A path dependence analysis of hospital dominance in China (1949–2018): lessons for primary care strengthening

Abstract Although China’s community health system helped inspire the 1978 Alma Ata Declaration on Health for All, it currently faces the challenge of strengthening primary care in response to hospital sector dominance. As the world reaffirms its commitment towards primary health services, China’s recent history provides a salient case study of the issues at stake in optimizing the balance of care. In this study, we have used path dependence analysis to explain China’s coevolution of hospital and primary care facilities between 1949 and 2018. We have identified two cycles of path-dependent development (1949–78 and 1978–2018) involving four sets of institutions related to medical professionalization, financing, organization and governance of health facilities. Both cycles started with a critical juncture amid a radically changing societal context, when institutions favouring hospitals were initiated or renewed, leading to a process of self-reinforcement empowering the hospitals. Later in each cycle, events occurred that modified this hospital dominance. However, pro-primary care policies during these conjunctures encountered resilience from the existing institutional environment. The result was continued consolidation of hospital dominance over the long term. These recurrent constraints suggest that primary care strengthening is unlikely to be successful without a comprehensive set of policy reforms driven by a primary care coalition with strong professional, bureaucratic and community stakes, co-ordinated and sustained over a prolonged period. Our findings imply that it is important to understand the history of health systems in China, where the challenges of health systems strengthening go beyond limited resources and include different developmental paths as compared with Western countries.

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Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Ethiopia

BMJ Global Health ◽

10.1136/bmjgh-2018-001108 ◽

2018 ◽

Vol 3 (Suppl 5) ◽

pp. e001108 ◽

Cited By ~ 6

Author(s):

Yibeltal Mekonnen ◽

Charlotte Hanlon ◽

Solomon Emyu ◽

Ruth Vania Cornick ◽

Lara Fairall ◽

...

Keyword(s):

Primary Care ◽

Health Systems ◽

Addis Ababa ◽

Scale Up ◽

Health Systems Strengthening ◽

Sub Saharan Africa ◽

Practical Approach ◽

Supervisory Support ◽

Ministry Of Health ◽

Systems Research

The Federal Ministry of Health, Ethiopia, recognised the potential of the Practical Approach to Care Kit (PACK) programme to promote integrated, comprehensive and evidence-informed primary care as a means to achieving universal health coverage. Localisation of the PACK guide to become the ‘Ethiopian Primary Health Care Clinical Guidelines’ (PHCG) was spearheaded by a core team of Ethiopian policy and technical experts, mentored by the Knowledge Translation Unit, University of Cape Town. A research collaboration, ASSET (heAlth Systems StrEngThening in sub-Saharan Africa), has brought together policy-makers from the Ministry of Health and health systems researchers from Ethiopia (Addis Ababa University) and overseas partners for the PACK localisation process, and will develop, implement and evaluate health systems strengthening interventions needed for a successful scale-up of the Ethiopian PHCG. Localisation of PACK for Ethiopia included expanding the guide to include a wider range of infectious diseases and an expanded age range (from 5 to 15 years). Early feedback from front-line primary healthcare (PHC) workers is positive: the guide gives them greater confidence and is easy to understand and use. A training cascade has been initiated, with a view to implementing in 400 PHC facilities in phase 1, followed by scale-up to all 3724 health centres in Ethiopia during 2019. Monitoring and evaluation of the Ministry of Health implementation at scale will be complemented by indepth evaluation by ASSET in demonstration districts. Anticipated challenges include availability of essential medications and laboratory investigations and the need for additional training and supervisory support to deliver care for non-communicable diseases and mental health. The strong leadership from the Ministry of Health of Ethiopia combined with a productive collaboration with health systems research partners can help to ensure that Ethiopian PHCG achieves standardisation of clinical practice at the primary care level and quality healthcare for all.

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Exploring the role of gender and women in the political economy of health in armed conflict: a narrative review

Globalization and Health ◽

10.1186/s12992-021-00738-9 ◽

2021 ◽

Vol 17 (1) ◽

Author(s):

Kristen Meagher ◽

Bothaina Attal ◽

Preeti Patel

Keyword(s):

Political Economy ◽

Health Systems ◽

Armed Conflict ◽

Narrative Review ◽

Health Systems Strengthening ◽

The Political ◽

Systems Research ◽

Political Economy Of Health ◽

And Gender

Abstract Background The ripple effects of protracted armed conflicts include: significant gender-specific barriers to accessing essential services such as health, education, water and sanitation and broader macroeconomic challenges such as increased poverty rates, higher debt burdens, and deteriorating employment prospects. These factors influence the wider social and political determinants of health for women and a gendered analysis of the political economy of health in conflict may support strengthening health systems during conflict. This will in turn lead to equality and equity across not only health, but broader sectors and systems, that contribute to sustainable peace building. Methods The methodology employed is a multidisciplinary narrative review of the published and grey literature on women and gender in the political economy of health in conflict. Results The existing literature that contributes to the emerging area on the political economy of health in conflict has overlooked gender and specifically the role of women as a critical component. Gender analysis is incorporated into existing post-conflict health systems research, but this does not extend to countries actively affected by armed conflict and humanitarian crises. The analysis also tends to ignore the socially constructed patriarchal systems, power relations and gender norms that often lead to vastly different health system needs, experiences and health outcomes. Conclusions Detailed case studies on the gendered political economy of health in countries impacted by complex protracted conflict will support efforts to improve health equity and understanding of gender relations that support health systems strengthening.

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Learning health systems in primary care: a systematic scoping review

BMC Family Practice ◽

10.1186/s12875-021-01483-z ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Danielle M. Nash ◽

Zohra Bhimani ◽

Jennifer Rayner ◽

Merrick Zwarenstein

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Health Systems ◽

Scoping Review ◽

Early Stage ◽

Point Of Care ◽

The United States ◽

Stage Of Development ◽

Integrated Health ◽

Google Search

Abstract Background Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions. Methods We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature. Results We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research. Conclusions We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care.

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The contribution of depressive ‘disorder characteristics’ to determinations of prognosis for adults with depression: an individual patient data meta-analysis

Psychological Medicine ◽

10.1017/s0033291721001367 ◽

2021 ◽

pp. 1-14

Author(s):

Joshua E. J. Buckman ◽

Rob Saunders ◽

Zachary D. Cohen ◽

Phoebe Barnett ◽

Katherine Clarke ◽

...

Keyword(s):

Primary Care ◽

Depressive Symptoms ◽

Depressive Symptom ◽

Panic Disorder ◽

Symptom Severity ◽

Individual Patient Data ◽

Antidepressant Treatment ◽

Patient Data ◽

History Of ◽

Depressive Symptom Severity

Abstract Background This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care. Methods We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted. Results Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3–4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3–4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions. Conclusions When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.

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Family History of Mental Health Disorders and Parental Help-Seeking for Behavioral Health Concerns in Pediatric Primary Care Offices

Journal of Pediatric Health Care ◽

10.1016/j.pedhc.2021.04.004 ◽

2021 ◽

Author(s):

Alyssa Linkenheil ◽

Lisa Honigfeld ◽

Anne Pidano

Keyword(s):

Mental Health ◽

Primary Care ◽

Family History ◽

Behavioral Health ◽

Help Seeking ◽

Mental Health Disorders ◽

Pediatric Primary Care ◽

Health Concerns ◽

History Of ◽

Health Disorders

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The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

BMC Health Services Research ◽

10.1186/s12913-021-06140-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dimuthu Rathnayake ◽

Mike Clarke

Keyword(s):

Primary Care ◽

Health Systems ◽

Elective Surgery ◽

Waiting Times ◽

Surgical Care ◽

High Income ◽

Surgical Patients ◽

Timely Access ◽

Referral Systems

Abstract Background Long waiting times for elective surgery are common to many publicly funded health systems. Inefficiencies in referral systems in high-income countries are more pronounced than lower and middle-income countries. Primary care practitioners play a major role in determining which patients are referred to surgeon and might represent an opportunity to improve this situation. With conventional methods of referrals, surgery clinics are often overcrowded with non-surgical referrals and surgical patients experience longer waiting times as a consequence. Improving the quality of referral communications should lead to more timely access and better cost-effectiveness for elective surgical care. This review summarises the research evidence for effective interventions within the scope of primary-care referral methods in the surgical care pathway that might shorten waiting time for elective surgeries. Methods We searched PubMed, EMBASE, SCOPUS, Web of Science and Cochrane Library databases in December-2019 to January-2020, for articles published after 2013. Eligibility criteria included major elective surgery lists of adult patients, excluding cancer related surgeries. Both randomised and non-randomised controlled studies were eligible. The quality of evidence was assessed using ROBINS-I, AMSTAR 2 and CASP, as appropriate to the study method used. The review presentation was limited to a narrative synthesis because of heterogeneity. The PROSPERO registration number is CRD42019158455. Results The electronic search yielded 7543 records. Finally, nine articles were considered as eligible after deduplication and full article screening. The eligible research varied widely in design, scope, reported outcomes and overall quality, with one randomised trial, two quasi-experimental studies, two longitudinal follow up studies, three systematic reviews and one observational study. All the six original articles were based on referral methods in high-income countries. The included research showed that patient triage and prioritisation at the referral stage improved timely access and increased the number of consultations of surgical patients in clinics. Conclusions The available studies included a variety of interventions and were of medium to high quality researches. Managing patient referrals with proper triaging and prioritisation using structured referral formats is likely to be effective in health systems to shorten the waiting times for elective surgeries, specifically in high-income countries.

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COVID‐19 calls for health systems strengthening in Africa: A case of Nigeria

The International Journal of Health Planning and Management ◽

10.1002/hpm.3296 ◽

2021 ◽

Author(s):

Emmanuel Ebuka Elebesunu ◽

Gabriel Ilerioluwa Oke ◽

Yusuff Adebayo Adebisi ◽

Ifeanyi McWilliams Nsofor

Keyword(s):

Health Systems ◽

Health Systems Strengthening

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Reducing unscheduled hospital care for adults with diabetes following a hypoglycaemic event: which community-based interventions are most effective? A systematic review

Journal of Diabetes & Metabolic Disorders ◽

10.1007/s40200-021-00817-z ◽

2021 ◽

Author(s):

Aoife Watson ◽

Donna McConnell ◽

Vivien Coates

Keyword(s):

Systematic Review ◽

Primary Care ◽

Integrated Care ◽

Hospital Care ◽

Hospital Admissions ◽

Community Based Interventions ◽

Community Based ◽

Integrated Care Pathways ◽

Effective Community ◽

Balance Of Care

Abstract Aim To determine which community-based interventions are most effective at reducing unscheduled hospital care for hypoglycaemic events in adults with diabetes. Methods Medline Ovid, CINAHL Plus and ProQuest Health and Medical Collection were searched using both key search terms and medical subject heading terms (MeSH) to identify potentially relevant studies. Eligible studies were those that involved a community-based intervention to reduce unscheduled admissions in adults with diabetes. Papers were initially screened by the primary researcher and then a secondary reviewer. Relevant data were then extracted from papers that met the inclusion criteria. Results The search produced 2226 results, with 1360 duplicates. Of the remaining 866 papers, 198 were deemed appropriate based on titles, 90 were excluded following abstract review. A total of 108 full papers were screened with 19 full papers included in the review. The sample size of the 19 papers ranged from n = 25 to n = 104,000. The average ages within the studies ranged from 41 to 74 years with females comprising 57% of the participants. The following community-based interventions were identified that explored reducing unscheduled hospital care in people with diabetes; telemedicine, education, integrated care pathways, enhanced primary care and care management teams. Conclusions This systematic review shows that a range of community-based interventions, requiring different levels of infrastructure, are effective in reducing unscheduled hospital care for hypoglycaemia in people with diabetes. Investment in effective community-based interventions such as integrated care and patient education must be a priority to shift the balance of care from secondary to primary care, thereby reducing hospital admissions.

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