Two decades of primary health care expansion in Latin America: evaluation and forecasting study for health-related SDGs

The recent Astana Declaration emphasizes the importance of health systems based on a strong Primary Health Care (PHC), which should be part and coordinate multisectoral actions addressing economic and social determinants of health. PHC should be one of the main hubs of the network of interventions composing the welfare state, synergistically connecting the healthcare system with social and poverty-relief interventions. Several Latin American countries (LAC) have implemented and expanded over the last two decades PHC, healthcare system components, and social assistance interventions with different degrees of intensity and connection. However, recent economic crisis and austerity measures are threatening the consolidation of public healthcare systems and of the welfare state in the majority of LAC. Some evaluations of PHC in a limited number of countries have found positive effects on specific health outcomes, but no study has performed multi-country comparisons or adopted a comprehensive approach for the estimation of the effects -including long-term effects- of PHC programs on a broad range of health outcomes (notifiable diseases, hospitalizations and mortality - overall and for specific causes and age-groups), measuring its synergistic impact with the other healthcare system components and with social assistance, in particular conditional (CCT) and social pensions (SP). Similarly, no research has measured the influence of PHC coverage duration and of contextual factors such as local governance indexes or human development index. While the synergistic impact of PHC with CCT is expected because the health conditionalities should be attended in the PHC units, the interaction effects of SP with PHC are plausible because of the physiological effects of the relief from poverty, in particular in the pathways of prevention and cure. The aim of this project is to systematically address all these issues for a comprehensive evaluation of the effectiveness of PHC on the broadest possible range of morbidity and mortality outcomes in Brazil, Colombia, Ecuador and Mexico (BCEM). The comparative evaluation will be possible because BCEM have undertaken different PHC, healthcare and social assistance implementations during the last two decades. Aggregate and individual-level, longitudinal and cross-sectional, socioeconomic and health data from a wide range of sources in each BCEM will be merged and the most robust quasi-experimental designs will be used to evaluate these comprehensive PHC impacts on such a wide number of outcomes. With the large amount of data and parameters from all the retrospective impact evaluations, and using a microsimulation modelling approach -arguably one of the most accurate forecasting techniques up-to-date - we will forecast the effects of different PHC coverage reductions - due to budget constraints or austerity measures - in conjunction with the above mentioned welfare state components, versus scenarios of coverage stabilization or coverage expansion, evaluating differences in a broad range of health outcomes in BCEM up to 2030. Using all the granularity of data and effect estimates, we will evaluate the most effective
PHC, CCT and SP expansion coverage dynamics -on specific subpopulations- in the next years. We will also calibrate and select the best policy scenarios for the reduction of health inequalities and the achievement of each health-related SDG in each BCME.
This project will also consolidate a network of researchers in LAC and will develop algorithms and methods to integrate ex-post and ex-ante impact evaluations of public policies using ecologic and individual-level data. All the datasets created in the study will be made available in an open dynamic platform of comprehensive LAC data from healthcare systems, social interventions and health outcome, and the research network will use the platform and the developed algorithms to stimulate continuous cycles of monitoring, evaluation and forecasting.

A strong Primary Health Care(PHC) is essential for achieving Universal Health Coverage(UHC) and should be an integral part of and coordinate multi-sectoral actions addressing economic and social determinants of health, acting synergistically with social interventions such as cash transfer programmes(CCT) and social pensions(SP). The evidence of PHC effectiveness in LMICs is sparse, with most studies conducted in North America and Europe, moreover PHC's long-term effects and synergistic interactions with social assistance interventions have rarely been evaluated. We will perform a multi-country study in Brazil, Colombia, Ecuador and Mexico (BCEM) with the aim to: 1)Evaluate of the effects of PHC coverage on all the range of notifiable diseases, hospitalizations and mortality (overall, for specific causes and age-groups) over the last two decades using ecologic longitudinal data at municipal level in each BCEM from 2000 to 2018. We will also measure the effects of duration of PHC coverage (expressed as the average coverage of the previous years) and the presence of long-term effects (with lag and age-cohorts analyses). 2)We will evaluate the synergistic effects of PHC with the other healthcare system components (secondary and tertiary levels of care),CCT and SP on the full range of health outcomes at the municipal level. We will also measure as local factors, such as human development index(HDI) or local administration capacity, affected the effectiveness of PHC, paying attention to the heterogeneity of effects within and between countries.3)Using individual-level data from national health cohorts, surveys and censuses and multilevel modelling we will evaluate the granularity of PHC effectiveness on health outcomes in all BCEM.4)Using an integrated microsimulation approach we will forecast the effects of PHC coverage changes, calibrating the best implementation scenarios for achievement of health-related SDGs and reduction of health inequalities in BCEM up to 2030.

Our project will produce multiple impacts on health research and health policy in BCEM, Latin American Countries (LAC) and other LMIC. Its ambition is justified by the fact that all the investigators have already a strong track record on the subjects and methods proposed, have already worked with the majority of these data and have already evaluated these policies in their own country. Our project has the potential to provide important and timely evidences with an evaluation effort innovative and unique on its comprehensiveness from several points of view: 1) the multi-country perspective, 2) the evaluation of immediate and long term effects on the widest range of health outcomes possible, 3) the broad evaluation of synergies with other interventions and 4) the integrated forecast of several policy scenarios.

The project will produce several peer-reviewed papers, working papers and PAHO/UNDP reports, which will be extremely important for health system researchers and experts of primary care, cash transfer programs and social pensions. They will help to develop a new understanding of PHC effectiveness, and the importance of long-term and contextual effects. They will show where PHC can be more effective, and where its synergistic impact with poverty-relief programs is stronger. Besides the intervention-specific interests, our project could stimulate a new generation of studies with an innovative comprehensive approach, which evaluates multiple synergistic interventions on several outcomes, and integrates retrospective evaluation with forecasting models.

The outcomes from this research study, which will be disseminated also in local scientific journals in English, Portuguese and Spanish, not only have the potential to influence global understanding of PHC programmes, but also establish a strong model for policy-maker and researcher relationships. This integrated research package will ensure policy-maker and implementers focus specific research questions to maximum relevance, whilst results can be quickly disseminated and inform implementation actions on the ground. There will be capacity building through joint management and sharing of different data sources, collaborative efforts towards a joint research goal, and improvements in the interface of the research translation pathway. During the continue collaboration along the project, BCEM high-level managers of the government will also evaluate and better understand the potentialities of the mathematical modelling and policy scenarios forecasting for more evidence-based policy-making processes.

The project will create a novel and multi-country dataset that links welfare benefit, health care, morbidity and mortality data from administrative and other secondary sources, combining aggregate and individual level, that will be available for the scientific community, and in particular LAC researchers. By fostering links with researchers with strong experience in micro-simulation and primary care, the project will expand local research capacity in BCEM, LAC and within partner institutions in the US and EU. The dataset will be associated with the integrated platform for evaluation and forecasting (IPEF) for policy evaluation and research - as open dynamic platform - which will be able to stimulate the creation of continuous cycles of monitoring, evaluation and forecasting, using consolidated algorithms and automatized procedures, discussed and agreed among researchers, policy makers and all health systems strengthening stakeholders. Associated with the IPEF and the data platform, the project will also promote the enlargement of its original network of researchers to consolidate methods and algorithms for integrated ex-post and ex-ante impact evaluations of public policies in all LAC. IPEF will also be built with a user-friendly interactive interface, which will allow researchers with low programming skills and policy makers to simulate policy scenarios interactively.