Barriers and strategies for primary health care workforce development: synthesis of evidence.

BACKGROUND: Having a sufficient and well-functioning health workforce is crucial for reducing the burden of disease and premature death. Health workforce development, focusing on availability, recruitment, retention, and education, is inseparable from acceptability, motivation, burnout, role and responsibility, and performance. Each aspect of workforce development may face several challenges, requiring specific strategies. However, there was little evidence on barriers and strategies towards comprehensive health workforce development. Therefore, this review explored barriers and strategies for health workforce development at the primary health care level around the world. METHODS: A scoping review of reviews was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews. The article search was performed in Google Scholar, PubMed, Web of Science, and EMBASE. We used EndNote x9 for managing the collected articles, screening processes, and citation purpose. The scoping review included any kind of review articles on the application of health workforce development concepts, such as availability, recruitment, retention, role and responsibility, education and training, motivation, and burnout, with primary health care and published in English anywhere in the world. Based on the concepts above, barriers and strategies for health workforce development were identified. The findings were synthesized qualitatively based on the building blocks of the health system framework. The analysis involved specific activities such as familiarization, construction of the thematic framework, indexing, charting, and interpretation. The results were presented in texts, tables, and figures. RESULTS: The search strategies yielded 7,276 papers were found. Of which, 69 were included in the scoping review. The most frequently cited barriers were financial challenges and issues related to health care delivery, such as workloads. Barriers affecting healthcare providers directly, including lack of training and ineffective teamwork, were also prominent. Other health system and governance barriers include lack of support, unclear responsibility, and inequity. Another notable barrier was the shortage of health care technology, which pertains to both health care supplies and information technology. The most common cited effective strategies were ongoing support and supervision, engaging with communities, establishing appropriate primary care settings, financial incentives, fostering teamwork, and promoting autonomous health care practice. CONCLUSIONS: Effective leadership/governance, a robust health financing system, integration of health information and technology, such as mobile health and ensuring a consistent supply of adequate resources are also vital components of primary health care workforce development. The findings highlight the importance of continuous professional development, which includes training new cadres, implementing effective recruitment and retention mechanisms, optimising the skill mix, and promoting workplace wellness. These elements are essential in fostering a well-trained and resilient primary health care workforce.

Preparedness, impacts, and responses of public health emergencies towards health security: qualitative synthesis of evidence.

BACKGROUND: Natural and human-made public health emergencies (PHEs), such as armed conflicts, floods, and disease outbreaks, influence health systems including interruption of delivery and utilization of health services, and increased health service needs. However, the intensity and types of impacts of these PHEs vary across countries due to several associated factors. This scoping review aimed to synthesise available evidence on PHEs, their preparedness, impacts, and responses. METHODS: We conducted a scoping review of published evidence. Studies were identified using search terms related to two concepts: health security and primary health care. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines to select studies. We adapted the review framework of Arksey and O'Malley. Data were analyzed using a thematic analysis approach and explained under three stages of PHEs: preparedness, impacts, and responses. RESULTS: A total of 64 studies were included in this review. Health systems of many low- and middle-income countries had inadequate preparedness to absorb the shocks of PHEs, limited surveillance, and monitoring of risks. Health systems have been overburdened with interrupted health services, increased need for health services, poor health resilience, and health inequities. Strategies of response to the impact of PHEs included integrated services such as public health and primary care, communication and partnership across sectors, use of digital tools, multisectoral coordination and actions, system approach to responses, multidisciplinary providers, and planning for resilient health systems. CONCLUSIONS: Public health emergencies have high impacts in countries with weak health systems, inadequate preparedness, and inadequate surveillance mechanisms. Better health system preparedness is required to absorb the impact, respond to the consequences, and adapt for future PHEs. Some potential response strategies could be ensuring need-based health services, monitoring and surveillance of post-emergency outbreaks, and multisectoral actions to engage sectors to address the collateral impacts of PHEs. Mitigation strategies for future PHEs could include risk assessment, disaster preparedness, and setting digital alarm systems for monitoring and surveillance.

People-centred primary health care: a scoping review.

BACKGROUND: Integrated people-centred health services (IPCHS) are vital for ensuring comprehensive care towards achieving universal health coverage (UHC). The World Health Organisation (WHO) envisions IPCHS in delivery and access to health services. This scoping review aimed to synthesize available evidence on people-centred primary health care (PHC) and primary care. METHODS: We conducted a scoping review of published literature on people-centred PHC. We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar) using search terms related to people-centred and integrated PHC/primary care services. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to select studies. We analyzed data and generated themes using Gale's framework thematic analysis method. Themes were explained under five components of the WHO IPCHS framework. RESULTS: A total of fifty-two studies were included in the review; most were from high-income countries (HICs), primarily focusing on patient-centred primary care. Themes under each component of the framework included: engaging and empowering people and communities (engagement of community, empowerment and empathy); strengthening governance and accountability (organizational leadership, and mutual accountability); reorienting the model of care (residential care, care for multimorbidity, participatory care); coordinating services within and across sectors (partnership with stakeholders and sectors, and coordination of care); creating an enabling environment and funding support (flexible management for change; and enabling environment). CONCLUSIONS: Several people-centred PHC and primary care approaches are implemented in HICs but have little priority in low-income countries. Potential strategies for people-centred PHC could be engaging end users in delivering integrated care, ensuring accountability, and implementing a residential model of care in coordination with communities. Flexible management options could create an enabling environment for strengthening health systems to deliver people-centred PHC services.

Digital Health Interventions to Improve Access to and Quality of Primary Health Care Services: A Scoping Review.

Global digital technology advances offer the potential to enhance primary health care (PHC) quality, reach, and efficiency, driving toward universal health coverage (UHC). This scoping review explored how digital health solutions aid PHC delivery and UHC realization by examining the context, mechanisms, and outcomes of eHealth interventions. A comprehensive literature search was conducted, capturing qualitative and quantitative studies, process evaluations, and systematic or scoping reviews. Our analysis of 65 articles revealed that a well-functioning digital ecosystem-featuring adaptable, interoperable digital tools, robust Information and Communications Technology foundations, and enabling environments-is pivotal for eHealth interventions' success. Facilities with better digital literacy, motivated staff, and adequate funding demonstrated a higher adoption of eHealth technologies, leading to improved, coordinated service delivery and higher patient satisfaction. However, eHealth's potential is often restricted by existing socio-cultural norms, geographical inequities in technology access, and digital literacy disparities. Our review underscores the importance of considering the digital ecosystem's readiness, user behavior, broader health system requirements, and PHC capacity for adopting digital solutions while assessing digital health interventions' impact.

Successes and challenges towards improving quality of primary health care services: a scoping review.

BACKGROUND: Quality health services build communities' and patients' trust in health care. It enhances the acceptability of services and increases health service coverage. Quality primary health care is imperative for universal health coverage through expanding health institutions and increasing skilled health professionals to deliver services near to people. Evidence on the quality of health system inputs, interactions between health personnel and clients, and outcomes of health care interventions is necessary. This review summarised indicators, successes, and challenges of the quality of primary health care services. METHODS: We used the preferred reporting items for systematic reviews and meta-analysis extensions for scoping reviews to guide the article selection process. A systematic search of literature from PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE), Scopus, and Google Scholar was conducted on August 23, 2022, but the preliminary search was begun on July 5, 2022. The Donabedian's quality of care framework, consisting of structure, process and outcomes, was used to operationalise and synthesise the findings on the quality of primary health care. RESULTS: Human resources for health, law and policy, infrastructure and facilities, and resources were the common structure indicators. Diagnosis (health assessment and/or laboratory tests) and management (health information, education, and treatment) procedures were the process indicators. Clinical outcomes (cure, mortality, treatment completion), behaviour change, and satisfaction were the common indicators of outcome. Lower cause-specific mortality and a lower rate of hospitalisation in high-income countries were successes, while high mortality due to tuberculosis and the geographical disparity in quality care were challenges in developing countries. There also exist challenges in developed countries (e.g., poor quality mental health care due to a high admission rate). Shortage of health workers was a challenge both in developed and developing countries. CONCLUSIONS: Quality of care indicators varied according to the health care problems, which resulted in a disparity in the successes and challenges across countries around the world. Initiatives to improve the quality of primary health care services should ensure the availability of adequate health care providers, equipped health care facilities, appropriate financing mechanisms, enhance compliance with health policy and laws, as well as community and client participation. Additionally, each country should be proactive in monitoring and evaluation of performance indicators in each dimension (structure, process, and outcome) of quality of primary health care services.

Multisectoral actions in primary health care: A realist synthesis of scoping review.

BACKGROUND: Multisectoral actions (MSAs) on health are key to implementation of primary health care (PHC) and achieving the targets of the Sustainable Development Goal 3. However, there is limited understanding and interpretation of how MSAs on health articulate and mediate health outcomes. This realist review explored how MSAs influence on implementing PHC towards universal health coverage (UHC) in the context of multilevel health systems. METHODS: We reviewed published evidence that reported the MSAs, PHC and UHC. The keywords used in the search strategy were built on these three key concepts. We employed Pawson and Tilley's realist review approach to synthesize data following Realist and Meta-narrative Evidence Syntheses: Evolving Standards publication standards for realist synthesis. We explained findings using a multilevel lens: MSAs at the strategic level (macro-level), coordination and partnerships at the operational level (meso-level) and MSAs employing to modify behaviours and provide services at the local level (micro-level). RESULTS: A total of 40 studies were included in the final review. The analysis identified six themes of MSAs contributing to the implementation of PHC towards UHC. At the macro-level, themes included influence on the policy rules and regulations for governance, and health in all policies for collaborative decision makings. The meso-level themes were spillover effects of the non-health sector, and the role of community health organizations on health. Finally, the micro-level themes were community engagement for health services/activities of health promotion and addressing individuals' social determinants of health. CONCLUSION: Multisectoral actions enable policy and actions of other sectors in health involving multiple stakeholders and processes. Multisectoral actions at the macro-level provide strategic policy directions; and operationalise non-health sector policies to mitigate their spillover effects on health at the meso-level. At micro-level, MSAs support service provision and utilisation, and lifestyle and behaviour modification of people leading to equity and universality of health outcomes. Proper functional institutional mechanisms are warranted at all levels of health systems to implement MSAs on health.

Continuity and care coordination of primary health care: a scoping review.

BACKGROUND: Healthcare coordination and continuity of care conceptualize all care providers and organizations involved in health care to ensure the right care at the right time. However, systematic evidence synthesis is lacking in the care coordination of health services. This scoping review synthesizes evidence on different levels of care coordination of primary health care (PHC) and primary care. METHODS: We conducted a scoping review of published evidence on healthcare coordination. PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science and Google Scholar were searched until 30 November 2022 for studies that describe care coordination/continuity of care in PHC and primary care. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines to select studies. We analysed data using a thematic analysis approach and explained themes adopting a multilevel (individual, organizational, and system) analytical framework. RESULTS: A total of 56 studies were included in the review. Most studies were from upper-middle-income or high-income countries, primarily focusing on continuity/care coordination in primary care. Ten themes were identified in care coordination in PHC/primary care. Four themes under care coordination at the individual level were the continuity of services, linkage at different stages of health conditions (from health promotion to rehabilitation), health care from a life-course (conception to elderly), and care coordination of health services at places (family to hospitals). Five themes under organizational level care coordination included interprofessional, multidisciplinary services, community collaboration, integrated care, and information in care coordination. Finally, a theme under system-level care coordination was related to service management involving multisectoral coordination within and beyond health systems. CONCLUSIONS: Continuity and coordination of care involve healthcare provisions from family to health facility throughout the life-course to provide a range of services. Several issues could influence multilevel care coordination, including at the individual (services or users), organizational (providers), and system (departments and sectors) levels. Health systems should focus on care coordination, ensuring types of care per the healthcare needs at different stages of health conditions by a multidisciplinary team. Coordinating multiple technical and supporting stakeholders and sectors within and beyond health sector is also vital for the continuity of care especially in resource-limited health systems and settings.

Community engagement initiatives in primary health care to achieve universal health coverage: A realist synthesis of scoping review.

BACKGROUND: Community engagement (CE) is an essential component in a primary health care (PHC) and there have been growing calls for service providers to seek greater CE in the planning, design, delivery and evaluation of PHC services. This scoping review aimed to explore the underlying attributes, contexts and mechanisms in which community engagement initiatives contribute to improved PHC service delivery and the realisation of UHC. METHODS: PubMed, PsycINFO, CINAHL, Cochrane Library, EMBASE and Google Scholar were searched from the inception of each database until May 2022 for studies that described the structure, process, and outcomes of CE interventions implemented in PHC settings. We included qualitative and quantitative studies, process evaluations and systematic or scoping reviews. Data were extracted using a predefined extraction sheet, and the quality of reporting of included studies was assessed using the Mixed Methods Appraisal Tool. The Donabedian's model for quality of healthcare was used to categorise attributes of CE into "structure", "process" and "outcome". RESULTS: Themes related to the structural aspects of CE initiatives included the methodological approaches (i.e., format and composition), levels of CE (i.e., extent, time, and timing of engagement) and the support processes and strategies (i.e., skills and capacity) that are put in place to enable both communities and service providers to undertake successful CE. Process aspects of CE initiatives discussed in the literature included: i) the role of the community in defining priorities and setting objectives for CE, ii) types and dynamics of the broad range of engagement approaches and activities, and iii) presence of an on-going communication and two-way information sharing. Key CE components and contextual factors that affected the impact of CE initiatives included the wider socio-economic context, power dynamics and representation of communities and their voices, and cultural and organisational issues. CONCLUSIONS: Our review highlighted the potential role of CE initiatives in improving decision making process and improving overall health outcomes, and identified several organisational, cultural, political, and contextual factors that affect the success of CE initiatives in PHC settings. Awareness of and responding to the contextual factors will increase the chances of successful CE initiatives.

Influence of contextual factors on strengthening key strategic and operational levers of primary healthcare to achieve universal health coverage: a protocol for a realist review.

INTRODUCTION: Existing scoping reviews on the link between primary healthcare (PHC) and universal health coverage (UHC) have not sufficiently addressed the underlying causal mechanisms in which key strategic and operational PHC levers contribute to improved health system and realisation of UHC. This realist review aims to examine how key PHC levers work (independently and holistically) to achieve an improved health system and UHC, and the conditions and caveats that influence the outcome. METHODS AND ANALYSIS: We will employ a four-step realist evaluation approach: (1) define the review scope and develop initial programme theory, (2) database search, (3) data extraction and appraisal, (4) synthesis of evidence. Electronic databases (PubMed/MEDLINE, Embase, CINAHL, SCOPUS, PsycINFO, Cochrane Library and Google Scholar) and grey literature will be searched to identify initial programme theories underlying the key strategic and operational levers of PHC and empirical evidence to test these matrices of programme theories. Evidence from each document will be abstracted, appraised and synthesised through a process of reasoning using a realistic logic of analysis (ie, theoretical, or conceptual frameworks). The extracted data will then be analysed using a realist context-mechanism-outcome configuration, including what caused an outcome, through which mechanism, and under which context. ETHICS AND DISSEMINATION: Given the studies are scoping reviews of published articles, ethics approval is not required. Key dissemination strategies will include academic papers, policy briefs and conference presentations. By capturing the relationship between sociopolitical, cultural and economic contexts and the pathways in which PHC levers interact with each other and the broader health system, findings from this review will facilitate the design and development of evidence-based, context-sensitive strategies that will enhance effective and sustainable PHC implementation strategies.