How do diverse low-income and middle-income countries implement primary healthcare team integration to support the delivery of comprehensive primary health care? A mixed-methods study protocol from India, Mexico and Uganda

Introduction Attainment of universal health coverage is feasible via strengthened primary health systems that are comprehensive, accessible, people-centred, continuous and coordinated. Having an adequately trained, motivated and equipped primary healthcare workforce is central to the provision of comprehensive primary healthcare (CPHC). This study aims to understand PHC team integration, composition and organisation in the delivery of CPHC in India, Mexico and Uganda. Methods and analysis A parallel, mixed-methods study (integration of quantitative and qualitative results) will be conducted to gain an understanding of PHC teams. Methods include: (1) Policy review on PHC team composition, organisation and expected comprehensiveness of PHC services, (2) PHC facility review using the WHO Service Availability and Readiness Assessment, and (3) PHC key informant interviews. Data will be collected from 20, 10 and 10 PHCs in India, Mexico and Uganda, respectively, and analysed using descriptive methods and thematic analysis approach. Outcomes will include an in-depth understanding of the health policies for PHC as well as understanding PHC team composition, organisation and the delivery of comprehensive PHC. Ethics and dissemination Approvals have been sought from the Institutional Ethics Committee of The George Institute for Global Health, India for the Indian sites, School of Medicine Research Ethics Committee at Makerere University for the sites in Uganda and the Research, Ethics and Biosecurity Committees of the Mexican National Institute of Public Health for the sites in Mexico. Results will be shared through presentations with governments, publications in peer-reviewed journals and presentations at conferences. The study will use the Primary Health Care Performance Initiative (PHCPI) conceptual framework (figure 1), and the research will be based on the service delivery and output domains (availability of effective PHC services and high-quality PHC, effective service coverage) with a specific focus on the relationship between comprehensiveness of PHC (one of the key quality related PHC issues) and the composition (availability of groups of PHC providers with diverse education and capabilities) and organisation (team-based organisation of care to leverage the distinct expertise of different groups for provision of comprehensive PHC) of PHC teams, and to compare models between countries.22 23 Primary healthcare performance initiative (PHCPI) conceptual framework. NCD, Non Communicable Disease; PHC, primary healthcare; RMNCH, Reproductive, Maternal, Newborn and Child Health. This will be a parallel mixed-methods study, which will combine qualitative and quantitative data in each country and support cross-country comparisons. Empirical data will be collected from PHC settings in a prespecified region from the three countries. It will comprise three steps as shown in figure 2. Mixed-methods study design. LMIC, low-income and middle-income country; PHC, primary healthcare; SARA, Service Availability and Readiness Assessment. Patients or public were not involved in the design, conduct or reporting or dissemination of this protocol. Region and site selection will occur purposively to capture the diversity and needs of the population. Each country will first select the regions, and then sites to represent the health needs and overall health system performance of the regions. Overall, 10 health units will be selected for each country except for India where 20 health units will be selected representing the regions, giving a total of 40 PHC units. In India, a total of 20 PHCs from two regions (Vizianagaram from Andhra Pradesh, South India and Jhajjar from Haryana, North India) have been chosen. In Mexico, 10 PHCs will be included (three PHCs from Northern region, two from Western region; three from Central region and finally two PHCs from South region). In Uganda, 10 PHCs will be selected from the Eastern (Tororo district) and Western (Buliisa district) regions and will include one general hospital (figure 3). Sample level distribution and methodological approach. HC, Health Care; HWC, Health and Wellness Centre; MLP, Mid Level Provider; MPW, Multipurpose Health Worker; PHC, primary healthcare. To review national and subnational policies on PHC team composition and organisation and expected comprehensiveness of PHC. A desktop review of published and grey literature documents as well as relevant policy documents will be conducted to identify the government regulations or policies related to PHC workforce. We will review the policies relating to PHC workforce and extract data to a standardised data collection tool template that uses the PHCPI conceptual framework (figure 1) with the below mentioned categories. (1) Governance and leadership; (2) Government spending on PHC; (3) PHC structure and organisation; (4) PHC workforce; (5) PHC service delivery and (6) PHC performance. Data will then be analysed qualitatively using NVivo software to create a narrative synthesis of the country’s policy on the areas of interest. Describe the actual composition and organisation of PHC teams. A cross-sectional descriptive survey will be conducted in the selected PHC facilities. Data collectors will be trained in WHO’s Service Availability and Readiness Assessment (SARA) tool and will complete the questionnaire using electronic devices. SARA is a health facility assessment tool designed to assess the available infrastructure, equipment and workforce, thereby determining the service availability and readiness of the facility to provide CPHC. We will not collect information about the availability of medicines at the PHC level as this study is focusing on health workforce. Data collection will occur at the PHC unit including its community-based outreach centres (eg, Health and Wellness Centres in India, at the selected PHC units in Mexico and health centres 2 and 3 in Uganda) to understand the PHC infrastructure, composition of PHC teams and the services delivered to the community. Data will be collected on electronic devices using the Open Data Kit platform, stored locally on the device, and when internet connectivity is available, uploaded to a central repository/server in respective countries for data analysis. When internet is not available, data from the devices can be manually saved in the central repository. Service availability will be described by three domains: health infrastructure, health workforce and service utilisation. Continuous variables will be summarised using either mean (SD) or median (IQR). All categorical variables will be summarised using frequencies and percentages. Assess the comprehensiveness of care provided by PHC teams. This comprises semistructured in-depth interviews (IDIs) to explore topics on the role and recruitment of the workforce, and how jobs are shared in the team, training, accreditation, supervision, performance evaluation, incentives, career progression, community involvement, team composition, organisation and comprehensiveness of services provided. Comprehensiveness of services will be assessed by asking which services are delivered, the range of conditions addressed by the team, if the workforce is trained in managing those conditions, and do the range of services include prevention, promotion, treatment, rehabilitation and palliation? For instance, does that PHC provide care for cardiovascular risk factors and if so, are the staff trained and do they have access to the necessary equipment to measure the risk factors? A purposive sample of participants including PHC workforce (community health workers, nurses, social workers, pharmacy staff, health promoters, primary care doctors), and National/Regional/District level policy makers and PHC managers will be invited for the IDIs. Trained researchers from each country will interview participants in local languages (Telugu, Hindi and English in India; Spanish in Mexico; and English, Ateso, Jopadhola and Runyoro in Uganda) using interview guides described in Appendix 1, 2 and 3. Debriefing sessions with the entire research team will be held each week. Interviews will take place over phone/zoom/skype or in-person depending on the local situation of COVID-19 pandemic and will be audiorecorded. Participants will be contacted at the health units or their office (policy makers) and will be interviewed in an area within the unit that meets the appropriate privacy conditions. We aim to conduct up to 60 interviews in each country (180 interviews in total) (see online supplemental files 1–3). bmjopen-2021-055218supp001.pdf bmjopen-2021-055218supp002.pdf bmjopen-2021-055218supp003.pdf Interviews will be transcribed verbatim in-country and transcripts in Hindi, Telugu, Spanish and Ateso, Jopadhola and Runyoro will be translated to English for analysis. The qualitative data for each country will be coded using NVivo software (QRS International, Vic) and analysed using an inductive approach. Two coders from each country will review and analyse the data. Weekly calls will be set up to discuss the emerging themes with the research team. This approach will enable us to explore and identify the important issues in PHC workforce organisation, composition and comprehensiveness, and will also help us to identify shared challenges and differences across countries. The emergent themes from the qualitative interviews in each country will be interpreted in conjunction with the SARA survey and outputs from the policy analysis. Data integration of the three objectives will help us identify the policy and implementation gaps for each country. Conduct a comparative analysis of the relationship between PHC team composition and organisation with the delivery of comprehensive PHC across the three countries. We will use a case-oriented research strategy where each ‘case’ (country) will be considered analytically as a whole.24 25 Comprehensiveness of services (which services such as prevention, promotion, treatment, rehabilitation or palliation; for what conditions and by whom) will be explored through the policy review, SARA (availability of infrastructure to deliver CPHC) and interviews with PHC team members. Cross country comparisons will be conducted to understand similarities and differences in PHC-related policies, especially in terms of the workforce composition, organisation and service delivery with the intention of learning about the different approaches to CPHC and PHC workforce organisation, the context in which PHC systems exist, and why they take the forms they do. The comparison will examine the differences and similarities between PHC policies, organisation and service delivery in the three countries.25