-oriented health care., Conclusions: Although this analysis is based on a study within a high-income country, we argue that because the dynamics between community health centres and broader healthcare systems are similar across national boundaries, the implications have applicability to low and middle-income countries.

Background: There is increased international focus on improving the rigour of clinical practice guideline (CPG) development practices. However, few empirical studies on CPG development have been conducted in low- and middle-income countries. This paper explores national stakeholders' perceptions of processes informing CPG development for primary healthcare in South Africa, focusing on both their aspirations and views of what is actually occurring., Methods: A qualitative study design was employed including individual interviews with 37 South African primary care CPG development role-players. Participants represented various disciplines, sectors and provinces. The data were analysed through thematic analysis and an interpretivist conceptual framework., Results: Strongly reflecting current international standards, participants identified six 'aspirational' processes that they thought should inform South African CPG development, as follows: (1) evidence; (2) stakeholder consultation; (3) transparency; (4) management of interests; (5) communication/co-ordination between CPG development groups; and (6) fit-for-context. While perceptions of a transition towards more robust processes was common, CPG development was seen to face ongoing challenges with regards to all six aspirational processes. Many challenges were attributed to inadequate financial and human resources, which were perceived to hinder capacity to undertake the necessary methodological work, respond to stakeholders' feedback, and document and share decision-making processes. Challenges were also linked to a complex web of politics, power and interests. The CPG development arena was described as saturated with personal and financial interests, groups competing for authority over specific territories and unequal power dynamics which favour those with the time, resources and authority to make contributions. These were all perceived to affect efforts for transparency, collaboration and inclusivity in CPG development., Conclusion: While there is strong commitment amongst national stakeholders to advance CPG development processes, a mix of values, politics, power and capacity constraints pose significant challenges. Contrasting perspectives regarding managing interests and how best to adapt to within-country contexts requires further exploration. Dedicated resources for CPG development, standardised systems for managing conflicting interests, and the development of a political environment that fosters collaboration and more equitable inclusion within and between CPG development groups are needed. These initiatives may enhance CPG quality and acceptability, with associated positive impact on patient care.

Background: In Kenya, cardiovascular diseases (CVDs) accounted for more than 10% of total deaths and 4% of total Disability-Adjusted Life Years (DALYs) in 2015 with a steady increase over the past decade. The main objective of this paper was to review the existing policies and their content in relation to prevention, control and management of CVDs at primary health care (PHC) level in Kenya., Methods: A targeted document search in Google engine using keywords "Kenya national policy on cardiovascular diseases" and "Kenya national policy on non-communicable diseases (NCDs)" was conducted in addition to key informant interviews with Kenyan policy makers. Relevant regional and international policy documents were also included. The contents of documents identified were reviewed to assess how well they aligned with global health policies on CVD prevention, control and management. Thematic content analysis of the key informant interviews was also conducted to supplement the document reviews., Results: A total of 17 documents were reviewed and three key informants interviewed. Besides the Tobacco Control Act (2007), all policy documents for CVD prevention, control and management were developed after 2013. The national policies were preceded by global initiatives and guidelines and were similar in content with the global policies. The Kenya health policy (2014-2030), The Kenya Health Sector Strategic and Investment Plan (2014-2018) and the Kenya National Strategy for the Prevention and Control of Non-communicable diseases (2015-2020) had strategies on NCDs including CVDs. Other policy documents for behavioral risk factors (The Tobacco Control Act 2007, Alcoholic Drinks Control (Licensing) Regulations (2010)) were available. The National Nutrition Action Plan (2012-2017) was available as a draft. Although Kenya has a tiered health care system comprising primary healthcare, integration of CVD prevention and control at PHC level was not explicitly mentioned in the policy documents., Conclusion: This review revealed important gaps in the policy environment for prevention, control and management of CVDs in PHC settings in Kenya. There is need to continuously engage the ministry of health and other sectors to prioritize inclusion of CVD services in PHC.

Background: Why issues get on the policy agenda, move into policy formulation and implementation while others drop off in the process is an important field of enquiry to inform public social policy development and implementation. This paper seeks to advance our understanding of health policy agenda setting, formulation and implementation processes in Ghana, a lower middle income country by exploring how and why less than three months into the implementation of a pilot prior to national scale up; primary care maternal services that were part of the basket of services in a primary care per capita national health insurance scheme provider payment system dropped off the agenda., Methods: We used a case study design to systematically reconstruct the decisions and actions surrounding the rise and fall of primary care maternal health services from the capitation policy. Data was collected from July 2012 and August 2014 through in-depth interviews, observations and document review. The data was analysed drawing on concepts of policy resistance, power and arenas of conflict., Results: During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus building to get antenatal, normal delivery and postnatal services included in the primary care per capita payment system. Once policy implementation started, policy makers were faced with unanticipated resistance. Service providers, especially the private self-financing used their professional knowledge and skills, access to political and social power and street level bureaucrat power to contest and resist various aspects of the policy and its implementation arrangements - including the inclusion of primary care maternal health services. The context of intense public arena conflicts and controversy in an election year added to the high level political anxiety generated by the contestation. The President and Minister of Health responded and removed antenatal, normal delivery and postnatal care from the per capita package., Conclusion: The tensions and complicated relationships between technical considerations and politics and bureaucratic versus public arenas of conflict are important influences that can cause items to rise and fall on policy agendas.

Background: The primary health care (PHC) sector is increasingly relevant as a site for population health interventions, particularly in relation to marginalized groups, where the greatest gains in health status can be achieved. The purpose of this paper is to provide an overview of an innovative multi-component, organizational-level intervention designed to enhance the capacity of PHC clinics to provide equity-oriented care, particularly for marginalized populations. The intervention, known as EQUIP, is being implemented in Canada in four diverse PHC clinics serving populations who are impacted by structural inequities. These PHC clinics serve as case studies for the implementation and evaluation of the EQUIP intervention. We discuss the evidence and theory that provide the basis for the intervention, describe the intervention components, and discuss the methods used to evaluate the implementation and impact of the intervention in diverse contexts., Design and Methods: Research and theory related to equity-oriented care, and complexity theory, are central to the design of the EQUIP intervention. The intervention aims to enhance capacity for equity-oriented care at the staff level, and at the organizational level (i.e., policy and operations) and is novel in its dual focus on: (a) Staff education: using standardized educational models and integration strategies to enhance staff knowledge, attitudes and practices related to equity-oriented care in general, and cultural safety, and trauma- and violence-informed care in particular, and; (b) Organizational integration and tailoring: using a participatory approach, practice facilitation, and catalyst grants to foster shifts in organizational structures, practices and policies to enhance the capacity to deliver equity-oriented care, improve processes of care, and shift key client outcomes. Using a mixed methods, multiple case-study design, we are examining the impact of the intervention in enhancing staff knowledge, attitudes and practices; improving processes of care; shifting organizational policies and structures; and improving selected client outcomes., Discussion: The multiple case study design provides an ideal opportunity to study the contextual factors shaping the implementation, uptake and impact of our tailored intervention within diverse PHC settings. The EQUIP intervention illustrates the complexities involved in enhancing the PHC sector's capacity to provide equity-oriented care in real world clinical contexts.

Background: This is the final of 10 papers that describe the implementation of the Expanded Census-Based, Impact-Oriented Approach (CBIO+) by Curamericas/Guatemala in the Cuchumatanes mountains of the Department of Huehuetenango and its effectiveness in improving the health and well-being of women and children in a population of 98,000 in three municipalities. The CBIO+ Approach consists of three components: the CBIO (Census-Based, Impact-Oriented) Approach, the Care Group Approach, and the Community Birthing Center Approach. Methods: Each of the preceding papers was summarized. An assessment was made regarding the degree to which the initial implementation research hypotheses were confirmed. The total field cost per capita for operation of the Project was calculated. An assessment of the cost-effectiveness of the Project was made based on the estimated impact of the Project, the number of lives saved, and the number of disability-adjusted life years averted. Results: The Project attained a number of notable achievements in terms of expanding the coverage of key maternal and child health interventions, improving the nutritional status of children, reducing the mortality of children and mothers, providing quality care for mothers at the Community Birthing Centers (Casas Maternas Rurales) that integrate traditional midwives (comadronas) into the care of women during childbirth at the birthing centers, as well as empowering women and building social capital in the communities. CBIO+ is an effective and affordable approach that is particularly notable for its capacity to engage communities in the process of improving the health of mothers and children. Overall, there is strong and consistent evidence in support of the research hypotheses. The findings did produce evidence of declines in under-5 and maternal mortality, but they were not as robust as had been hoped. Conclusion: CBIO+ is an approach that has been effective in engaging communities in the process of improving the health of their mothers and children and in reducing health inequities in this marginalized, difficult-to-reach population of Indigenous Maya people. The CBIO+ Approach is cost-effective and merits further development and broader application in Guatemala and beyond. [ABSTRACT FROM AUTHOR]

Background and objective: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. Methods: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. Results: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. Conclusions: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage. [ABSTRACT FROM AUTHOR]

Primary Health Care (PHC) is the most equitable and cost-effective way to enhance the health of populations and improve health security and is a requirement for achieving universal health coverage (UHC). Vital to advancing the PHC agenda is effective global health partnerships, particularly with Global Health Initiatives (GHIs) which provide financial support for improving population health. Despite progress, GHI support at times remained parallel to rather than embedded in national health strategies. To improve the impact of GHI support, World Health Organization (WHO) member states requested specific guidance to better align GHI support to national health strategies and PHC principles. We present the PHC-GHI Toolbox as a comprehensive set of resources for use by countries to apply the PHC approach to development of plans for securing and optimally utilizing funding received from GHIs, such as Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM); and the Global Financing Facility (GFF) as well as other donors. The PHC-GHI Toolbox includes a PHC resource database, GHI-specific overviews, a database of health system strengthening (HSS) investments, COVID-19 funding rapid assessment tool, and a focal point database for identifying expert technical assistance. This paper describes the process undertaken for Toolbox development and outlines its potential applications. [ABSTRACT FROM AUTHOR]

Background: Adaptation to climate change (CC) is a priority for Small Island Developing States (SIDS) in the Caribbean, as these countries and territories are particularly vulnerable to climate-related events. Primary health care (PHC) is an important contributor to CC adaptation. However, knowledge on how PHC is prepared for CC in Caribbean SIDS is very limited. The aim of this paper is to discuss health system adaptation to climate change, with a focus on PHC. Methods: We explored the perspectives of PHC professionals in Dominica on PHC adaptation to climate change. Focus group discussions (FGDs) were conducted in each of the seven health districts in Dominica, a Caribbean SIDS, between November 2021 and January 2022. The semi-structured interview guide was based on the Essential Public Health Functions: assessment, access to health care services, policy development and resource allocation. Data coding was organized accordingly. Results: Findings suggest that health care providers perceive climate change as contributing to an increase in NCDs and mental health problems. Climate-related events create barriers to care and exacerbate the chronic deficiencies within the health system, especially in the absence of high-level policy support. Healthcare providers need to take a holistic view of health and act accordingly in terms of disease prevention and health promotion, epidemiological surveillance, and ensuring the widest possible access to healthcare, with a particular focus on the environmental and social determinants of vulnerability. Conclusion: The primary health care system is a key stakeholder in the design and operationalization of adaptation and transformative resilience. The Essential Public Health Functions should integrate social and climate and other environmental determinants of health to guide primary care activities to protect the health of communities. This study highlights the need for improved research on the linkages between climate events and health outcomes, surveillance, and development of plans informed by contextual knowledge in the SIDS. [ABSTRACT FROM AUTHOR]

Background: The international study PRICOV-19 aims to assess the impact of the COVID-19 pandemic on the organisation of primary health care. The German part focuses on German general practitioners during the second wave of the COVID-19 pandemic. This paper addresses the following research questions: (1) How were changes in tasks on primary care and patient treatment perceived by GPs?, (2) What was the role of GPs during the pandemic, and how was their wellbeing?, (3) How did GPs perceive health policy measures?, and, (4) What influenced the attitudes of GPs on health policy measures? Methods: This study pursues a multi-country cross-sectional design. Data collection took place throughout Germany from 01.02. to 28.02.2021 with a quantitative online questionnaire consisting of 53 items. The questionnaire was analysed through descriptive and inferential analyses using correlation and multiple regression models. Results: The response rate was 20.4% (n = 349). The respondents were mainly GPs (59.6%) in single practices (62.5%) with a mean work experience of 15 to 20 years. GPs experienced a change in their work and practice organisation (80.3%). They felt a high responsibility (70.6%) and found their work has become more meaningful to them (76%). They also saw a lack of political support (75.2%) and that the measures taken by the government overburdened the daily practice (66.4%). Not many GPs were at risk of being distressed (53.4%) but rated the health policies rather negatively (60%). The multiple regression showed, the more GPs were exposed to risk of distress, the worse they assessed the government's measures. Conclusion: GPs perceived their work as relevant and felt confident they could fulfil their tasks, but noticed that health policy initially hardly supported the outpatient sector. Health policies should increase their competence in relation to primary care, ensure its needs and consider an active inclusion of GPs in preparedness plans. [ABSTRACT FROM AUTHOR]

Background: Although Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme's functioning and sustainability. An often-cited issue—contributing to the scheme's decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members—is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package. Methods: An existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of 'best buys'. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana's health sector, are presented and evaluated. Results: Implementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages. Conclusions: Current funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care. [ABSTRACT FROM AUTHOR]

Background: There is unfinished reform in primary care in Russia and other former Soviet Union (FSU) countries. The traditional 'Semashko' multi-specialty polyclinic model has been retained, while its major characteristics are increasingly questioned. The search for a new model is on a health policy agenda. It is relevant for many other countries. Objectives: In this paper, we explore the strengths and weaknesses of the multi-specialty polyclinic model currently found in Russia and other FSU countries, as well as the features of the emerging multi-disciplinary and large-scale primary care models internationally. The comparison of the two is a major research question. Health policy implications are discussed. Methods: We use data from two physicians' surveys and recent literature to identify the characteristics of multi-specialty polyclinics, indicators of their performance and the evaluation in the specific country context. The review of the literature is used to describe new primary care models internationally. Results: The Semashko polyclinic model has lost some of its original strengths due to the excessive specialization of service delivery. We demonstrate the strengths of extended practices in Western countries and conclude that FSU countries should "leapfrog" the phase of developing solo practices and build a multi-disciplinary model similar to the extended practices model in Europe. The latter may act as a 'golden mean' between the administrative dominance of the polyclinic model and the limited capacity of solo practices. The new model requires a separation of primary care and outpatient specialty care, with the transformation of polyclinics into centers of outpatient diagnostic and specialty services that become part of hospital services while working closely with primary care. Conclusion: The comprehensiveness of care in a big setting and potential economies of scale, which are major strengths of the polyclinic model, should be retained in the provision of specialty care rather than primary care. Internationally, there are lessons about the risks associated with models based on narrow specialization in caring for patients who increasingly have multiple conditions. Highlights: • The Semashko polyclinic model has lost strengths due to excessive specialization. • Solo and group PHC practices are no longer suitable to manage multimorbidity. • A new 'extended general practice' reorients the health system towards PHC. • Restructuring polyclinics is possible by transforming them into outpatient specialty units of hospital structures. [ABSTRACT FROM AUTHOR]

Background: Little is known about allied health (AH) clinical practice guideline (CPG) activity in South Africa, and particularly in relation to primary health care (PHC). This paper reports on a scoping study undertaken to establish a reference framework, from which a comprehensive maximum variation sample could be selected. This was required to underpin robust sampling for a qualitative study aimed at understanding South African primary care AH therapy CPG activities. This paper builds on findings from the South African Guidelines Evaluation (Project SAGE) Flagship grant. Methods: South African government websites were searched for structures of departments and portfolios, and available CPGs. Professional AH association websites were searched for CPGs, purposively-identified key informants were interviewed, and CPGs previously identified for priority South African primary care conditions were critiqued for AH therapy involvement. Results: Key informants described potentially complex relationships between players who may be engaged in South African AH CPGs, in both public and private sectors. There were disability/rehabilitation portfolios at national and provincial governments, but no uniformity in provincial government organisation of, or support for, PHC AH services. There were no AH primary care therapy CPGs on government websites, although there was 'clinical guidance' in various forms on professional association websites. Only two CPGs of priority South African PHC conditions included mention of any AH therapy (physiotherapy for adult asthma and chronic obstructive pulmonary disease). Conclusion: A comprehensive and wide-reaching stakeholder reference framework would be required in order to capture the heterogeneity of AH primary care CPG activity in South Africa. This should involve the voices of national and purposively-selected provincial governments, academic institutions, consultants, public sector managers and clinicians, private practitioners, professional associations, and private sector insurers. Provincial governments should be selected to reflect heterogeneity in local economics, population demographics and availability of university AH training programs. This investigation should aim to determine the areas of PHC in which AH are engaged. [ABSTRACT FROM AUTHOR]

Background New forms of leadership are required to bring about the fundamental health system changes demanded by primary health care (PHC). Using theory about complex adaptive systems and policy implementation, this paper considers how actors' sensemaking and the exercise of discretionary power currently combine to challenge PHC re-orientation in the South African health system; and provides examples of leadership practices that promote sensemaking and power use in support of PHC. Methods The paper draws on observational, interview, and reflective data collected as part of the District Innovation and Action Learning for Health Systems Development (DIALHS) project being implemented in Cape Town, South Africa. Undertaken collaboratively between health managers and researchers, the project is implemented through cycles of action-learning, including systematic reflection and synthesis. It includes a particular focus on how local health managers can better support front line facility managers in strengthening PHC. Results The results illuminate how the collective understandings of staff working at the primary level - of their working environment and changes within it - act as a barrier to centrally-led initiatives to strengthen PHC. Staff often fail to take ownership of such initiatives and experience them as disempowering. Local area managers, located between the centre and the service frontline, have a vital role to play in providing a leadership of sensemaking to mediate these challenges. Founded on personal values, such leadership entails, for example, efforts to nurture PHC-aligned values and mind-sets among staff; build relationships and support the development of shared meanings about change; instil a culture of collective inquiry and mutual accountability; and role-model management practices, including using language to signal meaning. Conclusions PHC will only become a lived reality within the South African health system when frontline staff are able to make sense of policy intentions and incorporate them into their everyday routines and practices. This requires a leadership of sensemaking that enables front line staff to exercise their collective discretionary power in strengthening PHC. We hope this theoretically-framed analysis of one set of experiences stimulates wider thinking about the leadership needed to sustain primary health care in other settings. [ABSTRACT FROM AUTHOR]

For the renewed global impetus on primary health care (PHC) to translate into action at a country level, it will be important to strengthen existing ways of understanding and assessing country PHC systems. The architecture and performance of primary care systems are widely acknowledged to be crucial determinants of the health of populations in high-income countries as well as in low- and middle-income countries. There is no one-size-fits-all model of a country-level PHC system, and countries have implemented diverse models, adapted to and conditioned by their respective social, economic and political contexts. This paper applies advances in the field of health policy and systems research (HPSR) to propose an approach to the assessment of country PHC systems, using a compendium of 70 elements of enquiry requiring mixed quantitative and qualitative assessment. The approach and elements of enquiry were developed based on a review of policy and guidance documents and literature on PHC and HPSR and were finalized as part of a consultation of experts on PHC. Key features of the approach include sensitivity to context, flexibility in allowing for in-depth enquiry where necessary, systems thinking, a learning emphasis, and complementarity with existing frameworks and efforts. Implemented in 20 countries to date, the approach is anticipated to have further utility in a single country as well as in comparative assessments of PHC systems. [ABSTRACT FROM AUTHOR]

Background: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. Methods: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. Results: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success. Conclusions: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally. [ABSTRACT FROM AUTHOR]

Background: Access of all people to the healthcare they need, without financial hardship is the goal of Universal Health Coverage (UHC). As UHC initiatives expand, assessing the needs of vulnerable populations can reveal gaps in the system which may be covered by relevant policies. In this study we (i) identify the met and unmet primary healthcare needs of the poorest population of Khyber Pakhtunkhwa province (KP), Pakistan, and (ii) explore why the gaps exist. Methods: We used Leveque's Framework of Patient-centred Access to Healthcare to examine unmet primary healthcare (PHC) needs and their underlying causes for the poorest population in four districts of Khyber Pakhtunkhwa province, Pakistan. Using a triangulation mixed methods design, we analysed data from a quantitative household survey of744 households, 17 focus group discussions with household members and, 11 interviews with healthcare providers. Results: Our results show that indicate that despite service utilization, PHC needs were not met, primarily due to prohibitively high costs at each stage of access. Furthermore, gaps in outreach and information (approachability), and varying availability of medicines and diagnostics at facilities (appropriateness) the supply side as well as difficulties in navigating the system (inability to perceive) and adhering to prescriptions (inability to engage) on the demand side, also led to unmet PHC needs. Going beyond utilization, our findings highlight that engagement with care is an important determinant of met needs for vulnerable populations. Conclusion: Social health protection policies can contribute to advancing UHC for primary care. However, in our setting, enhancing communication and outreach, addressing gender and age disparities, and improving quality of care and health infrastructure are necessary to fully meet the needs of the poorest populations. Highlights: • The primary health needs of the poorest population of Khyber Pakhtunkhwa remain largely unmet or are met with difficulties, across the care-seeking pathway. • Major contributors to unmet primary healthcare needs in the study area are: low outreach, crowded facilities and, varying availability of medicines and diagnostics at facilities on the supply side, and difficulties in navigating care and inability to afford prescribed care on the demand side. • Social Health Protection is a crucial tool for advancing Universal Health Coverage and improving primary healthcare, however these needs cannot be met without quality service provision and outreach from facilities. • Levesque's framework of access to care (2013) can be effectively employed to identify broad-based unmet needs and assess gaps in primary healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Countries with formal policies for palliative care, and advanced and integrated practices in this field, such as Portugal, face challenges in achieving excellence in care, particularly in home-based assistance. Issues include care coordination among providers, confusion regarding the roles of each health care professional in the network, and a lack of monitoring and evaluation of actions. Our objective was to analyze the implementation of palliative care in primary health care in Portugal. Methods: We conducted a qualitative, descriptive, and exploratory study in Portugal involving health care professionals with experience in palliative care. The data were collected through semistructured interviews and focus groups between March and October 2023. Eighteen health care professionals participated. We used the Alceste software for lexicographic analysis. The research was authorized by an Ethics Committee. Results: Four classes were identified; classes 1 and 2, comprising 77% of the corpus, addressed the study objectives. Participants highlighted inequitable access, strategic development plans with unattainable short-term goals; and low literacy. They emphasized the importance of legislation, professional training initiatives for generalist palliative care at home, and early referral. Home-based challenges included professionals' lack of exclusive dedication, absence of 24/7 coverage, and unavailability of capable family caregivers. The networks' response to hospital admissions and patient transitions from hospital to home, with access to the specialized team, was also inadequate. Conclusions: Health care professionals aim to increase patients' time spent at home, reduce emergency department visits, and minimize hospitalizations by leveraging the resources of the national palliative care network. In addition to investments to sustain network implementation and legally guaranteed palliative care rights, the country must focus on measurable indicators for evaluating and monitoring actions, providing better guidance in the short, medium, and long term. [ABSTRACT FROM AUTHOR]

Background: Setting and implementing evidence-informed health service packages (HSPs) is crucial for improving health and demonstrating the effective use of evidence in real-world settings. Despite extensive training for large groups on evidence generation and utilization and establishing structures such as evidence-generation entities in many countries, the institutionalization of setting and implementing evidence-informed HSPs remains unachieved. This study aims to review the actions taken to set the HSP in Iran and to identify the challenges of institutionalizing the evidence-informed priority-setting process. Methods: Relevant documents were obtained through website search, Google queries, expert consultations and library manual search. Subsequently, we conducted nine qualitative semi-structured interviews with stakeholders. The participants were purposively sampled to represent diverse backgrounds relevant to health policymaking and financing. These interviews were meticulously audio-recorded, transcribed and reviewed. We employed the framework analysis approach, guided by the Kuchenmüller et al. framework, to interpret data. Results: Efforts to incorporate evidence-informed process in setting HSP in Iran began in the 1970s in the pilot project of primary health care. These initiatives continued through the Health Transformation Plan in 2015 and targeted disease-specific efforts in 2019 in recent years. However, full institutionalization remains a challenge. The principal challenges encompass legal gaps, methodological diversity, fragile partnerships, leadership changeovers, inadequate financial backing of HSP and the dearth of an accountability culture. These factors impede the seamless integration and enduring sustainability of evidence-informed practices, hindering collaborative decision-making and optimal resource allocation. Conclusions: Technical aspects of using evidence for policymaking alone will not ensure sustainability unless it achieves the necessary requirements for institutionalization. While addressing all challenges is crucial, the primary focus should be on required transparency and accountability, public participation with an intersectionality lens and making this process resilience to shocks. It is imperative to establish a robust legal framework and a strong and sustainable political commitment to embrace and drive change, ensuring sustainable progress. [ABSTRACT FROM AUTHOR]

Patent and proprietary medicine vendors in Nigeria play a very integral role in providing primary health care services and are an important source of care for the poor. They are located close to communities and are often the first source of care for hygiene and family planning (FP) products and treatment of child illnesses. Since 2017, Pharmacy Council of Nigeria (PCN) has partnered with Society for Family Health through the IntegratE project to address the poor quality of services by patent and proprietary medicine vendors (PPMVs) and reposition them for better service delivery through piloting the three-tier accreditation system. The partnership has engendered innovation for human resource for health, and considering the peculiarity of their situation, new emerging methods and arrangements to deliver the training to PPMVs in diverse geographical locations within their catchment areas are developed. In this study, we aimed to discuss the role of patent and proprietary medicine vendors in the provision of quality health delivery and provide key lessons and recommendations which have been learned from the pilot scaling of training facilities for PPMVs in Nigeria through the IntegratE project. From the lessons learnt, we propose that, for a successful scale-up of implementation of the three-tier accreditation of PPMVs, PCN will have to establish a budget line for accreditation. In addition, the government should also consider supporting this training through the Basic Healthcare Provision Fund as a way of strengthening human resources at the primary healthcare level. Other alternative sources of funding include licensing and registration fees and other dues generated internally by PCN. [ABSTRACT FROM AUTHOR]

Background: Good quality clinical practice guidelines (CPGs) are a vehicle to implementing evidence into allied health (AH) care. This paper reports on the current 'state of play' of CPGs in a lower-to-middle-income country (South Africa), where primary healthcare (PHC) AH activities face significant challenges in terms of ensuring quality service delivery in the face of huge PHC need.Methods: A qualitative study was conducted, using semi-structured interviews with purposively-sampled individuals involved in AH PHC CPGs in South Africa. They included national and state government policy-makers, academics and educators, service managers, clinicians, representatives of professional associations, technical writers, and members of informal professional networks. The interview data was transcribed and de-identified, and analysed descriptively by hand-coding. The COREQ statement guided study conduct and reporting. A framework to guide research in other countries into perspectives of AH PHC CPG activities was established.Results: Of the 32 invited, 29 people participated: of these 25 were interviewed and four provided meeting notes. Most participants had multiple professional roles, being engaged concurrently in clinical practice, academia, professional associations and / or government. Key themes comprised Players (sub-themes of sampling frame, participants, advice, role players and collaboration); Guidance (sub-themes of nomenclature, drivers, purpose, evidence sources) and Role of AH in PHC (sub-themes of discipline groupings, disability and rehabilitation, AH recognition).Conclusion: There was consistently-expressed desire for quality guidance to support better quality AH PHC activities around the country. However no international CPGs were used, and there were no South African CPGs specific to local PHC AH practice. The guidance gap was filled by non-evidence-based documents produced often without training, to deal with specific clinical situations. This led to frustration, duplication and fragmentation of effort, confusing nomenclature, and an urgent need for standardised and agreed guidance. We provided a standardised framework to capture perspectives on CPGs activities in other AH PHC settings. [ABSTRACT FROM AUTHOR]

Background: The deployment of the mental health nurse, an additional healthcare provider for individuals in need of mental healthcare in Dutch general practices, was expected to substitute treatments from general practitioners and providers in basic and specialized mental healthcare (psychologists, psychotherapists, psychiatrists, etc.). The goal of this study was to investigate the extent to which the degree of mental health nurse deployment in general practices is associated with healthcare utilization patterns of individuals with depression. Methods: We combined national health insurers' claims data with electronic health records from general practices. Healthcare utilization patterns of individuals with depression between 2014 and 2019 (N = 31,873) were analysed. The changes in the proportion of individuals treated after depression onset were assessed in association with the degree of mental health nurse deployment in general practices. Results: The proportion of individuals with depression treated by the GP, in basic and specialized mental healthcare was lower in individuals in practices with high mental health nurse deployment. While the association between mental health nurse deployment and consultation in basic mental healthcare was smaller for individuals who depleted their deductibles, the association was still significant. Treatment volume of general practitioners was also lower in practices with higher levels of mental health nurse deployment. Conclusion: Individuals receiving care at a general practice with a higher degree of mental health nurse deployment have lower odds of being treated by mental healthcare providers in other healthcare settings. More research is needed to evaluate to what extent substitution of care from specialized mental healthcare towards general practices might be associated with waiting times for specialized mental healthcare. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. Methods: A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40–69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. Results: We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40–69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. Conclusions: Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care. [ABSTRACT FROM AUTHOR]

Background: In Ghana's health delivery services, facilitative supervisory visit (FSV) as a system of management is new. This paper presents the standard evaluation results of FSV, which formed an integral part of the community-based health planning services (CHPS) initiative. Methods: The study was conducted in the Upper West Region of Ghana. The Project developed guidelines and tools for FSV for four different health system levels - regional, district, sub-district and community levels. Electronic data from all four levels representing quarterly results were compiled into their annual equivalents, and summarized graphically for comparison. Results: The data show that all the nine districts embraced the FSV concept even though they differed markedly with regard to the degree of adherence to some set benchmarks. Three DHMTs (Wa Municipal, Lawra and Jirapa) were graded as good while the remaining six DHMTs were adjudged as fair in relation to management of supplies, transport and equipment, information, meeting, and technical support. Conclusions: The data further suggest that there is much to gain both individually and institutionally from FSVs. Generally, FSVs are crucial to the delivery of primary health care services in especially rural areas. [ABSTRACT FROM AUTHOR]

Background: The countries of Central and Eastern Europe have experienced a lot of changes at the end of the 20th century, including changes in the health care systems and especially in primary care. The aim of this paper is to systematically assess the position of family medicine in these countries, using the same methodology within all the countries. Methods: A key informants survey in 11 Central and Eastern European countries and Russia using a questionnaire developed on the basis of systematic literature review. Results: Formally, family medicine is accepted as a specialty in all the countries, although the levels of its implementation vary across the countries and the differences are important. In most countries, solo practice is the most predominant organisational form of family medicine. Family medicine is just one of many medical specialties (e.g. paediatrics and gynaecology) in primary health care. Full introduction of family medicine was successful only in Estonia. Conclusions: Some of the unification of the systems may have been the result of the EU request for adequate training that has pushed the policies towards higher standards of training for family medicine. The initial enthusiasm of implementing family medicine has decreased because there was no initiative that would support this movement. Internal and external stimuli might be needed to continue transition process. [ABSTRACT FROM AUTHOR]

The year 2008 celebrated 30 years of Primary Health Care (PHC) policy emerging from the Alma Ata Declaration with publication of two key reports, the World Health Report 2008 and the Report of the Commission on the Social Determinants of Health. Both reports reaffirmed the relevance of PHC in terms of its vision and values in today's world. However, important challenges in terms of defining PHC, equity and empowerment need to be addressed. This article takes the form of a commentary reviewing developments in the last 30 years and discusses the future of this policy. Three challenges are put forward for discussion (i) the challenge of moving away from a narrow technical bio-medical paradigm of health to a broader social determinants approach and the need to differentiate primary care from primary health care; (ii) The challenge of tackling the equity implications of the market oriented reforms and ensuring that the role of the State in the provision of welfare services is not further weakened; and (iii) the challenge of finding ways to develop local community commitments especially in terms of empowerment. These challenges need to be addressed if PHC is to remain relevant in today's context. The paper concludes that it is not sufficient to revitalize PHC of the Alma Ata Declaration but it must be reframed in light of the above discussion. [ABSTRACT FROM AUTHOR]

Background: The South African allied health (AH) primary healthcare (PHC) workforce is challenged with the complex rehabilitation needs of escalating patient numbers. The application of evidence-based care using clinical practice guidelines (CPGs) is one way to make efficient and effective use of resources. Although CPGs are common for AH in high-income countries, there is limited understanding of how to do this in low- to middle-income countries. This paper describes barriers and enablers for AH CPG uptake in South African PHC.Methods: Semi-structured individual interviews were undertaken with 25 South African AH managers, policymakers, clinicians and academics to explore perspectives on CPGs. Interviews were conducted by researcher dyads, one being familiar with South African AH PHC practice and the other with CPG expertise. Rigour and transparency of data collection was ensured. Interview transcripts were analysed by structuring content into codes, categories and themes. Exemplar quotations were extracted to support themes.Results: CPGs were generally perceived to be relevant to assist AH providers to address the challenges of consistently providing evidence-based care in South African PHC settings. CPGs were considered to be tools for managing clinical, social and economic complexities of AH PHC practice, particularly if CPG recommendations were contextusalised. CPG uptake was one way to deal with increasing pressures to make efficient use of scarce financial resources, and to demonstrate professional legitimacy. Themes comprised organisational infrastructures and capacities for CPG uptake, interactions between AH actors and interaction with broader political structures, the nature of AH evidence in CPGs, and effectively implementing CPGs into practice.Conclusion: CPGs contextualised to local circumstances offer South African PHC AH services with an efficient vehicle for putting evidence into practice. There are challenges to doing this, related to local barriers such as geography, AH training, workforce availability, scarce resources, an escalating number of patients requiring complex rehabilitation, and local knowledge. Concerted attempts to implement locally relevant CPGs for AH primary care in South Africa are required to improve widespread commitment to evidence-based care, as well as to plan efficient and effective service delivery models. [ABSTRACT FROM AUTHOR]

Focused ethnography is an applied and pragmatic form of ethnography that explores a specific social phenomenon as it occurs in everyday life. Based on the literature a problem-focused research question is formulated before the data collection. The data generation process targets key informants and situations so that relevant results on the pre-defined topic can be obtained within a relatively short time-span. As part of a theory based evaluation of alternative forms of consultation (such as video, phone and email) in primary care we used the focused ethnographic method in a multisite study in general practice across the UK. To date there is a gap in the literature on using focused ethnography in healthcare research.The aim of the paper is to build on the various methodological approaches in health services research by presenting the challenges and benefits we encountered whilst conducing a focused ethnography in British primary care. Our considerations are clustered under three headings: constructing a shared understanding, dividing the tasks within the team, and the functioning of the focused ethnographers within the broader multi-disciplinary team.As a result of using this approach we experienced several advantages, like the ability to collect focused data in several settings simultaneously within in a short time-span. Also, the sharing of experiences and interpretations between the researchers contributed to a more holistic understanding of the research topic. However, mechanisms need to be in place to facilitate and synthesise the observations, guide the analysis, and to ensure that all researchers feel engaged. Reflection, trust and flexibility among the team members were crucial to successfully adopt a team focused ethnographic approach. When used for policy focussed applied healthcare research a team-based multi-sited focused ethnography can uncover practices and understandings that would not be apparent through surveys or interviews alone. If conducted with care, it can provide timely findings within the fast moving context of healthcare policy and research. [ABSTRACT FROM AUTHOR]

Background: Primary healthcare researchers are under increasing pressure to demonstrate measurable and lasting improvement in clinical practice and healthcare policy as a result of their work. It is therefore important to understand the effectiveness of the research dissemination strategies used. The aim of this paper is to describe the pathways for research impact that have been achieved across several government-funded primary healthcare projects, and the effectiveness of these methods as perceived by their Chief Investigators.Methods: The project used an online survey to collect information about government-funded primary healthcare research projects. Chief Investigators were asked how they disseminated their findings and how this achieved impact in policy and practice. They were also asked to express their beliefs regarding the most effective means of achieving research impact and describe how this occurred.Results: Chief Investigators of 17 projects indicated that a number of dissemination strategies were used but that professional networks were the most effective means of promoting uptake of their research findings. Utilisation of research findings for clinical practice was most likely to occur in organisations or among individual practitioners who were most closely associated with the research team, or when research findings were included in educational programmes involving clinical practice. Uptake of both policy- and practice-related research was deemed most successful if intermediary organisations such as formal professional networks were engaged in the research. Successful primary healthcare researchers had developed critical relationships with intermediary organisations within primary healthcare before the initiation of the research and had also involved them in the design. The scale of research impact was influenced by the current policy environment, the type and significance of the results, and the endorsement (or lack thereof) of professional bodies.Conclusions: Chief Investigators believed that networks were the most effective means of research dissemination. Researchers who were embedded in professional, clinical or policy-focussed intermediary organisations, or had developed partnerships with clinical services, which had a vested interest in the research findings, were more able to describe a direct impact of their research. This suggests that development of these relationships and engagement of these stakeholders by primary healthcare researchers is a vital step for optimal research utilisation in the primary healthcare setting. [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history—even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs). Methods: We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources. Results: Looking across four decades of the program's history illuminates that issues of gender, workload, and pay—hotly debated in the CHW literature now—have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system. Conclusions: Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment. [ABSTRACT FROM AUTHOR]

Background: The general practitioner contracting initiative (GPCI) is a health systems strengthening initiative piloted in the first phase of national health insurance (NHI) implementation in South Africa as it progresses towards universal health coverage (UHC). GPCI aimed to address the shortage of doctors in the public sector by contracting-in private sector general practitioners (GPs) to render services in public primary health care clinics. This paper explores the early inception and emergence of the GPCI. It describes three models of contracting-in that emerged and interrogates key factors influencing their evolution. Methods: This qualitative multi-case study draws on three cases. Data collection comprised document review, key informant interviews and focus group discussions with national, provincial and district managers as well as GPs (n = 68). Walt and Gilson's health policy analysis triangle and Liu's conceptual framework on contracting-out were used to explore the policy content, process, actors and contractual arrangements involved. Results: Three models of contracting-in emerged, based on the type of purchaser: a centralized-purchaser model, a decentralized-purchaser model and a contracted-purchaser model. These models are funded from a single central source but have varying levels of involvement of national, provincial and district managers. Funds are channelled from purchaser to provider in slightly different ways. Contract formality differed slightly by model and was found to be influenced by context and type of purchaser. Conceptualization of the GPCI was primarily a nationally-driven process in a context of high-level political will to address inequity through NHI implementation. Emergence of the models was influenced by three main factors, flexibility in the piloting process, managerial capacity and financial management capacity. Conclusion: The GPCI models were iterations of the centralized-purchaser model. Emergence of the other models was strongly influenced by purchaser capacity to manage contracts, payments and recruitment processes. Findings from the decentralized-purchaser model show importance of local context, provincial capacity and experience on influencing evolution of the models. Whilst contract characteristics need to be well defined, allowing for adaptability to the local context and capacity is critical. Purchaser capacity, existing systems and institutional knowledge and experience in contracting and financial management should be considered before adopting a decentralized implementation approach. [ABSTRACT FROM AUTHOR]

Introduction: Australians in rural and remote areas experience poorer health status compared with many metropolitan residents, due partly to inequitable access to primary health care (PHC) services. Building on recent research that identified PHC services which all Australians should be able to access regardless of where they live, this paper aims to define the population thresholds governing which PHC services would be best provided by a resident health worker, and to outline attendant implementation issues. Methods: A Delphi method comprising panellists with expertise in rural, remote and/or Indigenous PHC was used. Five population thresholds reflecting Australia's diverse rural and remote geography were devised. Panellists participated in two electronic surveys. Using a Likert scale, they were asked at what population threshold each PHC service should be provided by a resident health worker. A follow-up focus group identified important underlying principles which guided the consensus process. Results: Response rates were high. The population thresholds for core PHC services provided by a resident worker were less in remote communities compared with rural communities. For example, the population threshold for 'care of the sick and injured,' was ≤ 100 for remote compared with 101-500 for rural communities. For 'mental health', 'maternal/ child health', 'sexual health' and 'public health' services in remote communities the population threshold was 101-500, compared to 501-1000 for rural communities. Principles underpinning implementation included the fundamental importance of equity; consideration of social determinants of health; flexibility, effective expenditure of resources, tailoring services to ensure consumer acceptability, prioritising services according to need, and providing services as close to home as possible. Conclusion: This research can assist policy makers and service planners to determine the population thresholds at which PHC services should be delivered by a resident health worker, to allocate resources and provide services more equitably, and inform consumers about PHC services they can reasonably expect to access in their community. This framework assists in developing a systematic approach to strategies seeking to address existing rural-urban health workforce maldistribution, including the training of generalists as opposed to specialists, and providing necessary infrastructure in communities most in need. [ABSTRACT FROM AUTHOR]

Introduction In Hong Kong, migrants arriving from Mainland China often have multiple roles and responsibilities while adapting to new lives in their host destination. This paper explored the factors that contribute to the inequity in health services utilisation experienced by these migrants; and, identified the elements that could constitute an effective health delivery model to address the service gap. Methods Site visits and a focus group discussion (n = 13) were held with both public and private health providers before a number of innovative health delivery models were formulated. They were then circulated among the panel in two further rounds of Delphi survey (n = 11) from March- April 2012 to systematically collect opinions and select the most endorsed health service models to serve this target population. Results Focus group members perceived that most migrants were unaware of, or even ignored, their own physical and mental health needs, and had low utilisation of healthcare services, because of their pre-occupation with daily chores and hardship as well as differing health values, practices and expectations. They further identified that the structural issues such as the healthcare setting or the operation of current service provisions had failed to meet migrants' health needs. Consequently, four new service models that incorporated professional advice and empowerment, which were identified as the two most important elements, were put forward. Thus, the model of having a nurse with social work training, supported by volunteer groups, was selected as the best option to familiarise and empower patients within the labyrinth of local healthcare services. Conclusion Implementation of a social empowerment model by way of targeted support and specific health information is recommended. Further evaluation of this model is needed to understand its effectiveness for improving health literacy and health status in this disadvantaged group in the long term. [ABSTRACT FROM AUTHOR]

Background: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective. Methods: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework. Results: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care. Conclusion: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems. [ABSTRACT FROM AUTHOR]

Background Globally, abundant opportunities exist for policymakers to improve the accessibility of rural and remote populations to primary health care through improving workforce retention. This paper aims to identify and quantify the most important factors associated with rural and remote Australian family physician turnover, and to demonstrate how evidence generated by survival analysis of health workforce data can inform rural workforce policy making. Methods A secondary analysis of longitudinal data collected by the New South Wales (NSW) Rural Doctors Network for all family physicians working in rural or remote NSW between January 1st 2003 and December 31st 2012 was performed. The Prentice, Williams and Peterson statistical model for survival analysis was used to identify and quantify risk factors for rural NSW family physician turnover. Results Multivariate modelling revealed a higher (2.65-fold) risk of family physician turnover in small, remote locations compared to that in small closely settled locations. Family physicians who graduated from countries other than Australia, United Kingdom, United States of America, New Zealand, Ireland, and Canada also had a higher (1.45-fold) risk of turnover compared to Australian trained family physicians. This was after adjusting for the effects of conditional registration. Procedural skills and public hospital admitting rights were associated with a lower risk of turnover. These risks translate to a predicted median survival of 11 years for Australian-trained family physician non-proceduralists with hospital admitting rights working in small coastal closely settled locations compared to 3 years for family physicians in remote locations. Conclusions This study provides rigorous empirical evidence of the strong association between population size and geographical location and the retention of family physicians in rural and remote NSW. This has important policy ramifications since retention grants for rural and remote family physicians in Australia are currently based on a geographical 'remoteness' classification rather than population size. In addition, this study demonstrates how survival analysis assists health workforce planning, such as through generating evidence to assist in benchmarking 'reasonable' lengths of practice in different geographic settings that might guide service obligation requirements. [ABSTRACT FROM AUTHOR]

Background: The concept of "mechanism" is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand).Methods: In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC.Results: We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions.Conclusions: We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation. [ABSTRACT FROM AUTHOR]

Background: Migrants is a large population in China. To improve the health and wellbeing of migrants is a critical policy and social issue in China, and to enhance the utilization of primary health care by migrants is one of the most important approaches in promoting equity in health. However, there exists little research about the association between social integration and the utilization of primary health care. To address the research gap, this research aims at exploring the relation between social integration and the utilization of primary health care among migrants in China. Methods: Using the national data from China Migrants Dynamic Survey (CMDS) in 2017, 169,989 migrants were included in this study. Social integration was measured by social communication, acculturation and self-identity, with 8 indicators. The utilization of primary health care was measured by the receiving of health education on infectious diseases (ID) and noncommunicable diseases (NCD) as well as the first visit institution when migrants were sick. After the descriptive statistical analysis, binary logistic regression was employed to evaluate the association between social integration and the utilization of primary health care. Results: 65.99% of the migrants received health education on infectious diseases (ID), 40.11% of the migrants received health education on noncommunicable diseases (NCD) and 8.48% of the migrants chose to go to Community Health Center (CHC) seeking for health services. There was a positive effect of social organization participation, the influence of hometown customs, differences of hygiene habits between migrants and local people, integration willingness and evaluation of identity on the receiving of health education on ID and NCD, as well as a positive effect of civil activities engagement and differences of hygiene habits between migrants and local people on the utilization of CHC after getting sick. Conclusions: Social integration was associated with the utilization of primary health care among migrants in China. Generally speaking, greater social integration was associated with higher possibility of receiving health education on ID and NCD. However, the effect of social integration on the utilization of CHC was more complex among different indicators. There should be more policy interventions to improve the social integration of migrant which help them to get familiar with the health resource available, as well as improve the capacity of CHC. [ABSTRACT FROM AUTHOR]

Background: The effects of the COVID-19 pandemic on older adults were felt throughout the health care system, from intensive care units through to long-term care homes. Although much attention has been paid to hospitals and long-term care homes throughout the pandemic, less attention has been paid to the impact on primary care clinics, which had to rapidly change their approach to deliver timely and effective care to older adult patients. This study examines how primary care clinics, in three Canadian provinces, cared for their older adult patients during the pandemic, while also navigating the rapidly changing health policy landscape. Methods: A qualitative case study approach was used to gather information from nine primary care clinics, across three Canadian provinces. Interviews were conducted with primary care providers (n = 17) and older adult patients (n = 47) from October 2020 to September 2021. Analyses of the interviews were completed in the language of data collection (English or French), and then summarized in English using a coding framework. All responses that related to COVID-19 policies at any level were also examined. Results: Two main themes emerged from the data: (1) navigating the noise: understanding and responding to public health orders and policies affecting health and health care, and (2) receiving and delivering care to older persons during the pandemic: policy-driven challenges & responses. Providers discussed their experiences wading through the health policy directives, while trying to provide good quality care. Older adults found the public health information overwhelming, but appreciated the approaches adapted by primary care clinics to continue providing care, even if it looked different. Conclusions: COVID-19 policy and guideline complexities obliged primary care providers to take an important role in understanding, implementing and adapting to them, and in explaining them, especially to older adults and their care partners. [ABSTRACT FROM AUTHOR]

Background: In 2019, the World Health Organization, set a target to halve the burden of snakebite, by 2030, and identified 'health systems strengthening' as a key pillar of action. In India, the country with most snakebite deaths, the Union Government identified (in September 2022) training of health workers as a priority action area. In this policy context, we provide empirical evidence by analysing the most recent nationwide survey data (District Level Household and Facility Survey − 4), to assess structural capacity and continuum of snakebite care in primary health care system in India. Methodology: We evaluated structural capacity for snakebite care under six domains: medicines, equipment, infrastructure, human resources, governance and finance, and health management information systems (HMIS). We categorised states (aspirant, performer, front-runner, achiever) based on the proportion of primary health centres (PHC) and community health centres (CHC), attaining highest possible domain score. We assessed continuum of snakebite care, district-wise, under five domains (connectivity to PHC, structural capacity of PHC, referral from PHC to higher facility, structural capacity of CHC, referral from CHC to higher facility) as adequate or not. Results: No state excelled (front-runner or achiever) in all six domains of structural capacity in PHCs or CHCs. The broader domains (physical infrastructure, human resources for health, HMIS) were weaker compared to snakebite care medicines in most states/UTs, at both PHC and CHC levels. CHCs faced greater concerns regarding human resources and equipment availability than PHCs in many states. Among PHCs, physical infrastructure and HMIS were aspirational in all 29 assessed states, while medicines, equipment, human resources, and governance and finance were aspirational in 8 (27.6%), 2 (6.9%), 17 (58.6%), and 12 (41.4%) states respectively. For CHCs, physical infrastructure was aspirational in all 30 assessed states/UTs, whereas HMIS, medicines, equipment, human resources, and governance and finance were aspirational in 29 (96.7%), 11 (36.7%), 27 (90%), 26 (86.7%), and 3 (10%) states respectively. No district had adequate continuum of snakebite care in all domains. Except for transport availability from CHC to higher facilities (48% of districts adequate) and transport availability from PHC to higher facilities (11% of districts adequate), fewer than 2% of districts were adequate in all other domains. Conclusion: Comprehensive strengthening of primary health care, across all domains, and throughout the continuum of care, instead of a piece-meal approach towards health systems strengthening, is necessitated to reduce snakebite burden in India, and possibly other high-burden nations with weak health systems. Health facility surveys are necessitated for this purpose. [ABSTRACT FROM AUTHOR]

Background: Effectiveness of interventions in pragmatic trials may not translate directly into population impact, because of limited uptake by clinicians and/or the public. Uptake of an intervention is influenced by a number of factors.Methods: We propose a method for calculating population impact of clinical interventions that accounts for the intervention uptake. We suggest that population impact may be estimated by multiplying the two key components: (1) the effectiveness of the intervention in pragmatic trials (trial effect); and, (2) its uptake in clinical practice. We argue that participation rates in trials may be a valid proxy for uptake in clinical practice and, in combination with trial effectiveness estimates, be used to rank interventions by their likely population impact. We illustrate the method using the example of four interventions to decrease antibiotic prescription for acute respiratory infections in primary care: delayed prescribing, procalcitonin test, C-Reactive Protein, shared decision making.Results: In order to estimate uptake of interventions from trial data we need detailed reporting on the recruitment processes used for clinician participation in the trials. In the antibiotic prescribing example, between 75 and 91% of the population would still be prescribed or consume antibiotics because effective interventions were not taken up. Of the four interventions considered, we found that delayed prescribing would have the highest population impact and shared decision making the lowest.Conclusion: Estimates of uptake and population impact of an intervention may be possible from pragmatic RCTs, provided the recruitment processes for these trials are adequately reported (which currently few of them are). Further validation of this method using empirical data on intervention uptake in the real world would support use of this method to decide on public funding of interventions. [ABSTRACT FROM AUTHOR]

Background: In the wake of terrorist attacks, protecting the health and psychosocial wellbeing of those affected and the general population, are important tasks for the healthcare system. The responses to such emergencies are often complex, including different phases and many actors, and may unveil insufficiencies that incite reforms to existing systems. Recently, initiatives have been promoted to strengthen cooperation and coordination regarding the governance of health threats in Europe. Comparative research is requested on how states prepare for health emergencies such as terrorist attacks. This study investigated how governments in two European countries with universal health coverage prepared to address the civilian population's health needs after terrorist attacks, and the factors that contributed to shaping their chosen approach. Methods: Utilizing document analysis and Walt and Gilson's model for the analysis of health policy, national plans for post-terror health responses in Norway and France were studied with a focus on context, process, content, and actors. Results: Whereas target groups for psychosocial care and certain measures were similar in both cases, the contents of prescribed policies and the actors responsible for enacting them differed. One of the most distinct differences was to what extent specialized mental healthcare was relied upon to provide psychosocial follow-up in the emergency phase. In the French approach, specialized mental healthcare practitioners, such as psychiatrists, psychologists and psychiatric nurses, provided early psychosocial support. In contrast, the Norwegian approach relied on interdisciplinary primary care crisis teams in the local municipalities to provide early psychosocial support, with further involvement of specialized mental healthcare if this was considered necessary. Historical, political, and systemic differences contributed to the variation in the countries' responses. Conclusions: This comparative study highlights the complexity and diversity of health policy responses to terrorist attacks across countries. Moreover, challenges and opportunities for research and health management in response to such disasters, including possibilities and potential pitfalls for the coordination of this work across Europe. An important first step could be to map out existing services and practices across countries to better understand if and how common core elements for psychosocial follow-up might be implemented internationally. [ABSTRACT FROM AUTHOR]

Background: The recent 2018 Declaration of Astana recognized primary health care (PHC) as a means to achieve universal health coverage (UHC) and the health-related Sustainable Development Goals (SDGs). Following this declaration, country progress on operationalization of the PHC agenda and attainment of UHC has been stalled by the new challenges posed by the COVID-19 pandemic. The pandemic has also disrupted the continuity of essential health service provision and tested the resilience of the region's health systems. Methods: In accordance with this, the WHO Regional Office for Africa convened the Fifth Health Sector Directors' Planning and Policy Meeting across the 47 Member States of the Region. The two-day forum focused on building health system resilience to facilitate service continuity during health threats, PHC revitalization, and health systems strengthening towards UHC. Results: The Regional Forum provided evidence on building resilient health systems in the WHO African Region and engaged participants in meaningful and critical discussion. It is from these discussions that four key themes emerged: (1) working multisectorally/intersectorally, (2) moving from fragmentation to integration, (3) ensuring implementation and knowledge exchange, and (4) rethinking resilience and embracing antifragility. These discussions and associated groupings by thematic areas lend themselves to recommendations for the WHO. Conclusions: This paper details the proceedings and key findings on building resilient health systems, the four themes that emerged from participant deliberation, and the recommendations that have emerged from the meeting. Deliberations from the Regional Forum are critical, as they have the potential to directly inform policy and program design, given that the meeting convenes health sector technocrats, who are at the helm of policy design, action, and implementation. [ABSTRACT FROM AUTHOR]

Background: Currently, China is in the process of medical and health care reform, and the establishment of primary medical and health services covering urban and rural residents is an important aspect of this process. Studying the satisfaction of residents of underdeveloped areas with their primary medical and health services and identifying the factors that can increase the satisfaction of different groups may improve patient compliance and ultimately improve health. Moreover, such research may provide a reference for the development of medical and health undertakings in similarly underdeveloped areas.Methods: A face-to-face survey was conducted on a stratified random sample of 2200 residents in Gansu by using structured questionnaires. Demographic characteristics were collated, and questionnaires were factor-analysed and weighted using SPSS software to obtain scores for each factor, as well as total satisfaction scores. The characteristics of poorly satisfied populations were determined by a multiple linear regression analysis using SAS software. A cluster analysis was performed using SAS software for classification and a separate discussion of populations.Results: The hypertension self-awareness rate (11.29%) of the sampled population was lower than the average hypertension prevalence (23.85%), as recorded in the 2014 Health Statistical Yearbook of the region. The disease knowledge awareness factor was the lowest factor (2.857), whereas the policy awareness factor was the highest factor (4.772). The overall satisfaction was moderate (3.898). The multivariate linear regression model was significant (p <0.05). The regression coefficients were -0.041 for minors; 0.065 for unemployed people; and 0.094 for people with an elementary school educational level, a value lower than that of other population groups. A cluster analysis was used to divide the respondents into five groups. The overall satisfaction was lowest in the second population group (rural, middle-aged)(Fz = 3.64) and was highest in the fourth population group(minors) (Fz = 4.13). Different population groups showed different satisfaction rates in F1 to F6.Conclusion: Hypertensive patients had low self-awareness, and residents had a poor grasp of disease and limited health knowledge. Their overall satisfaction was moderate. Residents expressed comparatively high satisfaction with the current policy. Minors, adults with low level of education, unemployed people and other vulnerable groups expressed low overall satisfaction. The degree of satisfaction varied greatly among the different groups. Targeted medical and health practices should be implemented for different groups; additionally, the public health practice should be strengthened. [ABSTRACT FROM AUTHOR]

Background: Taiwan is predicted to become a super-aged society by 2025, and primary health centers (PHCs) are set to play a crucial role in the care of older adults. The Taiwanese government has developed an age-friendly verification framework for PHC. The aims of this study were to explore the difficulties faced by PHC staff in the implementation of age-friendly policies and their solution strategies.Methods: This study adopted a qualitative research method. The first stage involved conducting five focus groups with the responsible staff of PHCs (n = 41) that have been certified "age-friendly." The focus groups covered the effectiveness, difficulties, and resources of PHCs in regards to the introduction of age-friendly policies. In the second stage, in-depth interviews were conducted with executives of PHCs (n = 5), both certified and not certified as age-friendly, to further compare the difficulties faced by these two types of PHCs, thereby gaining perspectives for solution strategies. The principles of grounded theory were used for data analysis.Results: Four major PHC strategies are employed in the promotion of age-friendliness. First, organizational management, through which managers apply management methods and analyze the present PHC-related health concerns; second, resource utilization, which refers to the tallying, linking, and integrating of resources; third, business operation process, in which work efficiency is improved through the combination of business operations and staff training; finally, hardware improvement, which is achieved through comprehensive cataloging of facility environments.Conclusion: The implementation of age-friendliness in PHCs requires the efforts of both the service units and government. With resources provided by the government, PHCs can integrate management methods, businesses operations, and essential resources. Moreover, PHC executives can lead their teams in promoting age-friendly policies, and closely monitor their effectiveness. [ABSTRACT FROM AUTHOR]

Background: Providing rehabilitation services in primary health care (PHC) is associated with numerous health, social, and economic benefits. Therefore, low and middle-income countries, such as Iran, should benefit from the advantages of integrating rehabilitation services into PHC. We conducted a qualitative study to determine policy solutions that could facilitate the integration of rehabilitation services into Iran's PHC network. Methods: Semi-structured interviews were conducted with 38 participants, including health policymakers, rehabilitation managers, faculty members, and rehabilitation practitioners. Purposive and snowball sampling strategies were adopted to recruit participants. The WHO Health System building blocks framework analysis was applied to analyze the collected data. Results: Participants' perspectives and experiences outlined potential policy options including: (1) stewardship: increasing political support, strengthening the leadership of the rehabilitation sector, and promoting inter-sectoral collaborations; (2) service delivery: increasing the knowledge of healthcare professionals, using local volunteers, deploying mobile rehabilitation teams, using telerehabilitation, and improving referral pathways; (3) financing: increasing government funding, preparing a package of rehabilitation services, and using appropriate payment mechanisms; (4) human resources: expanding rehabilitation workforce, training rehabilitation assistants, and enhancing employment and social opportunities; (5) information systems: establishing a comprehensive information system and an effective surveillance system; and (6) technologies: facilitating access to a range of rehabilitation equipment and raw materials, especially for prosthetics and orthotics services. Conclusion: Based on the WHO six building blocks framework, this study identified several policy options for integrating rehabilitation services into the Iranian PHC Network. Some of the policy options include increasing political support, promoting inter-sectoral collaborations, increasing the skills and knowledge of healthcare workers, establishing effective referral pathways, strengthening team-working, and increasing government funding. [ABSTRACT FROM AUTHOR]

Background: Trauma-informed (TI) approach is a framework for a system change intervention that transforms the organizational culture and practices to address the high prevalence and impact of trauma on patients and healthcare professionals, and prevents re-traumatization in healthcare services. Review of TI approaches in primary and community mental healthcare identified limited evidence for its effectiveness in the UK, however it is endorsed in various policies. This study aimed to investigate the UK-specific context through exploring how TI approaches are represented in health policies, and how they are understood and implemented by policy makers and healthcare professionals.Methods: A qualitative study comprising of a document analysis of UK health policies followed by semi-structured interviews with key informants with direct experience of developing and implementing TI approaches. We used the Ready Extract Analyse Distil (READ) approach to guide policy document review, and the framework method to analyse data.Results: We analysed 24 documents and interviewed 11 professionals from healthcare organizations and local authorities. TI approach was included in national, regional and local policies, however, there was no UK- or NHS-wide strategy or legislation, nor funding commitment. Although documents and interviews provided differing interpretations of TI care, they were aligned in describing the integration of TI principles at the system level, contextual tailoring to each organization, and addressing varied challenges within health systems. TI care in the UK has had piecemeal implementation, with a nation-wide strategy and leadership visible in Scotland and Wales and more disjointed implementation in England. Professionals wanted enhanced coordination between organizations and regions. We identified factors affecting implementation of TI approaches at the level of organization (leadership, service user involvement, organizational culture, resource allocation, competing priorities) and wider context (government support, funding). Professionals had conflicting views on the future of TI approaches, however all agreed that government backing is essential for implementing policies into practice.Conclusions: A coordinated, more centralized strategy and provision for TI healthcare, increased funding for evaluation, and education through professional networks about evidence-based TI health systems can contribute towards evidence-informed policies and implementation of TI approaches in the UK. [ABSTRACT FROM AUTHOR]