Banyan Academy of Leadership in Mental Health, Chennai, India.
Dvara Health Finance, Chennai, India.
Front Public Health. 2023 May 30;11:1209673. doi: 10.3389/fpubh.2023.1209673. eCollection 2023.
Comprehensive primary care is a key component of any good health system. Designers need to incorporate the requirements of (i) a defined population, (ii) comprehensive range, (iii) continuity of services, and (iv) easy accessibility, as well as address several related issues. They also need to keep in mind that the classical British GP model, because of the severe challenges of physician availability, is all but infeasible for most developing countries. There is, therefore, an urgent need for them to find a new approach which offers comparable, possibly even superior, outcomes. The next evolutionary stage of the traditional Community health worker (CHW) model may well offer them one such approach.
We suggest that there are potentially four stages in the evolution of the CHW - the health messenger, the physician extender, the focused provider, and the comprehensive provider. In the latter two stages, the physician becomes much more of an adjunct figure, unlike in the first two, where the physician is at the center. We examine the comprehensive provider stage () with the help of programs that have attempted to explore this stage, using Qualitative Comparative Analysis (QCA) developed by Ragin. Starting with the 4 principles, we first arrive at 17 potential characteristics that could be important. Based on a careful reading of the six programs, we then attempt to determine the characteristics that apply to each program. Using this data, we look across all the programs to ascertain which of these characteristics are important to the success of these six programs. Using a , we then compare the programs which have more than 80% of the characteristics with those that have fewer than 80%, to identify characteristics that distinguish between them. Using these methods, we analyse two global programs and four Indian ones.
Our analysis suggests that the global Alaskan and Iranian, and the Indian Dvara Health and Swasthya Swaraj programs incorporate more than 80% (> 14) of the 17 characteristics. Of these 17, there are 6 foundational characteristics that are present in all the six stage 4 programs discussed in this study. These include (i) of the CHW; (ii) for treatment not directly provided by the CHW; (iii) to be used to guide referrals; (iv) which closes the loop with patients on all the medicines that they need both immediately and on an ongoing basis (the only characteristic which needs engagement with a licensed physician); (v) : which ensures adherence to treatment plans; and (vi) in the use of scarce physician and financial resources. When comparing between programs, we find that the five essential added elements of a high-performance stage 4 program are (i) the full of a defined population; (ii) their , (iii) so that the focus can be on the high-risk individuals, (iv) the use of carefully defined , and (v) the use of both to learn from the community and to work with them to persuade them to adhere to treatment regimens.
综合初级保健是任何良好卫生系统的关键组成部分。设计者需要将以下要求纳入考虑：(i) 明确的人群，(ii) 全面的服务范围，(iii) 服务的连续性，以及 (iv) 易于获得，同时解决几个相关问题。他们还需要记住，由于医生可用性的严峻挑战，经典的英国全科医生模式对于大多数发展中国家来说几乎是不可行的。因此，他们迫切需要找到一种新的方法，提供可比的、甚至更优的结果。传统社区卫生工作者 (CHW) 模式的下一个发展阶段可能为他们提供了这样一种方法。
我们认为，CHW 的发展可能有四个阶段——健康使者、医生延伸者、重点提供者和综合提供者。在后两个阶段，医生更像是一个辅助角色，而在前两个阶段，医生则是中心人物。我们借助 Ragin 开发的定性比较分析 (QCA) 来研究综合提供者阶段 ()，检验了试图探索这一阶段的项目。我们从四个原则出发，首先得出了 17 个可能重要的特征。根据对六个项目的仔细阅读，我们试图确定适用于每个项目的特征。利用这些数据，我们在所有项目中进行比较，以确定这些特征对这六个项目的成功有何重要性。然后，我们使用 ，将具有超过 80%特征的项目与具有少于 80%特征的项目进行比较，以确定区分它们的特征。利用这些方法，我们分析了两个全球性项目和四个印度项目。
我们的分析表明，全球的阿拉斯加和伊朗，以及印度的 Dvara 健康和斯瓦斯特亚·斯瓦拉杰项目包含了超过 80%（>14）的 17 个特征。在这 17 个特征中，有 6 个基础特征存在于本研究中讨论的所有六个第四阶段项目中。这些特征包括：(i) 对 CHW 的充分授权；(ii) 为 CHW 未直接提供的治疗提供资金；(iii) 用于指导转诊；(iv) 用于指导转诊；(iv) 与患者进行沟通，了解他们正在使用的所有药物，包括他们立即需要和持续需要的药物（这是唯一需要与持牌医生合作的特征）；(v) 监督：确保患者遵守治疗计划；以及 (vi) 合理利用稀缺的医生和财务资源。在项目之间进行比较时，我们发现一个高性能第四阶段项目的五个必要附加要素是：(i) 明确的人群的全面覆盖；(ii) 其社区卫生工作者的充分授权；(iii) 充分授权；(iii) 以便能够关注高危人群；(iv) 仔细定义的转诊标准；以及 (v) 社区参与和与社区合作，以促使他们遵守治疗方案。
