Creating Socially Accountable Health Conferences: Guidance from Around the World.

BACKGROUND: Very little attention has been given to the social accountability of conferences, either in action or in scholarship, in particular, of scientific conferences. Concerns that have been raised include: (1) Local communities and regions suffer from ecological pressure caused by conferences, (2) There is limited value to the local community, (3) International conferences take place at locations irrelevant to the topics discussed; hence there is no connection with locals, and (4) It has been the observation of the authors that <10% of participants may come from the region where the conference is organized, which makes it challenging to make a "positive societal impact" locally. We conducted a natural experiment investigating the interactions between academia, conference organizers, and community leaders. METHODS: We utilized a case study approach to report on the outcomes of two 2022 annual international conferences that seek to improve community health. We used a mixed-methods approach of surveys and interviews. Thematic analysis was conducted to identify the key themes. RESULTS: We obtained 358 responses from all six World Health Organization regions. Results from both conferences were split into two categories: the why and the how. A strong consensus among participants is that bi-directional learning between conference organizers and local communities leads to shared understanding and mutual goals. The data emphasize that including communities in academic conferences helps us progress forward from intentions toward demonstrating accountability and reporting impact. DISCUSSION: A diversity of perspectives is needed to advance socially accountable health system transformation. Five best practices from conference participants are laid out as a framework to assist in the change: (1) Build trust, (2) provide funding for community member participation, (3) appreciation of local community knowledge, (4) involve the local community in the planning stages, and (5) make the local community part of the conference and learning.

From disease- to people-centred pandemic management: organized communities, community-oriented primary care and health information systems.

BACKGROUND: The COVID-19 pandemic exposed the health equity gap between and within countries. Western countries were the first to receive vaccines and mortality was higher among socially deprived, minority and indigenous populations. Surprisingly, many sub-Saharan countries reported low excess mortalities. These countries share experiences with community organization and participation in health. The aim of this article was to analyse if and how this central role of people can promote a successful pandemic response. METHODS: This analysis was partly based on local and national experiences shared during an international and Latin American conference on person-and people-centred care in 2021. Additionally, excess mortality data and pandemic control-relevant data, as well as literature on the pandemic response of countries with an unexpected low excess mortality were consulted. RESULTS: Togo, Mongolia, Thailand and Kenya had a seven times lower mean excess mortality for 2020 and 2021 than the United States of America. More successful pandemic responses were observed in settings with experience in managing epidemics like Ebola and HIV, well-established community networks, a national philosophy of mutual aid, financial government assistance, more human resources for primary care and paid community health workers. DISCUSSION: Since trust in authorities and health needs vary greatly, local strategies are needed to complement national and international pandemic responses. Three key levers were identified to promote locally-tailored pandemic management: well-organized communities, community-oriented primary care, and health information systems. An organized community structure stems from a shared ethical understanding of humanity as being interconnected with each other and the environment. This structure facilitates mutual aid and participation in decision making. Community-oriented primary care includes attention for collective community health and ways to improve health from its roots. A health information system supports collective health and health equity analysis by presenting health needs stratified for social deprivation, ethnicity, and community circumstances. CONCLUSIONS: The difference in excess mortality between countries during the COVID-19 pandemic and various country experiences demonstrate the potential of the levers in promoting a more just and effective health emergency response. These same levers and strategies can promote more inclusive and socially just health systems.

RESUMEN: ANTECEDENTES: La pandemia de COVID-19 expuso la brecha de equidad en salud dentro y entre países. Los países occidentales fueron los primeros en recibir vacunas y la mortalidad fue mayor entre las poblaciones indígenas, minoritarias y socialmente desfavorecidas dentro de los países. Sorprendentemente, muchos países subsaharianos reportaron un exceso de mortalidad bajo. Estos países comparten experiencias de organización y participación comunitaria en salud. El objetivo es analizar si y cómo este papel central de las personas puede promover una respuesta exitosa a la pandemia. MéTODOS: Este análisis se basa en parte en las experiencias locales y nacionales compartidas durante una conferencia internacional y latinoamericana sobre la atención centrada en las personas y comunidades en 2021. Además, se consultó los datos de exceso de mortalidad y los datos relevantes para el control de la pandemia, así como la literatura sobre la respuesta a la pandemia de países con un exceso de mortalidad inesperadamente bajo. RESULTADOS: Togo, Mongolia, Tailandia y Kenia tuvieron un exceso de mortalidad promedio por 2020 y 2021 siete veces menor que los Estados Unidos de América. Se observaron respuestas pandémicas más exitosas en entornos con experiencia en el manejo de epidemias como el ébola y el VIH, redes comunitarias bien establecidas, una filosofía nacional de ayuda mutua, asistencia financiera del gobierno, más recursos humanos para atención primaria y trabajadores de salud comunitarios remunerados. DISCUSIóN: Dado que la confianza en autoridades y las necesidades en salud varían mucho, se necesitan estrategias locales para complementar las respuestas nacionales e internacionales a la pandemia. Se identificaron tres palancas clave para promover la gestión de pandemias adaptada localmente: comunidades bien organizadas, atención primaria orientada a la comunidad y sistemas de información de salud. Una estructura comunitaria organizada surge de una comprensión ética compartida que concibe a la humanidad interconectada entre sí y con el medio ambiente. Esta estructura facilita la ayuda mutua y la participación en la toma de decisiones. La atención primaria orientada a la comunidad incluye la atención a la salud comunitaria colectiva y las formas de mejorar la salud desde sus raíces. Un sistema de información de salud puede apoyar el análisis de la salud colectiva y la equidad en salud al presentar las necesidades de salud estratificadas por privación social, etnicidad y circunstancias de la comunidad. CONCLUSIONES: La diferencia en el exceso de mortalidad entre países durante la pandemia de COVID-19 y las experiencias de varios países, demuestran el potencial de las palancas para promover una respuesta de emergencia sanitaria más justa y eficaz. Estas mismas palancas y estrategias pueden promover sistemas de salud más inclusivos y socialmente justos.

Operationalizing the Chronic Care Model with Goal-Oriented Care.

The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person's goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.

Integrated person- and people-centred primary care for diabetes in low- and middle-income countries: The nurses' perspective on patient needs.

AIMS: The aim of this study was to identify what nurses working in primary care settings perceive as necessary to support the life needs of people with type 2 diabetes. Articulate these needs with the needs expressed by people with diabetes in a previous study. Finally, illustrate the potential of the used method. DESIGN: A highly structured qualitative group method for brainstorming and idea sharing was used to generate a participant-owned concept map that can support and evaluate practice change. METHODS: Data were collected between April and May 2022 in two public primary healthcare centres in Sacaba, Bolivia, with 33 professional nurses, technical nurses, nurse trainees and one physician. The concept mapping process by Trochim was used to generate, share and structure ideas, maximizing equality of input. RESULTS: The nurses identified 73 unique needs that were structured in 11 conceptual clusters related to four different stakeholders or domains: organization of care and health policy, strengthening knowledge, skills and attitudes of healthcare providers, empower people living with diabetes and their family, and community-level health promotion and diabetes education. CONCLUSION: The needs and domains identified by nurses and people with type 2 diabetes are very similar and inform a multisectoral and transdisciplinary action plan to jointly monitor and evaluate progress towards people-centred care for people with diabetes. IMPACT: This study demonstrates nurses' important contribution to analysing and designing people-centred care in their community. They identify and act upon social determinants of health related to schools, safety and legislation. Besides global relevance, results inform the municipal health plan and an ongoing research project on cardiometabolic health. PATIENT OR PUBLIC CONTRIBUTION: Data from prior patient consultations were included in the study design, and study results inform the municipal health plan.

Understanding public procurement within the health sector: a priority in a post-COVID-19 world.

Every year, over 250,000 public authorities in the European Union (EU) spend about 14% of GDP on the purchase of services, works and supplies. Many are in the health sector, a sector in which public authorities are the main buyers in many countries. When these purchases exceed threshold values, EU public procurement rules apply. Public procurement is increasingly being promoted as a tool for improving efficiency and contributing to better health outcomes, and as a policy lever for achieving other government goals, such as innovation, the development of small and medium-sized enterprises, sustainable green growth and social objectives like public health and greater inclusiveness. In this paper, we describe the challenges that arise within health care systems with public procurement and identify potential solutions to them. We examined the tendering of pharmaceuticals, health technology, and e-health. In each case we identify a series of challenges relating to the complexity of the procurement process, imbalances in power on either side of transactions and the role of procurement in promoting broader public policy objectives. Finally, we recommend several actions that could stimulate better procurement, and suggest a few areas where further EU cooperation can be pursued.

Belgium's Healthcare System: The Way Forward to Address the Challenges of the 21st Century Comment on "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study".

In this paper we have tried, starting from the results of an analysis of the functioning of integrated care in the Belgian Health System by Martens et al, to design a strategy that could contribute to better addressing the challenges of the 21st century in Belgium. We proposed health system changes at the macro-, meso- and micro-level. We focused on health policy development and organization of care, emphasizing the importance of a shift from a hospital-centric towards a primary care based approach. Special attention was paid to the need for institutional reforms, in order to facilitate the further development of interprofessional integrated care, that focuses on the achievement of the life-goals of a person.

COVID-19 fosters social accountability in medical education.

The COVID-19 pandemic has highlighted embedded inequities and fragmentation in our health systems. Traditionally, structural issues with health professional education perpetuate these. COVID-19 has highlighted inequities, but may also be a disruptor, allowing positive responses and system redesign. Examples from health professional schools in high and low- and middle-income countries illustrate pro-equity interventions of current relevance. We recommend that health professional schools and planners consider educational redesign to produce a health workforce well equipped to respond to pandemics and meet future need.

Family Physician Perceptions of Climate Change, Migration, Health, and Healthcare in Sub-Saharan Africa: An Exploratory Study.

Although family physicians (FPs) are community-oriented primary care generalists and should be the entry point for the population's interaction with the health system, they are underrepresented in research on the climate change, migration, and health(care) nexus (hereafter referred to as the nexus). Similarly, FPs can provide valuable insights into building capacity through integrating health-determining sectors for climate-resilient and migration-inclusive health systems, especially in Sub-Saharan Africa (SSA). Here, we explore FPs' perceptions on the nexus in SSA and on intersectoral capacity building. Three focus groups conducted during the 2019 WONCA-Africa conference in Uganda were transcribed verbatim and analyzed using an inductive thematic approach. Participants' perceived interactions related to (1) migration and climate change, (2) migration for better health and healthcare, (3) health impacts of climate change and the role of healthcare, and (4) health impacts of migration and the role of healthcare were studied. We coined these complex and reinforcing interactions as continuous feedback loops intertwined with socio-economic, institutional, and demographic context. Participants identified five intersectoral capacity-building opportunities on micro, meso, macro, and supra (international) levels: multi-dimensional and multi-layered governance structures; improving FP training and primary healthcare working conditions; health advocacy in primary healthcare; collaboration between the health sector and civil society; and more responsibilities for high-income countries. This exploratory study presents a unique and novel perspective on the nexus in SSA which contributes to interdisciplinary research agendas and FP policy responses on national, regional, and global levels.

The best person (or machine) for the job: Rethinking task shifting in healthcare.

Globally, health systems are faced with the difficult challenge of how to get the best results with the often limited number of health workers available to them. Exacerbating this challenge is the task of meeting ever-changing needs of service users and managing unprecedented technological advances. The process of matching skills to changing needs and opportunities is termed task shifting. It involves questioning health service goals, what health workers do, asking if it can be done in a better way, and implementing change. Task shifting in healthcare is often conceptualised as a process of transferring responsibility for 'simple' tasks from high-skilled but scarce health workers to those with less expertise and lower pay, and predominantly viewed as a means to reduce costs and promote efficiency. Here we present a position paper based on the work and expertise of the European Commission Expert Panel on Effective ways of Investing in Health. It contends that this is over simplistic, and aims to provide a new task shifting framework, informed by relevant evidence, and a series of recommendations. While far from comprehensive, there is a growing body of evidence that certain tasks traditionally undertaken by one type of health worker can be undertaken by others (or machines), in some cases to a higher standard, thus challenging the persistence of rigid professional boundaries. Task shifting has the potential to contribute to health systems strengthening when accompanied by adequate planning, resources, education, training and transparency.

Quality of primary health care in China: challenges and recommendations.

China has substantially increased financial investment and introduced favourable policies for strengthening its primary health care system with core responsibilities in preventing and managing chronic diseases such as hypertension and emerging infectious diseases such as coronavirus disease 2019 (COVID-19). However, widespread gaps in the quality of primary health care still exist. In this Review, we aim to identify the causes for this poor quality, and provide policy recommendations. System challenges include: the suboptimal education and training of primary health-care practitioners, a fee-for-service payment system that incentivises testing and treatments over prevention, fragmentation of clinical care and public health service, and insufficient continuity of care throughout the entire health-care system. The following recommendations merit consideration: (1) enhancement of the quality of training for primary health-care physicians, (2) establishment of performance accountability to incentivise high-quality and high-value care; (3) integration of clinical care with the basic public health services, and (4) strengthening of the coordination between primary health-care institutions and hospitals. Additionally, China should consider modernising its primary health-care system through the establishment of a learning health system built on digital data and innovative technologies.

Strengthening vaccination programmes and health systems in the European Union: A framework for action.

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.

A scoping review on family medicine in sub-Saharan Africa: practice, positioning and impact in African health care systems.

BACKGROUND: Family medicine (FM) is a relatively new discipline in sub-Saharan Africa (SSA), still struggling to find its place in the African health systems. The aim of this review was to describe the current status of FM in SSA and to map existing evidence of its strengths, weaknesses, effectiveness and impact, and to identify knowledge gaps. METHODS: A scoping review was conducted by systematically searching a wide variety of databases to map the existing evidence. Articles exploring FM as a concept/philosophy, a discipline, and clinical practice in SSA, published in peer-reviewed journals from 2000 onwards and in English language, were included. Included articles were entered in a matrix and then analysed for themes. Findings were presented and validated at a Primafamed network meeting, Gauteng 2018. RESULTS: A total of 73 articles matching the criteria were included. FM was first established in South Africa and Nigeria, followed by Ghana, several East African countries and more recently additional Southern African countries. In 2009, the Rustenburg statement of consensus described FM in SSA. Implementation of the discipline and the roles and responsibilities of family physicians (FPs) varied between and within countries depending on the needs in the health system structure and the local situation. Most FPs were deployed in district hospitals and levels of the health system, other than primary care. The positioning of FPs in SSA health systems is probably due to their scarcity and the broader mal-distribution of physicians. Strengths such as being an "all- round specialist", providing mentorship and supervision, as well as weaknesses such as unclear responsibilities and positioning in the health system were identified. Several studies showed positive perceptions of the impact of FM, although only a few health impact studies were done, with mixed results. CONCLUSIONS: FM is a developing discipline in SSA. Stronger evidence on the impact of FM on the health of populations requires a critical mass of FPs and shared clarity of their position in the health system. As FM continues to grow in SSA, we suggest improved government support so that its added value and impact on health systems in terms of health equity and universal health coverage can be meaningfully explored.

The influence of general practitioners on access points to health care in a system without gatekeeping: a cross-sectional study in the context of the QUALICOPC project in Austria.

AIM: To assess the rates of specialist visits and visits to hospital emergency departments (ED) among patients in Austria with and without concurrent general practitioner (GP) consultation and among patients with and without chronic disease. METHODS: The cross-sectional questionnaire study was conducted in the context of the QUALICOPC project in 2012. Fieldworkers recruited 1596 consecutive patients in 184 GP offices across Austria. The 41-question survey addressed patients' experiences with regard to access to, coordination, and continuity of primary care, as well demographics and health status. Descriptive statistics as well as univariate and multivariate regression models were applied. RESULTS: More than 90% of patients identified a GP as a primary source of care. Among all patients, 85.5% reported having visited a specialist and 26.4% the ED at least once in the previous year. Having a usual GP did not change the rate of specialist visits. Additionally, patients with chronic disease had a higher likelihood of presenting to the ED despite having a GP as a usual source of care. CONCLUSION: Visiting specialists in Austria is quite common, and the simple presence of a GP as a usual source of care is insufficient to regulate pathways within the health care system. This can be particularly difficult for chronic care patients who often require care at different levels of the system and show higher frequency of ED presentations.