The objective of this article was to analyze the organizational capacity of the health centers to implement a BPS approach and to propose the intervention package of a BPS approach to be implemented in the analyzed health centers.
Using Jenna's adapted framework (Table 1), we observed that the different care structures are functioning effectively in providing care services to members of their community while reflecting clearly identified gaps per health center and by component for the Basic structures, people and values and Key processes. The ideal organizational level for the implementation of the BPS approach is not reached in the health centers analyzed
For the Basic structures, the results of the analysis show that the majority of health centers report an insufficiency in the application of Governance in relation to the sharing between staff members on the follow-up of people. In People and values, several health centers reported marked deficits in Organizational / Network Culture and in Focus on Patient- Centeredness & Engagement. In relation to the Key Processes, several health centers have not sufficiently developed Partnering with other health care structures as well as Delivering Care and Improving Quality in the health centers.
Analysis of data from the interviews, literature review and observation of the health centers shows that the organizational capacities associated with the domain of "People and values" are the least developed by the HCs to foster implementation of the BPS approach. Studies suggest that these capabilities namely Clinician Engagement & Leadership (27), Organizational / Network Culture (28), Focus on Patient- Centeredness & Engagement (28),(29), Commitment to Learning (29),(30) and Work Environment (31) should not be overlooked in the development of the person-centered care approach. Not considering the BPS approach into the normative organization of care works against the engagement of clinicians, the change of organizational culture of and the commitment for learning the BPS approach in the different health centers.
Qualitative studies on person-centered care also highlight the importance of Physical Features(32), Resources(33),Governance(34),(35),(36), Accountability(28),(37), Information Technology(38) et Organizational / Network(28) which are organizational capabilities under the domain "Basic structures" domain. Alongside the other components, the physical characteristics of the health centers stand out as an important structural element to be considered for the implementation of a person-centered approach due to the fact that they facilitate the continuity of care. The first line of care, as a point of contact with the population, is called upon to meet certain criteria in terms of the buildings and premises to be used for care activities. As the Ministry of Health's standards stipulate, medical care is possible in the various health centers. The presence of premises adapted to preserve people's privacy can facilitate follow-up activities and social care in functional health-care structures.
The financing of health structures is still a limiting factor in the implementation of care that involves a network for sharing and support experiences and supporting community members. The health centers are supported by funds from external donors, but this funding is most often directed towards the organization and support of specific care activities. In addition, health center workers are not regularly paid by the government, which would make them more interested in other financial incentives(39).
Organizational / Network design in the form of health mutuals or solidarity groups support the implementation of a BPS approach by promoting the use of health services and financial accessibility(40).
The media used in some health centers to store information on patients and their illness episodes can facilitate patient follow-up and the organization of psychosocial support when needed.
With the help of these tools, health center teams should ensure that the confidentiality of individuals is respected when organizing multidisciplinary follow-up of patients with psychosocial problems(41),(42).
Finally, studies show the importance of the components of the "Key processes" domain in the implementation of the BPS approach and in particular Partnering (43),(44), Delivering Care(45), Measuring Performance (46),(47) and Improving Quality (13),(46).
Collaboration with other health care providers and alternatives to modern medicine could ensure the success of a person-centered approach by enabling good coordination of care at all levels of the health system while ensuring good quality of care for community members (48).
Health center teams can certainly act on Improving Quality by insisting on interdisciplinarity between staff members and improving the leadership of the various health center managers supported by the other agents. Strong leadership motivates the implementation of an approach and thus consolidates its implementation(49).
Patient-reported information is probably the best way to measure the person-centered approach and its outcomes. Include patients as key informants would have been in the best position to determine whether the care they receive corresponds to their values, preferences and needs (26).
Moreover, only the patient knows whether he or she has received the desired level of information, and whether the information is understood and can be recalled. With respect to physical comfort, only patients can also report the severity of physical symptoms and their adequate relief from medication. The use of patient-reported measures of patient-centered care is essential to identify areas of health care where improvements are needed to enhance quality(50).
The components analyzed corroborate those of other studies including those of Luxford(28) and Shaller(46). These studies reveal that several organisational attributes and processes are key facilitators to making care more person-centered including strong and committed leadership, clear communication of the strategic vision to every member of the organization, active engagement of patients and families throughout the organization, a sustained focus on staff satisfaction in a supportive work environment for all employees, active measurement and systematic reporting of patient experiences, adequate resources for care delivery redesign, staff capacity building, accountability and incentives, a strong culture of change and learning, and the availability of supportive information technology.
Luxford mentions that the change in organizational culture from a 'provider orientation' to a 'patient orientation' as well as the time it took to move to such an orientation were the main barriers to the transforming the delivery of patient-centred care (28). Bokhour agrees, stressing the efforts that must be made at all levels of the health system on the basis that leadership must be the primum movens (49). To these barriers are added those reported in our previous study(21) namely lack of knowledge of BPS management by caregivers, home visits mainly used for disease control, solidarity initiatives not promoted locally, expected new resources and financial incentives and accountability summarized in the reporting of specific indicators.
The organizational analysis carried out in the health centers enabled us to highlight the deficits in the current care system, particularly in terms of values and key processes, which should be taken into account when implementing a BPS approach in the first line of care.
However, certain limitations in relation to our findings are worth mentioning. Our study explored the functioning of six health centers to understand how care is organized according to its current model and to identify characteristics specific to each health facility that may limit or facilitate a change in healthcare provision habits.
By an original using of organizational components, it allows for a better assessment of the functional elements of health centers that can give opportunity to the implementation of a BPS approach.
The fact that we did not interview the patients who use the services of the health centers did not allow us to obtain the users’ point of view on the organizational components to be improved in each structure.