Primary healthcare reform for chronic conditions in countries with high or very high human development index: A systematic review

Objective To address the growing burden of chronic disease globally, many countries have developed a national policy for primary healthcare reform. In some countries with high and very high human development index, evaluations of the implementation of these reforms have been published. To date, there has been no systematic review of these evaluations. The objectives of this review are to identify: (a) the vision for primary healthcare; (b) the features of primary healthcare reforms; and (c) evaluation findings of primary healthcare reforms. Methods A systematic literature review was conducted guided by the PRISMA statement. We searched for academic articles and grey literature from 1 March 2008 to 1 September 2020. Screening and data extraction were conducted by two authors. Descriptive analysis and narrative synthesis were applied. Results A vision for integrated primary healthcare shifting chronic disease management from specialist hospital services to primary care was found to require new organization and funding models such as collaborative primary healthcare networks and commissioning along with shared governance across health sectors. The need for general practitioner leadership and engagement to support primary healthcare reform was identified. Although there was evidence of barriers in progressing primary healthcare reform, evaluation results showed some positive outcomes, most notably shifts in services towards increased primary care access and utilization. Discussion A challenge in undertaking the review was the heterogeneity of articles with little consistency in how primary healthcare reform was evaluated and reported on across countries. Evaluation of national health reforms involves complex system-wide projects and is an area that needs further exploration and discussion to determine the most appropriate methodologies for collecting and analysing large-scale data with consideration for service and health outcomes.

Social Injustice by Prescription?

Since independence, Tanzania has instituted healthcare reforms in the quest for improving availability, quality, and social equity in access to public medical services. The extent to which the most recent healthcare reforms have impacted the existing patterns of medicinal prescription writing is largely opaque in the literature. This paper relies on data from two hospitals in Dar es Salaam. It emerges that the practice of categorising healthcare seekers into groups depending upon their varied health status and their entitlement to benefits has resulted in differential prescription allocations that might be interpreted as inequitable. The majority of very low income patients finance their healthcare through out-of-pocket payments and support of the Community Health Fund; this group receives a greater ratio of services with zero prescriptions, less poly-pharmacy and fewer prescribed generic medications than the proportion received by well-to-do patients with healthcare insurance. However, the medical and non-medical determinants of this differential in prescription allocation remain unclear, and so too, the ethical implications of such patterns in Tanzania’s out-patient medical service system are inconclusive.

Organizational Context and Healthcare Reforms: What Effect on the Professional Distress of Canadian Social Workers and Social Service Provision?

This study examined the lived experience of Canadian clinical social workers in light of the organizational context in which they work. The literature indicates an alarming rise of occupational psychological distress in social workers, which aligns with the rise of the neoliberal ideology within the Canadian healthcare sector. While we know that organizational constraints and structural reforms affect social worker’s workplace well-being, it remains unclear how these changes are represented by front-line practitioners and how they affect the provision of social services in healthcare settings. To deepen our understanding of this issue, we conducted a thematic analysis of thirty semi-directed interviews with social workers currently practicing in three Canadian cities (Ottawa, Moncton and Winnipeg). Discussions of daily work life, responsibilities, autonomy and subjective understandings of the social worker’s role revealed which organizational constraints were the most significant in everyday practice and how they relate to their professional identity and mandate. Provincial healthcare reforms were generally found to have negative effects on clinical social workers, whose struggles for recognition were impaired by the fundamentally neoliberal ideologies behind the large-scale restructuring of service provision, themselves at odds with the humanistic principles of social work. Our findings further suggest that structural changes under the New Public Management frame could be detrimental to both the quality of services provided by clinical social workers and their well-being. Overall, this investigation highlights the importance of organizational improvements in the workplace through systemic changes that would concurrently target managerial expectations, resources allocation, autonomy, work-life balance and respect for professional values.

The impact in Latin America of Basaglia and Italian psychiatric reform

Latin America is one of the regions of the world where Franco Basaglia’s vision found a more fertile ground and exerted a more fruitful and lasting influence. This chapter describes the process of transformation of mental healthcare that has taken place in Latin America in the last four decades. It analyses the main factors that made it possible, and discusses how it was influenced by Basaglia’s conceptualization of the reform. It critically reviews the advances and shortcomings of mental healthcare reforms carried out in the region, taking into consideration the specific political and social context of the countries in which they have taken place, as well as the direct and indirect influences of Basaglia’s concepts and the Italian reform. Finally, it describes how the implementation of the reforms in Latin America have contributed to the development of a comprehensive approach to mental healthcare that continues to be one of the most stimulating and comprehensive approaches in global mental health at the present time.