Is the quality of primary healthcare services influenced by the healthcare centre's type of ownership?-An observational study of patient perceived quality, prescription rates and follow-up routines in privately and publicly owned primary care centres

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Exploring differences between public and private providers in primary care: findings from a large Swedish region

This study contributes to the sparse literature on differences between public and private primary care practices (PCCs). The purpose was to explore if differences in performance and characteristics between public and PCCs persist over time in a welfare market with patient choice and provider competition, where public and private providers operate under similar conditions. The analysis is based on data from a national patient survey and administrative registries in a large Swedish region, covering PCC observations in 2010 and 2019, i.e., the year after and 10 years after introducing choice and competition in the region. The findings suggest that differences across owner types tend to decrease over time in welfare markets. Differences in patients' experiences, PCC size, patient mix and the division of labour have decreased or disappeared between 2010 and 2019. There were small but significant differences in process measures of quality in 2019; public PCCs complied better with prescription guidelines. While the results demonstrate a convergence between public and private PCCs in regards to their characteristics and performance, differences in patients' experiences in regards to socioeconomic conditions persisted. Such unwarranted variation calls for continued attention from policy makers and further research about causes.

Fifteen years with patient choice and free establishment in Swedish primary healthcare: what do we know?

Background:

In 2007, a reform of Swedish primary healthcare began when some regions implemented enhanced patient choice in combination with free establishment for private providers. Although heavily debated, in 2010 it became mandatory for all regions to implement this choice system.

Aim:

The aim of this article was to review all published research articles related to the primary healthcare choice reform in Sweden, to investigate what has been published about the reform and summarise its first 15 years.

Methods:

A scoping review was performed to cover the breadth of research on the reform. Searches were made in Scopus, Web of Science and PubMed for articles published between 2007 and 2021, resulting in 217 unique articles. In total, 52 articles were included.

Results:

The articles were summarised and presented in relation to six overarching themes: arguments about the primary healthcare choice reform; governance and financial reimbursements; choice of provider and use of information; effects on equity and access; effects on quality; and differences between private and public primary healthcare centres.

Conclusions:

The articles show that the reform has led to an increase in access to primary healthcare, but most studies indicate that the increase is inequitably distributed in terms of socioeconomy and geographical location. The effects on quality are unclear but several studies show that the mechanisms supposed to lead to quality improvements do not work as intended. Furthermore, from a population health perspective, it is time to discuss how such a responsibility can be reintegrated into primary healthcare and function with the choice system.

The relationship between ethical climate and nursing service behavior in public and private hospitals: a cross-sectional study in China

Background

Workplace climate is a great significant element that has an impact on nurses’ behavior and practice; moreover, nurses’ service behavior contributes to the patients’ satisfaction and subsequently to the long-term success of hospitals. Few studies explore how different types of organizational ethical climate encourage nurses to engage in both in-role and extra-role service behaviors, especially in comparing the influencing process between public and private hospitals. This study aimed to compare the relationship between the five types of ethical climate and nurses’ in-role and extra-role service behaviors in public and private hospitals.

Methods

This study conducted a cross-sectional survey on 559 nurses from China in May 2019. The questionnaire was distributed to nurses by sending a web link via the mobile phone application WeChat through snowball sampling methods. All participants were investigated using the Ethical Climate Scale and Service Behavior Questionnaire. SPSS 22.0 was used for correlation analysis, t-test, and analysis of variance test, and Mplus 7.4 was used for group comparison (p < .05).

Results

The law and code climate has a much greater influence on nurses’ in-role service behavior in private hospitals than on that in public hospitals (β = − 0.277; CI _95 % = [-0.452, − 0.075]; p < .01), and the instrumental climate has a stronger influence on nurses’ extra-role service behavior private hospitals than on that in public hospitals (β = − 0.352; CI _95 % = [-0.651, − 0.056]; p < .05). Meanwhile, the rules climate has a greater effect on nurses’ extra-role service behavior in public hospitals than it does in private hospitals (β = 0.397; CI 95 % = [0.120, 0.651]; p < .01).

Conclusions

As the relationship between the five types of ethical climate and nurses’ in-role and extra-role service behaviors in public and private hospitals were different, the strategies used to foster and enhance the types of ethical climate are various from public to private hospitals. The caring and instrumental climate are the key to promote extra-role service behavior for nurses in private hospitals. And the independent climate has a great effect on extra-role service behaviors for nurses in public hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00655-7.

Patients' perceptions of quality in Swedish primary care - a study of differences between private and public ownership

Purpose

The purpose of the paper is to describe and analyze differences in patients' quality perceptions of private and public primary care centers in Sweden.

Design/methodology/approach

The article explores the differences in quality perceptions between patients of public and private primary care centers based on data from a large patient survey in Sweden. The survey covers seven dimensions, and in this paper the measure Overall impression was used for the comparison. With more than 80,000 valid responses, the survey covers all primary care centers in Sweden which allowed for a detailed analysis of differences in quality perceptions among patients from the different categories of owners.

Findings

The article contributes with a detailed description of different types of private owners: not-for-profit and for profit, as well as corporate groups and independent care centers. The results show a higher quality perception for independent centers compared to both public and corporate groups.

Research limitations/implications

The small number of not-for-profit centers (21 out of 1,117 centers) does not allow for clear conclusions for this group. The results, however, indicate an even higher patient quality perception for not-for-profit centers. The study focus on describing differences in quality perceptions between the owner categories. Future research can contribute with explanations to why independent care centers receive higher patient satisfaction.

Social implications

The results from the study have policy implications both in a Swedish as well as international perspective. The differentiation between different types of private owners made in this paper opens up for interesting discussions on privatization of healthcare and how it affects patient satisfaction.

Originality/value

The main contribution of the paper is the detailed comparison of different categories of private owners and the public owners.

Interventions for prudent antibiotic use in primary healthcare: an econometric analysis

Background

Rational antibiotic prescribing is crucial to combat antibiotic resistance. Optimal strategies to improve antibiotic use are not known. Strama, the Swedish strategic program against antibiotic resistance, has been successful in reducing antibiotic prescription rates. This study investigates whether two specific interventions directed toward healthcare centers, an informational visit and a self-evaluation meeting, played a role in observed reduction in rates of antibiotic prescriptions in primary healthcare.

Methods

The study was a retrospective, observational, empirical analysis exploiting the variation in the timing of the interventions and considering past prescriptions through use of estimations from dynamic panel data models. Primary healthcare data from 2011 to 2014 were examined. Data were from public and private primary healthcare centers in western Sweden. The key variables were prescription of antibiotics and indicator variables for the two interventions.

Results

The first intervention, an educational information intervention, decreased the number of prescriptions among public healthcare centers, but this effect was only temporary. We found no proof that the second intervention, a self-evaluation meeting at the healthcare center, had an impact on the reduction of prescriptions.

Conclusions

Single educational interventions aimed at influencing rates of antibiotic prescriptions have limited impact. A multifaceted approach is needed in efforts to reduce the use of antibiotics in primary health care.

Diagnostic methods for acute otitis media in 1 to 12 year old children: a cross sectional study in primary health care

Background

Otoscopy alone has low sensitivity and specificity for acute otitis media (AOM). Otomicroscopy and pneumatic methods are superior to otoscopy. However, these methods require clinical skills. The use of different diagnostic methods for AOM differs between countries and has not been evaluated in Sweden since new guidelines were introduced in 2010. This study aimed to describe the extent of which diagnostic methods and written advice were used for AOM in children 1 to 12 years old.

Methods

In this cross-sectional study all general practitioners (GPs) and specialist trainees in primary care (STs) at 27 primary health care centres in Sweden were asked to complete a self-administrated questionnaire including diagnostic approach and the management of AOM; 75% (111/148) responded to the questionnaire. Outcome Measures: GPs versus STs and their gender, the use of otoscopy, pneumatic otoscopy, otomicroscopy, tympanometry and written advice. Logistic regressions were used to evaluate the association between GPs versus STs and their gender and the use of diagnostic methods and written advice.

Results

To diagnose AOM, 98% of the GPs and STs often or always used otoscopy, in addition to this 17% often or always used otomicroscopy, 18% pneumatic otoscopy and 11% tympanometry. Written advice to parents was provided often or always by 19% of the GPs and STs.

The GPs used otomicroscopy more often than STs, adjusted OR 4.9 (95% CI 1.5–17; p = 0.011). For the other diagnostic methods, no differences were found. Female GPs and STs provided written advice more often than male GPs and STs, OR 5.2 (95% CI, 1.6–17; p = 0.0061), adjusted for GP versus ST.

Conclusions

Otoscopy was by far the most commonly used method for the diagnosis of AOM. Female GPs and STs provided written advice more frequently than did their male colleagues. GPs used the significantly better method otomicroscopy more often than STs, therefore, it is important to emphasise teaching of practical skills in otomicroscopy in the specialist training programme for general practice. A correct diagnosis is important for avoiding potentially harmful antibiotic treatments, antimicrobial resistance and possible delay of other diagnoses.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-1018-4) contains supplementary material, which is available to authorized users.

Patient satisfaction with primary healthcare services: are there any links with patients' symptoms of anxiety and depression?

Background

The aim of our study was to determine the association of anxiety and depression symptoms, as well as the main socio-demographic factors, with patients’ satisfaction with primary healthcare services.

Methods

The respondents were asked to fill out an anonymous questionnaire that included information on the patients’ gender, age, place of residence, education, ethnicity, the type of clinic they visited and the presence of chronic diseases. Patient satisfaction was evaluated by using a short version of the Patient Satisfaction Questionnaire. We also used the Hospital Anxiety and Depression Scale.

Results

Poor evaluations of primary healthcare services were more characteristic of males, older patients, those living in district centres and villages, individuals with lower (secondary or lower) education levels, respondents of Russian ethnicity (compared to Lithuanian), patients with chronic diseases and higher anxiety and depression symptom scores. In the final regression analysis, better satisfaction with primary healthcare services was observed in respondents who were less depressed, of Polish ethnicity and who were living in a city rather than a village.

Conclusions

Being more depressed or anxious, living in the district centre or countryside related to patients’ worse satisfaction with primary healthcare services. The results of nationality of patients and their satisfaction are ambiguous. The is strong correlation between the symptoms of depression and anxiety.

Perceptions of Risk Stratification Workflows in Primary Care

Risk stratification (RS) in primary care is frequently used by policy-makers, payers, and health systems; the process requires risk assessment for adverse health outcomes across a population to assign patients into risk tiers and allow care management (CM) resources to be targeted effectively. Our objective was to understand the approach to and perception of RS in primary care practices. An online survey was developed, tested, and administered to 148 representatives of 37 primary care practices engaged in RS varying in size, location and ownership. The survey assessed practices’ approach to, perception of, and confidence in RS, and its effect on subsequent CM activities. We examined psychometric properties of the survey to determine validity and conducted chi-square analyses to determine the association between practice characteristics and confidence and agreement with risk scores. The survey yielded a 68% response rate (100 respondents). Overall, participants felt moderately confident in their risk scores (range 41–53.8%), and moderately to highly confident in their subsequent CM workflows (range 46–68%). Respondents from small and independent practices were more likely to have higher confidence and agreement with their RS approaches and scores (p < 0.01). Confidence levels were highest, however, when practices incorporated human review into their RS processes (p < 0.05). This trend was not affected by respondents’ professional roles. Additional work from a broad mixed-methods effort will add to our understanding of RS implementation processes and outcomes.

Does hospital ownership influence hand hygiene compliance?

The issue as to whether hospital ownership has an impact on the quality of care has long been a serious concern. Hand hygiene (HH) compliance is regarded as an important indicator of the quality of care in the control of hospital-acquired infections. However, little information is available on whether hospital ownership influences HH compliance. In this study, of 229 hospitals selected from Hubei province in China, 152 were public and 77 were private hospitals. A total of 23 652 healthcare workers (HCWs) were surveyed, using a convenience sampling. HH compliance, the WHO's "My Five Moments for hand hygiene" (5MHH), among HCWs, together with the factors of hospital ownership, training frequency, bed occupancy rates, etc. were collected. Univariate analysis and ordinal logistic regression analysis were used to analyze factors affecting HH compliance. Overall, HH compliance rates were 67% and 79% for public and private hospitals, respectively. The HH compliance rates of HCWs and 5MHH were between 55% and 95%, and influenced by hospital ownership (P<0.05), excluding compliance rate at the moment after body fluid exposure, and other influence factors included training frequency and bed occupancy rate (P<0.05). HH compliance is better in private than in public hospitals. Hospital ownership is a significant factor affecting HH compliance, in addition to training frequency and bed occupancy rate.

Local self governance in health - a study of it's functioning in Odisha, India

BACKGROUND

Local decision making is linked to several service quality improvement parameters. Rogi Kalyan Samitis (RKS) at peripheral decision making health units (DMHU) are composite bodies that are mandated to ensure accountability and transparency in governance, improve quality of services, and facilitate local responsiveness. There is scant literature on the nature of functioning of these institutions in Odisha. This study aimed to assess the perception of RKS members about their roles, involvement and practices with respect to local decision making and management of DMHUs; it further examined perceptual and functional differences between priority and non-priority district set-ups; and identified predictors of involvement of RKS members in local governance of health units.

METHODS

As members of RKS, health service providers, officials in administrative/managerial role, elected representatives, and officials from other departments (including independent members) constituted our study sample. A total of 112 respondents were interviewed across 6 districts, through a multi-stage stratified random sampling; we used a semi-structured interview schedule that comprised mainly of close-ended and some open-ended questions. Descriptive and inferential statistics were used to compare 3 priority (PD) and 3 non-priority districts (NPD), categorized on the basis of Infant Mortality Rate (IMR) estimates of 2011 as proxy of population health. Governance, human resource management, financial management and quality improvement functions were studied in detail. Opinion about various individual and organizational factors in local self-governance and predictors of involvement were identified.

RESULTS

The socio-demographic profile and composition of respondents were comparable between PD and NPD. Majority of respondents were 'satisfied' with their current roles in the governance of local health institutions. About one-fourth opined that the amount of funds allocated to RKS under National Health Mission (NHM) was 'grossly insufficient'. Fifty percent of respondents said they requested for additional funds, last year, and 38.8 % informed that they requested additional funds for purchase of drugs. About 87 % respondents were satisfied with their role in the local governance of the health units (PD = 94.3 % vs. NPD = 80.7 %). Almost all (PD = 98 % vs. NPD = 80.7 %) opined that local decision making helped in improving the performance of health units. For most of the open-ended questions the responses were non-specific. Staggering differences were found between PD and NPD with respect to their involvement in district plan preparation (NPD = 78.9 % vs. PD = 58.5 %), training in plan preparation (NPD = 47.4 % vs. PD = 27.5 %), participation of officials from other departments (PD = 96.9 % vs. NPD = 45.5 %), and inclusion of activities of other sectors (PD = 70.8 % vs. NPD = 41.8 %). Whereas, no significant PD-NPD difference was found about their perceived 'involvement' in undertaking the 12 designated responsibilities. Composite scores on various individual and organizational factors were compared and found to be varying significantly. Through regression, we inferred work experience, qualification and non-monetary incentives as strong determinants of current level of involvement of RKS members in governance and management of health units.

CONCLUSION

Poor knowledge/expectation of RKS members was diluting the decision making process at DMHUs. There is an urgent need to improve their knowledge, understanding and expertise in areas of governance and management practices. A locally-monitored and time-bound capacity building plan could achieve this. Yearly resource allocation for drug procurement needs revision. Specific eligibility criteria based on work experience and qualification may be fixed for RKS membership. Further research may focus on identifying the underlying individual and systemic factors behind such large PD-NPD differences.

Does decentralization influence efficiency of health units? A study of opinion and perception of health workers in Odisha

Background

Health systems in low and middle income countries are struggling to improve efficiency in the functioning of health units of which workforce is one of the most critical building blocks. In India, Rogi Kalyan Samiti (RKS) was established at every health unit as institutions of local decision making in order to improve productive efficiency and quality. Measuring efficiency of health units is a complex task. This study aimed at assessing the perception (opinion and satisfaction) of health workers about influence of RKS on improving efficiency of peripheral decision making health units (DMHU); examining differences between priority and non-priority set-ups; identifying predictors of satisfaction at work; and discussing suggestions to improve performance.

Methods

Following a cross-sectional, comparative study design, 130 health workers from 30 institutions were selected through a multi-stage stratified random sampling. A semi-structured questionnaire was administered to assess perception and opinion of health workers about influence of RKS on efficiency of decision making at local level, motivation and performance of staff, and availability of funds; improvement of quality of services, and coordination among co-workers; and participation of community in local decision making. Three districts with highest infant mortality rate (IMR), one each, from 3 zones of Odisha and 3 with lowest IMR were selected on the basis of IMR estimates of 2011. The former constituted priority districts (PD) and the latter, non-priority districts (NPD). Composite scores were developed and compared between PD and NPD. Adjusted linear regression was conducted to identify predictors of satisfaction at work.

Results

A majority of respondents felt that RKS was efficient in decision making that resulted in improvement of all critical parameters of health service delivery, including quality; this was significantly higher in PD. Further, higher proportion of respondents from PD was highly satisfied with the current set of provisions and manners of functioning of the sample health units. Active community engagement, participation of elected representatives, selection of a pro-active Chairman, and training to RKS members were suggested as the immediate priority action points for the state government. Mean scores differed significantly between PD and NPD with regard to: influence of RKS on individual-centric, organizational-centric and patient-centric performance, and the responsibilities to be entrusted with RKS. Absenteeism was strongly associated with satisfaction and local self-governance. Work-related factors, systemic factors, local accountability and patients’ involvement were found to be the key predictors of satisfaction of health workforce.

Conclusion

The understanding on quality improvement strategies was found to be very poor among the health workers. Tailor-made capacity building measures at district and sub-district levels could be critical to equip the peripheral health units to achieve the universal health coverage goals. Work environment, systemic factors and accountability need to be addressed on priority for retention of health workforce. The hypothesized link between efficient local decision making, perception of health workers about efficiency of health units and the health status of population needs further investigation.

Evaluation einer regionalen integrierten Vollversorgung mit GKV-Routinedaten – Probleme und Herausforderungen

Die Integrierte Versorgung Gesundes Kinzigtal (IVGK) ist eine regionale integrierte Vollversorgung und wird umfassend extern evaluiert. In einer kontrollierten Längsschnittstudie wird anhand von GKV-Routinedaten untersucht, wie sich die Versorgungsqualität in der Region Kinzigtal im Vergleich zu einer Kontrollgruppe aus dem restlichen Baden-Württemberg entwickelt. Hierfür wurden insgesamt 37 Kennziffern gebildet. An drei Beispielen zeigen wir, dass die Eignung einer Kennziffer als Qualitätsindikator und Endpunkt regional vergleichender Studien sehr voraussetzungsvoll ist.