PACES: a national leadership program in support of primary‐care reform in Portugal

Facilitators and barriers in general practitioners' choice to work in primary care units in Austria: a qualitative study

BACKGROUND

Recent reforms in Austria have focused on establishing team-based care within multiprofessional primary care units, to enhance amongst others, the work attractiveness of general practice. Nearly 75% of qualified general practitioners are not working as contracted physicians with the social health insurance. This study aims to explore the facilitators of and barriers to non-contracted general practitioners to work in a primary care unit.

METHODS

We conducted twelve semi-structured, problem-centered interviews among purposively sampled non-contracted general practitioners. To extract categories of facilitators and barriers for working in a primary care unit, transcribed interviews were inductively coded using qualitative content analysis. Subcategories were grouped into factors (facilitators and barriers) of thematic criteria and mapped on the macro-, meso-, micro-, and individual levels.

RESULTS

We identified 41 categories, including 21 facilitators and 20 barriers. Most facilitators were located at the micro-level, while most barriers were located at the macro-level. Teamwork and associated conditions made primary care units attractive as workplaces and corresponded with individual demands. In contrast, system factors tended to reduce the attractiveness of working as a general practitioner.

CONCLUSIONS

Multifaceted efforts are needed to address relevant factors at all of the levels mentioned above. These need to be carried out and consistently communicated by all stakeholders. Efforts to strengthen the holistic approach in primary care, like modern remuneration and patient steering mechanisms, are essential. Financial support, consulting services as well as training on entrepreneurship, management, leadership, and team-based care may help to reduce the risk and burden of founding and running a primary care unit.

FORMAÇÃO EM GESTÃO PARA APOIO À REFORMA DA ATENÇÃO PRIMÁRIA À SAÚDE EM PORTUGAL E PAÍSES AFRICANOS LUSÓFONOS

Resumo Apresentamos lições que resultaram de atividades de capacitação dos gestores conduzidas em Portugal no contexto da reforma da atenção primária em saúde e nos países africanos de língua oficial portuguesa, em termos do planejamento e da gestão dos serviços hospitalares e de saúde pública. Descrevemos três programas de formação-ação realizados pela Unidade de Saúde Pública Internacional do Instituto de Higiene e Medicina Tropical de Lisboa, com o apoio de parceiros portugueses e internacionais como a Organização Mundial da Saúde e o Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro. Os programas foram desenvolvidos na base da identificação das necessidades de competências dos participantes e focaram a resolução de problemas concretos com o objetivo de ajudar os gestores a enfrentar as dificuldades inerentes aos processos de reforma. Apesar do seu valor intrínseco, por si só não se mostram suficientes, uma vez que são sempre necessários outros mecanismos, como o acompanhamento continuado dos gestores, sistemas de incentivos coerentes com os objetivos das reformas, ferramentas e recursos (financiamento, sistemas de informação, pessoal qualificado suficiente) adequados para implementar as mudanças. Além disso, a sustentabilidade das intervenções de fortalecimento das capacidades carece de apoio continuado dos decisores políticos.

[Primary health care reform in Portugal, 2005-2018: the future and challenges of coming of age]

In order to reform Portugal's primary health care (PHC), the Ministry of Health planned a change that was launched in 2005 and 2006, and which is still under way today. This article aims to analyze PHC reform in Portugal according to different phases in its development, using Kingdon's multiple streams model to reflect on the evolution in the reform process and its future, from the perspective of a process that seeks to achieve universal access to health. The working methodology was a document and case study with a qualitative approach and evaluative dimensions. The study was based on material on PHC in Portugal, published both in Portugal and elsewhere. Kingdon's multiple streams model was used to explain the actual and contextual development of policies implemented during the PHC reform. Three phases were identified in the reform, each lasting about five years. The first phase, starting in 2005, featured family health units with a voluntary basis. The second phase began in 2010, with the model's consolidation. In the third phase, since 2015 and still under way, the model came of age, benefiting from the end of the financial crisis but still suffering from its effects. The three reform cycles represent three distinct periods with consistency in the coalition that the policymaker was able to establish, in which the windows of opportunity for internally built change were heavily influenced by external factors. The article identifies the contribution by PHC reform to improvement of the Portuguese population's health status.

The role of Primary Healthcare in the coordination of Health Care Networks in Rio de Janeiro, Brazil, and Lisbon region, Portugal

Considering the trajectory of Rio de Janeiro e Lisboa region regarding strengths of the their health local systems to achieve health for all and equity, the study aimed to compare the organization of the Primary Healthcare from both regions, searching to identify the advancement which in terms of the Delivery Health Networks' coordination. It is a case study with qualitative approach and assessment dimensions. It was used material available online such as scientific manuscripts and gray literature. The results showed the different grades regarding Delivery Health Networks. Lisboa region present more advancement, because of its historic issues, it has implemented Primary Healthcare expanded and nowadays it achieved enough maturity related to coordination of its health local system and Rio de Janeiro suffers still influence from historic past regarding Primary Healthcare selective. The both regions has done strong bids in terms of electronic health records and telemedicine. After of the study, it is clearer the historic, cultural and politics and legal issue that determined the differences of the Primary Healthcare coordinator of the Delivery Health Network in Rio de Janeiro and Lisboa region.

Reforma na atenção primária à saúde e implicações na cultura organizacional dos Agrupamentos dos Centros de Saúde em Portugal

A crescente complexidade dos desafios do setor da saúde implica um aumento das responsabilidades para aqueles que nela assumem funções de gestão. Há consenso que a qualidade da força de trabalho em saúde é um fator crítico para o sucesso de qualquer reforma no setor. O objetivo desta investigação é estudar e analisar a alteração induzida por uma intervenção de formação-ação intensiva na cultura organizacional de 73 diretores executivos dos Agrupamentos dos Centros de Saúde (ACES) em Portugal durante a reforma na atenção primária à saúde. Os dados foram coletados e analisados em dois períodos temporais, antes e depois da intervenção do Programa Avançado em Gestão, Governação Clínica e Liderança para os ACES, o qual teve um ano de duração. O modelo Competing Values Framework permitiu observar que, depois da intervenção de formação-ação, as percepções dos diretores executivos sobre a sua cultura organizacional se encontram mais alinhadas com a reforma da atenção primária à saúde, valorizando o tipo de práticas e valores que esta defende. É necessário continuar a monitorizar os resultados em vários períodos temporais para elaborar conclusões a esse respeito.

Teamwork in primary care: perspectives of general practitioners and community nurses in Lithuania

BACKGROUND

A team approach in primary care has proven benefits in achieving better outcomes, reducing health care costs, satisfying patient needs, ensuring continuity of care, increasing job satisfaction among health providers and using human health care resources more efficiently. However, some research indicates constraints in collaboration within primary health care (PHC) teams in Lithuania. The aim of this study was to gain a better understanding of the phenomenon of teamwork in Lithuania by exploring the experiences of teamwork by general practitioners (GPs) and community nurses (CNs) involved in PHC.

METHODS

Six focus groups were formed with 29 GPs and 27 CNs from the Kaunas Region of Lithuania. Discussions were recorded and transcribed verbatim. A thematic analysis of these data was then performed.

RESULTS

The analysis of focus group data identified six thematic categories related to teamwork in PHC: the structure of a PHC team, synergy among PHC team members, descriptions of roles and responsibilities of team members, competencies of PHC team members, communications between PHC team members and the organisational background for teamwork. These findings provide the basis for a discussion of a thematic model of teamwork that embraces formal, individual and organisational factors.

CONCLUSIONS

The need for effective teamwork in PHC is an issue receiving broad consensus; however, the process of teambuilding is often taken for granted in the PHC sector in Lithuania. This study suggests that both formal and individual behavioural factors should be targeted when aiming to strengthen PHC teams. Furthermore, this study underscores the need to provide explicit formal descriptions of the roles and responsibilities of PHC team members in Lithuania, which would include establishing clear professional boundaries. The training of team members is an essential component of the teambuilding process, but not sufficient by itself.

From policy to reality: clinical managers' views of the organizational challenges of primary care reform in Portugal

The primary healthcare reform in Portugal is based on the development of a new management model and clinical governance framework. The objective is to strengthen primary healthcare services to reduce the inappropriate utilization of secondary and emergency services and to make efficiency gains and to better control costs. New interventions include the introduction of a system of production-based incentives for family health units. This paper presents an initial assessment of the implementation of the new policies and tries to explain the gap between its expected results and what was observed in the field 5 years later. We used a Strengths, Weaknesses, Opportunities, and Threats analysis conducted in 12 regions, to collect the perceptions of members of Clinical Councils of Health Centers Groups, responsible for the implementation of the reform. The analysis looked at the dimensions of coverage, productivity, technical quality, and service quality. It identifies weaknesses in human resources management (shortages, incentives, team management) and lack of support from central and regional management. There is a perceived gap between the framework for reform as defined by law and the support made available for its implementation, leading to tensions between decision makers, managers, and health professionals.