What motivates people with substance use disorders to pursue treatment? A patient-centered approach to understanding patient experiences and patient-provider interactions.

OBJECTIVES: To identify and define potential positive and negative factors in patient experiences and patient-provider interactions that are associated with the pursuit and maintenance of treatment by those suffering from substance use disorders (SUD). METHODS: Two focus groups with patients in treatment for SUD were performed. The focus groups focused on questions aimed at mapping factors associated with initiating and maintaining treatment along the transtheoretical model of change. Four in-depth interviews with healthcare providers involved in the treatment of patients with SUD were also conducted to understand providers' perspective on similar factors. RESULTS: Fourteen patients were included in the focus groups. Patients identified their life prior to treatment as chaotic and further identified internal and external factors that influenced seeking treatment. The four healthcare providers identified primarily social issues such as lack of housing as an external barrier. Both patients and providers cited the importance of a trusting and empathetic relationship between the patient and providers, as well as the patient's willingness to change as primary motivating factors for the initiation and maintenance of treatment. CONCLUSIONS: From a patient and provider perspective, facilitators and barriers for initiating and maintaining may vary by person and are multifactorial.

Beyond accreditation: a multi-track quality-enhancing strategy for primary health care in low- and middle-income countries.

Many define an equitable health care system as one that provides logistical and financial access to "quality" care to the population. Realizing that fact, many low- and middle-income countries started investing in enhancing the quality of care in their health care systems, recently in primary health care. Unfortunately, in many instance, these investments have been exclusively focused on accreditation due to available guidelines and existing accrediting structures. A multi-track quality-enhancing strategy (MTQES) is proposed that includes, in addition to promoting resource-sensitive accreditation, other quality initiatives such as clinical guidelines, performance indicators, benchmarking activities, annual quality-enhancing projects, and annual quality summit/meeting. These complementary approaches are presented to synergistically enhance a continuous quality improvement culture in the primary health care sector, taking into consideration limited resources available, especially in low- and middle-income countries. In addition, an implementation framework depicting MTQES in three-phase interlinked packages is presented; each matches existing resources and quality infrastructure. Health care policymakers and managers need to think about accreditation as a beginning rather than an end to their quest for quality. Improvements in the structure of a health delivery organization or in the processes of care have little value if they do not translate to reduced disparities in access to "quality" care, and not merely access to care.

The path towards universal health coverage in the Arab uprising countries Tunisia, Egypt, Libya, and Yemen.

The constitutions of many countries in the Arab world clearly highlight the role of governments in guaranteeing provision of health care as a right for all citizens. However, citizens still have inequitable health-care systems. One component of such inequity relates to restricted financial access to health-care services. The recent uprisings in the Arab world, commonly referred to as the Arab spring, created a sociopolitical momentum that should be used to achieve universal health coverage (UHC). At present, many countries of the Arab spring are considering health coverage as a priority in dialogues for new constitutions and national policy agendas. UHC is also the focus of advocacy campaigns of a number of non-governmental organisations and media outlets. As part of the health in the Arab world Series in The Lancet, this report has three overarching objectives. First, we present selected experiences of other countries that had similar social and political changes, and how these events affected their path towards UHC. Second, we present a brief overview of the development of health-care systems in the Arab world with regard to health-care coverage and financing, with a focus on Egypt, Libya, Tunisia, and Yemen. Third, we aim to integrate historical lessons with present contexts in a roadmap for action that addresses the challenges and opportunities for progression towards UHC.

Acceptability of quality reporting and pay for performance among primary health centers in Lebanon.

Primary health care (PHC) is emphasized as the cornerstone of any health care system. Enhancing PHC performance is considered a strategy to enhance effective and equitable access to care. This study assesses the acceptability of and factors associated with quality reporting among PHC centers (PHCCs) in Lebanon. The managers of 132 Lebanese Ministry of Health PHCCs were surveyed using a cross-sectional design. Managers' willingness to report quality, participate in comparative quality assessments, and endorse pay-for-performance schemes was evaluated. Collected data were matched to the infrastructural characteristics and services database. Seventy-six percent of managers responded to the questionnaire, 93 percent of whom were willing to report clinical performance. Most expressed strong support for peer-performance comparison and pay-for-performance schemes. Willingness to report was negatively associated with the religious affiliation of centers and presence of health care facilities in the catchment area and favorably associated with use of information systems and the size of population served. The great willingness of PHCC managers to employ quality-enhancing initiatives flags a policy priority for PHC stakeholders to strengthen PHCC infrastructure and to enable reporting in an easy, standardized, and systematic way. Enhancing equity necessitates education and empowerment of managers in remote areas and those managing religiously affiliated centers.