Research gaps in the organisation of primary healthcare in low-income and middle-income countries and ways to address them: a mixed-methods approach

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Abstract

Introduction

Since the Alma-Ata Declaration 40 years ago, primary healthcare (PHC) has made great advances, but there is insufficient research on models of care and outcomes—particularly for low-income and middle-income countries (LMICs). Systematic efforts to identify these gaps and develop evidence-based strategies for improvement in LMICs has been lacking. We report on a global effort to identify and prioritise the knowledge needs of PHC practitioners and researchers in LMICs about PHC organisation.

Methods

Three-round modified Delphi using web-based surveys. PHC practitioners and academics and policy-makers from LMICs sampled from global networks. First round (pre-Delphi survey) collated possible research questions to address knowledge gaps about organisation. Responses were independently coded, collapsed and synthesised. Round 2 (Delphi round 1) invited panellists to rate importance of each question. In round 3 (Delphi round 2), panellists ranked questions into final order of importance. Literature review conducted on 36 questions and gap map generated.

Results

Diverse range of practitioners and academics in LMICs from all global regions generated 744 questions for PHC organisation. In round 2, 36 synthesised questions on organisation were rated. In round 3, the top 16 questions were ranked to yield four prioritised questions in each area. Literature reviews confirmed gap in evidence on prioritised questions in LMICs.

Conclusion

In line with the 2018 Astana Declaration, this mixed-methods study has produced a unique list of essential gaps in our knowledge of how best to organise PHC, priority-ordered by LMIC expert informants capable of shaping their mitigation. Research teams in LMIC have developed implementation plans to answer the top four ranked research questions.

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Most cited references 16

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Approaches, tools and methods used for setting priorities in health research in the 21st century

Sachiyo Yoshida (2015)

Background Health research is difficult to prioritize, because the number of possible competing ideas for research is large, the outcome of research is inherently uncertain, and the impact of research is difficult to predict and measure. A systematic and transparent process to assist policy makers and research funding agencies in making investment decisions is a permanent need. Methods To obtain a better understanding of the landscape of approaches, tools and methods used to prioritize health research, I conducted a methodical review using the PubMed database for the period 2001–2014. Results A total of 165 relevant studies were identified, in which health research prioritization was conducted. They most frequently used the CHNRI method (26%), followed by the Delphi method (24%), James Lind Alliance method (8%), the Combined Approach Matrix (CAM) method (2%) and the Essential National Health Research method (<1%). About 3% of studies reported no clear process and provided very little information on how priorities were set. A further 19% used a combination of expert panel interview and focus group discussion (“consultation process”) but provided few details, while a further 2% used approaches that were clearly described, but not established as a replicable method. Online surveys that were not accompanied by face–to–face meetings were used in 8% of studies, while 9% used a combination of literature review and questionnaire to scrutinise the research options for prioritization among the participating experts. Conclusion The number of priority setting exercises in health research published in PubMed–indexed journals is increasing, especially since 2010. These exercises are being conducted at a variety of levels, ranging from the global level to the level of an individual hospital. With the development of new tools and methods which have a well–defined structure – such as the CHNRI method, James Lind Alliance Method and Combined Approach Matrix – it is likely that the Delphi method and non–replicable consultation processes will gradually be replaced by these emerging tools, which offer more transparency and replicability. It is too early to say whether any single method can address the needs of most exercises conducted at different levels, or if better results may perhaps be achieved through combination of components of several methods.

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How Are Health Research Priorities Set in Low and Middle Income Countries? A Systematic Review of Published Reports

Skye McGregor, Klara Henderson, John Kaldor (2014)

Background Priority setting is increasingly recognised as essential for directing finite resources to support research that maximizes public health benefits and drives health equity. Priority setting processes have been undertaken in a number of low- and middle-income country (LMIC) settings, using a variety of methods. We undertook a critical review of reports of these processes. Methods and Findings We searched electronic databases and online for peer reviewed and non-peer reviewed literature. We found 91 initiatives that met inclusion criteria. The majority took place at the global level (46%). For regional or national initiatives, most focused on Sub Saharan Africa (49%), followed by East Asia and Pacific (20%) and Latin America and the Caribbean (18%). A quarter of initiatives aimed to cover all areas of health research, with a further 20% covering communicable diseases. The most frequently used process was a conference or workshop to determine priorities (24%), followed by the Child Health and Nutrition Initiative (CHNRI) method (18%). The majority were initiated by an international organization or collaboration (46%). Researchers and government were the most frequently represented stakeholders. There was limited evidence of any implementation or follow-up strategies. Challenges in priority setting included engagement with stakeholders, data availability, and capacity constraints. Conclusions Health research priority setting (HRPS) has been undertaken in a variety of LMIC settings. While not consistently used, the application of established methods provides a means of identifying health research priorities in a repeatable and transparent manner. In the absence of published information on implementation or evaluation, it is not possible to assess what the impact and effectiveness of health research priority setting may have been.

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Global health and primary care research.

John W Beasley, Barbara Starfield, Chris Weel … (2015)

A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and resource-poor countries. Although a direct link has not been proven, we can reasonably expect better economic status when the health of the population is improved. Research in primary care is essential to inform practice and to develop better health systems and health policies. Among the challenges for primary care, especially in countries with limited resources, is the need to enhance the research capacity and to engage primary care clinicians in the research enterprise. These caregivers need to be an integral part of the research enterprise so the right questions will be asked, the results from research will be used in practice, and a scholarly and evidence-based approach to primary care will become the norm. The challenge of developing research in primary care can be met only by creating a strong infrastructure. This will include strengthening academic departments, enhancing links to researchers in other fields, improving training programs for future primary care researchers, developing more practice-based primary care research networks, and increasing funding for research in primary care. A greatly increased commitment on the part of international organizations both within and outside of primary care is needed, in particular those organizations involved with funding research. We provide suggestions to improve the global primary care research enterprise for the benefit of the world's population.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Glob Health

Journal ID (iso-abbrev): BMJ Glob Health

Journal ID (hwp): bmjgh

Journal ID (publisher-id): bmjgh

Title: BMJ Global Health

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2059-7908

Publication date Collection: 2019

Publication date (Electronic): 16 August 2019

Volume: 4

Issue: Suppl 8

Electronic Location Identifier: e001482

Affiliations

[1 ] departmentDepartment of General Practice and Primary Health Care , University of Auckland Faculty of Medical and Health Sciences , Auckland, New Zealand

[2 ] Robert Graham Center Policy Studies in Family Medicine and Primary Care , Washington, District of Columbia, USA

[3 ] McGill University , Montreal, Quebec, Canada

[4 ] departmentPrimary Care , University of East Anglia Norwich Medical School , Norwich, UK

[5 ] departmentDepartment of Family and Community Medicine , University of Toronto and Southgate Institute for Health , Toronto, Ontario, Canada

[6 ] Flinders University , Adelaide, South Australia, Australia

[7 ] Research and Policy of the American Board of Family Medicine , Lexington, Kentucky, USA

[8 ] departmentRadboud Institute of Health Research, Department Primary and Community Care , Radboud Universiteit Nijmegen , Nijmegen, The Netherlands

[9 ] departmentDepartment of Health Services Research and Policy , Australian National University , Acton, Australian Capital Territory, Australia

Author notes

[Correspondence to ] Professor Felicity Goodyear-Smith; f.goodyear-smith@ 123456auckland.ac.nz

Author information

Felicity Goodyear-Smith http://orcid.org/0000-0002-6657-9401

Richard D W Fortier http://orcid.org/0000-0001-5305-991X

Katherine Rouleau http://orcid.org/0000-0001-6970-7539

Chris van Weel http://orcid.org/0000-0003-3653-4701

Article

Publisher ID: bmjgh-2019-001482

DOI: 10.1136/bmjgh-2019-001482

PMC ID: 6703507

PubMed ID: 31497316

SO-VID: b7d2b403-a710-4e01-a43d-d0acce81e68f

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 06 February 2019

Date revision received : 15 April 2019

Date accepted : 19 April 2019

Funding

Funded by: Ariadne Labs;

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Keywords: primary health care,developing countries,knowledge,research gaps,financing healthcare: low and middle income countries,delphi,models of care

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Keywords: primary health care, developing countries, knowledge, research gaps, financing healthcare: low and middle income countries, delphi, models of care

Research gaps in the organisation of primary healthcare in low-income and middle-income countries and ways to address them: a mixed-methods approach

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Most cited references 16

Approaches, tools and methods used for setting priorities in health research in the 21st century

How Are Health Research Priorities Set in Low and Middle Income Countries? A Systematic Review of Published Reports

Global health and primary care research.

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