■全面的初级保健是任何良好卫生系统的关键组成部分。设计师需要纳入(I)定义的人群的Starfield要求,(ii)全面范围,(三)服务的连续性,和(Iv)易于访问,以及解决几个相关问题。他们还需要记住,经典的英国GP模式,由于医生可用性的严峻挑战,对大多数发展中国家来说几乎是不可行的。有,因此,迫切需要他们找到一种提供可比的新方法,甚至可能优越,结果。传统社区卫生工作者(CHW)模型的下一个进化阶段很可能为他们提供一种这样的方法。
■我们认为CHW-健康使者的进化可能有四个阶段,医生延伸者,专注的提供者,和全面的供应商。在后两个阶段,医生变得更像是一个辅助人物,与前两个不同,医生在中心的地方。我们在尝试探索此阶段的程序的帮助下检查全面的提供者阶段(阶段4),使用Ragin开发的定性比较分析(QCA)。从4个星场原则开始,我们首先得出17个可能很重要的潜在特征。在仔细阅读这六个程序的基础上,然后,我们尝试确定适用于每个程序的特征。使用这些数据,我们查看所有计划,以确定哪些特征对这六个计划的成功很重要。使用真值表,然后,我们将具有80%以上特征的程序与具有80%以下特征的程序进行比较,来识别区分它们的特征。使用这些方法,我们分析了两个全球项目和四个印度项目。
■我们的分析表明,全球阿拉斯加和伊朗,印度DvaraHealth和SwasthyaSwaraj计划纳入了17个特征中的80%以上(>14)。在这17个中,本研究讨论的所有六个阶段4程序中都存在6个基本特征。其中包括(i)对CHW的密切监督;(ii)CHW未直接提供的治疗的护理协调;(iii)明确的转诊途径,用于指导转诊;(iv)药物管理,使患者立即和持续需要的所有药物与患者保持联系(需要与持牌医生合作的唯一特征);(v)主动护理:确保遵守治疗计划;(vi)成本效益。在程序之间进行比较时,我们发现,高绩效第四阶段计划的五个基本附加要素是(i)定义人口的全部成员;(ii)他们的综合评估,(iii)风险分层,以便将重点放在高风险个人上,(iv)使用精心定义的护理方案,(v)利用文化智慧向社区学习,并与他们合作,说服他们坚持治疗方案。
Comprehensive primary care is a key component of any good health system. Designers need to incorporate the Starfield 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 (stage 4) with the help of programs that have attempted to explore this stage, using Qualitative Comparative Analysis (QCA) developed by Ragin. Starting with the 4 Starfield 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 truth table, 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) close supervision of the CHW; (ii) care coordination for treatment not directly provided by the CHW; (iii) defined referral pathways to be used to guide referrals; (iv) medication management 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) proactive care: which ensures adherence to treatment plans; and (vi) cost-effectiveness 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 empanelment of a defined population; (ii) their comprehensive assessment, (iii) risk stratification so that the focus can be on the high-risk individuals, (iv) the use of carefully defined care protocols, and (v) the use of cultural wisdom both to learn from the community and to work with them to persuade them to adhere to treatment regimens.