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

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Study Justification:
– Attainment of universal health coverage is feasible through strengthened primary health systems.
– A trained and equipped primary healthcare workforce is essential for comprehensive primary healthcare (CPHC).
– This study aims to understand primary healthcare team integration, composition, and organization in India, Mexico, and Uganda.
Highlights:
– The study will use a mixed-methods approach, combining qualitative and quantitative data.
– Data will be collected from 20 PHCs in India, 10 PHCs in Mexico, and 10 PHCs in Uganda.
– The study will assess PHC team composition, organization, and the delivery of comprehensive PHC.
– Results will be shared through presentations, publications, and conferences.
Recommendations:
– Review national and subnational policies on PHC team composition and organization.
– Describe the actual composition and organization of PHC teams.
– Assess the comprehensiveness of care provided by PHC teams.
– Conduct a comparative analysis of the relationship between PHC team composition and organization with the delivery of comprehensive PHC across the three countries.
Key Role Players:
– Researchers from The George Institute for Global Health, India
– School of Medicine Research Ethics Committee at Makerere University, Uganda
– Research, Ethics, and Biosecurity Committees of the Mexican National Institute of Public Health, Mexico
– Government officials and policymakers in India, Mexico, and Uganda
– Primary healthcare providers and managers in the selected PHCs
Cost Items for Planning Recommendations:
– Research team salaries and benefits
– Travel and accommodation expenses for data collection
– Data collection tools and equipment
– Data analysis software
– Publication and conference presentation costs

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study protocol outlines a mixed-methods approach that includes policy review, facility review, and key informant interviews to understand primary healthcare team integration in India, Mexico, and Uganda. The study design and methods are clearly described, and the use of multiple data sources enhances the validity of the findings. However, the abstract does not provide information on the sample size or selection criteria, which could affect the generalizability of the results. To improve the strength of the evidence, the abstract should include details on the sample size and selection process, as well as information on the data analysis plan and potential limitations of the study.

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

Based on the provided description, the study aims to understand primary healthcare (PHC) team integration, composition, and organization in the delivery of comprehensive primary healthcare (CPHC) in India, Mexico, and Uganda. The study will use a mixed-methods approach, combining qualitative and quantitative data, to achieve its objectives. Here are some potential innovations that could improve access to maternal health based on the study’s focus on PHC team composition and organization:

1. Task Shifting: Implementing task shifting strategies where certain responsibilities traditionally performed by doctors are delegated to other healthcare professionals, such as nurses, midwives, or community health workers. This can help alleviate the shortage of skilled healthcare providers and improve access to maternal health services.

2. Interprofessional Collaboration: Promoting collaboration and teamwork among different healthcare professionals within PHC teams. This can enhance the delivery of comprehensive maternal health services by leveraging the expertise of diverse professionals and ensuring coordinated care.

3. Training and Capacity Building: Investing in training programs to enhance the skills and knowledge of PHC team members in providing maternal health services. This can include specialized training in areas such as antenatal care, childbirth, postnatal care, and family planning.

4. Community Engagement: Involving the community in the design and implementation of maternal health programs. This can include community health workers or volunteers who can provide education, support, and referrals for maternal health services, as well as community-based initiatives to raise awareness and address cultural barriers.

5. Technology Integration: Utilizing technology, such as telemedicine or mobile health applications, to improve access to maternal health services in remote or underserved areas. This can enable remote consultations, health monitoring, and access to information and resources for pregnant women and new mothers.

6. Strengthening Referral Systems: Establishing effective referral systems between PHC facilities and higher-level healthcare facilities, ensuring seamless transitions and continuity of care for pregnant women and mothers with complications.

7. Quality Improvement Initiatives: Implementing quality improvement programs to enhance the overall quality of maternal health services provided by PHC teams. This can involve regular monitoring, evaluation, and feedback mechanisms to identify areas for improvement and ensure adherence to evidence-based practices.

It’s important to note that these recommendations are based on the general focus of the study on PHC team composition and organization. The specific context and needs of each country should be considered when implementing these innovations to improve access to maternal health.
AI Innovations Description
The study described aims to understand primary healthcare (PHC) team integration, composition, and organization in the delivery of comprehensive primary healthcare (CPHC) in India, Mexico, and Uganda. The study will use a mixed-methods approach, combining qualitative and quantitative data, to gain an in-depth understanding of PHC policies, team composition, organization, and the delivery of comprehensive PHC.

The study will involve several steps:

1. Policy review: A review of national and subnational policies on PHC team composition, organization, and expected comprehensiveness of PHC will be conducted. This will involve analyzing published and grey literature documents as well as relevant policy documents. The data collected will be analyzed qualitatively using NVivo software to create a narrative synthesis of each country’s policy on the areas of interest.

2. PHC facility review: A cross-sectional descriptive survey will be conducted in selected PHC facilities using the WHO Service Availability and Readiness Assessment (SARA) tool. This tool assesses the available infrastructure, equipment, and workforce of the facilities to determine their readiness to provide CPHC. Data will be collected on electronic devices using the Open Data Kit platform and analyzed to describe the health infrastructure, health workforce, and service utilization.

3. In-depth interviews: Semistructured in-depth interviews will be conducted with PHC workforce members, policymakers, and PHC managers to assess the comprehensiveness of care provided by PHC teams. The interviews will explore topics such as the role and recruitment of the workforce, training, supervision, performance evaluation, and the range of services provided. The interviews will be conducted in local languages and transcribed verbatim for analysis.

4. Comparative analysis: A comparative analysis will be conducted to understand the relationship between PHC team composition and organization and the delivery of comprehensive PHC across the three countries. This analysis will involve examining similarities and differences in PHC-related policies, workforce composition, organization, and service delivery.

The findings of this study will help identify policy and implementation gaps in PHC team integration and organization, and provide insights into different approaches to CPHC and PHC workforce organization in diverse low-income and middle-income countries. The results will be shared through presentations with governments, publications in peer-reviewed journals, and presentations at conferences.
AI Innovations Methodology
Based on the provided information, the study aims to understand primary healthcare (PHC) team integration, composition, and organization in the delivery of comprehensive primary healthcare (CPHC) in India, Mexico, and Uganda. The methodology involves a parallel mixed-methods approach, combining qualitative and quantitative data collection and analysis. Here is a brief description of the methodology to simulate the impact of recommendations on improving access to maternal health:

1. Review of national and subnational policies: A desktop review of published and grey literature documents, as well as relevant policy documents, will be conducted to identify government regulations or policies related to PHC workforce. The policies will be reviewed and data will be extracted using a standardized data collection tool template based on the Primary Health Care Performance Initiative (PHCPI) conceptual framework.

2. Assessment of PHC team composition and organization: A cross-sectional descriptive survey will be conducted in selected PHC facilities using the WHO Service Availability and Readiness Assessment (SARA) tool. Data collectors will be trained in SARA and will collect information on the infrastructure, composition of PHC teams, and services delivered to the community. Data will be collected using electronic devices and analyzed using descriptive methods.

3. Assessment of comprehensiveness of care provided by PHC teams: Semi-structured in-depth interviews (IDIs) will be conducted with PHC workforce, policy makers, and PHC managers to explore topics related to the role and recruitment of the workforce, training, supervision, performance evaluation, and comprehensiveness of services provided. Interviews will be conducted in local languages, transcribed, and analyzed using NVivo software. The qualitative data will be coded and analyzed using an inductive approach.

4. Comparative analysis: A comparative analysis will be conducted to understand the relationship between PHC team composition and organization and the delivery of comprehensive PHC across the three countries. This analysis will involve exploring similarities and differences in PHC-related policies, workforce composition, organization, and service delivery. Cross-country comparisons will be made to learn about different approaches to CPHC and PHC workforce organization.

By following this methodology, the study aims to gain an in-depth understanding of PHC team integration, composition, and organization in the delivery of comprehensive primary healthcare in India, Mexico, and Uganda. The findings can then be used to identify recommendations and simulate their potential impact on improving access to maternal health.

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