Primary Care Service Delivery Redesign

Abstract

Primary Health Care (PHC) is considered capable of meeting 90% of people’s health needs and fundamental to achieving the Sustainable Development Number 3 of Good Health and Well-Being. Furthermore, there is abundant evidence of PHC’s positive health, equity, and economic outcomes in countries with well-resourced and well-functioning PHC platforms. However, despite the ample evidence regarding PHC’s effectiveness, PHC has also failed to deliver on its promises in several countries, particularly in LMICs. Because of this, it is increasingly recognized that to deliver on its promises, PHC must be of high-quality and high performing itself and, consequently, redesigned and reorganized. This thesis presents a set of themes and approaches to how the delivery of primary care can be redesigned and reorganized in LMICs to improve health outcomes based on an umbrella review of the evidence available in the peer-reviewed scientific literature on delivery arrangements, as defined by Cochrane’s Effective Practice and Organization, implemented in primary care settings and conducted in, or applicable to LMICs. Through the umbrella review, 1269 reviews were identified, and 84 of them were included. The findings of these reviews were grouped into the main delivery arrangements of the interventions that they evaluated, as well as according to their health categories (e.g., mental health). Some of the key findings of the umbrella review are the following: Nurses can take on responsibilities currently assigned to primary care physicians for highly prevalent conditions, such as NCD and HIV care; integration or linkages of care throughout the continuum of care consistently improved outcomes for some conditions; LHWs can substitute some in-service care with at-home or in-community care, as well as support and enhance the care for several conditions; and remote consulting was found effective for NCD care and mental health disorders. Through the analysis of these findings, it was identified that team-based delivery, proactive care, integration throughout the continuum of care, and leveraging mHealth and telemedicine for dialogue-based services were common elements of the design of highly effective interventions. Building from the findings, this project presents an approach to designing more effective PC models by using bundles of interventions, termed bundled primary care, for different conditions along the care continuum. The thesis concludes with a case study of Chiapas and Mexico City to illustrate the application and the suggested context-specific design of models of care in primary care. This project sets forth the idea that the provision of primary care should be designed in bundles of delivery arrangements or interventions at each step of the continuum of care, based on the best available evidence, delivered by a diverse group of providers.