Primary healthcare policy and governance in low-income and middle-income countries: an evidence gap map

Collaboration in a Partnership for Primary Health Care: A Case Study From Papua New Guinea

INTRODUCTION

In low- and middle-income countries, public-private partnerships (PPPs) are often used to support the delivery of primary health care (PHC). We explore the processes of collaboration in a corporate social responsibility investment in PHC that was delivered through a PPP model in Western Province, Papua New Guinea, in 2009-2018 to strengthen PHC services.

METHODS

Qualitative interviews were conducted with stakeholders in the PPP (N=20). Key program documents were also reviewed. Data were coded using a general inductive approach, and Actor-Network Theory (ANT) was used to frame the analysis.

RESULTS

Four dominant themes emerged: (1) interpersonal relationships accelerate collaboration, (2) collaboration requires time, (3) formal governance structures encourage collaboration, and (4) internal change disrupts collaboration. The research provides insight into the role of collaboration for more efficient, effective, and impactful design and implementation of PPP for PHC. It makes suggestions for how ANT may be used when designing PPPs and for the ongoing management of relationships between partners. We found ANT to be a useful framework to conceptualize the complex dynamics between the "actors" within the PPP and to identify opportunities for improvement where structural changes may be made to circumvent issues that may compromise effective collaboration.

CONCLUSION

Collaboration is key to the success of PPPs for PHC. We found collaboration is not formulaic but is driven by actors, relationships, time, and governance. ANT can assist in designing, understanding, and managing the complex relationships between stakeholders of a PPP, who often come with diverse agendas, experiences, values, and perspectives.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

Artificial intelligence and digital health in improving primary health care service delivery in LMICs: A systematic review

AIM

Technology including artificial intelligence (AI) may play a key role to strengthen primary health care services in resource-poor settings. This systematic review aims to explore the evidence on the use of AI and digital health in improving primary health care service delivery.

METHODS

Three electronic databases were searched using a comprehensive search strategy without providing any restriction in June 2023. Retrieved articles were screened independently using the "Rayyan" software. Data extraction and quality assessment were conducted independently by two review authors. A narrative synthesis of the included interventions was conducted.

RESULTS

A total of 4596 articles were screened, and finally, 48 articles were included from 21 different countries published between 2013 and 2021. The main focus of the included studies was noncommunicable diseases (n = 15), maternal and child health care (n = 11), primary care (n = 8), infectious diseases including tuberculosis, leprosy, and HIV (n = 7), and mental health (n = 6). Included studies considered interventions using AI, and digital health of which mobile-phone-based interventions were prominent. m-health interventions were well adopted and easy to use and improved the record-keeping, service deliver, and patient satisfaction.

CONCLUSION

AI and the application of digital technologies improve primary health care service delivery in resource-poor settings in various ways. However, in most of the cases, the application of AI and digital health is implemented through m-health. There is a great scope to conduct further research exploring the interventions on a large scale.

Cost and outcomes of routine HIV care and treatment: public and private service delivery models covering low-income earners in South Africa

BACKGROUND

While South Africa's national HIV program is the largest in the world, it has yet to reach the UNAIDS 95-95-95 targets. To reach these targets, the expansion of the HIV treatment program may be accelerated through the use private sector delivery models. This study identified three innovative non-governmental primary health care models (private sector) providing HIV treatment, as well as two government primary health clinics (public sector) that served similar populations. We estimated the resources used, and costs and outcomes of HIV treatment across these models to provide inputs to inform decisions around how these services might best be provided through National Health Insurance (NHI).

METHODS

A review of potential private sector models for HIV treatment in a primary health care setting was conducted. Models actively offering HIV treatment (i.e. in 2019) were considered for inclusion in the evaluation, subject to data availability and location. These models were augmented by government primary health clinics offering HIV services in similar locations. We conducted a cost-outcomes analysis by collecting patient-level resource usage and treatment outcomes through retrospective medical record reviews and a bottom-up micro-costing from the provider perspective (public or private payer). Patient outcomes were based on whether the patient was still in care at the end of the follow up period and viral load (VL) status, to create the following outcome categories: in care and responding (VL suppressed), in care and not responding (VL unsuppressed), in care (VL unknown) and not in care (LTFU or deceased). Data collection was conducted in 2019 and reflects services provided during the 4 years prior to that (2016-2019).

RESULTS

Three hundred seventy-six patients were included across the five HIV treatment models. Across the three private sector models there were differences in the costs and outcomes of HIV treatment delivery, two of the models had results similar to the public sector primary health clinics. The nurse-led model appears to have a cost-outcome profile distinct from the others.

CONCLUSION

The results show that across the private sector models studied the costs and outcomes of HIV treatment delivery vary, yet there were models that provided costs and outcomes similar to those found with public sector delivery. Offering HIV treatment under NHI through private delivery models could therefore be an option to increase access beyond the current public sector capacity.

Temporal trends in the burden of non-communicable diseases in countries with the highest malaria burden, 1990–2019: Evaluating the double burden of non-communicable and communicable diseases in epidemiological transition

Background

Non-communicable diseases (NCDs) are rapidly increasing in sub-Saharan African countries, where 96% of global malaria deaths occur. This study aimed to investigate the disease burden of NCDs in countries with the current highest malaria mortality.

Methods

Data for this study were obtained from the Global Burden of Disease 2019 study (1990–2019). We selected the ten countries with malaria’s highest age-standardised mortality rate (ASMR) and identified and ranked the five NCDs with the highest ASMR in each country. Measures of the NCDs disease burden included ASMR, age-standardised disability-adjusted life-years (DALY), years of life lost (YLL) and years lost due to a disability (YLD). The Estimated annual percentage change (EAPC) was used to examine the trends of the NCDs disease burden from 1990 to 2019.

Results

As of 2019, the ASMR of chronic liver disease, kidney disease, diabetes mellitus, Alzheimer’s disease and other dementias, hypertensive heart disease and stroke were higher than the global average. From 1990 to 2019, the ASMR for Alzheimer’s disease and other dementias, type II diabetes mellitus, and chronic kidney disease increased by 3.0%, 10.8%, 13.3%, and the age-standardised DALY rate increased by 3.7%, 27.6%, 6.3%, and the increases tended to be in younger populations.

Conclusion

The double burden of non-communicable and communicable diseases is crippling the health systems of many sub-Saharan African countries and is often neglected. The prevention, surveillance, and control of diseases require an integrated strategy, with governments and non-government organisations aligned and supported by the global initiative.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00882-w.

Universality of universal health coverage: A scoping review

BACKGROUND

The progress of Universal health coverage (UHC) is measured using tracer indicators of key interventions, which have been implemented in healthcare system. UHC is about population, comprehensive health services and financial coverage for equitable quality services and health outcome. There is dearth of evidence about the extent of the universality of UHC in terms of types of health services, its integrated definition (dimensions) and tracer indicators utilized in the measurement of UHC. Therefore, we mapped the existing literature to assess universality of UHC and summarize the challenges towards UHC.

METHODS

The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews was used. A systematic search was carried out in the Web of Science and PubMed databases. Hand searches were also conducted to find articles from Google Scholar, the World Bank Library, the World Health Organization Library, the United Nations Digital Library Collections, and Google. Article search date was between 20 October 2021 and 12 November 2021 and the most recent update was done on 03 March 2022. Articles on UHC coverage, financial risk protection, quality of care, and inequity were included. The Population, Concept, and Context framework was used to determine the eligibility of research questions. A stepwise approach was used to identify and select relevant studies, conduct data charting, collation and summarization, as well as report results. Simple descriptive statistics and narrative synthesis were used to present the findings.

RESULTS

Forty-seven papers were included in the final review. One-fourth of the articles (25.5%) were from the African region and 29.8% were from lower-middle-income countries. More than half of the articles (54.1%) followed a quantitative research approach. Of included articles, coverage was assessed by 53.2% of articles; financial risk protection by 27.7%, inequity by 25.5% and quality by 6.4% of the articles as the main research objectives or mentioned in result section. Most (42.5%) of articles investigated health promotion and 2.1% palliation and rehabilitation services. Policy and healthcare level and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, weak regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned as a cross-cutting barrier.

CONCLUSIONS

The review showed that majority of the articles were from the African region. Methodologically, quantitative research design was more frequently used to investigate UHC. Palliation and rehabilitation health care services need attention in the monitoring and evaluation of UHC progress. It is also noteworthy to focus on quality and inequity of health services. The study implies that urgent action on the identified policy, health system and cross-cutting barriers is required to achieve UHC.

Clients satisfaction at primary healthcare facilities and its association with implementation of client service charter in Tanzania

Background

Client service charter (CSC) provides information about what people can expect in a facility’s services; what is expected of clients and service providers. Tanzania implemented Star Rating Assessment (SRA) of primary health care (PHC) facilities in 2015/16 and 2017/18 using SRA tools with 12 service areas. This paper assesses the status of service area 7, namely client focus that checked if client was satisfied with services provided and implementation of CSC through three indicators–if: CSC was displayed; CSC was monitored; client feedback mechanism and complaints handling was in place.

Methods

We extracted and performed a cross-sectional secondary data analysis of data related to clients’ focus that are found in national SRA database of 2017/2018 using STATA version 15. Client satisfaction was regarded as dependent variable while facility characteristics plus three indicators of CSC as independent variables. Multivariate logistic regression with p-value of 5% and 95% confidence interval (CI) were applied.

Results

A total of 4,523 facilities met our inclusion criteria; 3,987 (88.2%) were dispensaries, 408 (9.0%) health centres and 128 (2.8%) hospitals. CSC was displayed in 69.1% facilities, monitored in 32.4% facilities, and 32.5% of the facilities had mechanisms for clients’ feedback and handling complaints. The overall prevalence of clients’ satisfaction was 72.8%. Clients’ satisfaction was strongly associated with all implementation indicators of CSC. Clients from urban-based facilities had 21% increased satisfaction compared rural-based facilities (AOR 1.21; 95%CI: 1.00–1.46); and clients from hospitals had 39% increased satisfaction compared to dispensaries (AOR 1.39; 95%CI: 1.10–1.77).

Conclusion

The implementation of CSC is low among Tanzanian PHC facilities. Clients are more satisfied if received healthcare services from facilities that display the charter, monitor its implementation, have mechanisms to obtain clients feedback and handle complaints. Clients’ satisfaction at PHC could be improved through adoption and implementation of CSC.

Medical Students’ Perception Regarding Health Policy Teaching and Their Participation in Health Policy Roles: A Survey at a Public University in Malaysia

Background: Health policy is a set of comprehensive principles and legislations that guide how healthcare should be effectively delivered in the community. Medical schools should prepare students to undertake managerial responsibilities by incorporating health policy into the curriculum to deal with the intricacies of healthcare systems and their clinical roles in their future professional careers. Objective: To examine medical students’ perception at a Public University in Malaysia regarding teaching health policy and their participation in health policy roles. Material and Methods: A cross-sectional study using universal sampling was carried out among the medical students using a paper-based questionnaire to collect the data. Results: Most respondents opined their willingness to learn health policy (80.9%) and that teaching health policy (83.6%) should be compulsory for medical students. The respondents thought health policy should be introduced earlier in Year 1 or 2. The student scores on their knowledge regarding health policy and year of study were significantly associated with their involvement in the health policy roles in both the simple and multiple logistic regression. Both statistical tests reported higher participation in health policy roles with the higher year of study, though only Year 4 and 5 were significant in the simple logistic regression and only Year 5 in the multiple logistic regression compared to Year 1. On the other hand, age and type of admission show significant results only in the simple logistic regression, while the race was only significant at the multivariate level. Conclusions: This study demonstrated that most respondents showed their willingness to learn health policy, participate in the health policy programs, and recommend that health policy be considered an essential topic in the medical curriculum, which should be taught right from the first year of medical school. We recommend encouraging students’ participation in health policy activities.

Fostering global primary care research: a capacity-building approach

The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.

Exploring access to government-led support for children with disabilities in Bangladesh

While access to support for individuals with disabilities has attracted international attention, children with disabilities and their families continue to face a range of barriers that limit their timely access to the needed support, including health service. This is even worse for children with disabilities living in resource poor settings like Bangladesh. The objective of this study was to determine the extent to which families of children with disabilities have knowledge about and access to government support for their children with disabilities in Bangladesh. We employed a cross-sectional study among 393 families of children with disabilities who sought services from the Centre for the Rehabilitation of the Paralysed for their children with disabilities in Bangladesh. We used chi-square test to measure the association between categorical variables and, Mann-Whitney U-test to compare mean across different sub-groups. Overall, family members of children with disabilities have limited knowledge about and access to government support. We found a significant association between knowledge and access to government support (p<0.001). Family members with children with disabilities aged younger than six years had less access to government support (p<0.001). We thus concluded with an urgent call on government agencies and service providers to provide relevant and timely information to families of children with disabilities to enable them to access the needed support.

Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries

The prevalence of long-term (chronic) non-communicable diseases (NCDs) is increasing globally due to an ageing global population, urbanization, changes in lifestyles, and inequitable access to healthcare. Although previously more common in high- and upper-middle-income countries, lower-middle-income countries (LMICs) are more affected, with NCDs in LMICs currently accounting for 85–90% of premature deaths among 30–69 years old. NCDs have both high morbidity and mortality and high treatment costs, not only for the diseases themselves but also for their complications. Primary health care (PHC) services are a vital component in the prevention and control of long-term NCDs, particularly in LMICs, where the health infrastructure and hospital services may be under strain. Drawing from published studies, this review analyses how PHC services can be utilized and strengthened to help prevent and control long-term NCDs in LMICs. The review finds that a PHC service approach, which deals with health in a comprehensive way, including the promotion, prevention, and control of diseases, can be useful in both high and low resource settings. Further, a PHC based approach also provides opportunities for communities to better access appropriate healthcare, which ensures more significant equity, efficiency, effectiveness, safety, and timeliness, empowers service users, and helps healthcare providers to achieve better health outcomes at lower costs.

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