PHC Quality Diagnostics tool

Primary Health Care (PHC) has been recognized globally for improving health outcomes, especially regarding maternal and child health. While significant efforts have been invested in the past few decades, especially since the Alma Ata Declaration (1978), in improving access to PHC, the focus has recently shifted towards improving the quality of said services. This moving has been no easy task, especially given the variability of meaning attributed to the concept of quality. If a PHC frontline manager does not clearly know what quality is, how can they successfully achieve it?

A model of PHC centred around the Alma Ata Declaration would function as a gateway to the wider health system in any given country. In Brazil, said model has been aspired to since the creation of the Unified Health System (SUS), in 1988. Said system is considered the largest public health system in the World, as it attends to approximately 70% of Brazil’s population (estimated at 212 million people in 2021). In the State of Bahia, where this concept would initially be piloted, the SUS is estimated to attend over 10 million people. PHC services, specifically, attend virtually the whole population (15,13 million, estimated in 2014), especially in the realization of generic government programmes, such as hygiene and sanitation, or epidemiological surveillance, as well as federal programmes benefiting the whole population individually, such as the National Immunization Programme.

Management issues have been widely associated with lower PHC services performance, therefore we have devised a tool that could guide managers - at the PHC team, PHC unit and municipal levels - in identifying shortfalls and determining priority setting for improving service delivery, and consequently improve the health of their population of reference.

At CIDACS, we are studying how the quality of PHC services is related to child health outcomes. Early results provide fundamental insights into how more adequate PHC infrastructure and services can decrease child mortality.

Based on our findings, we plan to develop an interactive tool - most likely a mobile device application - which could translate this knowledge into a practical tool for PHC managers - whether at the PHC team, PHC unit or municipal level.

In order to study how PHC quality affects child health outcomes, we have designed a theoretical model that aims to encompass the totality of PHC components that contribute to said outcomes. This model very practically identifies specific actions that should be completed to have adequate infrastructure, denoted as Building Blocks (BBs) in our model, available to PHC teams to adequately deliver their Clusters of Services (CSs) related to child health.

Within the PHC Quality Diagnostics APP, managers will be able to answer simple questions related to the resources (BBs) available to their teams, and the actions (CSs) the latter carry out when attending to the population. With these answers, the APP will generate tips for improving the areas assessed as “inadequate” (what is adequate and inadequate has been determined according to Brazilian legislation related to child care and PHC, as well as recommendations from the scientific literature).

Additionally, the APP will generate “adequacy scores”, in percentage terms, which would be calculated considering as weights for each PHC component the coefficients estimated by our model when assessing the PHC pathways that contribute to reducing child mortality. These would provide performance scores allowing PHC managers at all levels to identify the overall and component-specific performance of each PHC team and its evolution over time.

The app would serve both PHC managers, who would be aided in their decision-making and priority-setting for PHC performance improvement, and the population served by said services, which are expected to increase in quality, and, consequently, improve the population’s health.

Regarding the managers, their needs are currently under-served in that they have been evaluated for the past decade via the quality and productivity assessment of PHC services - but, studies show, they have not been clearly capacitated to efficiently invest in PHC quality improvement efforts.

As for the population, it will be given a stronger voice to relate their experience of PHC services. There are currently existing formal channels for the population to express their opinion on public services (via ombudsman), but these are rarely used and barely advertised. On the other hand, this app would be publicized through multiple posters at all PHC units.

This app would initially be piloted in the State of Bahia, in other words, part of the more disadvantaged population within Brazil (as part of the North-Eastern region). 

CIDACS is building an international name in terms of knowledge development related to the population's health and public policies' effect on the latter. It is an organisation with an ample variety of professional profiles - from epidemiologists and sociologists to statisticians and IT specialists, to communication experts and public health managers.

Various projects led by CIDACS have already established channels of collaboration with civil society representatives, and its professionals have worked closely with public health managers and decision-makers since the centre’s inception in 2016.

Focus Group discussions with frontline managers and other stakeholders (e.g. service users, community representatives, higher level managers from the municipal, state and federal level) will allow us to define additional details such as:

✔ Who should fill out the questions on the app, and with what frequency? (PHC team managers, supervised by municipal institutional support staff? Or municipal PHC supervisors? With a quartely frequency? Or monthly?)

✔ How to incorporate the opinion of service users? (e.g. having a code ticket for the service received, and filling out a brief satisfaction survey at a digital terminal in the health unit?)

✔ How to contemplate socio-economic context in the performance assessment? (e.g. using the Brazilian Deprivation area Index, developed by CIDACS)

This tool would be a direct output of research efforts, which were financed precisely with the purpose of knowledge creation. However, it is not common for there to be financing specifically for the pragmatic transformation of said knowledge into implementable measures. We see this Challenge as an opportunity to develop the prototype for what we believe could be a revolutionary tool that: a) transforms a very holistic term such as PHC into a list of concrete resources and actions; b) takes advantage of knowledge created from enormous natural cohorts, such as those that CIDACS works with by linking administrative socio-economic and health data; and, c) creates a direct link between research-generated knowledge into practical guidelines for implementers. We strongly believe in this tool, however, it is not something that easily falls within what is normally funded within the scope of public health research.

Whilst PHC is a very broad umbrella intervention that includes an extremely wide array of actions, this tool will help managers at all levels identify what are the key actions that will make a difference in the health of the population that they attend to.

We believe that the innovative nature of this tool resides in the direct and pragmatic translation of knowledge generated from research into concrete guidelines for implementers, and, in turn, in the low-cost generation of data on PHC performance, which can create further knowledge, in a continuous virtuous circle. 

If we won this Challenge, we could engage a team to develop a prototype of our PHC Diagnostics Tool over the next year. This year is election year, at the Federal and State levels, so next year would be a great moment to present our prototype to policy-makers - especially at the State level here in Bahia - and lobby for a pilot to be implemented over the next 2 or 3 years. With favorable results of said pilot, we could try to push the tool to the federal level before the next election. We will continuously present the tool, and the eventual results of a pilot, both nationally at policy-maker and academic events, and internationally through the extensive global partners network we already have established and are continuously expanding. 

Obtain financing for the development of a prototype

• Engage team for the development of a prototype
• Engage stakeholders for constructive collaboration on prototype
• Create prototype
• Present prototype to policy-makers and academics
• Present prototype to international partner community
• Design pilot programme in collaboration with policy-makers and other stakeholders
• Evaluate pilot programme
• Develop scale-up strategy in collaboration with policy-makers and other stakeholders

Theory of change based on a resources->activities->outputs->outcomes logic:

Resources: i. knowledge created from research; ii. technology to translate this knowledge into a tool; iii. existing collaboration network - both nationally and internationally.

Activities: i. translate knowledge created from research into app that can inform and guide PHC managers; ii. present and promote tool to stakeholders, including policy-makers, civil society, international partners; iii. provide technical support in the development of a pilot to implement the tool.

Outputs: i. PHC managers implement tha tool and use it to identify shortcomings; ii. PHC managers manage to prioritize quality improvement efforts; iii. data generated on PHC performance.

Outcomes: i. population receives better quality care; ii. population health improves; iii. further knowledge is created on PHC performance improvement.

The core technology of our solution would be an app for a mobile device. It will work offline as well as online, and will have a simple interface and be user-friendly. It will come with succinct and easy to understand guidelines, and will include a Help channel to support implementers that may be struggling with it.

The data we use to create the knowledge at the foundation of the tool is administrative data that is routinely collected by the government for other purposes, and then conceded to CIDACS for the purpose of knowledge creation.

CIDACS as an organization strives to be inclusive, as we believe growth lies in valuing diversity. Of course, in a society as unequal as Brazil, this is no easy feat. Nonetheless, we value, and thrive on, contributions from a variety of professionals and social groups. We even have an in-house Diversity and Equity Commission, which helps the organization navigate this complex process of inclusiveness and equity.

As a Research Lab of a government-affiliated organization, CIDACS primarily provides social value in the grooming of young researchers, and collaborations with policy-makers and civil society representatives.

CIDACS’ sustainability plan centers around the cementing of both national and international partnerships, as well as the provision of a Data Platform which will enable researchers to access CIDACS’ de-identified cohorts built from administrative databases.

CIDACS is growing exponentially thanks to its professionals’ dedication to the purpose of knowledge creation. It started as a single research project 6 years ago, and in the last 3 years the research team tripled in size - from approximately 50 researchers before the pandemic, to over 160 at the beginning of this year. Our financial sustainability lies in the excellence of the work that we develop, that is a national reference, and increasingly becoming known internationally.