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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]

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: 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 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]

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]

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: 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: 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: 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: 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]

Background: In 2002 Afghanistan's Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan. Methods: The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis. Results: While some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other. Conclusion: Three sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan's example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries. [ABSTRACT FROM AUTHOR]

Background: The completion of an implementation research project typically signals the end of research. In contrast, the Ghana Health Service has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research that monitors and guides the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+).Methods: A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample surveys with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process.Discussion: A process of exchanges, team interaction, and catalytic financing has accelerated the expansion of community-based primary health care in Ghana's Upper East Region (UER). Using two Northern and two Volta Region districts, the UER systems learning concept will be transferred to counterpart districts where a program of team-based peer training will be instituted. A mixed method research system will be used to assess the impact of this transfer of innovation in collaboration with national and regional program management. This arrangement will generate embedded science that optimizes prospects that results will contribute to national CHPS reform policies and action. [ABSTRACT FROM AUTHOR]

Background: In the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care. However, there are relatively few studies of either the medical outcome effects or cost benefits of HBPC. In this paper, we examine medical cost and mortality outcomes for enrollees in the HBPC program offered by Spectrum Health/Priority Health (SH/PH), a not-for-profit integrated health care/health insurance system located in Grand Rapids, MI, USA.Methods: We perform a concurrent matched cohort study. SH/PH HBPC enrollees during 2012-2014 are matched for prior costs, age, sex and comorbidities against controls selected from unenrolled insurance plan members. Twelve and twenty four-month medical costs are compared between HBPC participants and matched controls, overall and conditional on mortality status. Mortality rates of HBPC participants are studied on their own and in comparison to controls.Results: At 12 and 24 months, in comparison to matched controls HBPC participants show higher ($2933) and lower ($8620) costs respectively. Relative costs and savings of HBPC participants are a function of short term increased costs upon entry into the program (enrollees who survive the first year cost $5866 more than controls); substantial savings at end-of-life (approximately $37,037 in savings relative to controls are realized); and the overall mortality of HBPC participants (mean residual lifespan is 37.75 months from the time of enrollment). We project the present value of lifetime medical cost savings due to enrollment in the HBPC program to be at least $14,336.Conclusions: The SH/PC HBPC program reduces healthcare costs while enabling frail elders to remain at home. Reduction in costs is obtained at end-of-life and is offset with a smaller initial increase in costs upon enrollment. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta and Saskatchewan to understand how they inform the design and implementation of team-based primary health care service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada.Methods: We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewed relevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We compared and contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narratives prepared from the comparative analysis by offering contextual information on potential policy imperatives. Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtable event guided prioritization of policy imperatives.Results: The concept of team-based PHC varies widely across and within the three provinces. We noted policy gaps related to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policies speak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignment of goals and policies at different system levels; (2) investment of resources for system change; (3) compensation models for all members of the team; and (4) accountability through collaborative practice metrics.Conclusions: Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinated approach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanisms and performance monitoring could accelerate systemic transformation by removing some well-known barriers to team-based care. [ABSTRACT FROM AUTHOR]

Background: In South Africa, a new primary health care (PHC) re-engineering initiative aims to scale up the provision of community-based care (CBC). A central element in this initiative is the use of outreach teams comprising nurses and community health workers to provide care to the largely poor and marginalised communities across the country. The provision of care will inevitably lead to an increase in the amount of health care waste (HCW) generated in homes and suggests the need to pay more attention to the HCW that emanates from homes where there is care of a patient. CBC in South Africa is guided by the home-based care policy. However, this policy does not deal with issues about how HCW should be managed in CBC. This study sought to explore health care waste management (HCWM) in CBC in South Africa from the policy-makers' and stakeholders' perspective.Methods: Semi-structured interviews were conducted with 9 policy-makers and 21 stakeholders working in 29 communities in Durban, South Africa. Interviews were conducted in English; were guided by an interview guide with open-ended questions. Data was analysed thematically.Results: The Durban Solid waste (DSW) unit of the eThekwini municipality is responsible for overseeing all waste management programmes in communities. Lack of segregation of waste and illegal dumping of waste were the main barriers to proper management practices of HCW at household level while at the municipal level, corrupt tender processes and inadequate funding for waste management programmes were identified as the main barriers. In order to address these issues, all the policy-makers and stakeholders have taken steps to collaborate and develop education awareness programmes. They also liaise with various government offices to provide resources aimed at waste management programmes.Conclusions: HCW is generated in CBC and it is poorly managed and treated as domestic waste. With the rollout of the new primary health care model, there is a greater need to consider HCWM in CBC. There is need for the Department of Health to work together with the municipality to ensure that they devise measures that will help to deal with improper HCWM in the communities. [ABSTRACT FROM AUTHOR]

Background: Policy making, translation and implementation in politically and administratively decentralized systems can be challenging. Beyond the mere sub-national acceptance of national initiatives, adherence to policy implementation processes is often poor, particularly in low and middle-income countries. In this study, we explore the implementation fidelity of integrated PHC governance policy in Nigeria's decentralized governance system and its implications on closing implementation gaps with respect to other top-down health policies and initiatives.Methods: Having engaged policy makers, we identified 9 core components of the policy (Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Structure, and Office Establishment). We evaluated the level and pattern of implementation at state level as compared to the national guidelines using a scorecard approach.Results: Contrary to national government's assessment of level of compliance, we found that sub-national governments exercised significant discretion with respect to the implementation of core components of the policy. Whereas 35 and 32% of states fully met national criteria for the structural domains of "Office Establishment" and Legislation" respectively, no state was fully compliant to "Human Resource Management" and "Funding" requirements, which are more indicative of functionality. The pattern of implementation suggests that, rather than implementing to improve outcomes, state governments may be more interested in executing low hanging fruits in order to access national incentives.Conclusions: Our study highlights the importance of evaluating implementation fidelity in providing evidence of implementation gaps towards improving policy execution, particularly in decentralized health systems. This approach will help national policy makers identify more effective ways of supporting lower tiers of governance towards improvement of health systems and outcomes. [ABSTRACT FROM AUTHOR]

Background: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal.Methods: This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method.Results: There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team.Conclusions: Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues. [ABSTRACT FROM AUTHOR]

Background: Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals' views of this process. This study compares Primary Healthcare Professionals' perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland. Methods: Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests. Results: There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by GPs but not by nurses or clinical therapists. Conclusion: PCPs and GPs agree there is limited PCT implementation. GPs are most negative about this implementation. There is some disagreement about which resources are most important for effective PCT working. These findings provide valuable data for clinicians and policy makers about implementation of interdisciplinary teams in primary care. [ABSTRACT FROM AUTHOR]

Background: In China, most people tend to use hospitals rather than health centers for their primary care generally due to the perception that quality of care provided in the hospital setting is superior to that provided at the health centers. No studies have been conducted in China to compare the quality of primary care provided at different health care settings. The purpose of this study is to compare the quality of primary care provided in different types of health care facilities in China.Methods: A cross-sectional survey with patients was conducted in Guangdong province of China, using the validated Chinese Primary Care Assessment Tool (PCAT). ANOVA was performed to compare the overall and 10 domains of primary care quality for patients in tertiary, secondary, and primary health care settings. Multivariate analyses were used to assess the association between types of facility and quality of primary care attributes while controlling for sociodemographic and health care characteristics.Results: The final number of respondents was 864 including 161 from county hospitals, 190 from rural community health centers (CHCs), 164 from tertiary hospitals, 80 from secondary hospitals, and 269 from urban CHCs. Type of health care facilities was significantly associated with total PCAT score and domain scores. CHC was associated with higher total PCAT score and scores for first contact-access, ongoing care, comprehensiveness-services available, and community orientation than secondary and/or tertiary hospitals, after controlling for patients' demographic and health characteristics. Higher PCAT score was associated with greater satisfaction with primary care received. CHC patients were more likely to report satisfactory experiences compared to patients from secondary and tertiary facilities.Conclusions: The study demonstrated that CHCs provided better quality primary care when compared with secondary and tertiary health care facilities, justifying CHCs as a model of primary care delivery. [ABSTRACT FROM AUTHOR]

Background: The Mexican healthcare system is under increasing strain due to the rising prevalence of non-communicable diseases (especially type 2 diabetes), mounting costs, and a reactive curative approach focused on treating existing diseases and their complications rather than preventing them. Casalud is a comprehensive primary healthcare model that enables proactive prevention and disease management throughout the continuum of care, using innovative technologies and a patient-centred approach.Methods: Data were collected over a 2-year period in eight primary health clinics (PHCs) in two states in central Mexico to identify and assess enablers and inhibitors of the implementation process of Casalud. We used mixed quantitative and qualitative data collection tools: surveys, in-depth interviews, and participant and non-participant observations. Transcripts and field notes were analyzed and coded using Framework Analysis, focusing on defining and describing enablers and inhibitors of the implementation process.Results: We identified seven recurring topics in the analyzed textual data. Four topics were categorized as enablers: political support for the Casalud model, alignment with current healthcare trends, ongoing technical improvements (to ease adoption and support), and capacity building. Three topics were categorized as inhibitors: administrative practices, health clinic human resources, and the lack of a shared vision of the model.Conclusions: Enablers are located at PHCs and across all levels of government, and include political support for, and the technological validity of, the model. The main inhibitor is the persistence of obsolete administrative practices at both state and PHC levels, which puts the administrative feasibility of the model's implementation in jeopardy. Constructing a shared vision around the model could facilitate the implementation of Casalud as well as circumvent administrative inhibitors. In order to overcome PHC-level barriers, it is crucial to have an efficient and straightforward adaptation and updating process for technological tools. One of the key lessons learned from the implementation of the Casalud model is that a degree of uncertainty must be tolerated when quickly scaling up a healthcare intervention. Similar patient-centred technology-based models must remain open to change and be able to quickly adapt to changing circumstances. [ABSTRACT FROM AUTHOR]

Background: The world population has become more globalised with increasing number of people residing in another country for work or other reasons. Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia.Methods: Data were derived from the 2012 National Medical Care Survey (NMCS), a cross sectional survey of primary care encounters from public and private primary care clinics sampled from five regions in Malaysia. Patients with foreign nationality were identified and analysed for demographic profiles, reasons for encounter (RFEs), diagnosis, and provision of care.Results: Foreigners accounted for 7.7 % (10,830) of all patient encounters from NMCS. Most encounters were from private clinics (90.2 %). Median age was 28 years (IQR: 24.0, 34.8) and 69.9 % were male. Most visits to the primary care clinics were for symptom-based complaints (69.5 %), followed by procedures (23.0 %) and follow-up visit (7.4 %). The commonest diagnosis in public clinics was antenatal care (21.8 %), followed by high risk pregnancies (7.5 %) and upper respiratory tract infection (URTI) (6.8 %). Private clinics had more cases for general medical examination (13.5 %), URTI (13.1 %) and fever (3.9 %). Medications were prescribed to 76.5 % of these encounters.Conclusions: More foreigners were seeking primary medical care from private clinics and the encounters were for general medical examinations and acute minor ailments. Those who sought care from public clinics were for obstetric problems and chronic diseases. Medications were prescribed to two-thirds of the encounters while other interventions: laboratory investigations, medical procedures and follow-up appointment had lower rates in private clinics. Foreigners are generally of young working group and are expected to have mandatory medical checks. The preponderance of obstetrics seen in public clinics suggests a need for improved access to maternal care and pregnancy related care. This has implication on policy and health care provision and access for foreigners and future studies are needed to look into strategies to solve these problems. [ABSTRACT FROM AUTHOR]

Background: Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC's ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians' contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers' behaviour and practice organisation.Methods: Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists' opinions.Results: A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation.Conclusions: The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening. [ABSTRACT FROM AUTHOR]

Background: Primary care in Canada is the first point of entry for patients needing specialized services, the fundamental source of care for those living with chronic illness, and the main supplier of preventive services. Increased pressures on the system lead to changes such as an increased reliance on interdisciplinary teams, which are advocated to have numerous advantages. The functioning of teams largely depends on inter-professional relationships that can be supported or strained by the financial arrangements within teams. We assess which types of financial environments perpetuate and which reduce the challenge of medical dominance.Methods: Using qualitative interview data from 19 interdisciplinary teams/networks in three Canadian provinces, as well as related policy documents, we develop a typology of financial environments along two dimensions, financial hierarchy and multiplicity of funding sources. A financial hierarchy is created when the incomes of some providers are a function of the incomes of other providers. A multiplicity of funding sources is created when team funding is provided by several funders and a team faces multiple lines of accountability.Results: We argue that medical dominance is perpetuated with higher degrees of financial hierarchy and higher degrees of multiplicity. We show that the financial environments created in the three provinces have not supported a reduction in medical dominance. The longstanding Community Health Centre model, however, displays the least financial hierarchy and the least multiplicity-an environment least fertile for medical dominance.Conclusions: The functioning of interdisciplinary primary care teams can be negatively affected by the unique positioning of the medical profession. The financial environment created for teams is an important consideration in policy development, as it plays an important role in establishing inter-professional relationships. Policies that reduce financial hierarchies and funding multiplicities are optimal in this regard. [ABSTRACT FROM AUTHOR]

Background: Treatment for opioid dependence in Ireland is provided predominantly by general practitioners (GP) who have undergone additional training in opioid agonist treatment (OAT) and substance misuse. The National Methadone Treatment Programme (MTP) was introduced in 1998, and was designed to treat the opioid dependent population and to regulate the prescribing regimes at the time. The past two decades have seen the increased prescribing of methadone in primary care and changes in type of opioid abused, in particular, the increased use of over the counter (OTC) and prescription medications. Despite the scaling up of OAT in Ireland, drug related deaths however have increased and waiting lists for treatment exist in some areas outside the capital, Dublin. Two previous MTP reviews have made recommendations aimed at improving and scaling up of OAT in Ireland. This study updates these recommendations and is the first time that a group of national experts have engaged in structured research to identify barriers to OAT delivery in Ireland. The aim was to explore the views of national statutory and non-statutory stakeholders and experts on current barriers within the MTP and broader OAT delivery structures in order to inform their future design and implementation. Methods: A single focus group with a chosen group of national key stakeholders and experts with a broad range of expertise (clinical, addiction and social inclusion management, harm reduction, homelessness, specialist GPs, academics) (n = 11) was conducted. The group included national representation from the areas of drug treatment delivery, service design, policy and practice in Ireland. Results: Four themes emerged from the narrative analysis, and centred on OAT Choices and Patient Characteristics; Systemic Barriers to Optimal OAT Service Provision; GP Training and Registration in the MTP, and Solutions and Models of Good Practice: Using What You Have. Conclusion: The study identified a series of improvement strategies which could reduce barriers to access and the stigma associated with OAT, optimise therapeutic choices, enhance interagency care planning within the MTP, utilise the strengths of community pharmacy and nurse prescribers, and recruit and support methadone prescribing GPs in Ireland. [ABSTRACT FROM AUTHOR]

Background: There is wide variation in the overall one-year relative cancer survival rates across Europe, and this is thought to indicate national variations in stage of disease at diagnosis. However, there is little evidence to explain how different national systems influence a primary care practitioner's (PCP's) referral decisions, and how these relate to the variation in survival rates. This study investigates the health system factors that influence the thinking of PCPs when faced with patients who may have cancer, how they compare across European countries, and how they relate to national one-year relative cancer relative survival rates.Methods: An online quantitative questionnaire with closed-ended questions is used in a cross-sectional survey of 1250 PCPs in Europe, in 25 local health areas in 20 countries. Descriptive data are elicited for each country, including respondents' demographic details. An exploratory factor analysis will identify factors underlying the decision to refer patients for further investigations. Between-country variation in these factors will then be further investigated and presented as means with 95% confidence intervals. A regression model will be fitted for the vignettes using one-year relative survival as the outcome, with the proportion of PCPs opting to investigate as a single explanatory variable. Weighted regression will be used to explore which health system factors are associated with opting to investigate and with one-year relative survival. Linear correlations will be estimated between the proportions opting to investigate and national survival rates. When comparing between countries, weighted linear regression will be used to adjust for different sample sizes in each country.Discussion: This study investigates which system factors affect PCPs' decisions to refer and investigate patients who may have cancer, how they compare across 20 European countries, and how these factors relate to cancer survival rates. Knowledge of the extent and variability of the health system factors that affect referral decisions will inform future health service design, policy and research. [ABSTRACT FROM AUTHOR]