Innovations in Primary Health Care in the Americas

Special Edition of the Journal of Ambulatory Care Management:

April/June 2009, Volume 32, Issue 2 at: http://www.ambulatorycaremanagement.com/

From the preface:

“……For readers of this journal, it is no surprise that primary care has a long history of innovation both in the United States and elsewhere. In recent years, primary care has received increased attention worldwide, from the proliferation of interest in the concept of the medical home in the United States to the commemoration of the 30th anniversary of the Alma Ata Declaration in 2008 (American Academy of Family Physicians et al., 2007). This special edition of Journal of Ambulatory Care Management comprises a series of articles highlighting several innovative approaches to addressing primary care challenges in a variety of countries throughout the Americas.

The recent World Health Report 2008 summarized several steps necessary to revitalize a primary healthcare approach
to health systems' strengthening, including

(1) enhancing universal access to primary care,
(2) reforming the way primary care services are organized and delivered,
(3) integrating primary care with public health and public policy approaches to tackling the upstream determinants of health inequalities, and
(4) strengthening leadership and oversight of health systems and services to make them more relevant and responsive to population needs (World Health Organization, 2008). Each of the articles responds to one or more of these priority areas.

Several articles assess innovations in enhancing access to primary care services. Ruiz Chiriboga evaluates Ecuador's experience in expanding access to primary care through a national health insurance approach to providing free maternal and child care, finding that it was effective in increasing use of primary care services and effective in improving some outcomes, such as neonatal mortality. Báscolo and Yavich analyze the ways local governance structures helped determine variations in the effectiveness of the province of Buenos Aires' plan to provide health insurance to its citizens.

In terms of organizational reforms, Rubinstein and colleagues find that the use of pay-for-performance approaches can be effective in improving some aspects of primary care delivery but are careful to discuss how “generic” performance indicators adapted from countries such as the United Kingdom may need to be adapted to local contexts of their Buenos Aires–based health plan. Guanais and Macinko assess how the expansion of a community-based primary care program in Brazil may have altered hospital utilization patterns by reducing a number of ambulatory care–sensitive hospitalizations. Puig et al. address the challenges of assessing the quality of ambulatory care from the user's perspective, especially in the context of a health system with multiple payers and providers in the public, private, and nonprofit sectors in Mexico.

In addressing governance in primary healthcare, Shimizu and colleagues discuss an innovative feature of primary care in Brazil: local health councils. Their study suggests that such councils can improve public accountability but are still limited in their ability to affect health policy at the local level. Solicitation of public opinion on the development of health policies is another way to help align primary care with population health needs. White and Nanan discuss the results of British Colombia's attempts to engage the public in discussing the purpose and scope of primary healthcare and in prioritizing areas for reform efforts.

Finally, Macinko and colleagues review the evidence base for the effectiveness of primary healthcare on the health of populations living in low- and middle-income countries. They find that although the literature generally supports the contention that a strong primary healthcare approach enhances health outcomes, there is still considerable work to be done in systematically assessing experiences and building a more comprehensive evidence base on primary care and health outcomes.

Our intention for the issue is to provide a forum for facilitating international dialogue and exchange of experience on primary care organization, management, and effectiveness. Taken together, these articles show that primary care is alive and well in many countries of the Americas, and there are likely to be many additional experiences and lessons learned in other countries that have not been included here. Thus, this collection of articles should be viewed as the beginning of a process rather than a report on its conclusion.

We hope that the edition will help facilitate discussion and accelerate the exchange of information and practical tools to help strengthen primary care planning, practice, and policy in the United States and throughout the Americas. We encourage readers to reach out to contributors and begin to build this global primary care network. The many challenges faced by proponents of a primary care approach to strengthening health systems are more common than might first be imagined, and the diversity of ways to surmount such challenges provides a rich laboratory for innovation and cross-national learning….”
James Macinko, PhD, Guest Editor

Table of Contents:

Incremental Health System Reform Policy: Ecuador's Law for the Provision of Free Maternity and Child Care.
Sonia Ruiz Chiriboga, PhD
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

This study assessed the impact that the Ley de Maternidad Gratuita y Atencion a la Infancia (LMGAI) [Law for the Provision of Free Maternity and Child Care] in Ecuador has had on health services utilization and infant mortality. These outcomes were also examined by socioeconomic status. This retrospective study used demographic and health surveys, ENDEMAIN 1999 and 2004, with multivariate logistic regression to assess the impact post-LMGAI, controlling for mother's socioeconomic status, maternal and birth history, and demographic characteristics. Primary healthcare services utilization outcomes significantly improved post-LMGAI. Neonatal mortality decreased post-LMGAI. Further evaluation is needed as implementation continues to understand the expansion of primary healthcare services in future health system reforms.

Governance and the Effectiveness of the Buenos Aires Public Health Insurance Implementation Process.
Ernesto Báscolo, MSc, MPH; Natalia Yavich, MPH
Health Economics and Management Department, Juan Lazarte Health Institute, Rosario, Argentina.
This research was conducted with support from the Pan American Health Organization and the International Development Research Centre of Canada IDRC. The authors acknowledge the support of Roberto Bazzani, Eduardo Levcovitz, Soledad Urrutia, Claudia Travassos, and Víctor Martínez.

Multiple-case study was conducted to explain the relationship between the governance of the Buenos Aires Public Health Insurance (PHI) implementation process and its effectiveness in 8 municipalities. The heterogeneity in the effectiveness of PHI implementation was explained by the characteristics of the governance implementation process. The local health authorities' position on the PHI (favorable reception, formal acceptance, or rejection) influenced the nature of the articulation of the PHI within the municipal health system. Support for local management teams on the part of the municipal health and social development authorities affected the possibilities of implementing strategies to overcome unfavorable context-related conditions.

A Multimodal Strategy Based on Pay-Per-Performance to Improve Quality of Care of Family Practitioners in Argentina.
Adolfo Rubinstein, MD, MSc, PhD; Fernando Rubinstein, MPH, MD; Marcela Botargues, MD; Mariela Barani, MD; Karin Kopitowski, MD
Division of Family and Community Medicine, Hospital Italiano de Buenos Aires (Drs Adolfo Rubinstein, Fernando Rubinstein, Botargues, Barani, and Kopitowski), and Institute of Clinical Effectiveness and Health Policy (Drs Adolfo Rubinstein and Fernando Rubinstein), Buenos Aires, Argentina.
Pay-for-performance has become increasingly common to complement physician reimbursement. We designed a quality framework to measure family physicians' performance in a managed care setting in Buenos Aires. We aimed to assess the effectiveness of a multimodal intervention based on pay-for-performance, teamwork, continuous education, and audit and feedback to improve quality. After 2 years, a significant improvement was observed in most of the indicators measuring clinical effectiveness and some improvements were observed in other domains. Despite these results, a better performance matrix is needed to capture not only specific conditions but also other aspects like integrating, prioritizing, and personalizing care.

Primary Care and Avoidable Hospitalizations: Evidence From Brazil.
Frederico Guanais, PhD; James Macinko, PhD
Ministry of Social Development and Fight Against Hunger, Brasilia, Brazil (Dr Guanais); and Department of Nutrition, Food Studies, and Public Health, New York University, New York (Dr Macinko).

This article provides evidence of the effectiveness of family-based, community-oriented primary healthcare programs on the reduction of ambulatory care sensitive hospitalizations in Brazil. Between 1998 and 2002, expansions of the Family Health Program were associated with reductions in hospitalizations for diabetes mellitus and respiratory problems and Community Health Agents Program expansions were associated with reductions in circulatory conditions hospitalizations. Results were significant for only the female population only, suggesting that these programs were more effective in reaching women than men. Program coverage may have contributed to an estimated 126 000 fewer hospitalizations between 1999 and 2002, corresponding to potential savings of 63 million US dollars.

Assessing Quality Across Healthcare Subsystems in Mexico.
Andrea Puig, BSc; José A. Pagán, PhD; Rebeca Wong, PhD
Department of Health Care Management, the Wharton School, University of Pennsylvania, Philadelphia (Ms Puig); Department of Economics and Finance, University of Texas-Pan American, Edinburg (Dr Pagán); and Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston (Dr Wong).
This work was supported by a Consejo Nacional de Ciencia y Tecnología (CONACYT: Mexican National Council for Science and Technology

Recent healthcare reform efforts in Mexico have focused on the need to improve the efficiency and equity of a fragmented healthcare system. In light of these reform initiatives, there is a need to assess whether healthcare subsystems are effective at providing high-quality healthcare to all Mexicans. Nationally representative household survey data from the 2006 Encuesta Nacional de Salud y Nutrición (National Health and Nutrition Survey) were used to assess perceived healthcare quality across different subsystems. Using a sample of 7234 survey respondents, we found evidence of substantial heterogeneity in healthcare quality assessments across healthcare subsystems favoring private providers over social security institutions. These differences across subsystems remained even after adjusting for socioeconomic, demographic, and health factors. Our analysis suggests that improvements in efficiency and equity can be achieved by assessing the factors that contribute to heterogeneity in quality across subsystems.

Local Health Governance in Central Brazil.
Helena E. Shimizu, PhD; Jane Lynn G. Dytz, PhD; Maria da G. Lima, PhD; Marcio F. Pereira, MSc
Departments of Nursing (Drs Shimizu, Dytz, and Lima) and Collective Health (Ms Pereira), and the Nucleus for Studies in Public Health (NESP), University of Brasília, Brazil.

The study evaluates the performance of local health councils and their capacity to promote accountability and improve primary healthcare in central Brazil. An exploratory descriptive study was carried out with the application of questionnaires to analyze their organization and functioning. Results show that they approve health plans and management of public funds but have little autonomy to define health policies. They function mostly bureaucratically with minimum intersectorial articulation. Their capacity to improve delivery of healthcare is limited, but accountability has improved. Thus, it is necessary to enhance the autonomy of these councils, provide technical qualification, and enhance community participation.

A Conversation on Health in Canada: Revisiting Universality and the Centrality of Primary Healthcare.
Franklin White, MD; Debra Nanan, MPH
Pacific Health & Development Sciences, Inc (Dr White and Ms Nanan), and Centre for Health Leadership and Research, Royal Roads University (Ms Nanan), Victoria, British Columbia, Canada; and Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada (Dr White).

In 2006, British Columbia launched a public consultation on how to strengthen the health system. We report on the processes and the inputs and views submitted and examine the perceived importance of universality and primary healthcare (PHC). Public response revealed strong support for the Canada Health Act, which upholds 5 principles: public administration, comprehensiveness, universality, portability, and accessibility, and also a need for the system to be more open to innovation. It recognized that keys to improving population health and efficiency gains within the health system lie within the scope of PHC and that prevention, demand management, and self-management are all part of PHC.

The Impact of Primary Healthcare on Population Health in Low- and Middle-Income Countries.
James Macinko, PhD; Barbara Starfield, MD, MPH; Temitope Erinosho, PhD
Department of Nutrition, Food Studies, and Public Health, New York University, New York (Drs Macinko and Erinosho); and Department of Health Policy and Management, The Johns Hopkins Medical Institutions, Baltimore, Maryland (Dr Starfield). Dr Erinosho is now with Health Promotion Research Branch, National Cancer Institute, Rockville, Maryland.

This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC) on health outcomes in low- and middle-income countries. Studies were abstracted and assessed according to where they took place, the research design used, target population, primary care measures, and overall conclusions. Results indicate that the bulk of evidence for PHC effectiveness is focused on infant and child health, but there is also evidence of the positive role PHC has on population health over time. Although the peer-reviewed literature is lacking in rigorous experimental studies, a small number of relatively well-designed observational studies and the consistency of findings generally support the contention that an integrated approach to primary care can improve health. A few large-scale experiences also help identify elements of good practice.
The review concludes with several recommendations for future studies, including a focus on better conceptualizing and measuring PHC, further investigation into the advantages of comprehensive over selective PHC, need for experimental or quasi-experimental research designs that allow testing of the independent effect of primary care on outcomes over time, and a more detailed conceptual framework guiding overall evaluation design that places limits on the parameters under consideration and describes relationships among different levels and types of data likely to be collected in the evaluation process.

James Macinko, PhD Associate Professor of Public Health
Director, Global MPH Program New York University, Dept of Nutrition, Food Studies & Public Health
35 West 4th Street, 12th Floor New York NY 10012-1172
Phone (212) 998-5592| Fax (212) 995-4192 www.nyu.edu/mph - [james.macinko@nyu.edu]