Primary health care as a tool to promote equity and sustainability; a review of Latin American and Caribbean literature

Primary health care (PHC) has increased in global relevance as it has been demonstrated to be a useful strategy to promote community access to health services. Multilateral organizations and national governments have reached a consensus regarding the basic principles of PHC, but the application of these varies from country to country due to the particularities of local health systems.This article aims to review and summarize PHC strategies and the configuration of health networks in Latin American and Caribbean countries.The review was carried out using keywords in at least 9 databases. Papers in languages other than English, Portuguese, and Spanish were excluded, while non-refereed articles and regional gray literature were incorporated. As a result, 1,146 papers were identified. After three instances of analysis, 142 articles were selected for this investigation. Data were analyzed according to an analysis by theme.The evidence collected on health reforms in the region reflects the need to intensify care strategies supported by PHC and care networks. These must be resilient to changes in the population's needs and must be able to adapt to contexts of epidemiological accumulation.

Unravelling collaborative governance dynamics within healthcare networks: a scoping review

In many countries, healthcare systems suffer from fragmentation between hospitals and primary care. In response, many governments institutionalized healthcare networks (HN) to facilitate integration and efficient healthcare delivery. Despite potential benefits, the implementation of HN is often challenged by inefficient collaborative dynamics that result in delayed decision-making, lack of strategic alignment and lack of reciprocal trust between network members. Yet, limited attention has been paid to the collective dynamics, challenges and enablers for effective inter-organizational collaborations. To consider these issues, we carried out a scoping review to identify the underlying processes for effective inter-organizational collaboration and the contextual conditions within which these processes are triggered. Following appropriate methodological guidance for scoping reviews, we searched four databases [PubMed (n = 114), Web of Science (n = 171), Google Scholar (n = 153) and Scopus (n = 52)] and used snowballing (n = 22). A total of 37 papers addressing HN including hospitals were included. We used a framework synthesis informed by the collaborative governance framework to guide data extraction and analysis, while being sensitive to emergent themes. Our review showed the prominence of balancing between top-down and bottom-up decision-making (e.g. strategic vs steering committees), formal procedural arrangements and strategic governing bodies in stimulating participative decision-making, collaboration and sense of ownership. In a highly institutionalized context, the inter-organizational partnership is facilitated by pre-existing legal frameworks. HN are suitable for tackling wicked healthcare issues by mutualizing resources, staff pooling and improved coordination. Overall performance depends on the capacity of partners for joint action, principled engagement and a closeness culture, trust relationships, shared commitment, distributed leadership, power sharing and interoperability of information systems To promote the effectiveness of HN, more bottom-up participative decision-making, formalization of governance arrangement and building trust relationships are needed. Yet, there is still inconsistent evidence on the effectiveness of HN in improving health outcomes and quality of care.

[Patients on oral anticancer drugs and coordinated pathway: CHIMORAL, feedback from care providers]

INTRODUCTION

Oral anticancer drugs have raised the question of how to follow-up these patients and how to coordinate this follow-up. The CHIMORAL study evaluated the involvement of primary care providers and a coordination by territorial health networks. Training/information tools were provided, as well as weekly nursing follow-up at home.

METHODS

The operational feasibility of this model was assessed through a qualitative/quantitative analysis of territorial health network intervention and feedback from primary care providers.

RESULTS

One hundred and fifty four patients received coordinated care, with nursing follow-up for 89% of them (average 6.3 weeks). One in three nurses, one in five pharmacists and one in ten doctors used the tools provided, 41% of which were used for training and 16% for the management of an adverse event. The main reasons for using the networks concerned adverse effects (34%) and came mainly from nurses (45%) and patients and their relatives (47%). Patients felt safe, with more responsive management.

DISCUSSION

This intervention has strengthened the networks' links with primary care providers. The use of the community-based care system for adverse events was more frequent, with improved detection and patient awareness, with no observed impact on compliance. A proposed evolution is to maintain an in-home assessment for all patients and to define a frequency and duration of follow-up according to the patient's profile.

Designing a novel hybrid healthcare teleconsultation network: a benchtop study of telepathology in Iran and a systematic review

BACKGROUND

Growing demand for medical services has increased patient waiting time due to the limited number or unbalanced distribution of healthcare centers. Healthcare teleconsultation networks are one of the potentially powerful systems to overcome this problem. Medical pathology can hugely benefit from teleconsultation networks because having second opinions is precious for many cases; however, resource planning (i.e., assignment and distribution of pathology consultation requests) is challenging due to bulky medical images of patients. This results in high setup and operational costs. The aim of this study is to design an optimal teleconsultation network for pathology labs under the supervision of medical sciences universities in Tehran, Iran.

METHODS

To avoid the setup cost, we first propose a modified hybrid peer-to-peer (P2P) overlay architecture for our telepathology network, using Iran's National Healthcare Information Network (SHAMS) as the underlying infrastructure. Then we apply optimization techniques to solve the request assignment and distribution problems in the network. Finally, we present a novel mathematical model with the objective of minimizing the variable operational costs of the system.

RESULTS

The efficiency of the proposed method was evaluated by a set of practical-sized network instances simulated based on the characteristics of SHAMS. The results show that the presented model and architecture can obtain optimal solutions for network instances up to 350 nodes, which covers our target network.

CONCLUSIONS

We believe that the proposed method can be beneficial for designing large-scale medical teleconsultation networks by adjusting the constraints according to the rules and conditions of each country. Our findings showed that teleconsultation networks in countries with strong information technology (IT) infrastructures are under the influence of consultation fees, while in countries with weak IT infrastructure, the transmission costs are more critical. To the best of our knowledge, no research has so far addressed resource planning in medical teleconsultation networks using optimization techniques. Besides, the target network, i.e., pathology labs under the supervision of medical sciences universities in Tehran and the SHAMS network, are discussed for the first time in this work.

[Impact of a coordinated regional organization to secure the management of patients on oral anticancer drugs: CHIMORAL, a comparative trial]

INTRODUCTION

Oral anticancer drugs have disrupted hospital and community practices. A better coordination and patient support for medication and adverse events management by primary care providers (general practitioner, community pharmacist and liberal nurse) could improve the situation. The CHIMORAL study evaluated a model of coordination by territorial health networks.

METHODS

A here and elsewhere, prospective and multicentric study, comparing coordinated care with standard care. Primary outcome was the use of the hospital structure for adverse events within 6 months of initiating treatment.

RESULTS

In all, 283 patients were included. 92% had at least one adverse event, with a higher median number in the coordinated group (12.5 vs. 9.0, P=0.02). No difference in hospital use by arm (P=0.502). Increase in the use of community care for adverse events in the coordinated group (27% vs. 16%, P=0.009). No observed impact on progression rates, quality of life and treatment adherence. The overall survival rate at 6 months is numerically higher in the coordinated group (87% vs. 76%, P=0.064).

DISCUSSION

This model does not show any difference on the primary endpoint. The lack of randomization, patient selection, power loss, and local initiatives to monitor these patients may have biased the analysis. A large number of uses of the healthcare system were observed. These results confirm the need for a dedicated care pathway for the patient with oral anticancer drugs.

A network of networks

Purpose To further our insight into the role of networks in health system reform, the purpose of this paper is to investigate how one agency, the NSW Agency for Clinical Innovation (ACI), and the multiple networks and enabling resources that it encompasses, govern, manage and extend the potential of networks for healthcare practice improvement. Design/methodology/approach This is a case study investigation which took place over ten months through the first author's participation in network activities and discussions with the agency's staff about their main objectives, challenges and achievements, and with selected services around the state of New South Wales to understand the agency's implementation and large system transformation activities. Findings The paper demonstrates that ACI accommodates multiple networks whose oversight structures, self-organisation and systems change approaches combined in dynamic ways, effectively yield a diversity of network governances. Further, ACI bears out a paradox of "centralised decentralisation", co-locating agents of innovation with networks of implementation and evaluation expertise. This arrangement strengthens and legitimates the role of the strategic hybrid - the healthcare professional in pursuit of change and improvement, and enhances their influence and impact on the wider system. Research limitations/implications While focussing the case study on one agency only, this study is unique as it highlights inter-network connections. Contributing to the literature on network governance, this paper identifies ACI as a "network of networks" through which resources, expectations and stakeholder dynamics are dynamically and flexibly mediated and enhanced. Practical implications The co-location of and dynamic interaction among clinical networks may create synergies among networks, nurture "strategic hybrids", and enhance the impact of network activities on health system reform. Social implications Network governance requires more from network members than participation in a single network, as it involves health service professionals and consumers in a multi-network dynamic. This dynamic requires deliberations and collaborations to be flexible, and it increasingly positions members as "strategic hybrids" - people who have moved on from singular taken-as-given stances and identities, towards hybrid positionings and flexible perspectives. Originality/value This paper is novel in that it identifies a critical feature of health service reform and large system transformation: network governance is empowered through the dynamic co-location of and collaboration among healthcare networks, particularly when complemented with "enabler" teams of people specialising in programme implementation and evaluation.

Infection prevention in a connected world: the case for a regional approach

Results from microbiological and epidemiological investigations, as well as mathematical modelling, show that the transmission dynamics of nosocomial pathogens, especially of multiple antibiotic-resistant bacteria, is not exclusively amenable to single-hospital infection prevention measures. Crucially, their extent of spread depends on the structure of an underlying "healthcare network", as determined by inter-institutional referrals of patients. The current trend towards centralized healthcare systems favours the spread of hospital-associated pathogens, and must be addressed by coordinated regional or national approaches to infection prevention in order to maintain patient safety. Here we review recent advances that support this hypothesis, and propose a "next-generation" network-approach to hospital infection prevention and control.