Pathways to Enable Primary Healthcare Nurses in Providing Comprehensive Primary Healthcare to Rural, Tribal Communities in Rajasthan, India

Uneven primary healthcare supply of rural doctors and medical equipment in remote China: community impact and the moderating effect of policy intervention

BACKGROUND

Unequal access to primary healthcare (PHC) has become a critical issue in global health inequalities, requiring governments to implement policies tailored to communities' needs and abilities. However, the place-based facility dimension of PHCs is oversimplified in current healthcare literature, and formulating the equity-oriented PHC spatial planning remains challenging without understanding the multiple impacts of community socio-spatial dynamics, particularly in remote areas. This study aims to push the boundary of PHC studies one step further by presenting a nuanced and dynamic understanding of the impact of community environments on the uneven primary healthcare supply.

METHODS

Focusing on Shuicheng, a remote rural area in southwestern China, multiple data are included in this village-based study, i.e., the facility-level healthcare statistics data (2016-2019), the statistical yearbooks, WorldPop, and Chinese GDP's spatial distribution data. We evaluate villages' PHC service capacity using the number of doctors and essential equipment per capita, which are the major components of China's PHC delivery. The indicators describing community environments are selected based on extant literature and China's planning paradigms, including town- and village-level factors. Gini coefficients and local spatial autocorrelation analysis are used to present the divergences of PHC capacity, and multilevel regression model and (heterogeneous) difference in difference model are used to examine the driving role of community environments and the dynamics under the policy intervention.

RESULTS

Despite the general improvement, PHC inequalities remain significant in remote rural areas. The village's location, aging, topography, ethnic autonomy, and economic conditions significantly influence village-level PHC capacity, while demographic characteristics and healthcare delivery at the town level are also important. Although it may improve the hardware setting in village clinics (coef. = 0.350), the recent equity-oriented policy attempts may accelerate the loss of rural doctors (coef. = - 0.517). Notably, the associations between PHC and community environments are affected inconsistently by this round of policy intervention. The town healthcare centers with higher inpatient service capacity (coef. = - 0.514) and more licensed doctors (coef. = - 0.587) and nurses (coef. = - 0.344) may indicate more detrimental policy effects that reduced the number of rural doctors, while the centers with more professional equipment (coef. = 0.504) and nurses (coef. = 0.184) are beneficial for the improvement of hardware setting in clinics.

CONCLUSIONS

The findings suggest that the PHC inequalities are increasingly a result of joint social, economic, and institutional forces in recent years, underlining the increased complexity of the PHC resource allocation mechanism. Therefore, we claim the necessity to incorporate a broader understanding of community orientation in PHC delivery, particularly the interdisciplinary knowledge of the spatial lens of community, to support its sustainable development. Our findings also provide timely policy insights for ongoing primary healthcare reform in China.

India's Opportunity to Address Human Resource Challenges in Healthcare

India's health indicators have improved in recent times but continue to lag behind those of its peer nations. The country with a population of 1.3 billion, has an estimated active health workers density of doctors and nurses/midwives of 5.0 and 6.0 respectively, for 10,000 persons, which is much lower than the WHO threshold of 44.5 doctors, nurses, and midwives per 10,000 population. The issue is compounded by the skewed inter-state, urban-rural, and public-private sector divide. Calls to urgently augment the skilled health workforce reinforce the central role human resources have in healthcare, which has evolved into a complex multifactorial issue. The paucity of skilled personnel must be addressed if India is to accelerate its progress toward achieving universal health coverage and its sustainable development goals (SDGs). The recent increase in the federal health budget offers an unprecedented opportunity to do this. This article utilizes the ready materials, extract and analyze data, distill findings (READ) approach to adding to the authors' experiential learning to analyze the health system in India. The growing divide between the public and the burgeoning private health sector systems, with the latter's booming medical tourism industry and medical schools, are analyzed along with the newly minted National Medical Council, to recommend policies that would help India achieve its SDGs.

How to work with intangible software in public health systems: some experiences from India

This commentary focuses on "intangible software", defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this commentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evaluated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in conjunction with structural improvements. Also, such interventions require long-term investments. Based on our experiences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared.

Implementation of cancer screening in rural primary care practices after joining an accountable care organisation: a multiple case study

Objective

To describe common strategies and practice-specific barriers, adaptations and determinants of cancer screening implementation in eight rural primary care practices in the Midwestern United States after joining an accountable care organisation (ACO).

Design

This study used a multiple case study design. Purposive sampling was used to identify a diverse group of practices within the ACO. Data were collected from focus group interviews and workflow mapping. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. Data were cross-analysed by clinic and CFIR domains to identify common themes and practice-specific determinants of cancer screening implementation.

Setting

The study included eight rural primary care practices, defined as Rural-Urban Continuum Codes 5–9, in one ACO in the Midwestern United States.

Participants

Providers, staff and administrators who worked in the primary care practices participated in focus groups. 28 individuals participated including 10 physicians; one doctor of osteopathic medicine; three advanced practice registered nurses; eight registered nurses, quality assurance and licensed practical nurses; one medical assistant; one care coordination manager; and four administrators.

Results

With integration into the ACO, practices adopted four new strategies to support cancer screening: care gap lists, huddle sheets, screening via annual wellness visits and information spread. Cross-case analysis revealed that all practices used both visit-based and population-based cancer screening strategies, although workflows varied widely across practices. Each of the four strategies was adapted for fit to the local context of the practice. Participants shared that joining the ACO provided a strong external incentive for increasing cancer screening rates. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record (EHR) and fully engaging nurses in the screening process.

Conclusions

Joining an ACO can be a positive driver for increasing cancer screening practices in rural primary care practices. Characteristics of the practice can impact the success of ACO-related cancer screening efforts; engaging nurses to the fullest extent of their education and training and integrating cancer screening into the EHR can optimise the cancer screening workflow.

The gender responsiveness of social entrepreneurship in health - A review of initiatives by Ashoka fellows

There are vocal calls to act on the gender-related barriers and inequities in global health. Still, there are gaps in implementing programmes that address and counter the relevant dynamics. As an approach that focuses on social problems and public service delivery gaps, social entrepreneurship has the potential to be a closer health sector partner to tackle and transform the influence of gender in health to achieve health systems goals better. Nevertheless, social entrepreneurs' engagement and impact on gender and health remain understudied. Using the Ashoka Fellows database as a sampling frame in November 2020 (n = 3352, health n = 129), we identified and reviewed the work of 21 organizations that implemented gender-responsive health-related programmes between 2000 and 2020. We applied the UNU-IIGH 6-I Analytic Framework to review the gender issues, interventions, included populations, investments, implementation, and impact in each organization. We found that a low proportion of fellows engage in gender-responsive health programming (<1%). Many organizations operate in low-and middle-income countries (16/21). The gender-responsive programmes include established health sector practices, to address gendered-cultural dynamics and deliver people-centred resources and services. Interestingly, most organizations self-identify as NGOs and rely on traditional grant funding. Fewer organizations (6/21) adopt market-based and income-generating solutions - a missed opportunity to actualise the potential of social entrepreneurship as an innovative health financing approach. There were few publicly available impact evaluations-a gap in practice established in social entrepreneurship. All organizations implemented programmes at community levels, with some cross-sectoral, structural, and policy-level initiatives. Most focused on sexual and reproductive health and gender-based violence for predominantly populations of women and girls. Closer partnerships between social entrepreneurs and gender experts in the health sector can provide reciprocally beneficial solutions for cross-sectorally and community designed innovations, health financing, evidence generation and impact tracking that improve the gender-responsiveness of health programmes, policies, and systems.