The Lancet Global Health Commission on financing primary health care: putting people at the centre

Innovations in primary healthcare in Slovenia 2011-2020: Exploring the stepwise process behind effective implementation

Countries worldwide seek to strengthen their primary healthcare systems often through introducing health promotion and disease prevention, multidisciplinary teams, group practices and community approaches to advance universal health coverage. These strategies are underpinned by scientific evidence and international standards. Slovenia's primary healthcare system reflects many of these features, with universally accessible, multidisciplinary, and integrated health services, emphasizing health promotion, disease prevention, and equity. Municipal primary healthcare centres serve as hubs within local communities. Slovenia's efforts to strengthen the delivery model are continuous and follow a controlled stepwise implementation process. This approach has strong policy support and organizational and implementation capacities. This paper describes Slovenia's primary healthcare model and three innovations between 2011 and 2020: (1) family medicine model practices, (2) health promotion centres, and (3) mental health centres. These innovations are used both to showcase the efforts of Slovenia to enhance primary healthcare and as a lens to explore Slovenia's established primary healthcare innovation implementation approach. The three innovations have had a positive impact on health outcomes in the short- to medium-term, but mixed health system and implementation outcomes. Slovenia's experience can inspire other countries looking to sustainably integrate primary healthcare fully or effectively introduce single innovations in their primary healthcare systems.

Starfield's 4Cs of NCD management in primary healthcare: a conceptual framework development from a case study of 19 countries

INTRODUCTION

Faced with a backdrop of an increasing chronic disease burden from an ageing global population compounded with rising healthcare costs, health systems are required to implement cost-effective, safe and equitable care through efficient service delivery models. One approach to achieving this is through Starfield's 4Cs of primary healthcare (PHC), which delineates the key attributes of a high-performing PHC system that upholds the pillars of care coordination, first contact of care, continuity of care and comprehensive care. Therefore, this study aims to explore and elucidate the key themes and subthemes related to and extending beyond Starfield's 4Cs of PHC by integrating findings from a comprehensive literature review and a qualitative study.

METHODS

In this case study analysis, case studies of PHC systems from 19 countries were purposefully selected to represent a range of income levels and diversity in health systems and PHC landscapes. A review of existing literature of peer-reviewed articles, policy documents and technical reports made publicly available data on PHC was complemented with data obtained from 61 in-depth interviews with health systems experts from a larger study. The research team thematically analysed the data and organised the key themes and subthemes into a conceptual framework that is anchored on Starfield's 4Cs of PHC.

RESULTS

Broadly, we developed a conceptual framework with the 4Cs, placing providers and patients at the centre. The key subthemes that manifested from Starfield's 4Cs included maximising the use of existing fiscal resources, leveraging technology, improving accessibility to health services and task sharing. Other relevant and overarching themes were the deployment of national frameworks, equity, healthcare provider retention, service integration, emergency preparedness and community engagement.

DISCUSSION

The subthemes derived point health systems in the right direction based on the trialled and tested PHC models of various countries. Their strong points were highlighted in our case studies to depict how Starfield's 4Cs are leveraged to strengthen PHC, and the themes we identified that went beyond the 4Cs are necessary considerations for modifying PHC policies going forward.

CONCLUSION

As the world enters an era of ageing populations and acute system shocks, PHC needs to be fortified and integrated into the more extensive system to protect the health of the population and safeguard the well-being of providers. Our conceptual framework offers health systems a glimpse of how this can be achieved.

Continuity of care and mortality in patients with type 2 diabetes: a cohort study

BACKGROUND

How GP continuity of care (GP-CoC) affects mortality in patients with type 2 diabetes (T2D) is unclear.

AIM

To examine the effect of having no continuity of care (CoC) and GP-CoC on mortality in primary health care (PHC) patients with T2D.

DESIGN & SETTING

A cohort study in patients aged ≥60 years with T2D, which was conducted within the public PHC of the city of Vantaa, Finland.

METHOD

The inclusion period was between 2002 and 2011 and follow-up period between 2011 and 2018. Six groups were formed (no appointments, one appointment and Modified, Modified Continuity Index [MMCI] quartiles). Mortality was measured with standardised mortality ratio (SMR) and adjusted hazard ratio (aHR). GP-CoC was measured with MMCI. Comorbidity status was determined with Charlson Comorbidity Index (CCI).

RESULTS

In total, 11 020 patients were included. Mean follow-up time was 7.3 years. SMRs for the six groups (no appointments, one appointment, MMCI quartiles) were 2.46 (95% confidence interval [CI] = 2.24 to 2.71), 3.55 (95% CI = 3.05 to 4.14), 1.15 (95% CI = 1.06 to 1.25), 0.97 (95% CI = 0.89 to 1.06), 0.92 (95% CI = 0.84 to 1.01) and 1.21 (95% CI = 1.11 to 1.31), respectively. With continuous MMCI, mortality formed a U-curve. The inflection point was at a MMCI value of 0.65 with corresponding SMR of 0.86. Age and CCI aHR for death between men and women was 1.45 (95% CI = 1.35 to 1.58).

CONCLUSION

Patients with no CoC had the highest mortality. In patients having care over time, the effect of GP-CoC on mortality was minor and mortality increased with high GP-CoC.

[Family and Community Medicine in the degree of Medicine in Spanish universities: analysis of the current situation]

OBJECTIVE

To analyse the specific training in Family and Community Medicine (FCM) that is taught in the medical degrees in Spain.

METHOD

Descriptive and cross-sectional study based on the content analysis of the study programs and teaching guides based on the official information that universities offer on their study programs and teaching guides for the 2023-2024 academic year. The specific FCM subjects, the number of credits, their theoretical-practical nature and the clinical rotations were identified. The universities were classified according to their training offer in FCM, both theoretical and practical, and as a whole.

RESULTS

There are 49 Spanish universities with a degree in Medicine, 35 public and 14 private. Of these, 40 degrees include some theoretical-practical subject with content on FCM, 27 of which with some specific subject on FCM and 13 degrees with more general subjects in which other specialties are also addressed. On the other hand, 44 degrees have clinical rotations or supervised internships that include MF&C, 21 of which are specific to MF&C and 23 general courses that include several specialties. In the overall classification, 7 universities would be at the level corresponding to the degrees in which there is sufficient training in theory and practice of MF&C; 33 would be at an intermediate level, with some training in MF&C in one of the two types of subjects considered, and 9 universities would be at the bottom level, with deficiencies both at the level of theoretical-practical subjects and clinical rotations.

CONCLUSIONS

The presence of MF&C in the degrees of Medicine of Spanish universities has been increasing in recent years, but it is still insufficient. There is a great variability between universities, but at a general level there is a significant lack of theoretical-practical subjects specific to MF&C and specific clinical rotations in Primary Care or with sufficient credits.

Empowering Health: Innovative Strategies to Successfully Increase Physical Activity Promotion in Brazilian Primary Health Care Settings

BACKGROUND

Implementation of physical activity (PA) initiatives within the scope of Primary Health Care (PHC) is still a challenge for the field of public health. It is necessary to consolidate operational processes to promote PA in the daily lives of patients in PHC. The use of implementation science has significant potential for advancing PA initiatives.

METHODS

The present study is a methodological study, which includes a macroproject titled "Saúde a Partir de Atividades Físicas Exitosas-SAFE Research." The project is organized by 5 steps, and a descriptive manuscript about an intervention as well, to increase, or promote PA in a community settings.

RESULTS

Eight strategies have been developed, related to the attributes of a successful PA promotion initiative in PHC (autonomy, participation, planning, replication, and sustainability), and the dimensions of RE-AIM (reach, effectiveness, adoption, implementation, and maintenance). Each strategy presents a set of processes that can be systematically operationalized to make the PA initiative more successful.

CONCLUSION

The strategies were based on practical experiences in the PHC context in Brazil, which can potentially be replicated in low- and middle-income countries. These strategies make it possible to cover other initiatives in the field of health promotion so that they can be implemented in an organized, systematized way and with robust processes in community interventions.

Negative experiences with primary care services in Norway expressed in patient and next-of-kin complaints - a qualitative study

BACKGROUND

Primary health care has been central to achieving universal health coverage. In Norway, there has been increased pressure on primary care services in recent years. Patient complaints offer key insights into care quality, and qualitative analysis of patient complaints can help healthcare professionals reflect on and improve their practices. The aim of this study is to provide an understanding of negative experiences with primary care in Norway, as expressed in complaints to the Health and Social Services Ombudsman (Ombudsman).

METHODS

An explorative descriptive qualitative design was employed. Document analysis was used to examine earlier complaints. A total of 221 complaints were analysed via reflexive thematic analysis. The participants consisted of a sample of patients and next of kin who made complaints regarding primary care services to the Ombudsman in Norway in 2019.

RESULTS

Four themes were developed through thematic analysis: 1) the services patients received did not align with their perceived needs; 2) patients experienced disrupted transitions between healthcare services; 3) patients and next of kin encountered substandard case handling; and 4) insufficient services placed a heavy burden on next of kin. These findings were integrated to a patient-centred framework to provide structure and make them more accessible to healthcare providers.

CONCLUSIONS

This study highlights the challenges faced by patients and their next of kin related to Norwegian primary care services, pointing to a gap between the expected quality of healthcare services and the services received and to nudging next of kin to provide informal care.

Geographic variations, temporal trends, and equity in healthcare resource allocation in China, 2010-21

Background

Inequity in healthcare resources has been identified as a global public health priority, yet the geographic variations and temporal trends in distribution and inequity in China remain unclear. We aimed to investigate these variations and temporal trends in healthcare resources and evaluate inequity in healthcare resource allocation in China.

Methods

In this nationwide descriptive study, we used provincial-level data on healthcare infrastructure, human, and service resources from 31 provinces of mainland China, publicly released by the National Health Commission of China between 2010-21. We assessed the spatial autocorrelation of healthcare infrastructure, human, and service resources using Moran's I index, and identified spatial clusters of resource allocation. We evaluated the equity in healthcare resource allocation using the Lorenz curve, Gini coefficient, and Theil index by population and geographic dimensions.

Results

Between 2010-21, the density of healthcare infrastructure and human resources in China increased, with the average stay decreasing from 10.5 to 9.2 days. There were substantial regional disparities, with higher resource density exhibited in eastern regions compared to western regions. Spatial autocorrelation was more pronounced for the density of practising (assistant) physicians (Moran's I = 0.465; P < 0.001), practising physicians (Moran's I = 0.351; P < 0.001), and bed occupancy rate (Moran's I = 0.256; P < 0.001), with significant geographic clusters of resource allocation. Lorenz curves showed that healthcare resource allocation was closer to the absolute equity by population but not geographic dimension, with Gini coefficients indicating severe inequity (>0.6) by geographic dimension compared to perfect equity (<0.2) by population dimension. Intraregional Theil index by population was higher than the inter-regional index, with contribution rates exceeding 60%.

Conclusions

Per capita access to healthcare resources in China has improved, but significant geographic variations and clustering exist, particularly with higher resource density in eastern regions. While resource allocation by population showed better equity than by geographic area, substantial intra-regional disparities highlight the need for targeted strategies to enhance equitable distribution, particularly in the western regions.

Patient-reported outcomes of zirconia dental implants: a systematic review and future directions

PURPOSE

Zirconia dental implants show excellent biocompatibility and tissue integration, low affinity for plaque, and favorable biomechanical properties. However, these objective measures do not adequately replicate the patient's perception. This systematic review evaluated the evidence on patient-reported outcome (PROs) in zirconia dental implant treatment.

METHODS

A systematic literature review was conducted following the PRISMA guidelines, utilizing six electronic databases, and supplemented by a manual search of relevant journals and websites to ensure a thorough and comprehensive screening process. The identified studies were subjected to preidentified inclusion criteria. Only controlled clinical trials published in English were considered without limitations on the year of publication. Data on the study characteristics (follow-up, survival rate (%), implant system, number of implants, and type of treatment), PROMs, level of evidence, and Methodological Index for Nonrandomized Studies (MINORS) Bias Score were extracted.

RESULTS

The initial database and hand search yielded 596 articles; 189 were included in the title and abstract screening after excluding the duplicates. Eighteen articles were selected based on the inclusion criteria, among which six were excluded because they did not match the research question. Thus, the final selection comprised 12 articles. Most PROMs (aesthetics, speaking, comfort, chewing ability, and general satisfaction) at prosthetic delivery revealed significantly improved average scores than those at pretreatment.

CONCLUSIONS

Despite the respective limitations of the articles included in this systematic review, patients revealed high satisfaction levels with regard to zirconia dental implants. A high level of heterogeneity was observed among the instruments used for measuring the patient-reported outcomes in patients with zirconia implants, thus highlighting the need to develop specific PROMs in the future.

Reducing fragmentation of primary healthcare financing for more equitable, people-centred primary healthcare

Despite primary healthcare (PHC) being recognised in global declarations-Alma Ata in 1978 and Astana in 2018-and prioritised in national health strategies, chronic under-resourcing of PHC persists in most low-income and middle-income countries. More public spending is needed for PHC, but macrofiscal and political constraints often limit the ability of governments to allocate more public resources to PHC. Under-resourcing has been compounded by fragmented and rigid funding flows, which are inefficient and may erode equity, quality of care and public trust in PHC.This article explores the drivers of fragmentation in PHC financing-low public spending, which results in over-reliance on external sources to fund critical health interventions, and the proliferation of new financing schemes that do not take a system-wide view or adhere to the principles of universality. It then highlights some of the possible consequences of this fragmentation for the efficiency, equity and effectiveness of service delivery.Four countries-Argentina, Burkina Faso, Indonesia and Tanzania-are used to illustrate practical steps that may be taken to minimise the consequences of fragmentation in PHC financing: (1) consolidating multiple coverage schemes, (2) avoiding further fragmentation, (3) harmonising health purchasing functions and (4) streamlining funding flows to the provider level.The country examples reveal lessons for policy-makers grappling with the consequences of fragmented PHC financing. The paper concludes with a research agenda to generate additional evidence on what works to address fragmentation.

Clinical outcomes following acute sore throat assessment at community pharmacy versus general practice: a retrospective, longitudinal, data linkage study

BACKGROUND

To date, no research has compared longer-term outcomes (antibiotic provision; re-consultations; hospital admissions for quinsy; cost-effectiveness) following presentation with acute sore throat at general practice (GP) versus newer, pharmacy-led services.

METHODS

A retrospective, longitudinal cohort study of sore throat consultations between 1 November 2018 and 28 February 2020 either with the Wales pharmacy-led sore throat test and treat (STTT) service or with a healthcare professional at GP. Individual-level pharmacy consultation data from the national Choose Pharmacy IT application were securely uploaded to the Secure Anonymised Information Linkage Databank and linked to routinely collected, anonymized, population-scale, individual-level, anonymized health and administrative data.

RESULTS

Of 72 736 index consultations, 6495 (8.9%) were with STTT and 66 241 (91.1%) with GP. Antibiotic provision at the index consultation was 1382 (21%) with STTT and 25 506 (39%) with GP [adjusted odds ratio (AOR), 0.30; 95% CI, 0.27 to 0.32]. Antibiotic provision within 28 days of index occurred in 1820 (28%) STTT and 26 369 (40%) GP consultations (AOR, 0.44; 95% CI, 0.41 to 0.47). GP re-consultation rate within 28 days of index date was 21% (n = 1389) with STTT compared with 7.4% (n = 4916) with GP (AOR, 3.8; 95% CI, 3.5 to 4.1). Coding limitations may lead to overestimates of GP re-consultations rates in the STTT group. Hospital admissions for quinsy were rare in both STTT (n = 20, 0.31%) and GP (n = 274, 0.41%) (AOR, 0.68; 95% CI, 0.43 to 1.1). STTT was less costly than consultation with GP.

CONCLUSIONS

The pharmacy-led STTT service is safe, cost-effective, and contributes to antimicrobial stewardship.

Airway clearance techniques for people with acute exacerbation of COPD: a scoping review

INTRODUCTION

Acute exacerbations of COPD (AECOPD) often involve mucus hypersecretion. Thus, management of sputum retention is critical. However, the use of airway clearance techniques (ACTs) in people with AECOPD across different healthcare settings and factors influencing their selection remain unclear.

OBJECTIVE

To identify and map ACTs used for AECOPD in different healthcare settings and the factors influencing clinical decision-making worldwide.

METHODS

Four electronic databases and grey literature were searched from 1995 to December 2023, with hand-searching of eligible records. The Joanna Briggs Institute methodology for scoping reviews was followed.

RESULTS

25 articles were included: 14 clinical studies, five guidelines/statements and six surveys/audits. Clinical studies reported the use of a wide range of single or combined ACTs, with no clear pattern in using particular ACTs in different parts of the world. Recent guidelines advise using ACTs for certain patients with AECOPD, particularly those with hypersecretion, with most guidelines recommending positive expiratory pressure (PEP) therapy. According to surveys, the most used ACTs in Australia and Europe are active cycle of breathing techniques, PEP or forced expiratory technique, while vibrations are most frequently used in Canada. Factors influencing the selection of specific ACTs include the presence of contraindications, level of dyspnoea, access to resources/equipment and ease of learning/performing the technique. All information was derived from hospital settings.

CONCLUSIONS

This scoping review identified and mapped ACTs used for people with AECOPD worldwide and their decision-making factors. Future work should focus on community settings.

Resilience of Primary Health Care in Ukraine: Challenges of the Pandemic and War

This commentary examines the resilience of primary health care in Ukraine amidst the ongoing war, drawing a few reflections relevant for other fragile and conflict-affected situations. Using personal observations and various published and unpublished reports, this article outlines five reflections on the strengths, challenges, and necessary adaptations of Primary Health Care (PHC) in Ukraine. It underscores the concerted efforts of the government to maintain public financing of PHC, thereby averting system collapse. The research also highlights the role of strategic adaptations during the COVID-19 pandemic in fostering resilience during the war, including the widespread use of digital communication and skills training. The commentary emphasizes the role of managerial and financial autonomy in facilitating quick and efficient organizational response to crisis. It also recognizes emerging challenges, including better access to PHC services among the internally displaced persons, shifting patient profiles and service needs, and challenges related to reliance on local government financing. Finally, the authors advocate for a coordinated approach in humanitarian response, recovery efforts, and development programs to ensure the sustainability and effectiveness of PHC in Ukraine.

Healthcare Financing in Saudi Arabia: A Comprehensive Review

Saudi Vision 2030 is a game-changer for all aspects of the economy, including healthcare. This article provides a comprehensive overview of healthcare financing in the Kingdom of Saudi Arabia (KSA). It identifies key healthcare financing challenges that must be addressed to achieve the initiative's envisioned health system goals. The review also examines and demonstrates how healthcare funds in the KSA are allocated among different healthcare services, to offer a perspective on resource use efficiency at various healthcare levels. This research used a mixed-method design which includes a literature review and secondary data analysis. A literature review was conducted aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. The secondary data were gathered from the reports and websites of government agencies, international organizations, and non-governmental organizations. Despite implementing significant reforms in its healthcare system, the share of private healthcare expenditure in total healthcare spending has seen only marginal growth. The current healthcare financing system appears insufficient to adequately support the chronically ill and the poor. There is a significant imbalance in the allocation of government budgets between hospitals and primary care, with four-fifths of financial resources directed towards hospital services. The Ministry of Health's budget allocation prioritizes personnel compensation, potentially reducing the available budget for medicines and other essential healthcare supplies. Ongoing reforms in the health sector, including privatization, public-private partnership initiatives, and the government's commitment to developing a robust primary healthcare network, are expected to play a significant role in controlling rapidly increasing public healthcare expenditures in Saudi Arabia.

An Assessment of Provider Payment Mechanisms (PPMs) in Ethiopia: Implications for Redesign of PPMs and Progress Toward Universal Health Coverage

Ethiopia has made great strides in improving population health but sustaining health system and population health improvements in the current fiscal environment is challenging. Provider payment, as a function of purchasing, is a tool to use limited health resources better. This study describes the design and implementation of Ethiopia's provider payment mechanisms (PPMs) and how they influence health system objectives and contribute to universal health coverage goals. The research team adapted the framework and analytical tools of the Joint Learning Network for Universal Health Coverage guide for assessing PPMs. Data were collected through literature review and key informant interviews with 11 purchasers and 17 health care providers. Content analysis was used to describe PPM design and implementation arrangements, and thematic analysis was used to distill effects on equity in resource distribution and access to care, efficiency, quality of care, and financial sustainability. The study revealed the PPMs had positive and negative consequences. Line-item budgets were perceived to be predictable and sustainable but had little effect on efficiency and provider performance. Fee-for-service was perceived to have negative effects on efficiency and financial sustainability but viewed positively on its ability to incentivize quality health services. Capitation and performance-based financing effects were viewed positively on equity in distribution of resources and quality respectively, but both were perceived negatively on their high administrative burden to providers. Ethiopia may consider a more nuanced approach to design blended provider payment to mitigate negative consequences while providing incentives for better quality of care and efficiency.

Promoting Global Cardiovascular Health to Advance the Sustainable Development Agenda

The burden of cardiovascular disease has declined in high-income countries in the past 3 decades but is growing in low- and middle-income countries due to epidemiological, demographic, and socioeconomic shifts. A range of cost-effective policies and interventions are available for advancing cardiovascular health (CVH) through primordial, primary, and secondary prevention. We showcase multifaceted challenges that stifle the global progress of CVH including shortcomings in financial protection, health systems, primary health care, national health policies, service coverage, and surveillance. We highlight the under-acknowledged global disparities in health expenditure and health workforce capacities. We emphasize the need of addressing social and commercial determinants of health and a more granular analysis of challenges to implement context-appropriate national CVH responses, particularly in low- and middle-income countries. Finally, we propose progressive realization of universal health coverage and national health policy reform as sustainable strategies for overcoming the barriers to achieve CVH in order to reduce premature mortality from noncommunicable diseases by one-third by 2030 (Sustainable Development Goal target 3.4).

Costing curative outpatient care for the poorest in Burkina Faso: informing universal health coverage and leaving no one behind

INTRODUCTION

The poorest in Burkina Faso face numerous barriers to healthcare access, including financial and geographic obstacles, as well as a high burden of chronic conditions and multimorbidity. This study estimates the average cost of providing curative outpatient consultations at first-level healthcare facilities to the poorest in Burkina Faso. It also estimates the budgetary impact of scaling up free access to these services nationwide. The findings provide essential evidence on cost structures to inform decision-makers in developing policies aimed at achieving universal health coverage and ensuring that no one is left behind.

METHODS

We conducted a micro-costing study to estimate the economic costs of providing curative outpatient healthcare services to the poorest at first-level healthcare facilities, considering a health system perspective. We measured the consumption of capital costs (building and equipment) using survey data from 32 primary health facilities and recurrent costs (drugs and consumables) from medical records of 1380 poor patients in Diébougou district. These individuals were targeted and exempted from user fees through a community-based targeting approach. We obtained unit costs from official price lists, pharmacy registries, and expert interviews. We calculated the national budget for providing curative care services to the exempted poorest based on the average cost per first-level consultation.

RESULTS

The estimated capital and recurrent costs of providing curative care services ranged between USD 0.59 - USD 0.61 and USD 2.58 - USD 5.00, respectively. The total cost ranged between USD 3.17 - USD 5.61 per first-level consultation. Providing curative care to the bottom 20% of the population, assuming 0.25 healthcare contacts per person per year, would result in an annual expense ranging from USD 2.77 M to USD 5.38 M (0.74-1.43% of the healthcare budget in 2019). With 2 healthcare contacts per person per year, costs increase to USD 22.19 M to USD 43.05 M (5.91-11.45% of the healthcare budget).

CONCLUSION

The results can inform policies aimed at expanding access to curative care for the poorest in Burkina Faso, contributing to the goals of universal health coverage and leaving no one behind. Further research is needed to enhance cost estimation and budgeting for higher-level care in the country.

Evaluating the effectiveness of the National Health Insurance Subsidy Programme within Kenya's universal health coverage initiative: a study protocol

BACKGROUND

Low-income and middle-income countries, including Kenya, are pursuing universal health coverage (UHC) through the establishment of Social Health Insurance programmes. As Kenya rolls out the recently unveiled UHC strategy that includes a national indigent cover programme, the goal of this study is to evaluate the impact of health insurance subsidy on poor households' healthcare costs and utilisation. We will also assess the effectiveness and equity in the beneficiary identification approach employed.

METHODOLOGY AND ANALYSIS

Using a quantitative design with quasi-experimental and cross-sectional methods, our matched cohort study will recruit 1350 households across three purposively selected counties. The 'exposure' arm, enrolled in the UHC indigent programme, will be compared with a control arm of eligible but unenrolled households over 12 months. Coarsened exact matching will be used to pair households based on baseline characteristics, analysing differences in expenses and catastrophic health expenditure. A cross-sectional design will be employed to evaluate the effectiveness and equity in beneficiary identification, estimating inclusion errors associated with the subsidy programme while assessing gender equity.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Scientific and Ethics Review Unit at Kenya Medical Research Institute, with additional permissions sought from County Health Departments. Participants will provide written informed consent. Dissemination strategies include peer-reviewed publications, conference presentations and policy-maker engagement for broad accessibility and impact.

Dual assurance for healthcare and future education development: normalized assistance for low-income population in rural areas-evidence from the population identification

Introduction

This study aims to explore the relationship between healthcare and future education among the rural low-income population, using J City in Guangdong Province as the focal area. Addressing both healthcare and educational concerns, this research seeks to provide insights that can guide policy and support for this demographic.

Methods

Utilizing big data analysis and deep learning algorithms, a targeted intelligent identification classification model was developed to accurately detect and classify rural low-income individuals. Additionally, a questionnaire survey methodology was employed to separately investigate healthcare and future education dimensions among the identified population.

Results

The proposed model achieved a population identification accuracy of 91.93%, surpassing other baseline neural network algorithms by at least 2.65%. Survey results indicated low satisfaction levels in healthcare areas, including medical resource distribution, medication costs, and access to basic medical facilities, with satisfaction rates below 50%. Regarding future education, issues such as tuition burdens, educational opportunity disparities, and accessibility challenges highlighted the concerns of rural low-income families.

Discussion

The high accuracy of the model demonstrates its potential for precise identification and classification of low-income populations. Insights derived from healthcare and education surveys reveal systemic issues affecting satisfaction and accessibility. This research thus provides a valuable foundation for future studies and policy development targeting rural low-income populations in healthcare and education.

Evaluating the implementation of the National Primary Health Care Development Agency (NPHCDA) gateway for the Basic Healthcare Provision Fund (BHCPF) across six Northern states in Nigeria

BACKGROUND

This evaluation research utilized both qualitative and quantitative methods to assess the implementation of the National Primary Health Care Development Agency (NPHCDA) gateway of the Basic Health Care Provision Fund (BHCPF) across six states in Northern Nigeria: Bauchi, Borno, Kaduna, Kano, Sokoto, and Yobe.

METHODS

This was a mixed-method research that utilized longitudinal surveys and Key informant interviews to gather information about the implementation status of the BHCPF-NPHCDA gateway. Checklists were developed based on the BHCPF's national guidelines to gather quantitative data, while simple open-ended questionnaires were used to collect qualitative data from the state BHCPF Program Implementation Unit (PIU) focal persons as key informants.

RESULTS

The result revealed that the NPHCDA had accredited these six states to use one Primary Health Care (PHC) facility in each political ward to implement the BHCPF. Factors that contributed to the success achieved in some states included the early completion of contingent start-up activities, well-established coordination structures, strong support from partners, and the availability of established financial management systems. However, the delays in the submission of quarterly business plans by the BHCPF facilities affected timely approval and fund disbursement. Other challenges included staff capacity gaps, inadequate human resources, and poor management and supervision from the state health agency teams.

CONCLUSION

There was suboptimal implementation of the BHCPF in at least one thematic area across all states. Therefore, actions such as government commitment for improved coordination, continuous capacity building, effective monitoring and evaluation, and targeted supportive supervision using innovative approaches should be undertaken to improve the program's implementation. In a broader setting, the insights from BHCPF implementation are valuable for LMICs, offering guidance on overcoming implementation challenges associated with PHC financing. This research provides a resource for enhancing healthcare financing strategies in similar contexts.

The role of pharmacy in promoting public health: Pharmacy and public health in 2050

From 2000 to 2025, the profession of pharmacy expanded into vaccinations, point-of-care testing, and chronic disease prevention and management. In the next 25 years, pharmacy will continue to advance in new ways. This paper focuses on expanded roles of community and ambulatory care pharmacy to more directly improve public health. Built around the ten essential services of public health, this paper calls upon the profession of pharmacy to stretch beyond traditional roles to assume roles that would strengthen the public health workforce and make seminal contributions to improved population health. Barriers to be overcome in pursuit of that future are also addressed. The paper will conclude with a public health-focused call to pharmacy.

Primary Care Informatics: Vitalizing the Bedrock of Health Care

Primary care informatics (PCI) professionals address workflow and technology solutions in a wide spectrum of health, ranging from optimizing the experience of the individual patient in the clinic room to supporting the health of populations and augmenting the work of frontline primary care clinical teams. PCI overlaps uniquely with 2 disciplines with an impact on societal health-primary care and health informatics. Primary care is a gateway to health care access and aims to synthesize and coordinate numerous, complex elements of patients' health and medical care in a holistic manner. However, over the past 25 years, primary care has become a specialty in crisis: in a post-COVID-19 world, workforce shortages, clinician burnout, and continuing challenges in health care access all contribute to difficulties in sustaining primary care. Informatics professionals are poised to change this trajectory. In this viewpoint, we aim to inform readers of the discipline of PCI and its importance in the design, support, and maintenance of essential primary care services. Although this work focuses on primary care in the United States, which includes general internal medicine, family medicine, and pediatrics (and depending on definition, includes specialties such as obstetrics and gynecology), many of the principles outlined can also be applied to comparable health care services and settings in other countries. We highlight (1) common global challenges in primary care, (2) recent trends in the evolution of PCI (personalized medicine, population health, social drivers of health, and team-based care), and (3) opportunities to move forward PCI with current and emerging technologies using the 4Cs of primary care framework. In summary, PCI offers important contributions to health care and the informatics field, and there are many opportunities for informatics professionals to enhance the primary care experience for patients, families, and their care teams.

Organizational innovations related to Primary Care Access Points (GAP) for unattached patients in Quebec: a multi-case qualitative study

BACKGROUND

Being attached to a primary care (PC) provider is at the core of a strong primary health care system. Centralized waiting lists (CWL) for unattached patients have been implemented in eight provinces of Canada to support the attachment process. In Quebec, the Ministry of Health mandated the implementation of Primary Care Access Points (GAP) across the province to help unattached patients navigate the health system while awaiting attachment through the CWL. Several local health territories developed complementary innovations to the GAP to respond to local population needs. This paper aims to describe five organizational innovations implemented locally.

METHODS

This multi-case qualitative study was conducted in four local health territories in the province of Quebec. Fifty-two semi-structured interviews with healthcare managers, nurses, physicians, other health professionals and administrative staff were conducted between April 2023 and April 2024. An interview guide was developed based on existing frameworks on the implementation of innovations and the evaluation of the GAP. Thematic analysis was conducted using NVivo software. Inductive and deductive approaches were used to develop relevant codes and themes. Logic models were built to describe the organizational innovations.

RESULTS

Five organizational innovations are described. First, a multidisciplinary clinic aimed at responding to patients with mental health issues was implemented. Second, a nurse clinic was implemented to provide temporary care for patients with unstable chronic illnesses. The third innovation is a mobile proximity clinic where unattached GAP patients are first evaluated by a paramedic before receiving care from a nurse. Fourth, a pharmacist trajectory was implemented to increase engagement of community pharmacists to respond to GAP patients. The last innovation is a decentralized GAP offering in-person nursing care to unattached GAP patients.

CONCLUSIONS

Descriptions of these five innovations are key to inform other territories and provinces on ways to improve access for unattached patients while they are waiting to be attached. The introduction of the GAP and the organizational innovations, suggests a transition where access to PC services does not rely solely on attachment status.

Roles and experiences of nurses in primary health care during the COVID-19 pandemic: a scoping review

BACKGROUND

Nurses form the frontline of the healthcare system's response to both epidemics and pandemics, and this was especially the case during the novel coronavirus disease (COVID-19) pandemic. Although the influence of COVID-19 on nursing roles has attracted interest, there is no integrated knowledge of nurses' roles and experiences in primary health care settings during the COVID-19 pandemic. Thus, this study identifies the roles and experiences of nurses in primary health care during the COVID-19 pandemic.

METHODS

A scoping review study design and the Joanna Briggs Institute methodology were used. The study searched five electronic databases (PubMed, CINAHL, EMBASE, Scopus, and PsychINFO) and included studies published in English from March 2020 to June 2023 that focused on the roles and experiences of nurses (participants) during COVID-19 (concept) in primary health care settings (context).

RESULTS

Fourteen articles were selected for review, involving a total of 1,487 nurses as study participants. The various roles undertaken by nurses in primary health care settings were categorized as comprehensive care providers, supporters and empowerers, coordinators and collaborators, information navigators, and change agents. Challenges and strategies are multilevel intrapersonal, interpersonal, organizational, community, and societal issues, but are not mutually exclusive.

CONCLUSIONS

The pandemic-induced challenges revealed primary health care nurses' vital and indispensable roles and resilience. They also fostered a heightened awareness of technological influence on the progression of primary health care in the current milieu. Policymakers and healthcare organizations need to integrate primary health care nurses' expanding and emerging roles within the scope of practice, ensuring their effective implementation without excessive regulatory constraints. This study emphasizes the importance of developing multilevel interventions to address the support needs of primary health care nurses through a system-based approach. Building a strong infrastructure to support nurses' self-care, offering continuing professional development opportunities, and securing official government recognition will be essential for enhancing the resilience of primary healthcare nurses in preparation for future, potentially devastating pandemics.

Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared?

In the south Asian region, delivering non-communicable disease (NCD) prevention and control services through existing primary health-care (PHC) facilities is urgently required yet currently challenging. As the first point of contact with the health-care system, PHC offers an ideal window for prevention and continuity of care over the life course, yet the implementation of PHC to address NCDs is insufficient. This review considers evidence from five south Asian countries to derive policy-relevant recommendations for designing integrated PHC systems that include NCD care. Findings reveal high political commitment but poor multisectoral engagement and health systems preparedness for tackling chronic diseases at the PHC level. There is a shortage of skilled human resources, requisite infrastructure, essential NCD medicines and technologies, and dedicated financing. Although innovations supporting integrated interventions exist, such as innovations focusing on community-centric approaches, scaling up remains problematic. To deliver NCD services sustainably, governments must aim for increased financing and a redesign of PHC service.

Exploring the lack of continuity of care in older cancer patients under China's 'integrated health system' reform

BACKGROUND

Continuity of care is essential to older patients' health outcomes, especially for those with complex needs. It is a key function of primary healthcare. Despite China's policy efforts to promote continuity of care and an integrated healthcare system, primary healthcare centres (PHCs) are generally very underused.

OBJECTIVES

To explore the experience and perception of continuity of care in older cancer patients, and to examine how PHCs play a role in the continuity of care within the healthcare system in China.

METHODS

A qualitative study using semi-structured interviews was conducted in two tertiary hospitals in Nantong city, Jiangsu province, China. A combination of deductive and inductive analysis was conducted thematically.

RESULTS

Interviews with 29 patients highlighted three key themes: no guidance for patients in connecting with different levels of doctors, unmet patients' needs under specialist-led follow-up care, and poor coordination and communication across healthcare levels. This study clearly illustrated patients' lack of personal awareness and experience of care continuity, a key issue despite China's drive for an integrated healthcare system.

CONCLUSION

The need for continuity of care at each stage of cancer care is largely unmeasured in the current healthcare system for older patients. PHCs offer benefits which include convenience, less burdened doctors with more time, and lower out-of-pocket payment compared to tertiary hospitals, especially for patients with long-term healthcare needs. However, addressing barriers such as the absence of integrated medical records and unclear roles of PHCs are needed to improve the crucial role of PHCs in continuity of care.

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.

The gender gap in outpatient care for non-communicable diseases in Mexico between 2006 and 2022

BACKGROUND

Equitable health service utilization is key to health systems' optimal performance and universal health coverage. The evidence shows that men and women use health services differently. However, current analyses have failed to explore these differences in depth and investigate how such gender disparities vary by service type. This study examined the gender gap in the use of outpatient health services by Mexican adults with non-communicable diseases (NCDs) from 2006 to 2022.

METHODS

A cross-sectional population-based analysis of data drawn from National Health and Nutrition Surveys of 2006, 2011-12, 2020, 2021, and 2022 was performed. Information was gathered from 300,878 Mexican adults aged 20 years and older who either had some form of public health insurance or were uninsured. We assessed the use of outpatient health services provided by qualified personnel for adults who reported having experienced an NCD and seeking outpatient care in the 2 weeks before the survey. Outpatient service utilization was disaggregated into four categories: non-use, use of public health services from providers not corresponding to the user's health insurance, use of public health services from providers not corresponding to the user's health insurance, and use of private services. This study reported the mean percentages (with 95% confidence intervals [95% CIs]) for each sociodemographic covariate associated with service utilization, disaggregated by gender. The percentages were reported for each survey year, the entire study period, the types of service use, and the reasons for non-use, according to the type of health problem. The gender gap in health service utilization was calculated using predictive margins by gender, type of disease, and survey year, and adjusted through a multinomial logistic regression model.

RESULTS

Overall, we found that women were less likely to fall within the "non-use" category than men during the entire study period (21.8% vs. 27.8%, P < 0.001). However, when taking into account the estimated gender gap measured by incremental probability and comparing health needs caused by NCDs against other conditions, compared with women, men had a 7.4% lower incremental likelihood of falling within the non-use category (P < 0.001), were 10.8% more likely to use services from providers corresponding to their health insurance (P < 0.001), and showed a 12% lower incremental probability of using private services (P < 0.001). Except for the gap in private service utilization, which tended to shrink, the others remained stable throughout the period analyzed.

CONCLUSION

Over 16 years of outpatient service utilization by Mexican adults requiring care for NCDs has been characterized by the existence of gender inequalities. Women are more likely either not to receive care or resort to using private outpatient services, often resulting in catastrophic out-of-pocket expenses for them and their families. Such inequalities are exacerbated by the segmented structure of the Mexican health system, which provides health insurance conditional on formal employment participation. These findings should be considered as a key factor in reorienting NCD health policies and programs from a gender perspective.

Un/met: a mixed-methods study on primary healthcare needs of the poorest population in Khyber Pakhtunkhwa province, Pakistan

BACKGROUND

Access of all people to the healthcare they need, without financial hardship is the goal of Universal Health Coverage (UHC). As UHC initiatives expand, assessing the needs of vulnerable populations can reveal gaps in the system which may be covered by relevant policies. In this study we (i) identify the met and unmet primary healthcare needs of the poorest population of Khyber Pakhtunkhwa province (KP), Pakistan, and (ii) explore why the gaps exist.

METHODS

We used Leveque's Framework of Patient-centred Access to Healthcare to examine unmet primary healthcare (PHC) needs and their underlying causes for the poorest population in four districts of Khyber Pakhtunkhwa province, Pakistan. Using a triangulation mixed methods design, we analysed data from a quantitative household survey of744 households, 17 focus group discussions with household members and, 11 interviews with healthcare providers.

RESULTS

Our results show that indicate that despite service utilization, PHC needs were not met, primarily due to prohibitively high costs at each stage of access. Furthermore, gaps in outreach and information (approachability), and varying availability of medicines and diagnostics at facilities (appropriateness) the supply side as well as difficulties in navigating the system (inability to perceive) and adhering to prescriptions (inability to engage) on the demand side, also led to unmet PHC needs. Going beyond utilization, our findings highlight that engagement with care is an important determinant of met needs for vulnerable populations.

CONCLUSION

Social health protection policies can contribute to advancing UHC for primary care. However, in our setting, enhancing communication and outreach, addressing gender and age disparities, and improving quality of care and health infrastructure are necessary to fully meet the needs of the poorest populations.

Variations in out-of-pocket spending and factors influencing catastrophic health expenditure of households with patients suffering from chronic conditions in four districts in Sri Lanka

INTRODUCTION

Healthcare financing systems, dependent on out-of-pocket expenditure(OOPE), impose a heavy burden on those who use the services regularly, such as patients suffering from chronic diseases. High OOPE for health services leads to decreased utilization of the services and/or catastrophic health expenditure, which would significantly impede the achievement of Universal Health coverage.

OBJECTIVE

We aimed to determine variations in OOPE and factors associated with Catastrophic Health Expenditure (CHE) of households with patients suffering from non-communicable diseases(NCDs) in four districts.

METHODS

A survey was conducted among 2344 adult patients having selected NCD/s. Multi-stage stratified cluster sampling selected respondents from 4 districts representing urban, rural, semi-urban, and estate. Data was collected using a validated interviewer-administered questionnaire. Logistic regression identified the predictors of CHE(> 40%). Significance was considered as 0.05.

RESULTS

Common NCDs were hypertension(29.1%), diabetes(26.8.0%), hyperlipidaemia(9.8%) and asthma(8.2%). Only 13% reported complications associated with NCDs. Fifty-six percent(N = 1304) were on regular clinic follow-up, and majority utilized western-medical government hospitals(N = 916,70.2%). There were 252 hospital admissions for chronic-disease management in the past 12 months. Majority(86%) were admitted to government sector hospitals. Most patients incurred nearly SLR 3000 per clinic visit and SLR 3300 per hospital admission. CHE was beyond 40% for 13.5% of the hospital admissions and 6.1% of the regular clinic follow-up. Patients admitted to private sector hospitals had 2.61 times higher CHE than those admitted to government sector hospitals.

CONCLUSIONS

Patients with NCDs incurred high OOPE and faced CHE during healthcare seeking in Sri Lanka. The prevalence of NCDs and complications were high among the participants. Patients with chronic conditions incur high OOPE for a single clinic visit and a hospital admission. Patients incur high OOPE on direct medical costs, and district-wise variations were observed. The proportion with more than 40% CHE on monthly clinic care was high. Patients being followed up in the government sector are more likely to have CHE when obtaining healthcare and are more likely to face barriers in obtaining needed health services. The services rendered to patients with chronic conditions warrant a more integrative approach to reduce the burden of costs and related complications.

Reorienting health systems towards Primary Health Care in South Asia

This series, "Primary health care in South Asia", is an effort to provide region-specific, evidence-based insights for reorienting health systems towards PHC. Led by regional thinkers, this series draws lessons from five countries in South Asia: Bangladesh, India, Nepal, Pakistan, and Sri Lanka. This is the last paper in the series that outlines points for future action. We call for action in three areas. First, the changing context in the region, with respect to epidemiological shifts, urbanisation, and privatisation, presents an important opportunity to appraise existing policies on PHC and reformulate them to meet the evolving needs of communities. Second, reorienting health systems towards PHC requires concrete efforts on three pillars-integrated services, multi-sectoral collaboration, and community empowerment. This paper collates nine action points that cut across these three pillars. These action points encompass contextualising policies on PHC, scaling up innovations, allocating adequate financial resources, strengthening the governance function of health ministries, establishing meaningful public-private engagements, using digital health tools, reorganising service delivery, enabling effective change-management processes, and encouraging practice-oriented research. Finally, we call for more research-policy-practice networks on PHC in South Asia that can generate evidence, bolster advocacy, and provide spaces for cross-learning.

Funding

WHO SEARO funded this paper. This source did not play any role in the design, analysis or preparation of the manuscript.

Allocation of Financial Resources to Primary Healthcare: A Scoping Review Protocol

Background

Countries possessing robust primary healthcare (PHC) systems typically yield superior health outcomes, reduced inequality, and diminished healthcare expenses for their citizens. Moreover, PHC demonstrates a direct correlation with the efficient utilization of resources. However, the allocation of financial resources dedicated to PHC varies significantly among countries and lacks explicit clarity. Therefore, this paper aims to conduct a review of published literature to ascertain the extent of resource allocation to PHC across diverse nations. In addition, it aims to explore associated factors, challenges, and mechanisms influencing this allocation.

Methods

This scoping review protocol will adopt the Joanna Briggs Institute's scoping review methodology, which was updated in 2020. It will leverage library studies and refer to reputable databases. The inclusion criteria will include studies conducted between January 2000 and December 2023, focusing on criteria, amounts, mechanisms, and challenges associated with financial resource allocation to PHC globally. In addition, studies must be published in either English and Persian. Studies lacking full-text availability will be excluded from the review. Mendeley software will be utilized to organize and manage the collected studies. The study selection process will be visually depicted using the PRISMA-SCR diagram. Conventional content analysis will be employed to analyze the studies.

Conclusions

Considering the position and role of primary health care in promoting the health of society, by implementing this protocol, the data obtained from the proposed scoping review will enable the managers and officials of the health system to follow the experiences of different countries in the field of scientific and fair allocation of financial resources to PHC, reinforcing Universal Health Coverage (UHC).

Political factors and arrangements influencing primary health care financing and resource allocation: A scoping review protocol

INTRODUCTION

Primary health care is a key element in the structuring and coordination of health systems, contributing to overall coverage and performance. PHC financing is therefore central in this context, with variations in sufficiency and regularity depending on the "political dimension" of health systems. Research that systematically examines the political factors and arrangements influencing PHC financing is justified from a global and multidisciplinary perspective. The scoping review proposed here aims to systematically map the evidence on this topic in the current literature, identifying groups, institutions, priorities and gaps in the research.

METHODS AND ANALYSIS

A scoping review will be conducted following the method proposed by Arksey and O'Malley to answer the following question: What is known from the literature about political factors and arrangements and their influence on and repercussions for primary health care financing and resource allocation models? The review will include peer-reviewed papers in Portuguese, English or Spanish published between 1978 and 2023. Searches will be performed of the following databases: Medline (PubMed), Embase, BVS Salud, Web of Science, Scopus and Science Direct. The review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Inclusion and exclusion criteria will be used for literature screening and mapping. Screening and data charting will be conducted by a team of four reviewers.

REGISTRATION

This protocol is registered on the Open Science Framework (OSF) platform, available at https://doi.org/10.17605/OSF.IO/Q9W3P.

Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middle-income countries: evidences from China

BACKGROUND

To achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform.

METHODS

We identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics.

RESULTS

The findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket.

CONCLUSIONS

This study shares the lessons from China's health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing.

Healthcare leaders' experiences of implementing artificial intelligence for medical history-taking and triage in Swedish primary care: an interview study

BACKGROUND

Artificial intelligence (AI) holds significant promise for enhancing the efficiency and safety of medical history-taking and triage within primary care. However, there remains a dearth of knowledge concerning the practical implementation of AI systems for these purposes, particularly in the context of healthcare leadership. This study explores the experiences of healthcare leaders regarding the barriers to implementing an AI application for automating medical history-taking and triage in Swedish primary care, as well as the actions they took to overcome these barriers. Furthermore, the study seeks to provide insights that can inform the development of AI implementation strategies for healthcare.

METHODS

We adopted an inductive qualitative approach, conducting semi-structured interviews with 13 healthcare leaders representing seven primary care units across three regions in Sweden. The collected data were subsequently analysed utilizing thematic analysis. Our study adhered to the Consolidated Criteria for Reporting Qualitative Research to ensure transparent and comprehensive reporting.

RESULTS

The study identified implementation barriers encountered by healthcare leaders across three domains: (1) healthcare professionals, (2) organization, and (3) technology. The first domain involved professional scepticism and resistance, the second involved adapting traditional units for digital care, and the third inadequacies in AI application functionality and system integration. To navigate around these barriers, the leaders took steps to (1) address inexperience and fear and reduce professional scepticism, (2) align implementation with digital maturity and guide patients towards digital care, and (3) refine and improve the AI application and adapt to the current state of AI application development.

CONCLUSION

The study provides valuable empirical insights into the implementation of AI for automating medical history-taking and triage in primary care as experienced by healthcare leaders. It identifies the barriers to this implementation and how healthcare leaders aligned their actions to overcome them. While progress was evident in overcoming professional-related and organizational-related barriers, unresolved technical complexities highlight the importance of AI implementation strategies that consider how leaders handle AI implementation in situ based on practical wisdom and tacit understanding. This underscores the necessity of a holistic approach for the successful implementation of AI in healthcare.

Cost-effectiveness of implementing performance-based financing for improving maternal and child health in Ethiopia

INTRODUCTION

Performance Based Financing (PBF) supports realization of universal health coverage by promoting bargaining between purchasers and health service providers through identifying priority services and monitoring indicators. In PBF, purchasers use health statistics and information to make decisions rather than merely reimbursing invoices. In this respect, PBF shares certain elements of strategic health purchasing. PBF implementation began in Ethiopia in 2015 as a pilot at one hospital and eight health centers. Prior to this the system predominantly followed input-based financing where providers were provided with a predetermined budget for inputs for service provision. The purpose of the study is to determine whether the implementation of PBF is cost-effective in improving maternal and child health in Ethiopia compared to the standard care.

METHODS

The current study used cost-effectiveness analysis to assess the effects of PBF on maternal and child health. Two districts implementing PBF and two following standard care were selected for the study. Both groups of selected districts share common grounds before initiating PBF in the selected group. The provider perspective costing approach was used in the study. Data at the district level were gathered retrospectively for the period of July 2018 to June 2021. Data from health service statistics were transformed to population level coverages and the Lives Saved Tool method used to compute the number of lives saved. Additionally for purpose of comparison, lives saved were translated into discounted quality-adjusted life years.

RESULTS

The number of lives saved under PBF was 261, whereas number of lives saved under standard care was 194. The identified incremental cost per capita due to PBF was $1.8 while total costs of delivering service at PBF district was 8,816,370 USD per million population per year while the standard care costs 9,780,920 USD per million population per year. QALYs obtained under PBF and standard care were 6,118 and 4,526 per million population per year, respectively.

CONCLUSIONS

The conclusion made from this analysis is that, implementing PBF is cost-saving in Ethiopia compared to the standard care.

LIMITATIONS OF THE STUDY

Due to lack of district-level survey-based data, such as prevalence and effects on maternal and child health, national-level estimates were used into the LiST tool.There may be some central-level PBF start-up costs that were not captured, which may have spillover effects on the existing health system performance that this study has not considered.There may be health statistics data accuracy differences between the PBF and non-PBF districts. The researchers considered using data from records as reported by both groups of districts.

Efficiency evaluation and promoter identification of primary health care system in China: an enhanced DEA-Tobit approach

BACKGROUND

With Primary Health Care (PHC) being a cornerstone of accessible, affordable, and effective healthcare worldwide, its efficiency, especially in developing countries like China, is crucial for achieving Universal Health Coverage (UHC). This study evaluates the efficiency of PHC systems in a southwest China municipality post-healthcare reform, identifying factors influencing efficiency and proposing strategies for improvement.

METHODS

Utilising a 10-year provincial panel dataset, this study employs an enhanced Data Envelopment Analysis (DEA) model integrating Slack-Based Measure (SBM) and Directional Distance Function (DDF) with the Global Malmquist-Luenberger (GML) index for efficiency evaluation. Tobit regression analysis identifies efficiency determinants within the context of China's healthcare reforms, focusing on horizontal integration, fiscal spending, urbanisation rates, and workforce optimisation.

RESULTS

The study reveals a slight decline in PHC system efficiency across the municipality from 2009 to 2018. However, the highest-performing county achieved a 2.36% increase in Total Factor Productivity (TFP), demonstrating the potential of horizontal integration reforms and strategic fiscal investments in enhancing PHC efficiency. However, an increase in nurse density per 1,000 population negatively correlated with efficiency, indicating the need for a balanced approach to workforce expansion.

CONCLUSIONS

Horizontal integration reforms, along with targeted fiscal inputs and urbanisation, are key to improving PHC efficiency in underdeveloped regions. The study underscores the importance of optimising workforce allocation and skillsets over mere expansion, providing valuable insights for policymakers aiming to strengthen PHC systems toward achieving UHC in China and similar contexts.

Evaluating the effects, implementation experience and political economy of primary healthcare facility autonomy reforms within counties in Kenya: a mixed methods study protocol

Introduction

There is a growing emphasis on improving primary health care services and granting frontline service providers more decision-making autonomy. In October 2023, Kenya enacted legislation mandating nationwide facility autonomy. There is limited understanding of the effects of health facility autonomy on primary health care (PHC) facilities performance. It is recognized that stakeholder interests influence reforms, and gender plays a critical role in access to health and its outcomes. This protocol outlines the methods for a study that plans to evaluate the effects, implementation experience, political economy, and gendered effects of health facility autonomy reforms in Kenya.

Methods and Analysis

The research will use a before-and-after quasi-experimental study design to measure the effects of the reform on service readiness and service utilization, and a cross-sectional qualitative study to explore the implementation experience, political economy, and gendered effects of these reforms. Data to measure the effects of autonomy will be collected from a sample of 80 health facilities and 1600 clients per study arm. Qualitative interviews will involve approximately 83 facility managers and policymakers at the county level, distributed across intervening (36), and planning to intervene (36) counties. Additionally, 11 interviews will be conducted at the national level with representatives from the Ministry of Health, the National Treasury, the Controller of Budget, the Council of Governors, the Auditor General, and development partners. Given the uncertainty surrounding the implementation of the reforms, this study proposes two secondary designs in the event our primary design is not feasible - a cross-sectional study, and a quasi-experimental interrupted time series design. The study will use a difference-in-difference analysis for the quantitative component to evaluate the effects of the reforms, while using thematic analysis for the qualitative component to evaluate the political economy and the implementation experience of the reforms.

Ethics and Dissemination

This study was approved by the Kenya Medical Research Institute Scientific and Ethics Review Unit (KEMRI/SERU/CGMR-C/294/4708) and the National Commission for Science, Technology and Innovation (NACOSTI/P/23/28111). We plan to disseminate the findings through publications, policy briefs and dissemination workshops.

Documenting Community Health Worker Compensation Schemes and Their Perceived Effectiveness in Seven sub-Saharan African Countries: A Qualitative Study

INTRODUCTION

Community health worker (CHW) incentives and remuneration are core issues affecting the performance of CHWs and health programs. There is limited documentation on the implementation details of CHW financial compensation schemes used in sub-Saharan African countries, including their mechanisms of delivery and effectiveness. We aimed to document CHW financial compensation schemes and understand CHW, government, and other stakeholder perceptions of their effectiveness.

METHODS

A total of 68 semistructured interviews were conducted with a range of purposefully selected key informants in 7 countries: Benin, Burkina Faso, Ghana, Malawi, Mali, Niger, and Zambia. Thematic analysis of coded interview data was conducted, and relevant country documentation was reviewed, including any documents referenced by key informants, to provide contextual background for qualitative interpretation.

RESULTS

Key informants described compensation schemes as effective when payments are regular, distributions are consistent, and amounts are sufficient to support health worker performance and continuity of service delivery. CHW compensation schemes associated with an employed worker status and government payroll mechanisms were most often perceived as effective by stakeholders. Compensation schemes associated with a volunteer status were found to vary widely in their delivery mechanisms (e.g., cash or mobile phone distribution) and were perceived as less effective. Lessons learned in implementing CHW compensation schemes involved the need for government leadership, ministerial coordination, community engagement, partner harmonization, and realistic transitional financing plans.

CONCLUSION

Policymakers should consider these findings in designing compensation schemes for CHWs engaged in routine, continuous health service delivery within the context of their country's health service delivery model. Systematic documentation of the tasks and time commitment of volunteer status CHWs could support more recognition of their health system contributions and better determination of commensurate compensation as recommended by the 2018 World Health Organization Guidelines on Health Policy and System Support to Optimize Community Health Worker Programs.

Survey and analysis on the resource situation of primary health care institutions in rural China

Background

China's rural population is immense, and to ensure the well-being of rural residents through healthcare services, it is essential to analyze the resources of rural grassroots healthcare institutions in China. The objective is to examine the discrepancies and deficiencies in resources between rural grassroots healthcare institutions and the national average, providing a basis for future improvements and supplementation of rural healthcare resources.

Methodology

The study analyzed data from 2020 to 2022 on the number of healthcare establishments, the capacity of hospital beds, the number of healthcare professionals, and the number of physicians in both rural and national settings. Additionally, it examined the medical service conditions and ratios of township health centers in rural areas to assess the resource gap between rural areas and the national average.

Results

Healthcare establishments: On average, there were 2.2 fewer healthcare institutions per 10,000 persons in rural areas compared to the national average over three years. Hospital beds: On average, there were approximately 36 fewer hospital beds per 10,000 persons in rural areas compared to the national average over three years. Healthcare professionals and physicians: On average, there were about 48 fewer healthcare technical personnel and 10 fewer practicing (including assistant) physicians per 10,000 persons in rural areas compared to the national average over three years.

Conclusion

Compared to the national average, there are significant discrepancies and deficiencies in grassroots healthcare resources in rural China. This underscores the necessity of increasing funding to progressively enhance the number of healthcare institutions in rural areas, expand the number of healthcare personnel, and elevate medical standards to better align with national benchmarks. Improving rural healthcare resources will strategically equip these institutions to cater to rural communities and effectively handle public health emergencies. Ensuring that the rural population in China has equal access to healthcare services as the rest of the country is crucial for promoting the well-being of rural residents and achieving health equity.

Through the lens: A qualitative exploration of nurses' experiences of smart glasses in urgent care

AIM

To investigate the real-world experiences of nurses' using smart glasses to triage patients in an urgent care centre.

DESIGN

A parallel convergent mixed-method design.

METHODS

We collected data through twelve in-depth interviews with nurses using the device and a survey. Recruitment continued until no new themes emerged. We coded the data using a deductive-thematic approach. Qualitative and survey data were coded and then mapped to the most dominant dimension of the sociotechnical framework. Both the qualitative and quantitative findings were triangulated within each dimension of the framework to gain a comprehensive understanding of user experiences.

RESULTS

Overall, nurses were satisfied with using smart glasses in urgent care and would recommend them to others. Nurses rated the device highly on ease of use, facilitation of training and development, nursing empowerment and communication. Qualitatively, nurses generally felt the device improved workflows and saved staff time. Conversely, technological challenges limited its use, and users questioned its sustainability if inadequate staffing could not be resolved.

CONCLUSION

Smart glasses enhanced urgent care practices by improving workflows, fostering staff communication, and empowering healthcare professionals, notably providing development opportunities for nurses. While smart glasses offered transformative benefits in the urgent care setting, challenges, including technological constraints and insufficient organisational support, were barriers to sustained integration.

IMPLICATIONS FOR PRACTICE

These real-world insights encompass both the benefits and challenges of smart glass utilisation in the context of urgent care. The findings will help inform greater workflow optimisation and future technological developments. Moreover, by sharing these experiences, other healthcare institutions looking to implement smart glass technology can learn from the successes and barriers encountered, facilitating smoother adoption, and maximising the potential benefits for patient care.

REPORTING METHOD

COREQ checklist (consolidated criteria for reporting qualitative research).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Improving access to primary health care through financial innovation in rural China: a quasi-experimental synthetic difference-in-differences approach

BACKGROUND

Inadequate financing constrains primary healthcare (PHC) capacity in many low- and middle-income countries, particularly in rural areas. This study evaluates an innovative PHC financing reform in rural China that aimed to improve access to healthcare services through supply-side integration and the establishment of a designated PHC fund.

METHODS

We employed a quasi-experimental synthetic difference-in-differences (SDID) approach to analyze county-level panel data from Chongqing Province, China, spanning from 2009 to 2018. The study compared the impact of the reform on PHC access and per capita health expenditures in Pengshui County with 37 other control counties (districts). We assessed the reform's impact on two key outcomes: the share of outpatient visits at PHC facilities and per capita total PHC expenditure.

RESULTS

The reform led to a significant increase in the share of outpatient visits at PHC facilities (14.92% points; 95% CI: 6.59-23.24) and an increase in per capita total PHC expenditure (87.30 CNY; 95% CI: 3.71-170.88) in Pengshui County compared to the synthetic control. These effects were robust across alternative model specifications and increased in magnitude over time, highlighting the effectiveness of the integrated financing model in enhancing PHC capacity and access in rural China.

CONCLUSIONS

This research presents compelling evidence demonstrating that horizontal integration in PHC financing significantly improved utilization and resource allocation in rural primary care settings in China. This reform serves as a pivotal model for resource-limited environments, demonstrating how supply-side financing integration can bolster PHC and facilitate progress toward universal health coverage. The findings underscore the importance of sustainable financing mechanisms and the need for policy commitment to achieve equitable healthcare access.

Knowledge, attitudes, and practices of primary healthcare practitioners regarding pharmacist clinics: a cross-sectional study in Shanghai

BACKGROUND

Pharmacist clinics offer professional pharmaceutical services that can improve public health outcomes. However, primary healthcare staff in China face various barriers and challenges in implementing such clinics. To identify existing problems and provide recommendations for the implementation of pharmacist clinics, this study aims to assess the knowledge, attitudes, and practices of pharmacist clinics among primary healthcare providers.

METHODS

A cross-sectional survey based on the Knowledge-Attitude-Practice (KAP) model, was conducted in community health centers (CHCs) and private hospitals in Shanghai, China in May, 2023. Descriptive analytics and the Pareto principle were used to multiple-answer questions. Chi-square test, Fisher's exact test, and binary logistic regression models were employed to identify factors associated with the knowledge, attitudes, and practices of pharmacist clinics.

RESULTS

A total of 223 primary practitioners participated in the survey. Our study revealed that most of them had limited knowledge (60.1%, n = 134) but a positive attitude (82.9%, n = 185) towards pharmacist clinics, with only 17.0% (n = 38) having implemented them. The primary goal of pharmacist clinics was to provide comprehensive medication guidance (31.5%, n = 200), with medication education (26.3%, n = 202) being the primary service, and special populations (24.5%, n = 153) identified as key recipients. Logistic regression analysis revealed that education, age, occupation, position, work seniority, and institution significantly influenced their perceptions. Practitioners with bachelor's degrees, for instance, were more likely than those with less education to recognize the importance of pharmacist clinics in medication guidance (aOR: 7.130, 95%CI: 1.809-28.099, p-value = 0.005) and prescription reviews (aOR: 4.675, 95% CI: 1.548-14.112, p-value = 0.006). Additionally, practitioners expressed positive attitudes but low confidence, with only 33.3% (n = 74) feeling confident in implementation. The confidence levels of male practitioners surpassed those of female practitioners (p-value = 0.037), and practitioners from community health centers (CHCs) exhibited higher confidence compared to their counterparts in private hospitals (p-value = 0.008). Joint physician-pharmacist clinics (36.8%, n = 82) through collaboration with medical institutions (52.0%, n = 116) emerged as the favored modality. Daily sessions were preferred (38.5%, n = 86), and both registration and pharmacy service fees were considered appropriate for payment (42.2%, n = 94). The primary challenge identified was high outpatient workload (30.9%, n = 69).

CONCLUSIONS

Although primary healthcare practitioners held positive attitudes towards pharmacist clinics, limited knowledge, low confidence, and high workload contributed to the scarcity of their implementation. Practitioners with diverse sociodemographic characteristics, such as education, age, and institution, showed varying perceptions and practices regarding pharmacist clinics.

Reconciling devolution with health financing and public financial management: challenges and policy options for the health sector

The interplay between devolution, health financing and public financial management processes in health-or the lack of coherence between them-can have profound implications for a country's progress towards universal health coverage. This paper explores this relationship in seven Asian and African countries (Burkina Faso, Kenya, Mozambique, Nigeria, Uganda, Indonesia and the Philippines), highlighting challenges and suggesting policy solutions. First, subnational governments rely heavily on transfers from central governments, and most are not required to allocate a minimum share of their budget to health. Central governments channelling more funds to subnational governments through conditional grants is a promising way to increase public financing for health. Second, devolution makes it difficult to pool funding across populations by fragmenting them geographically. Greater fiscal equalisation through improved revenue sharing arrangements and, where applicable, using budgetary funds to subsidise the poor in government-financed health insurance schemes could bridge the gap. Third, weak budget planning across levels could be improved by aligning budget structures, building subnational budgeting capacity and strengthening coordination across levels. Fourth, delays in central transfers and complicated procedures for approvals and disbursements stymie expenditure management at subnational levels. Simplifying processes and enhancing visibility over funding flows, including through digitalised information systems, promise to improve expenditure management and oversight in health. Fifth, subnational governments purchase services primarily through line-item budgets. Shifting to practices that link financial allocations with population health needs and facility performance, combined with reforms to grant commensurate autonomy to facilities, has the potential to enable more strategic purchasing.

A community health worker led approach to cardiovascular disease prevention in the UK-SPICES-Sussex (scaling-up packages of interventions for cardiovascular disease prevention in selected sites in Europe and Sub-saharan Africa): an implementation research project

Background

This paper describes a UK-based study, SPICES-Sussex, which aimed to co-produce and implement a community-based cardiovascular disease (CVD) risk assessment and reduction intervention to support under-served populations at moderate risk of CVD. The objectives were to enhance stakeholder engagement; to implement the intervention in four research sites and to evaluate the use of Voluntary and Community and Social Enterprises (VCSE) and Community Health Worker (CHW) partnerships in health interventions.

Methods

A type three hybrid implementation study design was used with mixed methods data. This paper represents the process evaluation of the implementation of the SPICES-Sussex Project. The evaluation was conducted using the RE-AIM framework.

Results

Reach: 381 individuals took part in the risk profiling questionnaire and forty-one women, and five men participated in the coaching intervention. Effectiveness: quantitative results from intervention participants showed significant improvements in CVD behavioural risk factors across several measures. Qualitative data indicated high acceptability, with the holistic, personalised, and person-centred approach being valued by participants. Adoption: 50% of VCSEs approached took part in the SPICES programme, The CHWs felt empowered to deliver high-quality and mutually beneficial coaching within a strong project infrastructure that made use of VCSE partnerships. Implementation: Co-design meetings resulted in local adaptations being made to the intervention. 29 (63%) of participants completed the intervention. Practical issues concerned how to embed CHWs in a health service context, how to keep engaging participants, and tensions between research integrity and the needs and expectations of those in the voluntary sector. Maintenance: Several VCSEs expressed an interest in continuing the intervention after the end of the SPICES programme.

Conclusion

Community-engagement approaches have the potential to have positively impact the health and wellbeing of certain groups. Furthermore, VCSEs and CHWs represent a significant untapped resource in the UK. However, more work needs to be done to understand how links between the sectors can be bridged to deliver evidence-based effective alternative preventative healthcare. Reaching vulnerable populations remains a challenge despite partnerships with VCSEs which are embedded in the community. By showing what went well and what did not, this project can guide future work in community engagement for health.

Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019

BACKGROUND

Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs).

METHODS

We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables.

FINDINGS

A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57).

INTERPRETATION

Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands.

FUNDING

UK National Institute for Health and Care Research.

Utilization of Health Care Services and Accessibility Challenges among Adults Aged 50+ before and after Austerity Measures across 27 European Countries: Secular Trends in the SHARE Study from 2004/05 to 2019/20

This study aimed to assess and compare the utilization of preventive and other health services and the cost or availability in different regions of Europe, before and during the economic crisis. The data used in the study were obtained from Wave 8 of the Survey of Health, Ageing and Retirement in Europe (2019/2020) and Wave 1 data (2004/5), with a sample size of 46,106 individuals aged ≥50 across 27 countries, adjusted to represent a population of N = 180,886,962. Composite scores were derived for preventive health services utilization (PHSU), health care services utilization (HCSU), and lack of accessibility/availability in health care services (LAAHCS). Southern countries had lower utilization of preventive services and higher utilization of other health services compared to northern countries, with a significant lack of convergence. Moreover, the utilization of preventive health services decreased, whereas the utilization of secondary care services increased during the austerity period. Southern European countries had a significantly higher prevalence of lack of accessibility. An increase in the frequency of lack of accessibility/availability in health care services was observed from 2004/5 to 2019/20. In conclusion, our findings suggest that health inequalities increase during crisis periods. Therefore, policy interventions could prioritize accessibility and expand health coverage and prevention services.

Antibiotic prescribing practices in community and clinical settings during the COVID-19 pandemic in Nairobi, Kenya

The COVID-19 pandemic has significantly impacted healthcare systems, including antibiotic use practices. We present data on patterns of antibiotic dispensing and use in community and hospital settings respectively in Nairobi, Kenya during the pandemic. We conducted interviews with 243 pharmacies in Nairobi using a standardised questionnaire from November to December 2021. The data collected included demographic characteristics, antibiotic customers, types of antibiotics sold, and antibiotic prescribing practices. Additionally, we retrospectively reviewed health records for 992 and 738 patients admitted in COVID-19 and general wards at two large inpatient hospitals between April 2020 and May 2021, and January 2019 to October 2021, respectively. Demographic, utilisation of laboratory services, treatment, clinical, and outcome data were collected using a modified Global WHO Point Prevalence Surveys (Global-PPS) tool. Almost all pharmacies (91.4%) served customers suspected of having COVID-19 with a mean weekly number of 15.6 customers. All pharmacies dispensed antibiotics, mainly azithromycin and beta lactams to suspected COVID-19 infected customers. 83.4% of hospitalised COVID-19 patients received at least one antibiotic at some point during their hospitalisation, which was significantly higher than the 53.8% in general ward patients (p<0.001). Similarly, the average number of antibiotics administered to COVID-19 patients was higher than that of patients in the general ward (1.74 vs 0.9). Azithromycin and ceftriaxone were the most commonly used antibiotics in COVID-19 patients compared to ceftriaxone and metronidazole in the general wards. Only 2% of antibiotic prescriptions for COVID-19 patients were supported by microbiological investigations, which was consistent with the proportion of 6.8% among the general ward population. Antibiotics were commonly prescribed to customers and patients suspected of having COVID-19 either in community pharmacies or in hospital, without a prescription or laboratory diagnosis. These findings emphasize the crucial role of antibiotic stewardship, particularly in community pharmacies, in the context of COVID-19.

A mixed methods study examining the impact of primary health care financing transitions on facility functioning and service delivery in Kenya: a study protocol

Background

Kenya has experienced several health financing changes that have implications for financing primary healthcare (PHC). These include transitions from funding by two key donors (the World Bank and the Danish International Development Agency (DANIDA)) and the abolishment of conditional grants that were earmarked for financing primary healthcare facilities. This protocol lays out study plans to evaluate the impact and implementation experience of these financing changes on PHC facility functioning and service delivery in Kenya.

Methods/design

A sequential mixed methods design will be applied to address our research objectives. Firstly, we will perform a document review to understand the evolution of policy changes understudy. Second, we will conduct an interrupted time series analysis across all 47 counties in Kenya to assess these financing changes' impact on health service utilization in all public primary healthcare facilities (level 2 and 3 facilities). Data for this analysis will be obtained from the Kenya Health Information System (KHIS). Third, we will carry out in-depth interviews with health financing stakeholders at the national, county, and health facility levels to examine their perceptions of the experiences with these changes in health financing.

Discussion

This mixed methods study will contribute to evidence on the sustainability of financing primary healthcare in low and middle-income countries facing financing changes and donor transitions.