ABSTRACT

Ethiopia’s healthcare system strives to make numerous efforts to improve the primary healthcare system. The fragmentation of the public health and healthcare systems, challenges in accessing comprehensive care, and repeated epidemics are becoming increasingly complicated. The study aimed to examine the integration of essential public health functions in the primary care provided in the southern Ethiopia—Southern Nation and Nationalities People (SNNP) region. The readiness, opportunity, and barrier that improve effective integration were also explored.

The cross-sectional descriptive design was applied at 20 primary healthcare facilities in the SNNPR central zones to explore the degree of essential public health integration. Followed by the instrumental case study technique to build evidence on the factors that interfere with the integration. Data were collected using two questionnaires from patients and health service managers again, followed by an interview with an expert.

The primary health care facilities are implementing EPHFs to a certain degree that did not optimally integrate them into routine primary care services. Of the respondents, 30.8%(n=84) received optimal integrated health services. Whereas 40% (n=8) of health facilities sub-optimally integrated the four essentials function of public health in the PHC delivery (disease surveillance, health promotion, monitoring for preparedness response, and disease prevention). Plus, 100% (n=20) of health facilities lacked a clear organizational mandate, defined role and function, and strategic coordination to integrate the EPHFs. Besides, HFs have limited resources (financial, human, space, and material) to provide optimal integrated health services to the existing system.

This dissertation sought to open the dialogue between healthcare practitioners, stakeholders, and policymakers on integrated health services prioritizing EPHFs in the Ethiopian setting. Public health and primary care must continue to build partnerships and cascade new integration activities.

1.           Introduction

Many countries’ Global health actors advocate collaboration between healthcare organizations and other sectors to improve population health. As a good opportunity, the coronavirus disease (COVID-19) pandemic galvanized the rapid need for close public health and clinical care partnerships to combat the COVID-19 pandemic leveraging the way to think of a systematic and organizational strategy for connecting the two sectors. Primary Health Care (a set of principles and policies) includes both public health (PH) and primary care (PC) and has become a core component of effective health systems.[1]

Conventionally, primary care and public health are better positioned to tackle complex health problems internationally and locally.[2] In line with this, the World Health Organization’s primary healthcare model encompasses the following:

A whole-of-society approach to health that aims to maximize the level and distribution of health and wellbeing through three components: (a) primary care and essential public health functions as the core of integrated health services; (b) multisectoral policy and action; and (c) empowered people and communities.[3]

For this to happen, the Declaration of Astana in 2018 advanced the agenda to a renewed focus on primary health care (PHC), focusing on a broad inter-sectoral collaboration in dealing with community problems.[4] Indeed, the Resolution of World Health Assembly (WHA) 69.1 identified “essential public health functions (EPHFs) as the most cost-effective, comprehensive and sustainable way to enhance populations and individuals’ health and reduce the burden of disease.”[5] Therefore, the implication of stronger PHC—integrated EPHFs was elaborated in the following:

The operational framework for primary health care is a key consideration in providing public health services and building the health system’s resilience toward universal health coverage (UHC). Health security recommended investing in EPHFs as a key means for countries’ health systems recovery and transformation during COVID-19 and beyond.[6]

In line with the above statement, Ethiopia enacted the health services policy integration to enhance health service utilization by increasing accessibility and availability of all healthcare services at the PHC level.[7] Since then, the policy has evolved and served as the country-specific health delivery system designed to reach the rural communities where most people live.[8] In this context, prioritizing primary health care is becoming mandatory to sustain universal health coverage, moving beyond vertical programming toward integrated health systems.[9] And now, practically, there is a diagonal approach—mainly to disease control programs, health-systems strengthening, community empowerment, and multisectoral action in Ethiopia.[10]

In addition, Ethiopia has implemented Public Health Emergency Management (PHEM) since 2009 with a multi-hazard approach.[11] These strategies have enabled the Government to increase health services coverage and public health actions but didn’t improve the Population’s health status.[12]

The four-stage Health Sector Development Plan (HSDP) that was in place from 1995 to 2015 resulted in significant reforms across the Ethiopian health system—improved financial, geographic, and timely access to care in Ethiopia.[13] And health-service delivery is structured in a three-tier system: primary, secondary, and tertiary. The primary level of care includes primary hospitals, health centers (HCs), and health posts (HPs).[14] The primary health care unit (PHCU) comprises five satellite HPs (the lowest-level health system facility, village level) and referral HCs. Alongside this, the PHEM integrated disease surveillance system is designed to ensure rapid detection, notification, and investigation of any public health threats and preparedness related to logistic and fund administration, prompt response, and recovery from various public health emergencies.[15]

The primary level is the most accessible service-delivery point, where basic health care is provided and managed.[16] In 2019, there were 353 hospitals, 3,735 health centers, and 17,550 health posts.[17] As a result, access to primary health coverage has increased from 50.7% in 2000 to more than 90% in 2019, and the UHC service coverage index remains at 43%.[18] Regarding health service, the study conducted in Addis Ababa, Ethiopia, on integrated primary health care delivery revealed only 0.8% (n=7) received “optimal” integrated health care service and the curative health care provided by the health facilities.[19]

Therefore, this study aimed to explore integrating essential public health functions services with the primary care provided at the primary hospitals and health centers in the SNNPs’ central district. Plus, investigate factors that limit the provision of these integrated services, and propose a framework for enhancing the integration of public health function and primary care in Ethiopia.

i)          The lack of primary care and public health integrated service delivery

The health systems in most countries are based on an outdated “disease model,” focused on treating illnesses rather than disease prevention, which—cannot meet the individual, Population, and community health needs in today’s rapidly changing world.[20]

Ethiopia has been implementing primary healthcare focusing on fair access to health services, emphasizing prevention and the control of common diseases, and community participation.[21] However, the health policy for implementing the PHC system and integration was beleaguered and faced multiple challenges. Especially the lack of clear guidelines, strategies, and instructions on the national and sub-national-level policies hampered effective integration. It resulted in suboptimal care, repeated epidemic, higher cost due to duplication, and poor accessibility to care.[22]

Accordingly, multiple efforts were made to bolster the provision of health services to go beyond an emphasis on the hospital sector towards a more coordinated one that embraces primary and community care-led strategies for a more cost-effective way of delivering care.[23]   For instance, based on the Federal Ministry of Health mandate, the Ethiopian Public Health Institute has an integral role in strengthening the country’s health system. The EPHI has established a Public Health Emergency Management (PHEM) center for preparedness, early warning, response, and recovery of public health emergencies.[24] The PHEM system was structured and established from the national to the health post level. However, the existing surveillance system mainly operates passive surveillance that detects cases at the health facility level when patients seek treatment.[25]

Moreover, the MOH revised EHSP to reduce Ethiopia’s disease burden by making high-priority interventions available and affordable, including increasing equitable access to health services and improving the health system’s efficiency. However, the priority level for public health intervention, such as monitoring risk, mitigating the infectious disease, and preparing the system for the potential outbreak, left meager.[26]

Despite the growing progress, there are still high morbidity and mortality rates from preventable causes. Pneumonia and sepsis are Ethiopia’s leading causes of morbidity and mortality. Also, chronic non-communicable diseases are increasing, often associated with the aging of populations.[27] At the same time, many long-standing infectious diseases remain public health problems, and some, such as malaria, measles, cholera, and yellow fever, may worsen.

Moreover, the threat of emerging and re-emerging infectious diseases is increasing, raising national surveillance’s importance. On top of this, comprehensive service delivery remains poor due to the heightened focus on curative approaches in these health facilities.[28] The current public health surveillance system regularly collects health and health-related information from health facilities. However, health threats can occur in areas that existing health facilities cannot reach.[29]

To this end, the author argues that health systems founded on the primary healthcare approach can improve population health by providing advanced interventional public health and personal services through an integrated service. Arguably, the integration will be complex because public health and primary care have limited resources (e.g., funding and time), making integration an additional burden rather than an opportunity. Within this discussion, there is limited substantive evidence in Ethiopia about the crucial influences on successful Primary Care and EPHF integration, how these sectors relate, and the mechanisms occurring within these relationships.

ii)        Strengths of Primary Health Care System

The global health actors argued it could not solve public health problems successfully by modernizing only the health care system outside a broad socioeconomic and socio-cultural context.[30] Indeed, health is central to the 2030 Agenda for Sustainable Development—ensuring healthy lives and promoting well-being. Simultaneously, universal health coverage is part of the plan focusing on all individuals and communities receiving the necessary health services. It includes promotive, protective, preventive, curative, rehabilitative, and palliative of sufficient quality without experiencing financial hardship.[31]

According to the primary health care performance Initiative (PHCPI), the PHC is prioritized in the Ethiopian health system. The percentage of government health spending allocated to PHC was 80.2%. The healthcare budget allocated was US$ 1.6 billion in 2015.[32] This commitment shows the system demonstrated efficient delivery with better outcomes and greater equity in reducing maternal and under-five mortality per 1000 live births, reduced to 401 and 58 in 2017.[33]

Recently, as a piece of supporting evidence, the WHO, on the seventy-fifth assembly, analyzed the recommendation of strengthening preparedness for and response to the health emergency under the system with consistent priority themes, including the integration of core capacities for emergency preparedness, surveillance, and response within the broader health system and essential public health functions.[34]

Most importantly, strengthening PHC through integration allows health providers (e.g., physicians, nurses, and health workers) to use individual and community-level interventions to influence individual behavior and community health.[35] Similarly, Levesque et al. note collaboration between PC and PH can enable more effective individual and population services.[36] These are communicable disease prevention and control, health promotion and protection, improved chronic disease prevention and management, maternal and child health, youth health, women’s health, and working with vulnerable populations.[37]

Therefore, the goal for integrated health service in Ethiopia between primary care and essential public health can be seen as a strategy for improving access to comprehensive care. Notably, that meets community health needs, achieving improved service delivery methods, reducing preventable deaths, leveraging emergency preparedness, and enhancing access to health promotion information.

iii)      Theoretical Assumption for Integration Model

The author tried to adapt Martin-Misener R. et al.[38] and Lasker’s models of Primary care and Public Health collaborations adapted by Shahzad et al.[39] as a theoretical ground for this study since there is no widely implemented model for primary care and public health integration. Thus,  selected one of Lasker’s categorizations for collaboration intervention. The successful integrations could improve quality health service delivery and population health outcomes by applying a population perspective to medical practice.[40]

The ecological framework helps identify relevant systemic, organizational, and interpersonal factors and how essential public health function components and treatment interventions should be integrated with efforts to achieve an integrated health system model. Additionally, the framework assisted the development of instruments for this study and was further utilized during the data analysis process leading to the development of a modified framework specific to the context of the study.

Moreover, the author formulated the hypothesis: “Does integrating essential public health and primary care strengthen primary health care service delivery to improve population health?”

Therefore, the premise of this study underscores integrated health services, building on robust primary health care (PHC) and essential public health (PH). And propose a framework on how best to design and rapidly test evidence-based approaches that can address public health priorities, improve the health and wellbeing of the Population, and support evidence-informed policymaking in Ethiopia.

2.          METHODOLOGY

The author chose a research design of mixed quantitative and qualitative data collection methods to answer the research problem comprehensively. In the first step, the researcher deployed exploratory and descriptive designs to explore and measure how health promotion, protection, disease prevention, surveillance, and emergency preparedness and response intervention are practiced in the primary healthcare setting in the SNNP region of Ethiopia. A qualitative assessment followed the second part to explore various experts’ viewpoints about barriers and facilitators of integrating EPHF into PC.

The study was conducted in the SNNP region, with 13,611,965 inhabitants. i.e., the region has 11 zones and six special districts administration. Due to the challenge of accessibility, the author has chosen the region’s center as accessible to frame the site population and sample size. The surveyed central zone of the region were eight: Gamo, Gedeo, Guraghe, Hadiya, Halaba, Kembata Tembaro, Siltie, and Woliata. Therefore, the site population for the study was 405 primary healthcare facilities, stratified into 33 primary hospitals and  372 health centers.

The study used multistage sampling since, in the region, there are different administrative stages. A stratified and simple random sampling approach was used to select the sample site. Finally, 5% of HFs were taken as sample sites to participate in because they are located in dispersed districts and are somewhat challenging for the researcher to access quickly. Besides, a simple random sample (SRS) technique was deployed to randomly select the facilities from the two strata (primary hospital and health center). The site chosen sample was 20 health facilities (5 primary hospitals and 15 health centers) from the central zone targeting the medical Inpatient Department (IPD) and Outpatient Department (OPD) sections for data collection.

The author deployed systematic sampling to select patients at regular intervals. Then, a random table number randomly selected the first patient cardfirst patient card from the availab Consequently, the data collectors systematically interviewed every fifth patient during their exit until the sample size was obtained. Similarly, the author directly included the 20 health facilities managers to participate in the study. Moreover, the author applied a purposive sampling approach for the qualitative assessment to have 16 key informants to ensure representation across disciplines, positions, and sectors.

The sample size was determined using the single proportion formula below.  The first part considered a 36% proportion of patients receiving optimal and suboptimal health promotion and disease prevention services from the study conducted in Addis Ababa, Ethiopia.[41]  The confidence level is at 95% with a standard error of 5% and a z value of 95% confidence interval of 1.96. Thus, it was calculated n= (1.96)2x36x(100-36%)/25=355. In addition, the author added a 10% non-response rate to the sample size

for patients at the exit interview, making it 391. Moreover, the author considered a design effect of 2 from the previously conducted research to obtain the sample size needed under the stratified sampling of 781.

Furthermore, 20 health service managers or providers from the selected hospital and health center participated. Plus, for the second part of the study, sixteen disease surveillance, health facilities head, health promotion, and disease prevention experts were selected to participate in the second part. Overall, the study’s total sample size to have participated was 817.

2.1.      Validity and Reliability

The researcher conducted a literature review and derived questions from the Routine Health Information Systems (RHIS)— essential for patient management, facility management, disease surveillance, and monitoring of service provision and resource use.[42] Thus, public health specialists have reviewed and commented on the instruments for patient and manager groups before data collection. The author also applied Cronbach’s alpha test to assess a questionnaire’s internal consistency during pre-testing; the result was 0.788, which was adequate to be used as a standard instrument.

3.          RESULT

3.1.      Background of Respondent

The total number of participants was 817 in the study. Of these, 781 were patients, 20 were health facilities managers, and 16 key informants were involved. The response rates in the first part were (100%).

In the first part, the male respondents during the exit interview were 52.2% (n=408) and 47.8% (n=373) female. The mean age of the respondents was 34.6 years old. The resident of the respondent’s samples were allocated based on the population proportions of the zones’ towns, 19.5% (n=152) were from Woliata; 16.6% (n=130) were from Gurage; 16.3% (n= 127) Hadiya; 14.6% (n=114) Gamo; 11.3% (n=88) Gedeo; 9.7% (n=76) were from Siltie; 8.8% (n=69) were from Kembata Temabro and, 3.2% (n=25) were from Halaba.

Majority of the respondents, 47.5% (n=371) were attended primary or secondary school; 28.6% (n=224) were diploma and above; and 23.8% (n=186) were illiterate or attended no school. One-third of the respondents, 34.7% (n=271), have no income; 27.7% (n=216) have income above 4,500 Birr (equivalent to 88.34 USD) and 15.7% (n=123) earn below 1500 Birr (29.44 USD).

Three hundred sixty-six (46.9%) of respondents were attending the PHC facilities for outpatient visits for the onset of more than 24 hours and less than two weeks; 4.5% (n=35) were visiting for periodic health follow-ups; 13.4% (n=105) for emergency care less than 24 hours onset; 14% (n=109) came for chronic health care services more than two weeks complaints; 14.2% (n=111) came for maternal, and child health services; 5.1% (n=40) were inpatients attendants and, 7% (n=55) were attending for mental health, palliative and youth-friendly services collectively. And again, 13.4% (n=105) of respondents received free service, 36.2% (n=283) out-of-pocket payments, 49.8% (n=389) covered by community-based health insurance and 0.5% (n=4) don’t know. Of the respondents, 34.1% (n=266) can afford yearly check-ups for access to preventive and protective health, which cost up to 1000-2000 Birr, and 65.9% (n=515) could not afford the check-up cost.

From part one, 85% (n=17) of the health facilities manager respondents were males, and 15% (n=3) were females. Of the manager, 65% (n=13) were aged between 20-29 years old, 30% (n=6) were aged between 30-39 years old, and 5% (n=1) were aged between 40-49 years. The majority 60% (n=12) had 1-5 years of work experience, 35% (n=7) had 6-10 years of work experience, and 5% (n=1) had experience in 11-15 years. Concerning academic qualification, 65% (n=13) had a bachelor’s degree; 10% (n=2) had medical doctor qualifications; and 20% (n=4) were master. Of these, 5% (n=1) were at the capacity of medical director; 35% (n=7) managers; 35% (n=7) were department heads and 25% (n=5) were head nurses.

In part two, 16 experts in primary healthcare service participated, with years of experience ranging from 5 to 21. The qualification of the experts was 31.2% (n=5) master’s in public health, 31.2% (n=5) of medical doctors, 31.2% (n=5) nurse, and 6.2% (n=1) Ph.D. in public health.   Of the respondents, 31.2% (n=5) were from the health center, 18.7% (n=3) were from the hospital, 18.7% (n=3) were from the regional health bureau, and 31.2% (n=5) from the non-governmental organizations.

3.2.    The Primary Care Function

Of the patient respondents, 80% (n=625) stated the primary health care facilities as the first point of contact and accessible during their time of need; 73% (n=570) accessed the service with a reasonable waiting time. And 71.1% (n=555) found the health workers in the health facilities with fewer absentees and sufficient time for discussion, including 77.5% (n=605) of respondents who stated that they trust and value the health care service they received. Of the manager respondents, 100% (n=20) replied that their service delivery was first-contact accessibility according to their patient experience. Because the service provider is consistently available, respected by the community, and competent. Plus, 50% (n=10) stated they provide accessible and quality service for the community.

Of the facilities manager respondents, 50% (n=10) stated they did not provide optimal person-centered care, especially in engaging the service user to develop the skills to decide on their health and knowledge of health systems and services. Conversely, 68.4% (n=534) of patient respondents did not receive any additional information or education from the health facilities during their care, empowering them with the skill and knowledge to deal with social and cultural needs and preferences.

Regarding the continuity of care, 34.3% (n=268) received health services from the same clinician who consistently tried to fulfill their medical needs and personal context over time. Similarly, 20% (n=4) of managers stated they were working on delivering relational continuity of care that promotes communication with their target community to maintain continuity.

The health facilities manager responded that 70% (n=14) provide coordinated primary health care that integrates primary care with behavioral health. In addition, 55.4% (n=433) of the respondents replied they had received joint, integrated community health services from the health facilities’ health workers on disease prevention, including case management, screening, vaccination, health promotion, and infectious disease case search. Of the respondents visited by the health workers at home, 64.7% (n=280) were informed about covid prevention and screened; 15.2% (n=66) were informed about general health education and prevention of chronic disease, and 9.9% (n=43) educated about healthy pregnancy and health facilities delivery.

3.3.     Health Promotion and Disease Prevention

The health facilities manager respondents stated that 100% (n=20) of facilities provided disease prevention services for patients seeking curative care, and 70% (n=14) of health facilities charged the patients for some preventive services. Moreover, 95% (n=19) of health facilities provide periodic physical examinations as a disease prevention measure for patients seeking health services.

Of the respondents whose ages were above 40 years, 65% (n=136) were asked about the risk and prevention of hypertension; 20.2% (n=158) of the respondents replied that they were asked and advised about cancer risk; of these, 11% (n=86) were screened and advised for cervical cancer, 4.6% (n=36) asked about breast cancer, 4.1% (n=32) about the prostate, and 0.1% about colorectal. Moreover, 9.7% (n=76) replied they were asked about their smoking habits. Of these, 75% (n=57) were advised about the danger of cigarette smoking and its cancer risk.  Further, 20.4% (n=159) were asked about their harmful drinking habits and replied there were drinkers, too. Of the respondents who revealed they are alcohol drinkers, 48.4% (n=77) were advised about the risk factors for liver disease and the prevention mechanism, including undergoing a liver function test

Of the respondents, 48.8% (n=381) were assessed about the risk of respiratory disease symptoms such as a prolonged cough, wheezing, and shortness of breath and advised on the prevention mechanism.  Plus, 45.5% (n=355) were asked and advised on arthritis and joint pain problems. Furthermore, 39.2% (n=306) asked about the risk of kidney disease, and adjusting a diet, salt, and water intake can help prevent kidney disease.  Of the respondents, 37.1% (n=290) were asked and advised on diabetes; 18.4% (n=144) inspected their eyes, including the Snellen chart; 10.8% (n=84) examined their ears; 56.0% (n=434) were asked about their HIV test status and counseled.

Similarly, 65% (n=13) of facilities provide integrated health promotion services with other primary care for their patients without charging them. Of these, 50% (n=10) provided specific health education for the patients based on their needs. In line with this, the method for health promotion service delivery is 30% (n=6) using daily morning using mass media; 10% (n=2) using recorded audio material; whereas; 60% (n=12) using multiple methods of leaflets, posters, and one to one counseling.

Of the respondents, 36.5% (n=262) were asked if they had received adult vaccination as prevention against diseases and advised on the importance of the vaccine; 69.7% (n=544) were advised on regular physical exercise; 33.8% (n=264) were asked and advised on STI risk reduction; 11.1% (n=87) were given written materials in the form of leaflets and pamphlets for the purpose of health education and risk communication; 27.7% (216%) were asked and advised about their housing conditions.

3.4.    Disease Surveillance, Health Protection, and Health Security

All health facilities managers stated that 100% (n=20) of the health facilities conducted integrated disease surveillance for weekly and immediately notifiable diseases. Of the patient respondents, 35.6% (n=278) asked about their risk of contacting someone with infectious disease symptoms. Of these, 76.3% (n=212) had contact with covid-19 patients and were informed to avoid it; 6.8% (n=19) had contact with scabies cases; 4.7% (13) had contact with acute watery diarrhea cases; 2.6% (n=8) had contact with active TB patient; 7.6% (n=21) had contact with other types of infectious disease, and 1.8% (n=5) had contact with measles cases. Finally, 61.5% (n=471) were asked about malaria risk and preventive mechanisms.

In contrast, 100% (n=20) of primary healthcare facilities had no platform of health protection—to collaborate with various experts in identifying, preventing, and mitigating the impact of disease outbreaks and public health threats in the community. Furthermore, 85% (n=17) of health facilities had no strong public health system that monitors the preparedness for early detection, notifying them within 2 hours to the next level and response within 72 hours.

Table 1 Extent of essential public health function integrated into primary health care service provision to patients (n= 781)

PHC Service	Optimal	Sub Optimal	Not Provided
Health Promotion	11.1%(n=87)	30.3%(n=237)	58.5%(n=457)
Disease Prevention	7.29%(n=57)	16.3% (n=128)	76.3%(n=596)
Disease Surveillance	35.6%(n=278)	—	64.4% (n=503)
Health Protection	—	—	100% (n=781)
Health Security	5.12%(n=40)	35.8%(n=280)	59%(n=461)
Integrated Health Service	30.8%(n=84)	66.1%(n=180)	65.2%(n=509)

 

From the perspective of the health facilities manager, 40% (n=8) Sub optimally integrated the four essentials function of public health in the PHC delivery (disease surveillance, health promotion, monitoring for preparedness response, and disease prevention). In comparison, 60% (n=12) did not adequately incorporate the public health function into the primary health care delivery.

3.5.     Correlation between respondent’s socio-demographic, health-related characteristics and comprehensive primary health care

To assess the relationship of the variable with the biographical, health service provision, and patient-related characteristics, the researcher, applied Spearman’s rho technique to compute the correlation using an ordinal (ranking) scale.[43] In table 2 below, the Pearson correlational finding depicts a significant but weak correlation between independent and dependent variables in both positive and negative directions. There was a positive correlation between respondents receiving comprehensive primary health care and the age group (r=.100; p<0.01); respondents’ marital status (r=.164; p<0.01); respondents’ ability to afford routine check-ups (r=.265; p<0.01); respondents routine check-ups experience (r=.214; p<0.01); respondents proper referral linkage (r=.143; p<0.01); respondents advised on regular exercise (r=.301; p<0.01); respondents asked/received emotional support (r=.149; p<0.01); female respondents advised on healthy pregnancy (r=.161; p<0.01); respondents advised on adult vaccination (r=.173; p<0.01); respondents received leaflets/pamphlets about prevention, promotion & risk of disease (r=.139; p<0.01); respondents advised on housing condition (r=.209; p<0.01); respondents stressed for not having money to buy food (r=.074; p<0.05) and respondents received integrated community-level health care service (r=.169; p<0.01). Thus, the author concluded that PHC facilities provide more comprehensive integrated health care services to respondents in the higher age group than those younger, for respondents who were married than unmarried/divorced. The integrated, comprehensive care provision also linked to respondents who could afford routine checks-up than those who could not; to respondents who had experienced routine check-ups than those who did not; respondents who received proper referral service than those who did not; respondents who were advised on regular exercise than those who do not. Moreover, respondents received emotional support, women advised on healthy pregnancy, and respondents advised on adult vaccination received comprehensive, integrated services than those who did not. Furthermore, comprehensive, integrated service was provided better for respondents who received leaflets/pamphlets about prevention, promotion & risk of disease; advice on housing conditions; advice to those who stressed lack of money to buy food; and respondents who received community health service.

There was also a weak negative correlation between respondents receiving comprehensive primary health care and the occupation of the respondents (r=-0.091; p<0.05); respondents’ income (r=-0.132; p<0.05); respondents’ health bill coverage (r=-0.073; p<0.05) and respondents living in a crowded room (r=-0.097; p<0.01). Similarly, respondents with no occupation or income were less likely to receive integrated health care than those with an occupation or monthly income. Moreover, respondents who cannot cover the bill for health services and living conditions in a crowded room tend to receive less integrated service from the health facilities.

Therefore, addressing the factors positively associated with providing integrated services is feasible by tackling the aspects of providing comprehensive, integrated primary health care that includes essential public health functions. For example, the PHC was not providing integrated service for those who could not afford it and had no routine check-up experience. Moreover, for the patients, the factors for not receiving integrated health services are linked to no occupation, income, or inability to pay for health services; the primary healthcare facilities should look for solutions. Such as health insurance that enables them to access comprehensive services.

Table 2 Correlation between comprehensive PHC service delivery and socio-demographic and health-related characteristics (n= 781)

Variables	Correlation Coefficient
Age	Correlation Coefficient	.100**
	Sig. (2-tailed)	.005
	N	781
Marital Status	Correlation Coefficient	.164**
	Sig. (2-tailed)	.000
	N	781
Occupation	Correlation Coefficient	-.091*
	Sig. (2-tailed)	.011
	N	781
Income	Correlation Coefficient	-.132**
	Sig. (2-tailed)	.000
	N	781
Ability to afford routine check-ups	Correlation Coefficient	.265**
	Sig. (2-tailed)	.000
	N	781
Health Bill coverage	Correlation Coefficient	-.073*
	Sig. (2-tailed)	.041
	N	781
Routine check-ups experience	Correlation Coefficient	.214**
	Sig. (2-tailed)	.000
	N	781
Refferal Linkage	Correlation Coefficient	.143**
	Sig. (2-tailed)	.000
	N	781
Advice on regular exercise	Correlation Coefficient	0.301**
	Sig. (2-tailed)	.000
	N	781
Asked about smoking	Correlation Coefficient	.166**
	Sig. (2-tailed)	.000
	N	781
Asked about Alcohol consumption	Correlation Coefficient	.274**
	Sig. (2-tailed)	.000
	N	781
Asked about nutritional food intake	Correlation Coefficient	.263**
	Sig. (2-tailed)	.000
	N	781
Asked about the need for emotional support	Correlation Coefficient	.149**
	Sig. (2-tailed)	.000
	N	781
Advised on healthy pregnancy	Correlation Coefficient	.161**
	Sig. (2-tailed)	.009
	N	781
Counseled on family planning	Correlation Coefficient	.156**
	Sig. (2-tailed)	.010
	N	781
Advised on the importance of adult vaccine	Correlation Coefficient	.173**
	Sig. (2-tailed)	.000
	N	781
Advised on the importance of child vaccine	Correlation Coefficient	.100**
	Sig. (2-tailed)	.005
	N	781
Leaflet provided on prevention, promotion, and risk of infection	Correlation Coefficient	.139**
	Sig. (2-tailed)	.000
	N	781
Advised on housing condition	Correlation Coefficient	.209**
	Sig. (2-tailed)	.000
	N	781
Housing conditions living in a crowded room	Correlation Coefficient	-.097**
	Sig. (2-tailed)	.007
	N	781
Stressed for not having money to buy food	Correlation Coefficient	.074*
	Sig. (2-tailed)	.040
	N	781
Community health service by the HWs provided during the household visit	Correlation Coefficient	.169**
	Sig. (2-tailed)	.000
	N	781

*Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).

3.6.    Organizational Level Factors Influencing Integration of EPHF & PC

The organizational level factors and elements that influence the integration of essential public health functions into primary care include: None of 100% (n=20) of the respondents’ health facilities had the organizational mandate vision and goal that enables working to the optimal scope of integrated services. However, 100% (n=20) had a formalized communication process—information-sharing protocols, tools, and mechanisms such as quarterly meetings and supportive supervision with the public health institute as a communication mechanism to ensure regular opportunities to stay connected. On the other hand, 100% (n=20) of facilities had no strategic plan developed that standardized the coordinated clinical and program services, such as vaccine and screening activities, even if the PHC implemented these activities.

Of the respondents’ health facilities, 30% (n=6) have an incentive mechanism for staff motivation, equipping them with knowledge and skill to value and implement PH activities. Only 25% (n=5) of health facilities train the management of the health facilities to improve leadership qualities and skills for collaboration work. In comparison, 75% (n=15) had no organizational leader as a collaboration champion.

Regarding resources, 50% (n=10) of health facilities had the financial resources to work on limited public health activities from various partners and sources as an emergency response intervention after the emergency occurred. 95% (n=19) of HF also had enough time to work collaboratively with public health activities. Similarly, 85% (n=17) replied they had enough material and space to provide integrated, proactive, comprehensive health services. Plus, 60% (n=12) had enough human resources needed to implement integrated EPHFs with PC.

In this research, it is clear that the scope of inquiry needs to occur both within subdisciplines of public health (epidemiology, biostatistics, clinical trials, health communications, global health) and across the disciplines identified in the phase of inductive research.

3.7.     Expert’s responses on integrating EPHF into the health system framework

The experts indicated the following elements would increase the integration of EPHF in the primary health care framework:

Table 3. Experts’ viewpoints on the identified factors to integrating EPHFs into Primary care (n= 16)

Identified Factors to integrate Public Health in Primary care	No. of experts agreed	%
Establishing a clear mandate, vision, and goal as a structure in the health facility plan to operate integrated service	10	62.5
Developing a strategic plan at the PHC level enables IHS for coordinated and standardize clinical and program services	13	82.22
Strengthening strategic communication at the PHC facilities level can ensure a functional information system between PHC and public health institutes	13	82.22
Incentivization or equipping with continuous training improves EPHFs in the PHC operation	16	100
Training and support for managers can promote effective integrated health services	16	100
PHC staff has enough time to add EPHF without compromising the quality PC	16	100
Adding sufficient resources (human, material, and Space) in PHC can improve the integration of EPHF into the PC	3	18.7
Establishing a well-defined role and function for emergency management in the PHC risk plan could improve HIS	10	62.5

 

Overall, 62.5% of experts agreed that the recommended model recognized the EPHFs as an appropriate intervention to improve accessibility and responsiveness and prepare a system that protects against emergencies. In summary, this part represents the first attempt to gain experts’ opinions and explore the factors that interfere with integrating the core content of public health functions in developing a new primary healthcare model. Plus, the finding of this study emphasize the need for governments and stakeholders to continuously monitor and support, including a deeper analysis of the delivery of integrated EPHFs within the primary healthcare facilities.

 

4.          Discussion

The researcher believes that a fundamental cause of these problems is the absence of a systemic and organizational framework for primary health care connected directly to any robust strategy beyond enhancing the coordination work of the sectors.[44] Valaitis et al., in their study, described the major barriers to collaboration at the organizational level, including a lack of a common agenda, resource limitations, and a lack of knowledge and skills.[45]

The study has revealed that enhancing the integrated health service prioritized EPHF could justify the improved access to healthcare and population health. Of the respondents, 46.9% (n=366) attended the primary health care facilities for acute outpatient services, which can be considered an opportunity to provide proactive, comprehensive service to all ages by paying due attention to meeting their health needs.

Similarly, 80% (n=625) stated the primary health care facilities as the first point of contact, 73% (n=570) accessed the service with a reasonable waiting time, and 71.1% (n=555) found the health workers in the health facilities during their needs with less absentee accessible. This care-seeking behavior reflects a good public trust in the primary care system to effectively meet their expectations and needs. So, the regional health bureau must emphasize integration with public health functions.

In the case of disease prevention and health promotion, primary health care provided optimal disease prevention and curative care for only 7.29% (n=57) of patients. In contrast, optimal health promotion services were provided for 11.1% (n=87). Health facilities should strive to create supportive environments for disease prevention and health promotion services, strengthen the patient to choose healthy behaviors, and make changes that reduce the risk of developing.

100% (n=20) of health facilities assigned IDSR focal to collect and report the immediately and weekly monitored disease to the respective public health office. On top of that, 35.6% (n=278) of patients assessed their risk of contact with someone with infectious disease symptoms such as Covid-19, scabies, active TB, and acute watery diarrhea. The primary healthcare missed to detect the highest proportion of 64.4% (n=503) of the patient to conduct active cases search, which shows that disease surveillance officers alone may not be adequate for ACS; there is a need to define the role and function along with the curative care in the primary health care.

Preparedness programs enable healthcare facilities and communities to deal with emergencies effectively and appropriately. In this case, the preparedness for and response to health emergencies in primary health care include screening and counseling, risk communication on emergency preventive measures, and community preparedness and engagement on prevention, promotive, and protection for mitigating the impacts. To this end, the healthcare provider reached 5.12% (n=40) of patients effectively and informatively during the visit; 35.8% (n=280) were sub-optimal. The PHC facilities must improve the method of entering patients into their “emergency system” using the preparedness program.

The organizational level factors identified at the primary healthcare facilities level, there was no clear mandate or structure that guided for integration of essential public health components in the service delivery. Moreover, the health facilities had no strategic plan that helped in standardizing the collaborative work between clinical and program services, such as vaccine and screening activities, even if the PHC implemented the joint exercises. Mainly, lack of coordinated planning and challenges with multiple stakeholder engagement.

However, there is a formalized communication process between health facilities and public health institutes—information-sharing protocols, reporting tools, and mechanisms such as quarterly meetings and supportive supervision. There was a resource limitation in health facilities to work on public health risk monitoring and preparedness activities. But majority claim there is enough time to work collaboratively on public health activities within the routine.

5.          Conclusions and Recommendation

This study explored integrating essential public health functions with the primary care provided at primary hospitals and health centers in SNNPR central zone. It has also examined the factors linked with inadequate integrated services provision, thereby suggesting a framework for enhancing the integration of EPHF and PC care in Ethiopia. The results of this dissertation are to be seen as a general profile for further investigation.

The study’s recommendation emphasized the inclusion of essential public health practice and knowledge to be guided by a framework of widely accepted values and denotes the need to add the evidence-based output of academia to the integration of the practice in service delivery. The study has also focused on advocating the need for policy action to encourage the innovative approach that allows public health services to be prioritized in a way that integrates them into the health system strengthening agenda. Plus, addressing the current fragmented health care services at health facilities focused mainly on curative aspects.

Acknowledgment

Acknowledgments go to EUCLID University for granting ethical permission to conduct the research. In addition, Prof. Laurent Cleenewerck and Prof. Moyosola A. Bamidele for their insightful comments and assistance at every research project stage, including direct support of the methodology and analysis. Sincere appreciation goes to these colleagues from the south regional health bureau colleagues for supporting and facilitating permission and communication with health facilities and managers. And many thanks to all participants who participated in the study and made this research possible.

 

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