7b OPTIMIZING STAFFING MODELS AND TEAM STRUCTURE… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION THE CHALLENGE In many low- and middle-income countries (LMICs), rapid urbanization, population growth, and changing lifestyles are driving a growing burden fuelled by noncommunicable disease and injury, while poor sanitation and overcrowding create conditions for infectious pathogens to spread and thrive. This changing burden of disease is increasing pressure on the health work force, with many conditions going undiagnosed and thus untreated. Coping with these new threats will require transitioning toward models of primary care that support an expanded focus on health promotion, disease prevention, and integrated multidisciplinary care to ensure equitable health gains for all —including the urban poor. URBAN HEALTH NEEDS ARE RAPIDLY EVOLVING LMICs are facing rising incidence of noncommunicable disease (NCDs), leading to a growing burden of chronic illness, disability and multi-morbidity. Over 85 percent of NCD deaths before the age of 70 years (“premature deaths”) occur in LMICs, with the largest burdens arising from cardiovascular disease (heart disease and stroke), cancer, chronic lung disease, and diabetes.i Rapid urbanization and poverty increase exposure to cheap, energy-dense diets, and concentrate issues of road traffic injury, violence, and substance abuse.ii HIV/AIDS is caused by an infectious virus, yet its lifelong treatment more closely mimics chronic diseases like hypertension or diabetes. iii Infectious and chronic disease alike too often remain undiagnosed and untreated; for example, estimates suggest that, globally, 50% of all people with diabetes or hypertension are unaware of their condition.iv Japan Trust Fund for OCTOBER 2018 Scaling Up Nutrition IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION The Urban Poor Face Particular Vulnerabilities More people now live in cities than in rural areas. While urbanization offers opportunities for economic growth and improved living standards for some, chaotic urban development can also concentrate overcrowding and poverty, and further entrench inequality.v Estimates suggest that up to one-third of urban dwellers live in slums;vi in these communities, poverty is rife and health risks related to overcrowding, including air pollution and rapid spread of infectious diseases, are amplified.vii Individuals in these communities may live near health facilities and services but still not get the care they need because of financial or informational barriers. Staffing models for the frontline must ensure that populations at highest risk, such as the urban poor, are effectively engaged in care. Traditional Health Services Are Ill-Equipped to Confront These Pressures Responding to this changing burden of disease requires a fundamental shift in how primary health care is delivered: moving towards models of frontline care that incorporate health promotion, risk factor modification, and stratification of high-risk individuals. Current models of primary health care are largely ill-equipped to deal with these pressures: often, services are fragmented, continuity of care is poor, and treatment quality is low. New approaches should promote horizontal integration across providers and foster continuity of care to optimize management of chronic disease. Opportunistic case finding will also be increasingly important given the staggering number of people living with undiagnosed chronic disease. THE PATH FORWARD: BUILDING EFFECTIVE CARE TEAMS AT THE FRONTLINE Community-Based Primary Health Teams Multidisciplinary community-based health teams are increasingly recognized as a Evidence suggests central strategy for delivering high-quality and cost-effective primary health care. that team-based Evidence from high-income countries suggests that team-based service delivery service delivery models may offer advantages in facilitating higher patient satisfaction, continuity of models may care, and improved chronic disease management.viii As urbanization and the demographic transition create changing demands on primary health systems in low improve patient and middle-income settings, team-based models may allow greater integration of satisfaction, care care and optimization of coverage. Empanelling patients (i.e., assigning them to a continuity, and specific health care team, usually geographically based), can naturally improve chronic disease continuity of care as patients have repeated interaction with the same health care management. team.ix Among low- and middle-income countries, national programs in Brazil, Costa Rica, and Thailand are widely regarded as exemplars of team-based health care delivery. The Brazilian Family Health Strategy (FHS)—the best evaluated program among this cohort—created “family health teams” consisting of a doctor, nurse, nursing OCTOBER 2018 2 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION assistant, and 4-6 community-health workers (CHWs) that provide care to around 3,500 patients in a defined geographic region.x With over 37,000 family health teams now deployed, Brazil has demonstrated remarkable health gains, with studies linking the FHS to impressive reductions in child mortality,xi lower rates of hospitalizationxii and more equitable health care use.xiii Improving Cohesive Care: Optimizing Multidisciplinary Team Structure Despite the potential advantages of team-based models, there is limited rigorous Case studies have evidence to guide optimal construction of the primary care team; however, case highlighted the studies have highlighted the importance of clear delineation of roles and importance of responsibilities. Different health systems have taken different approaches to clear delineation constructing care teams and assigning tasks. In Costa Rica, for example, primary of roles and health teams (called the Equipos Básicos de Atención Integral de Salud, or EBAIS) responsibilities. consist of a doctor, nurse, CHW, and pharmacist, each with a clearly defined role and Different health set of responsibilities.xiv In this system, CHWs perform home visits to deliver health promotion and household screening; nurses undertake basic clinical tasks and systems have counselling; and physicians lead management of acute and chronic conditions.xv In taken different Thailand, primary health “matrix teams” consist of four care providers working at approaches to different levels within the health system: a family doctor (district hospital level), constructing care nurse (sub-district level), CHW (village level), and family member/caregiver.xvi teams and Recognizing the complexity of community support for chronic disease management, assigning tasks. other models have sought to broaden the primary health care team to include allied health practitioners, or to support greater integration with social services. From 2008, for example, the Brazil FHS introduced Family Health Support Centers (NASF) where interdisciplinary teams (including psychologists, for example) deliver extended care to support the family health team.xvii From Reactive Services to Proactive Health Care In urban areas, proactive frontline strategies can help address disparities in health outcomes by supporting basic health education and promotion, identifying subclinical illness, and helping sustain adherence to treatment. In Brazil, community heath agents are each assigned around 150 households for monthly visits, during which they offer health promotion and support basic health care.xviii In Costa Rica, CHWs within EBAIS teams calculate risk scores for individual households in their catchment areas; these scores are used to determine the frequency of future in-person visits.xix Similarly, a recent study in peri-urban Mali found that an intensive, proactive strategy of community case management was associated with dramatic reductions in under-5 mortality.xx OCTOBER 2018 3 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION SPOTLIGHT Brazil’s Family Health Strategy ► The Brazil Family Health Strategy (FHS, Programa Saude da Familia) was introduced in 1994 as part of a comprehensive health system reform to strengthen primary health care. Central to the FHS are family health teams as the basic unit for primary health care delivery. Each multidisciplinary team consists of a doctor, nurse, nursing assistant, and 4-6 community health workers (CHWs), with some teams also including social workers and/or dental professionals.xxi Together, the team is responsible for delivering primary health care to a geographically empanelled area with around 3,500 people.xxii While doctors and nurses provide medical treatment in fixed health facilities, CHWs proactively engage with up to 150 households, delivering health information, providing preventive care (such as childhood immunizations), and, more recently, expanding their focus to support chronic disease care within the community.xxiii This strategy represents a transition away from traditional physician-centric models, emphasising community-based, multidisciplinary delivery of care. The FHS was initially launched as a pilot program, but has since been scaled up with more than 37,000 family health teams deployed, including over 260,000 CHWs.xxiv By 2015, coverage of the program had reached 63% of the population.xxv Building upon the initial success of the program, more recent initiatives have focussed on expanding multidisciplinary services (including addition of nutritionists, psychologists, and pharmacists) through the NASF (“Family Health Support Centers”) in 2008,xxvi and improving the quality and accessibility of programs.xxvii Formal evaluation of the FHS has been complex due to the difficulty of disentangling effects from other concurrent initiatives, in particular the Bolsa Familia (conditional cash transfer program). A systematic review of 31 studies showed significant improvements in child mortality rates related to the FHS program ,xxviii with Aquino et al. showing reductions of up to 22% in infant mortality rate in areas with high program coverage, compared to only 13% in areas with lower coverage.xxix Other studies have linked the FHS to lower rates of hospitalization (for conditions that could otherwise be managed in the community),xxx and reduced mortality from cardiovascular disease and stroke,xxxi although ecological design limits quality of findings. The FHS also facilitated advances in health equity in Brazil, with increases in health care use greatest among the poorest Brazilians.xxxii The program appears remarkably cost-effective, with one study suggesting costs of $50 per capita (based on 40% program coverage at the time).xxxiii Ongoing challenges for Brazil include continuing expansion of program coverage and strengthening quality of care.xxxiv Costa Rica’s Equip Basico de Atencion Integral de Salud (EBAIS) ► To address health care quality deficits, Costa Rica embarked on major health system reform in the mid-1990s, creating a new primary care model centred around integrated primary health care teams (EBAIS teams). EBAIS multidisciplinary teams consist of a doctor, nurse, CHW (technical officer), medical clerk, and pharmacist, who deliver holistic primary health care to a geographically empaneled region of around 4500 OCTOBER 2018 4 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION people.xxxv Health teams are organized into integrated regional networks; groups of 5-15 EBAIS teams form “Health Areas”, which subsequently feed into secondary referral clinics with more advanced services.xxxvi Notably, the EBAIS model emphasized integration of care across multidisciplinary providers, bridging the gap from health promotion and screening to curative care.xxxvii There is clear role delineation across team members: with CHWs performing home and community visits with a focus on health promotion, nurses undertaking basic clinical tasks, and doctors providing more complex patient care. During proactive home visits, CHWs may screen household members to calculate household risk scores, which can then be used to determine the need for future home visits or referral to clinics for further medical input.xxxviii From 1994 to 2016, Costa Rica saw dramatic progress in healthcare access and outcomes. During this period, access to primary health care increased from 25% to 93%,xxxix while mortality from communicable diseases fell from 65 deaths per 100,000 (1990) to 4 per 100,000 in 2010.xl Significant reductions in child and adult mortality have also been reported.xli Despite these promising findings, overall data quality is limited and it is difficult to distinguish the effects of the EBAIS teams from health improvements related to economic growth. ENDNOTES i World Health Organization, “Noncommunicable Diseases,” World Health Organization, 2018, http://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases; Robert Beaglehole et al., “Improving the Prevention and Management of Chronic Disease in Low-Income and Middle-Income Countries: A Priority for Primary Health Care,” The Lancet 372, no. 9642 (September 13, 2008): P940-949, https://doi.org/10.1016/S0140-6736(08)61404-X. ii Knowledge Network on Urban Settings, “Our Cities, Our Health, Our Future: Acting on Social Determinants for Health Equity in Urban Settings,” WHO Commission on Social Determinants of Health (Japan: World Health Organization, 2008), http://www.who.int/social_determinants/resources/knus_final_report_052008.pdf. iii World Health Organization, “Global Health Observatory (GHO) Data,” World Health Organization, 2018, http://www.who.int/gho/en/. iv International Diabetes Federation, IDF Diabetes Atlas (Brussels, Bulgium: International Diabetes Foundation, 2017), http://www.diabetesatlas.org. v World Health Organization and 1000 Cities, 1000 Lives, “Why Urban Health Matters” (World Health Organization, 2010), http://www.who.int/world-health- day/2010/media/whd2010background.pdf. vi World Health Organization and 1000 Cities, 1000 Lives. vii Knowledge Network on Urban Settings, “Our Cities, Our Health, Our Future: Acting on Social Determinants for Health Equity in Urban Settings.” viii Anita D. Misra-Hebert et al., “A Team-Based Model of Primary Care Delivery and Physician-Patient Interaction,” The American Journal of Medicine 128, no. 9 (September 2015): 1025–28, https://doi.org/10.1016/j.amjmed.2015.03.035; Gillian Lê et al., “Can Service Integration Work for Universal Health Coverage? Evidence from around the Globe,” Health Policy (Amsterdam, Netherlands) 120, no. 4 (April 2016): 406–19, https://doi.org/10.1016/j.healthpol.2016.02.007; Shammima Jesmin, Amardeep Thind, and Sisira Sarma, “Does Team-Based Primary Health Care Improve Patients’ Perception of Outcomes? Evidence from the 2007-08 Canadian Survey of Experiences with Primary Health,” Health Policy (Amsterdam, Netherlands) 105, no. 1 (April 2012): 71–83, https://doi.org/10.1016/j.healthpol.2012.01.008; Kevin Grumbach and Thomas Bodenheimer, “Can Health Care Teams Improve Primary Care Practice?,” JAMA 291, no. 10 (March 10, 2004): 1246–51, https://doi.org/10.1001/jama.291.10.1246. OCTOBER 2018 5 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION ix PHCPI, “Primary Health Care System Performance in Low and Middle-Income Countries: A Rapid Scoping Review of the Evidence from 2010-2017” (Primary Health Care Measurement and Implementation Research Consortium, 2017). x James Macinko, Matthew J. Harris, and Marcia Gomes Rocha, “Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ): Fulfilling the Potential of the World’s Largest Payment for Performance System in Primary Care,” The Journal of Ambulatory Care Management 40 Suppl. 2 Supplement, The Brazilian National Program for Improving Primary Care Access and Quality (PMAQ) (June 2017): S4–11, https://doi.org/10.1097/JAC.0000000000000189; James Macinko and Matthew J. Harris, “Brazil’s Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System,” New England Journal of Medicine 372, no. 23 (June 4, 2015): 2177–81, https://doi.org/10.1056/NEJMp1501140. xi Mayara Lisboa Bastos et al., “The Impact of the Brazilian Family Health on Selected Primary Care Sensitive Conditions: A Systematic Review,” ed. Hajo Zeeb, PLOS ONE 12, no. 8 (August 7, 2017): e0182336, https://doi.org/10.1371/journal.pone.0182336. xii James Macinko et al., “The Influence of Primary Care and Hospital Supply on Ambulatory Care- Sensitive Hospitalizations among Adults in Brazil, 1999-2007,” American Journal of Public Health 101, no. 10 (October 2011): 1963–70, https://doi.org/10.2105/AJPH.2010.198887; James Macinko et al., “Major Expansion of Primary Care in Brazil Linked to Decline in Unnecessary Hospitalization,” Health Affairs (Project Hope) 29, no. 12 (December 2010): 2149–60, https://doi.org/10.1377/hlthaff.2010.0251. xiii James Macinko and Maria Fernanda Lima-Costa, “Horizontal Equity in Health Care Utilization in Brazil, 1998–2008,” International Journal for Equity in Health 11, no. 1 (June 21, 2012): 33, https://doi.org/10.1186/1475-9276-11-33. xiv M. Pesec et al., “Primary Health Care That Works: The Costa Rican Experience,” Health Affairs, Millwood, 36, no. 3 (March 2017): 531–38, https://doi.org/10.1377/hlthaff.2016.1319. xv Pesec et al. xvi The Alliance for Health Policy and Systems Research and Bill & Melinda Gates Foundation, “Report of the Expert Consultation on Primary Care Systems Profiles & Performance (PRIMASYS)” (Geneva, July 2015). xvii Macinko, Harris, and Rocha, “Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ).” xviii Macinko and Harris, “Brazil’s Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System.” xix Pesec et al., “Primary Health Care That Works.” xx Ari D. Johnson et al., “Proactive Community Case Management and Child Survival in Periurban Mali,” BMJ Global Health 3, no. 2 (March 2018): e000634, https://doi.org/10.1136/bmjgh-2017- 000634. xxi Macinko, Harris, and Rocha, “Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ)”; Bastos et al., “The Impact of the Brazilian Family Health on Selected Primary Care Sensitive Conditions”; Amanda Glassman and Miriam Temin, eds., “Tackling Disease at Its Roots: Brazil’s Programa Saude Da Familia,” in Millions Saved: New Cases of Proven Success in Global Health (Washington, DC: Brookings Institution Press, 2016), https://www.jstor.org/stable/10.7864/j.ctt1dgn643; James Macinko et al., “Evaluation of the Impact of the Family Health Program on Infant Mortality in Brazil, 1990-2002,” Journal of Epidemiology and Community Health 60, no. 1 (January 2006): 13–19, https://doi.org/10.1136/jech.2005.038323. xxii Macinko, Harris, and Rocha, “Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ)”; Bastos et al., “The Impact of the Brazilian Family Health on Selected Primary Care Sensitive Conditions.” xxiii Glassman and Temin, “Tackling Disease at Its Roots: Brazil’s Programa Saude Da Familia.” xxiv Glassman and Temin. xxv Bastos et al., “The Impact of the Brazilian Family Health on Selected Primary Care Sensitive Conditions.” xxvi Thaís Titon de Souza et al., “Evaluation of the Family Health Support Centers Focusing on the Integration to Supported Teams,” Revista de Saúde Pública 52 (2018), https://doi.org/10.11606/s1518-8787.2018052000122. xxvii Macinko, Harris, and Rocha, “Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ).” OCTOBER 2018 6 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION xxviii Bastos et al., “The Impact of the Brazilian Family Health on Selected Primary Care Sensitive Conditions.” xxix Rosana Aquino, Nelson F. de Oliveira, and Mauricio L. Barreto, “Impact of the Family Health Program on Infant Mortality in Brazilian Municipalities,” American Journal of Public Health 99, no. 1 (January 2009): 87–93, https://doi.org/10.2105/AJPH.2007.127480. xxx Bastos et al., “The Impact of the Brazilian Family Health on Selected Primary Care Sensitive Conditions”; Macinko et al., “The Influence of Primary Care and Hospital Supply on Ambulatory Care-Sensitive Hospitalizations among Adults in Brazil, 1999-2007”; Macinko et al., “Major Expansion of Primary Care in Brazil Linked to Decline in Unnecessary Hospitalization.” xxxi Davide Rasella et al., “Impact of Primary Health Care on Mortality from Heart and Cerebrovascular Diseases in Brazil: A Nationwide Analysis of Longitudinal Data,” BMJ 349 (July 3, 2014): g4014, https://doi.org/10.1136/bmj.g4014. xxxii Macinko and Lima-Costa, “Horizontal Equity in Health Care Utilization in Brazil, 1998–2008.” xxxiii Romero Rocha and Rodrigo R. 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