Espinosa-González Ana Belén, Normand Charles
Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK.
Professor of the Economics of Palliative Care and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK.
BMJ Open. 2019 Jul 19;9(7):e027492. doi: 10.1136/bmjopen-2018-027492.
This study aims to assess the implementation of the Family Medicine Programme (FMP), which has taken place in Turkey from 2005 to 2010 as a set of comprehensive primary health care (PHC) reforms and involved changes in professional organisation (eg, family medicine specialisation) and service provision (eg, patients' registration list). Our particular interest is to identify the challenges and limitations that PHC physicians and academicians have encountered in the implementation of the FMP which could have influenced the delivery of care and utilisation of services.
We applied the framework method to analyse data obtained through semi-structured interviews conducted in the field. This qualitative approach involved the categorisation of raw data into a predefined framework, which comprised challenges and limitations identified in the literature, and the emergence of a new framework, whose categories corresponded to challenges and limitations identified through thematic analysis of our data.
PHC centres and academic departments from five Turkish provinces.
PHC physicians and academicians involved in training and/or research were invited to participate. 20 participants agreed to take part and, due to schedule limitations, 15 participants (seven PHC physicians and eight academicians) completed the interviews.
Shortcomings in the planning of the reforms, inadequate commitment to integration of PHC in the system and collateral effects of a market model in healthcare emerged as limitations to successful FMP implementation. Uncertainty about care quality and physicians' ethical values as well as perceptions of organisational injustice among healthcare workers were contributing challenges.
A systems thinking approach in the FMP design and implementation could help foresee and address these limitations. In decentralisation processes, such as FMP, shared governance by including PHC stakeholders in policy-making and planning could alleviate misalignment of interests and positively affect PHC performance, for example, by removing barriers to gatekeeping implementation.
本研究旨在评估家庭医学项目（FMP）的实施情况。该项目于2005年至2010年在土耳其实施，是一系列全面的初级卫生保健（PHC）改革，涉及专业组织（如家庭医学专业化）和服务提供（如患者登记名单）的变化。我们特别感兴趣的是确定初级卫生保健医生和学者在实施FMP过程中遇到的挑战和限制，这些挑战和限制可能影响了医疗服务的提供和服务的利用。
我们应用框架方法来分析通过在实地进行的半结构化访谈获得的数据。这种定性方法包括将原始数据分类到一个预定义的框架中，该框架包括文献中确定的挑战和限制，以及一个新框架的出现，其类别对应于通过对我们的数据进行主题分析确定的挑战和限制。
土耳其五个省份的初级卫生保健中心和学术部门。
邀请参与培训和/或研究的初级卫生保健医生和学者参加。20名参与者同意参加，由于时间安排限制，15名参与者（7名初级卫生保健医生和8名学者）完成了访谈。
改革规划中的缺陷、对初级卫生保健融入系统的承诺不足以及医疗保健市场模式的附带影响成为FMP成功实施的限制因素。护理质量和医生道德价值观的不确定性以及医护人员对组织不公正的看法是造成挑战的因素。
在FMP设计和实施中采用系统思维方法有助于预见和解决这些限制。在诸如FMP这样的分权过程中，通过让初级卫生保健利益相关者参与决策和规划来实现共同治理，可以缓解利益不一致的问题，并对初级卫生保健绩效产生积极影响，例如，通过消除守门人实施的障碍。
