Crise global da atenção primária à saúde / Global crisis in primary health care / Crisis global de la atención primaria

Enquanto no Norte Global se discute uma crise na Atenção Primária à Saúde, a maioria dos países nunca chegou a constituir sistemas de saúde baseados propriamente numa atenção primária robusta. Nesse cenário, o Brasil apresenta uma tendência mais favorável, com conquistas importantes para a atenção primária e a medicina de família e comunidade nos últimos dez anos. Restam desafios a serem superados para que o Sistema Único de Saúde alcance níveis satisfatórios de acesso a seus serviços, com profissionais adequadamente formados e valorizados pela população.

While the Global North is discussing a crisis in primary health care, the majority of countries have never managed to establish health systems based on robust primary care. Brazil presents a more favorable trend, with important achievements for primary care and family practice over the last ten years. There are still challenges to be overcome so that the Unified Health System achieves satisfactory levels of access to its services, with professionals who are properly trained and valued by the public.

Mientras que en el Norte Global se habla de una crisis de la atención primaria, la mayoría de los países nunca han creado realmente sistemas sanitarios basados en una atención primaria robusta. Brasil, muestra una tendencia más favorable, con importantes logros para la atención primaria y la medicina familiar y comunitaria en los últimos diez años. Aún quedan retos por superar para que el Sistema Único de Salud alcance niveles satisfactorios de acceso a sus servicios, con profesionales debidamente formados y valorados por la población.

Identification of Priority Health Topics at the Primary Care Level in the Dominican Republic / Identificación de temáticas prioritarias de salud en el primer nivel de atención en República Dominicana

Introduction: The Sustainable Development Goals (SDGs), especially SDG 3, aim to ensure healthy lives and promote well-being through universal health coverage, which includes equitable access to essential health services and medicines. The Primary Health Care (PHC) strategy, endorsed since 1978 and reaffirmed in the Astana Declaration, is pivotal for achieving these goals by strengthening the first level of care. However, in the Dominican Republic, the first level of care remains inadequate due to constraints in human resources, supplies, and technology, impacting the health system's effectiveness and leading to higher costs and poorer health outcomes. Coordinated efforts and evidence-based policies are crucial for improving primary care and addressing the country's epidemiological needs to progress towards universal health coverage. Objective: To identify priority themes for evidence-based decision-making for primary health care professionals in the Dominican Republic. Methods: An electronic survey was conducted with a stratified sampling and comparison with epidemiological data. A total of 475 individuals providing services at the first level of care within the National Health Service (SNS) of the Dominican Republic participated during the period from October 2022 to July 2023. Results: High-demand services included pharmaceutical care (52.2%), general medicine consultations (56.0%), and vaccination (37.3%). The most challenging conditions to diagnose were seizures and loss of consciousness in children (38.1%), seizures and loss of consciousness in adults (32.2%), ear problems (29.9%), vision changes (25.7%), and chest pain (22.4%). The diagnoses with the greatest difficulty in formulating a treatment plan and/or intervention were airway obstruction due to a foreign body (27.4%), threatened abortion/abortion (19.8%), organophosphate poisoning (19.4%), acute myocardial infarction (18.8%), and bacterial meningitis (16.7%). Conclusions: To enhance the primary health care system in the Dominican Republic and address priority needs, it is essential to expand the service portfolio, strengthen the competencies of health professionals, and provide technological tools and support for evidence-based decision-making.

Introducción. Los Objetivos de Desarrollo Sostenible (ODS), especialmente el ODS 3, buscan garantizar una vida sana y promover el bienestar a través de la cobertura sanitaria universal, que incluye acceso equitativo a servicios de salud esenciales y medicamentos. La estrategia de Atención Primaria de Salud (APS), promovida desde 1978 y reafirmada en la Declaración de Astaná, se considera fundamental para lograr estos objetivos al fortalecer el primer nivel de atención. Sin embargo, en República Dominicana, el primer nivel de atención sigue siendo insuficiente debido a limitaciones en recursos humanos, insumos y tecnología, lo que afecta la eficacia del sistema de salud y resulta en mayores costos y peores resultados de salud. Es crucial coordinar esfuerzos y políticas basadas en evidencia para mejorar la atención primaria y abordar las necesidades epidemiológicas del país, y así avanzar hacia la cobertura sanitaria universal. Objetivo. Identificar temáticas prioritarias para la toma de decisiones basadas en evidencia para los profesionales de salud del primer nivel de atención en la República Dominicana. Métodos. Se realizó una encuesta electrónica con un muestreo estratificado y comparación con datos epidemiológicos. Participaron 475 personas que prestaron servicio en el primer nivel de atención en el Servicio Nacional de Salud (SNS) de la República Dominicana, durante el periodo octubre 2022- julio del 2023. Resultados: Los servicios de alta demanda fueron: atención farmacéutica (52.2%), consulta de medicina general (56.0%) y vacunación (37.3%). L,as situaciones con una mayor dificultad para ser diagnosticadas fueron: convulsiones y pérdida de conocimiento en niños (38.1%),  convulsiones y pérdida de conocimiento en adultos (32.2%), problemas del oído (29.9%), cambios en la visión (25.7%) y dolor en el pecho (22.4%). Los diagnósticos con mayor dificultad a la hora de elaborar un plan de tratamiento y/o intervención fueron: obstrucción de vías respiratorias por cuerpo extraño (27.4%), amenaza de aborto/aborto (19.8%), intoxicación por órganos fosforados (19.4%), infarto agudo del miocardio (18.8%) y meningitis bacteriana (16.7%).  Conclusiones: Para fortalecer el primer nivel de atención en salud en la República Dominicana y dar respuesta a las necesidades prioritarias es necesario: ampliar la cartera de servicios, fortalecer las competencias de los recursos humanos en salud y proveer de herramientas tanto de tecnología sanitaria como de toma de decisiones basadas en evidencia. 

Leveraging investments, promoting transparency and mobilising communities: a qualitative analysis of news articles about how the Ebola outbreak informed COVID-19 response in five African countries.

BACKGROUND: The WHO declared the novel COVID-19 outbreak a pandemic in March 2020. While the COVID-19 pandemic was unprecedented, prior experiences with diseases such as Middle East respiratory syndrome, severe acute respiratory syndrome and Ebola shaped many countries' preparedness and response strategies. Although lessons learnt from outbreak responses have been documented from a variety of sources, news media play a special role through their dissemination of news to the general public. This study investigated news media to explore how lessons learnt from the West African Ebola outbreak in 2014-2016 informed the COVID-19 responses in several African countries. METHODS: We conducted qualitative analysis on a dataset of previously compiled COVID-19-related news articles published from 1 March 2020 to 31 August 2020. This dataset included 34,225 articles from 6 countries. We filtered the dataset to only include articles with the keyword 'Ebola'. We used a machine-learning text classification model to identify relevant articles with clear and specific lessons learnt. We conducted inductive and deductive coding to categorise lessons learnt and identify emergent themes. RESULTS: Of the 861 articles containing the word 'Ebola', 18.4% (N=158) with lessons learnt from Ebola were included across five of the countries: Ethiopia, Ghana, Kenya, Liberia and Sierra Leone. News articles highlighted three emergent themes: the importance of leveraging existing resources and past response system investments, promoting transparency in public health messaging and engaging community leaders in all phases of the response. CONCLUSIONS: Findings suggest fostering trust prior to and throughout an outbreak facilitates timely implementation and compliance of mitigation strategies. Trust can be built by leveraging existing resources, being communicative and transparent about their funding allocation and decision-making and engaging communities.

International comparison of hospitalizations and emergency department visits related to mental health conditions across high-income countries before and during the COVID-19 pandemic.

OBJECTIVE: To explore variation in rates of acute care utilization for mental health conditions, including hospitalizations and emergency department (ED) visits, across high-income countries before and during the COVID-19 pandemic. DATA SOURCES AND STUDY SETTING: Administrative patient-level data between 2017 and 2020 of eight high-income countries: Canada, England, Finland, France, New Zealand, Spain, Switzerland, and the United States (US). STUDY DESIGN: Multi-country retrospective observational study using a federated data approach that evaluated age-sex standardized rates of hospitalizations and ED visits for mental health conditions. PRINCIPAL FINDINGS: There was significant variation in rates of acute mental health care utilization across countries. Among the subset of four countries with both hospitalization and ED data, the US had the highest pre-COVID-19 combined average annual acute care rate of 1613 episodes/100,000 people (95% CI: 1428, 1797). Finland had the lowest rate of 776 (686, 866). When examining hospitalization rates only, France had the highest rate of inpatient hospitalizations of 988/100,000 (95% CI 858, 1118) while Spain had the lowest at 87/100,000 (95% CI 76, 99). For ED rates for mental health conditions, the US had the highest rate of 958/100,000 (95% CI 861, 1055) while France had the lowest rate with 241/100,000 (95% CI 216, 265). Notable shifts coinciding with the onset of the COVID-19 pandemic were observed including a substitution of care setting in the US from ED to inpatient care, and overall declines in acute care utilization in Canada and France. CONCLUSION: The study underscores the importance of understanding and addressing variation in acute care utilization for mental health conditions, including the differential effect of COVID-19, across different health care systems. Further research is needed to elucidate the extent to which factors such as workforce capacity, access barriers, financial incentives, COVID-19 preparedness, and community-based care may contribute to these variations. WHAT IS KNOWN ON THIS TOPIC: Approximately one billion people globally live with a mental health condition, with significant consequences for individuals and societies. Rates of mental health diagnoses vary across high-income countries, with substantial differences in access to effective care. The COVID-19 pandemic has exacerbated mental health challenges globally, with varying impacts across countries. WHAT THIS STUDY ADDS: This study provides a comprehensive international comparison of hospitalization and emergency department visit rates for mental health conditions across eight high-income countries. It highlights significant variations in acute care utilization patterns, particularly in countries that are more likely to care for people with mental health conditions in emergency departments rather than inpatient facilities The study identifies temporal and cross-country differences in acute care management of mental health conditions coinciding with the onset of the COVID-19 pandemic.

Patient and professional perspectives on physical activity promotion in routine cancer care: a qualitative study.

BACKGROUNDS: Physical activity is associated with many benefits in reducing cancer symptoms and treatments side effects. Yet, studies consistently show that knowledge about physical activity is under-promoted among people diagnosed with cancer. Therefore, we aimed to contribute to filling this gap by ascertaining patient and professional perspectives regarding physical activity promotion. METHODS: This study took place in Montreal, Canada. We conducted individual, semi-structured interviews with cancer patients who participated in a physical activity program and professionals working in the healthcare system. Participants had to be aged over 18 years, be able to communicate verbally in either English or French, and consent to an audio-recorded interview. A hybrid deductive-inductive approach to content analysis was applied to analyze interview transcripts using Dedoose and Microsoft Excel software. RESULTS: Our sample comprised 21 patients (76.2% women) and 20 professionals (80% women). We identified 24 factors (barriers, facilitators, and improvement suggestions) influencing physical activity promotion across organizational, community, and social levels. Results suggest that to improve physical activity promotion in cancer care, it is necessary to showcase exercise specialists as a healthcare resource, to champion for this change within health organizations, to develop partnerships between public and private sectors of the health and fitness industries, and to reassess social norms concerning cancer survivorship and treatment. CONCLUSION: These findings shed light on the gaps and the bright lights in physical activity promotion for people diagnosed with cancer across numerous levels.

Assessment of the compliance with minimum quality standards by public primary healthcare facilities in Nigeria.

Achieving universal health coverage (UHC) and the Sustainable Development Goals (SDG) by 2030 relies on the delivery of quality healthcare services through effective primary healthcare (PHC) systems. This necessitates robust infrastructure, adequately skilled health workers and the availability of essential medicines and commodities. Despite the critical role of minimum standards in benchmarking PHC quality, no global consensus on these standards exists. Nigeria has established minimum standards to enhance healthcare accessibility and quality, including the Revised Ward Health System Strategy (RWHSS) by the National Primary Health Care Development Agency (NPHCDA). This paper outlines the evolution of PHC minimum standards in Nigeria, evaluates compliance with RWHSS standards across all public PHC facilities, and examines the implications for ongoing PHC revitalization efforts. The study used a cross-sectional descriptive design to assess compliance across 25 736 public PHC facilities in Nigeria. Data collection involved a national survey using a standardized assessment tool focussing on infrastructure, staffing, essential medicines and service delivery. Compliance with RWHSS minimum standards was found to be below 50% across all facilities, with median compliance scores of 40.7%. Outreach posts had a median compliance of 32.6%, level 1 facilities 31.5% and level 2+ facilities 50.9%. Key findings revealed major gaps in health infrastructure, human resources and availability of essential medicines and equipment. Compliance varied regionally, with the North-west showing the highest number of facilities but varied performance across standards. The lessons learned underscore the urgent need for targeted interventions and resource allocation to address the identified deficiencies. This study highlights the critical need for regular, comprehensive compliance assessments to guide policy-makers in identifying gaps and strengthening PHC systems in Nigeria. Recommendations include enhancing monitoring mechanisms, improving resource distribution and focussing on infrastructure and human resource development to meet UHC and SDG targets. Addressing these gaps is essential for advancing Nigeria's healthcare system and ensuring equitable, quality care for all.

Essential core competencies for health policy graduates: a multi-method consensus type study.

BACKGROUND: In light of the multi-faceted challenges confronting health systems worldwide and the imperative to advance towards development goals, the contribution of health policy graduates is of paramount importance, facilitating the attainment of health and well-being objectives. This paper delineates a set of core skills and competencies that are requisite for health policy graduates, with the objective of preparing these graduates for a spectrum of future roles, including both academic and non-academic positions. METHODS: The study was conducted in three phases: a scoping review, qualitative interviews and the validation of identified competencies through brainstorming with experts. In the initial phase, a scoping review was conducted on the databases. The following databases were searched: PubMed, Scopus, Web of Science and Google Scholar search engine. Additionally, the WebPages of universities offering health policy programmes were manually searched. In the second phase, 36 semi-structured interviews were conducted with students, graduates and distinguished academics from Iran and other countries. These interviews were conducted in person or via email. In the third phase, the draft version of the competencies and their associated learning objectives, derived from the preceding stages, was subjected to independent review by an expert panel and subsequently discussed. In light of the expert panel's findings, the authors undertook a subsequent revision of the list, leading to the finalization of the core competencies through a process of consensus. RESULTS: In the scoping review phase, the analysis included six studies and nine university curricula. The results of the scoping review could be classified into five domains: health system understanding, health policy research, knowledge translation, multidisciplinary work and knowledge of public health. In the second phase, six core competencies were extracted from the interviews and combined with the results of the first phase, which were then discussed by the expert panel at the third phase. The final five core competencies, derived from the brainstorming session and presented in no particular order, encompass health policy research, policy analysis, educational competencies, decision-making and multidisciplinary work. CONCLUSIONS: It is essential that the curriculum is appropriate and contextually tailored, as this is crucial to foster multi-dimensional competencies that complement the specific disciplines of future health policy scholars. These scholars must possess the ability to genuinely serve their health systems towards achieving health-system goals and sustainable development.

Role and promise of health policy and systems research in integrating rehabilitation into the health systems.

Despite recognized need and reasonable demand, health systems and rehabilitation communities keep working in silos, independently with minimal recognition to the issues of those who require rehabilitation services. Consolidated effort by health systems and rehabilitation parties, recognizing the value, power and promise of each other, is a need of the hour to address this growing issue of public health importance. In this paper, the importance and the need for integration of rehabilitation into health system is emphasized. The efforts being made to integrate rehabilitation into health systems and the potential challenges in integration of these efforts were discussed. Finally, the strategies and benefits of integrating rehabilitation in health systems worldwide is proposed. Health policy and systems research (HPSR) brings a number of assets that may assist in addressing the obstacles discussed above to universal coverage of rehabilitation. It seeks to understand and improve how societies organize themselves to achieve collective health goals; considers links between health systems and social determinants of health; and how different actors interact in policy and implementation processes. This multidisciplinary lens is essential for evidence and learning that might overcome the obstacles to the provision of rehabilitation services, including integration into health systems. Health systems around the world can no longer afford to ignore rehabilitation needs of their populations and the World Health Assembly (WHA) resolution marked a global call to this effect. Therefore, national governments and global health community must invest in setting a priority research agenda and promote the integration of rehabilitation into health systems. The context-specific, need-based and policy-relevant knowledge about this must be made available globally, especially in low- and middle-income countries. This could help integrate and implement rehabilitation in health systems of countries worldwide and also help achieve the targets of Rehabilitation 2030, universal health coverage and Sustainable Development Goals.

Responding to fluctuations in public and community trust and health seeking behaviour during the COVID-19 pandemic: a qualitative study of national decision-makers' perspectives in Guinea and Sierra Leone.

BACKGROUND: The level of trust in health systems is often in flux during public health emergencies and presents challenges in providing adequate health services and preventing the spread of disease. Experiences during previous epidemics has shown that lack of trust can impact the continuity of essential health services and response efforts. Guinea and Sierra Leone were greatly challenged by a lack of trust in the system during the Ebola epidemic. We thus sought to investigate what was perceived to influence public and community trust in the health system during the COVID-19 pandemic, and what strategies were employed by national level stakeholders in order to maintain or restore trust in the health system in Guinea and Sierra Leone. METHODS: This qualitative study was conducted through a document review and key informant interviews with actors involved in COVID-19 and/or in malaria control efforts in Guinea and Sierra Leone. Key informants were selected based on their role and level of engagement in the national level response. Thirty Six semi-structured interviews (16 in Guinea, 20 in Sierra Leone) were recorded, transcribed, and analyzed using an inductive and deductive framework approach to thematic analysis. RESULTS: Key informants described three overarching themes related to changes in trust and health seeking behavior due to COVID-19: (1) reignited fear and uncertainty among the population, (2) adaptations to sensitization and community engagement efforts, and (3) building on the legacy of Ebola as a continuous process. Communication, community engagement, and on-going support to health workers were reiterated as crucial factors for maintaining trust in the health system. CONCLUSION: Lessons from the Ebola epidemic enabled response actors to consider maintaining and rebuilding trust as a core aim of the pandemic response which helped to ensure continuity of care and mitigate secondary impacts of the pandemic. Monitoring and maintaining trust in health systems is a key consideration for health systems resilience during public health emergencies.

Truth to Action: Lived Experiences of Indigenous Healthcare Professionals Redressing Indigenous-Specific Racism.

STUDY BACKGROUND: The experience of discrimination through stereotyping, profiling, and bias-informed care not only leads to poor access to healthcare services, but low retention rates of Indigenous health professionals (IHP). As health systems transformation evolves, a significant gap remains in supporting IHP to safely address racism, to be supported culturally to bring their authentic selves and voices to work, and to attend to one's own intellectual, physical, relational, cultural and spiritual wellness within a westernized model of care. PURPOSE: The aim of the study was to investigate the experiences of IHP working in mainstream healthcare in order to understand how their work environment impacts the delivery of cultural safe practices. What is reported in this manuscript, as an exercise in truth-telling, is findings about lived experiences of IHP working in one mainstream provincial healthcare region, and not the whole context and outcomes of the study. METHODS: Using Indigenous research methodologies, we embodied our Indigeneity into every facet of the research process. We facilitated three talking circles with participants grounded in a distinct cultural and ceremonial context following Secwepemc protocols. RESULTS: The collective voices of IHP revealed the following common experiences: confronting genocide; addressing Indigenous-specific racism; uprooting toxicity and inequities; and upholding Indigenous human rights while enhancing accountability of systems transformation. CONCLUSIONS: The experience of IHP working in health systems goes beyond mere individual employment obligations, its often about a families and communities advocacy for Indigenous rights, culturally safe working environments and access to dignified and respectful healthcare service. This study highlights the need for IHP to be actively involved in health system transformation to ensure the redesigning and restructuring of healthcare service delivery by and for Indigenous Peoples remains centered on Indigenous health and human rights.

"We don't get that information right back to us unless it's a full-blown cancer": Challenges coordinating lung cancer screening across healthcare systems.

OBJECTIVE: To examine how lung cancer screening (LCS) is coordinated across healthcare systems, specifically Veterans Affairs (VA) and non-VA settings. DATA SOURCES AND STUDY SETTING: We conducted primary qualitative data collection in six VA medical centers with established LCS programs from November 2020 to November 2021. STUDY DESIGN AND DATA COLLECTION METHODS: Semi-structured interviews were conducted with 48 primary care providers, LCS program coordinators and directors, and pulmonologists. Thematic analysis examined spontaneously raised narratives related to initiating and coordinating LCS for Veterans screened in non-VA settings. We mapped coordination challenges to each step of the LCS care continuum. PRINCIPAL FINDINGS: While non-VA options increased access to LCS for Veterans, VA medical centers lacked clear processes for initiating LCS referrals and tracking Veterans across the LCS continuum when screening occurred in non-VA settings. The responsibility of coordinating LCS with community providers often fell to VA primary care providers rather than LCS programs. Gaps in communication and data transfer contributed to delayed evaluation of potentially cancerous nodules post-screening, raising concerns about compromised care quality when LCS was shared with non-VA settings. CONCLUSIONS: While policies expanding LCS for Veterans in non-VA settings increase access, lack of consistent processes to initiate referrals, obtain results, and promote timely downstream evaluation fragmented care and delayed evaluation of concerning nodules. These unintended consequences highlight a need to address cross-system coordination challenges. Strategies to better coordinate LCS between VA and non-VA settings are essential to achieve high quality LCS and prevent Veterans from falling through the cracks.

Measuring the Maturity of Integrated Care in Singapore with the SCIROCCO Exchange Tool.

Background: How have we progressed and where are the gaps of integrated care in Singapore? Social-health care provision in the context of an ageing population is critical in the city-state's management of the unprecedented demand as the proportion of seniors with multiple complex medical needs have almost doubled in the past decade. Objective: This study measures the maturity level of Singapore's integrated care, identifies key gaps and discusses their implications using the SCIROCCO Exchange tool, an online self-assessment tool consisting of the 12 dimensions necessary for the provision of integrated care. Methods: A three-step mixed method Delphi study was used to derive expert consensus. Participants across the social-healthcare sector as well as representatives from all three public healthcare delivery networks with at least five years of experience were included. Participants rated each of the twelve dimensions of the SCIROCCO Exchange tool on a six-point ordinal scale and provided justifications for each rating. Criteria from the RAND UCLA appropriateness method and thematic analysis were adopted for the analysis. Results: All participants completed the study. The study found five dimensions in the "Initial" maturity level and five dimensions in the "Progressing" maturity level. There were two dimensions which were "Uncertain" because of split responses, possibly due to their differing vantage points and conceptualisations of integrated care. The overall medians were plotted on a spider diagram. The absence of a systematic approach for integrated care was the most common subtheme across all dimensions. This is foundational for integrated care as this would enable stakeholders across health and social care to identify with a common goal. Implications: The findings emphasise the imperative to reshape social-health care delivery by focusing on foundational dimensions (such as structure, governance and citizen empowerment) to enable progress in other dimensions. Following the conclusion of this study, Singapore initiated a primary care reform with the launch of Healthier SG in July 2023. Future research may wish to explore the impact of Healthier SG on maturity of integrated care in Singapore.

Analysis of social investment in health systems reform: a case study of results-based financing in Marondera District, Zimbabwe.

Introduction: suboptimal use of donor funds and poor health systems performance is rife across most developing countries; to address this, results-based financing (RBF) models were developed. However, it is imperative to explore the emic and context specific influence of results-based financing in health systems performance. This study therefore sought to explore the influence of results-based financing on health worker motivation and governance, temporal perspective, distributional principle, and policy coherence. Finally, the influence of results-based financing on interrelations across donors, technical partners, and health workers was explored. Methods: the study adopted a qualitative, exploratory, descriptive, phenomenological design using audio-recorded face-to-face semi-structured interviews to capture diverse perspectives from the remaining and available two health financing experts, two technical partner organization representatives, and six health workers who have been implementing results-based financing from 2011 to 2022 in the Marondera district of Zimbabwe. Data was transcribed and collectively analyzed using NVIVO software. Results: improved staff motivation, better governance, health system development, equity, and policy consistency were attributable to results-based financing, notwithstanding several challenges including understaffing, increased workload, procurement red tape, financial rigidity, and delays in subsidy payments, which eroded gains of better performance. Additionally, a lack of continuum of care due to user fees faced by the poor at higher levels of care, and limited engagement between donors and healthcare facility workers were also observed. Conclusion: reinforcing pinpointed positives is vital for sustaining realized health gains; however, urgent attention is required to address the challenges to safeguard the milestones achieved thus far.

Applying Implementation Science to Advance Electronic Health Record-Driven Learning Health Systems: Case Studies, Challenges, and Recommendations.

With the widespread implementation of electronic health records (EHRs), there has been significant progress in developing learning health systems (LHSs) aimed at improving health and health care delivery through rapid and continuous knowledge generation and translation. To support LHSs in achieving these goals, implementation science (IS) and its frameworks are increasingly being leveraged to ensure that LHSs are feasible, rapid, iterative, reliable, reproducible, equitable, and sustainable. However, 6 key challenges limit the application of IS to EHR-driven LHSs: barriers to team science, limited IS experience, data and technology limitations, time and resource constraints, the appropriateness of certain IS approaches, and equity considerations. Using 3 case studies from diverse health settings and 1 IS framework, we illustrate these challenges faced by LHSs and offer solutions to overcome the bottlenecks in applying IS and utilizing EHRs, which often stymie LHS progress. We discuss the lessons learned and provide recommendations for future research and practice, including the need for more guidance on the practical application of IS methods and a renewed emphasis on generating and accessing inclusive data.

The impact of a multi-faceted intervention on non-prescription dispensing of antibiotics by urban community pharmacies in Indonesia: a mixed methods evaluation.

INTRODUCTION: Non-prescription antibiotic dispensing is prevalent among community pharmacies in several low- and middle-income countries. We evaluated the impact of a multi-faceted intervention to address this challenge in urban community pharmacies in Indonesia. METHODS: A pre-post quasi-experimental study was carried out in Semarang city from January to August 2022 to evaluate a 7-month long intervention comprising: (1) online educational sessions for pharmacists; (2) awareness campaign targeting customers; (3) peer visits; and (4) pharmacy branding and pharmacist certification. All community pharmacies were invited to take part with consenting pharmacies assigned to the participating group and all remaining pharmacies to the non-participating group. The primary outcome (rate of non-prescription antibiotic dispensing) was measured by standardised patients displaying symptoms of upper respiratory tract infection, urinary tract infection (UTI) and seeking care for diarrhoea in a child. χ2 tests and multivariate random-effects logistic regression models were conducted. Thirty in-depth interviews were conducted with pharmacists, staff and owners as well as other relevant stakeholders to understand any persistent barriers to prescription-based dispensing of antibiotics. FINDINGS: Eighty pharmacies participated in the study. Postintervention, non-prescription antibiotics were dispensed in 133/240 (55.4%) consultations in the participating group compared with 469/570 (82.3%) in the non-participating group (p value <0.001). The pre-post difference in the non-prescription antibiotic dispensing rate in the participating group was 20.9% (76.3%-55.4%) compared with 2.3% (84.6%-82.3%) in the non-participating group (p value <0.001).Non-prescription antibiotics were less likely to be dispensed in the participating group (OR=0.19 (95% CI 0.09 to 0.43)) and more likely to be dispensed for the UTI scenario (OR=3.29 (95% CI 1.56 to 6.94)). Barriers to prescription-based antibiotic dispensing included fear of losing customers, customer demand, and no supervising pharmacist present. INTERPRETATION: Multifaceted interventions targeting community pharmacies can substantially reduce non-prescription antibiotic dispensing. Future studies to evaluate the implementation and sustainability of this intervention on a larger scale are needed.

Investing in health workers: a retrospective cost analysis of a cohort of return-of-service bursary recipients in Southern Africa.

BACKGROUND: Return-of-service (RoS) schemes are investment strategies that governments use to increase the pool of health professionals through the issuing of bursaries and scholarships to health sciences students in return for service after graduation. Despite using these schemes for many years, Eswatini, South Africa, Botswana and Lesotho have not assessed the costs and return on investment of these schemes. This study aimed to assess the costs and relative rates of contract defaulting in these four Southern African countries. METHODS: A retrospective cohort study was carried out by reviewing databases of RoS beneficiaries for selected health sciences programmes who were funded between 2000 and 2010. Costs of the schemes were assessed by country, degree type and whether bursary holders completed their required service or defaulted on their public service obligations. RESULTS: Of the 5616 beneficiaries who studied between 1995 and 2019 in the four countries, 1225 (21.8%) beneficiaries from 2/9 South African provinces and Eswatini were presented in the final analysis. Only Eswatini had data on debt recovery or financial repayments. Beneficiaries were mostly medical students and slightly biased towards males. Medical students benefited from 56.7% and 81.3% of the disbursement in Eswatini (~US$2 million) and South Africa (~US$57 million), respectively. Each South African medical student studying in Cuba cost more than five times the rate of medical students who studied in South Africa. Of the total expenditure, 47.7% and 39.3% of the total disbursement is spent on individuals who default the RoS scheme in South Africa and Eswatini, respectively. CONCLUSIONS: RoS schemes in these countries have loss of return on investment due to poor monitoring. The schemes are costly, ineffective and have never been evaluated. There are poor mechanisms for identifying beneficiaries who exit their contracts prematurely and inadequate debt recovery processes.

Precision emergency medicine in health care delivery and access: Framework development and research priorities.

BACKGROUND: The integration of precision emergency medicine (EM) into our conceptualization of the health care system affords the opportunity to improve health care access, delivery, and outcomes for patients. As part of the Society for Academic Emergency Medicine (SAEM) Consensus Conference, we conducted a rapid literature review to characterize the current state of knowledge pertaining to the intersection of precision EM (defined as the use of big data and technology to deliver acute care for individual patients and their communities) with health care delivery and access. We then used our findings to develop a proposed conceptual model and research agenda. METHODS: We completed a rapid review of the existing literature on the utilization of big data and technology to ensure and enhance access to acute/unscheduled care for individual patients and their communities. Literature searches were conducted using Ovid MEDLINE, Embase.com, Cochrane CENTRAL via Ovid, and ClinicalTrials.gov in January 2023. Using the identified articles, we determined core domains, developed a framework to guide the conceptualization of precision EM in health care delivery and access, and used these to identify a research agenda. RESULTS: Of the 815 studies identified for initial screening, 60 underwent full-text review by our technical expert panel and 21 were included in the evaluation. Core domains identified included expedited/personalized prehospital care, delivery to the right level of care, personalized ED care, alternatives to ED care/post-ED care, prediction tools for system readiness, and creation of equitable systems of care. A research agenda with four priority research questions was defined following identification of the core domains. CONCLUSIONS: Precision EM includes consideration of the health care delivery system as a mechanism for improving access to emergency care using data-driven strategies. This provides a unique opportunity to use data and technology to advance systems of care while also centering patients, communities, and equity in these advances.

Advancing governance for digital transformation in health: insights from Georgia's experience.

Enhancing digital health governance is critical to healthcare systems in low-income and middle-income countries. However, implementing governance-enhancing reforms in these countries is often challenging due to the multiplicity of external players and insufficient operational guidance that is accessible. Using data from desktop research, in-depth interviews, focus group discussions and three stakeholder workshops, this paper aims to provide insights into Georgia's experience in advancing digital health governance reforms. It reveals how Georgia has progressed on this path by unpacking the general term 'governance' into operational domains, where stakeholders and involved institutions could easily relate their institutional and personal roles and responsibilities with the specific function needed for digital health. Based on this work, the country delineated institutional responsibilities and passed the necessary regulations to establish better governance arrangements for digital health. The Georgia experience provides practical insights into the challenges faced and solutions found for advancing digital health governance in a middle-income country setting. The paper highlights the usefulness of operational definitions for the digital health governance domains that helped (a) increase awareness among stakeholders about the identified domains and their meaning, (b) discuss possible governance and institutional arrangements relevant to a country context, and (c) design the digital health governance architecture that the government decreed. Finally, the paper offers a broad description of domains in which the governance arrangements could be considered and used for other settings where relevant. The paper points to the need for a comprehensive taxonomy for governance domains to better guide digital health governance enhancements in low-middle-income country settings.

Bypassing sources of care by level and coverage: Access to essential services in Peru and Uruguay in the post-pandemic era.

BACKGROUND AND AIMS: Healthcare provision to distinct social groups in Latin America contributes to inequities. Individuals make active choices by bypassing their coverage and intended healthcare source. After the pandemic, we sought to characterize bypassing behaviors and quantify their effects on access to essential services. METHODS: Cross-sectional data from a population-based telephone survey in Peru and Uruguay were analyzed. Participants were selected by random digit dialing. Outcomes were defined as access to preventive screenings and satisfaction of emerging health needs. Bypassing by level was defined as when participants went around primary care for the usual source of care or last preventive visit; bypassing by coverage when care was sought outside of public coverage or social security. Sociodemographic characteristics were included, and the adjusted average treatment effect was calculated. RESULTS: Data from 1,255 participants in Peru and 1,237 participants in Uruguay were analyzed. Bypassing behaviors by level (32% Peru; 60% Uruguay) and coverage (29% Peru; 21% Uruguay) were more prevalent in more privileged groups, especially in Peru. System competence was low overall and varied by bypassing mode, especially in Peru. In the adjusted analysis, statistically significant differences were found in bypassing by coverage in Peru (-8% difference in unmet health needs) and by level in Uruguay (5% more unmet needs). CONCLUSION: Provision of essential preventive services was insufficient in both countries. In Peru, bypassing could serve as a proxy measure of inequities. Reminders of preventive services could be offered to bypassers of primary care. Profound health system reforms are needed to ensure equitable access to essential services.

The Transformative Care Continuum: implementing an accelerated pathway that addresses the new roles of the family medicine physician.

BACKGROUND: The Transformative Care Continuum (TCC) emerged in 2018 at Ohio University's Heritage College of Osteopathic Medicine, combining a three-year medical education track with a three-year family medicine residency. TCC aligns evolving family physician roles through the Kern model, AMA's Master Adaptive Learner model, Health Systems Science Training, and Kirkpatrick's evaluation model. METHODS: The TCC curriculum emphasizes intensive coaching, clinical encounter video evaluation, reflection, and case-log review. It fosters longitudinal clinical integration, community engagement, and a dynamic learning atmosphere. Students receive rigorous patient-centered communication training and engage in residency-based quality improvement projects, targeting care gap closure and community health in an accelerated 3-year program. OUTCOMES: Assessment of TCC graduates demonstrates advanced team communication, leadership, and project management skills, with entrustable professional activities (EPA) scores meeting or surpassing those of traditional program graduates. Projects led by students have yielded notable clinical enhancements, national recognition, and significant philanthropic funding for non-medical determinants of health. Finally, there is an overall increase in scholarly activity and leadership roles within the residency programs that have engaged these students. DISCUSSION: Lessons reveal intrinsic challenges and heightened academic demands for students and residency programs. Additional educational support for students may be necessary, though costly. Limitations in residency slots and faculty availability as student educators potentially hinder scalability. Ongoing faculty training, cultural support, and early integration of digital systems for curriculum management and evaluation are vital for success. Obtaining patient satisfaction, health outcomes, and program measures remains challenging due to privacy concerns and approval processes between institutions. CONCLUSION: Programs like TCC effectively prepare students for family physician leadership and change management roles through tailored learning, longitudinal experiences, health systems training, and addressing critiques of traditional medical education. Continuous feedback and robust communication strategies are essential for program improvement, fostering well-prepared family physicians committed to health system enhancement.