Research gaps in the organisation of primary healthcare in LMICs

17 September, 2019

This new paper reports on a global effort to identify and prioritise the knowledge needs of PHC practitioners and researchers in LMICs about PHC organisation.

Citation, abstract, selected extracts and a comment from me below.

CITATION: Research gaps in the organisation of primary healthcare in low-income and middle-income countries and ways to address them: a mixed-methods approach.

Goodyear-Smith F(1), Bazemore A(2), Coffman M(2), Fortier RDW(1)(3), Howe A(4), Kidd M(5)(6), Phillips R(7), Rouleau K(5), van Weel C(8)(9).

BMJ Glob Health. 2019 Aug 16;4(Suppl 8):e001482. doi: 10.1136/bmjgh-2019-001482.

https://gh.bmj.com/content/4/Suppl_8/e001482

ABSTRACT

Introduction: Since the Alma-Ata Declaration 40 years ago, primary healthcare (PHC) has made great advances, but there is insufficient research on models of care and outcomes-particularly for low-income and middle-income countries (LMICs). Systematic efforts to identify these gaps and develop evidence-based strategies for improvement in LMICs has been lacking. We report on a global effort to identify and prioritise the knowledge needs of PHC practitioners and researchers in LMICs about PHC organisation.

Methods: Three-round modified Delphi using web-based surveys. PHC practitioners and academics and policy-makers from LMICs sampled from global networks. First round (pre-Delphi survey) collated possible research questions to address knowledge gaps about organisation. Responses were independently coded, collapsed and synthesised. Round 2 (Delphi round 1) invited panellists to rate importance of each question. In round 3 (Delphi round 2), panellists ranked questions into final order of importance. Literature review conducted on 36 questions and gap map generated.

Results: Diverse range of practitioners and academics in LMICs from all global regions generated 744 questions for PHC organisation. In round 2, 36 synthesised questions on organisation were rated. In round 3, the top 16 questions were ranked to yield four prioritised questions in each area. Literature reviews confirmed gap in evidence on prioritised questions in LMICs.

Conclusion: In line with the 2018 Astana Declaration, this mixed-methods study has produced a unique list of essential gaps in our knowledge of how best to organise PHC, priority-ordered by LMIC expert informants capable of shaping their mitigation. Research teams in LMIC have developed implementation plans to answer the top four ranked research questions.

SELECTED EXTRACTS

The final top four ranked questions are:

1. What are the factors to be considered and negotiated for successful referral from primary to secondary care and back?

2. How should care be horizontally integrated and coordinated among the multidisciplinary PHC team?

3. How can the public and private sectors work more collaboratively to improve and integrate PHC coverage and prevent segmentation of the services?

4. How can different stakeholders (eg, policy-makers, health system managers, health workforce organisations, academic institutions and communities) support and assist the primary healthcare workforce and successful team functioning?

[Other questions that are especially relevant to the HIFA remit include:]

1. How can family physicians be supported to provide comprehensive community-based care instead of resources being directed into vertical programmes?

2. What are the drivers for PHC teams to deliver high-quality services (intrinsic and extrinsic factors such as pay, status, career pathway/promotion etc)?

3. How can education and training support the PHC workforce to deliver the range of services that address priority health needs of the community?

5. What are the factors that facilitate recruitment and retention of a PHC workforce in underserved community settings?

6. What are the best strategies to implement and monitor best practice in PHC?

7. Are the services and scope of practice of PHC aligned with people's health needs, considering variations in population needs, resources and geography, and what is the evidence on which the range of services/scope of care provided should be decided?

8. What strategies can be undertaken to ensure quality in the delivery of PHC service to patients (eg, training/research/quality control)?

10. How can different stakeholders (eg, policy-makers, health system managers, health workforce organisations, academic institutions and communities) support and assist the PHC workforce and successful team functioning?

11. How can PHC services be integrated with other community-based health and social services?

19. How can different stakeholders (eg, health system managers, health workforce members, academic institutions and communities) advise policy-makers on how to ensure that PHC services address population health needs?

20. What can be done to prioritise limited resources and what alternatives including telemedicine can assist in providing PHC to under-resourced areas?

27. What role is there for specialists to see patients in community settings and for PHC workers including family physicians to work in secondary and tertiary settings?

32. How can traditional healers be accommodated within a PHC system?

COMMENT (NPW): Dynamic interaction on communities of practice such as HIFA can complement and enhance survey-based studies such as the one above. I have emailed the authors to suggest this for future research.

Best wishes, Neil

Coordinator, HIFA Project on Evidence-Informed Policy and Practice

http://www.hifa.org/projects/evidence-informed-policy-and-practice

Let's build a future where people are no longer dying for lack of healthcare information - Join HIFA: www.hifa.org

HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with almost 20,000 members in 180 countries, interacting on six global forums in four languages (English, French, Spanish, Portuguese). Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org