Exploring the perspectives of healthcare providers that care for non-insured individuals utilizing emergency departments in Toronto.

BACKGROUND: Non-insured individuals have different healthcare needs from the general Canadian population and face unique barriers when accessing emergency department (ED) care. This qualitative study aims to better understand the system of emergency care for non-insured individuals from the perspective of healthcare providers. METHODS: The study uses a critical realist framework to explore structural factors that facilitate or impede access to care for non-insured individuals. Semi-structured interviews were conducted with 13 interdisciplinary healthcare professionals with experience working with non-insured populations in the ED and in community health centres. Data were analyzed with the use of Braun and Clark's thematic analysis framework and organized into themes through an iterative process until thematic saturation was reached. RESULTS: Healthcare providers face distinct challenges when providing care for non-insured patients including patients presenting with increased illness complexity and providers having to navigate systemic barriers. Interview participants noted stigma and bias, lack of privacy, unclear care pathways, and access to post-ED care as challenges facing non-insured patients. Suggestions to improve the ED experience for non-insured patients include improved staff training, clearer policies, and consistency between hospitals. Most of all, healthcare providers believed that the most effective way to improve the care of non-insured patients would be to make permanent the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic. CONCLUSION: Interviews with healthcare professionals have highlighted that marginalized populations, including non-insured individuals, face multiple barriers when accessing the ED, especially during the COVID-19 pandemic. At the same time, the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic has likely improved patients' healthcare experience, which we will explore directly with non-insured patients in a future study. In this post-COVID world, we now have an opportunity to learn from our experiences and build a more equitable ED system together.

RéSUMé: CONTEXTE: Les personnes non assurées ont des besoins en matière de soins de santé différents de ceux de la population canadienne en général et sont confrontées à des obstacles uniques lorsqu'elles veulent accéder aux soins d'urgence. Cette étude qualitative vise à mieux comprendre le système de soins d'urgence pour les personnes non assurées du point de vue des prestataires de soins de santé. MéTHODES: L'étude utilise un cadre réaliste critique pour explorer les facteurs structurels qui facilitent ou entravent l'accès aux soins pour les personnes non assurées. Des entretiens semi-structurés ont été menés auprès de 13 professionnels de la santé interdisciplinaires ayant l'expérience du travail avec les populations non assurées aux urgences et dans les centres de santé communautaires. Les données ont été analysées à l'aide du cadre d'analyse thématique de Braun & Clark et organisées en thèmes par un processus itératif jusqu'à ce que la saturation thématique soit atteinte. RéSULTATS: Les prestataires de soins de santé sont confrontés à des défis distincts lorsqu'ils fournissent des soins à des patients non assurés, notamment des patients présentant une complexité de maladie accrue et des prestataires devant surmonter les obstacles systémiques. Les participants aux entretiens ont noté que la stigmatisation et les préjugés, le manque d'intimité, le manque de clarté des parcours de soins et l'accès aux soins post-urgence sont des défis auxquels sont confrontés les patients non assurés. Les suggestions visant à améliorer l'expérience des patients non assurés aux urgences comprennent une meilleure formation du personnel, des politiques plus claires et une cohérence entre les hôpitaux. Par-dessus tout, les prestataires de soins de santé ont estimé que le moyen le plus efficace d'améliorer les soins aux patients non assurés serait de pérenniser l'extension temporaire de la couverture médicale aux patients non assurés promulguée pendant la pandémie de COVID-19. CONCLUSION: Les entretiens avec les professionnels de la santé ont mis en évidence que les populations marginalisées, notamment les personnes non assurées, sont confrontées à de multiples obstacles lorsqu'elles accèdent aux urgences, en particulier pendant la pandémie de COVID-19. En même temps, l'extension temporaire de la couverture médicale aux patients non assurés, promulguée pendant la pandémie de COVID-19, a probablement amélioré l'expérience des patients en matière de soins de santé, ce que nous explorerons directement auprès des patients non assurés dans une étude future. Dans ce monde post-COVID, nous avons maintenant l'occasion de tirer les leçons de nos expériences et de construire ensemble un système d'urgence plus équitable.

Conceptual framework for task shifting and task sharing: an international Delphi study.

BACKGROUND: Task shifting and sharing (TS/S) involves the redistribution of health tasks within workforces and communities. Conceptual frameworks lay out the key factors, constructs, and variables involved in a given phenomenon, as well as the relationships between those factors. Though TS/S is a leading strategy to address health worker shortages and improve access to services worldwide, a conceptual framework for this approach is lacking. METHODS: We used an online Delphi process to engage an international panel of scholars with experience in knowledge synthesis concerning TS/S and develop a conceptual framework for TS/S. We invited 55 prospective panelists to participate in a series of questionnaires exploring the purpose of TS/S and the characteristics of contexts amenable to TS/S programmes. Panelist responses were analysed and integrated through an iterative process to achieve consensus on the elements included in the conceptual framework. RESULTS: The panel achieved consensus concerning the included concepts after three Delphi rounds among 15 panelists. The COATS Framework (Concepts and Opportunities to Advance Task Shifting and Task Sharing) offers a refined definition of TS/S and a general purpose statement to guide TS/S programmes. COATS describes that opportunities for health system improvement arising from TS/S programmes depending on the implementation context, and enumerates eight necessary conditions and important considerations for implementing TS/S programmes. CONCLUSION: The COATS Framework offers a conceptual model for TS/S programmes. The COATS Framework is comprehensive and adaptable, and can guide refinements in policy, programme development, evaluation, and research to improve TS/S globally.

Overcoming vaccine deployment challenges among the hardest to reach: lessons from polio elimination in India.

After more than 30 years of efforts to eliminate polio, India was certified polio free by WHO in 2014. The final years prior to polio elimination were characterised by concentrated efforts to vaccinate hard-to-reach groups in the state of Uttar Pradesh, including migrant workers, religious minority Muslims and impoverished communities with poor pre-existing social support systems. This article aims to describe the management strategies employed by India to improve the deployment and acceptance of vaccines among hard-to-reach groups in Uttar Pradesh in the final years prior to polio elimination.Three main management principles contributed to polio elimination among the hardest to reach in Uttar Pradesh: bundling of health services, local stakeholder engagement and accountability mechanisms for public health initiatives. In an effort to market the polio campaign as an authentic health-oriented programme, vaccine acceptance was improved by packaging other basic healthcare services such as routine check-ups and essential medications. India also prioritised local stakeholder engagement by using influential community leaders to reach vaccine hesitant groups. Lastly, the accountability mechanisms developed between non-profit organisations and decision-makers in the field ensured accurate reporting and identified deficiencies in healthcare worker training. The lessons learnt from India's polio vaccination programme have important implications for the implementation of future mass vaccination initiatives, particularly when trying to reach vulnerable communities.