A rapid mixed-methods assessment of Libya's primary care system.

BACKGROUND: Libya has experienced decades of violent conflict that have severely disrupted health service delivery. The Government of National Unity is committed to rebuilding a resilient health system built on a platform of strong primary care. AIM: Commissioned by the government, we set out to perform a rapid assessment of the system as it stands and identify areas for improvement. DESIGN AND SETTING: We used a rapid applied policy explanatory-sequential mixed-methods design, working with Libyan data and Libyan policymakers, with supporting interview data from other primary care policymakers working across the Middle East and North Africa region. METHOD: We used the Primary Health Care Performance Initiative framework to structure our assessment. Review of policy documents and secondary analysis of WHO and World Bank survey data informed a series of targeted policymaker interviews. We used deductive framework analysis to synthesise our findings. RESULTS: We identified 11 key documents and six key policymakers to interview. Libya has strong policy commitments to providing good quality primary care, and a high number of health staff and facilities. Access to services and trust in providers is high. However, a third of facilities are non-operational; there is a marked skew towards axillary and administrative staff; and structural challenges with financing, logistics, and standards has led to highly variable provision of care. CONCLUSION: In reforming the primary care system, the government should consolidate leadership, clarify governance structures and systems, and focus on setting national standards for human resources for health, facilities, stocks, and clinical care.

Improving quality of non-communicable disease services at primary care facilities in middle-income countries: A scoping review.

Health systems in middle-income countries face important challenges in managing the high burden of Non-Communicable Diseases (NCD). Primary health care is widely recognized as key to managing NCDs in communities. However, the effectiveness of this approach is limited by poor quality of care (QoC), among others. This scoping review identifies the types of interventions that have been used in middle-income countries to improve the quality of NCD services at primary care facilities. Further, it identifies the range of outcomes these quality interventions have influenced. This scoping review covered both the grey and peer-reviewed literature. The 149 articles reviewed were classified into four domains - governance, service-delivery systems, health workforce, and patients and communities. There was a remarkable unevenness in the geographic distribution of studies - lower middle-income countries and some regions (Middle East, North Africa, and South East Asia) had a scarcity of published studies. NCDs such as stroke and cardiovascular disease, mental health, cancer, and respiratory disorders received less attention. The thrust of quality interventions was directed at the practice of NCD care by clinicians, facilities, or patients. Few studies provided evidence from interventions at the organizations or policy levels. Overall, effectiveness of quality interventions was mixed across domains. In general, positive or mixed effects on provider clinical skills and behavior, as well as, improvements in patient outcomes were found across interventions. Access to care and coverage of screening services were positively influenced by the interventions reviewed. This review shows that quality improvement interventions tried in middle-income countries mostly focused at the provider and facility level, with few focusing on the organizational and policy level. There is a need to further study the effectiveness of organizational and policy level interventions on the practice and outcomes of NCD care.