From inequities to fairness and accountability

Integrated data platforms are essential to improve care coherence and enhance patient experience; nevertheless, health data protections, and informed consent for the use of personal data are also important. Without strong protections in place, patients may not know how their data are used, the extent to which they are de-identified, who has access to their confidential clinical data, or how public and private providers share sensitive data. Under these conditions, patients are not in a position to determine how their data should be used and to refuse the use for purposes with which they are not comfortable. Appropriate regulations should include safeguards that limit how governments link and access clinical data from outside the health sector. Data protection regulations should guard against potential abuses with a clear mandate for an independent body to act as a data steward.

At the PHC facility level, data and measurement systems need to be part of a larger continuous quality-improvement process.Simply having data is not sufficient to improve performance. Team-based network managers must have the capacity to analyze the data, review performance regularly, and adapt care processes as needed (PHCPI 2018). Facility managers need to strike the right balance between collecting the appropriate data and avoiding the administrative burden on providers that can result from obligatory data reporting (OECD 2016a). Performance measurement and management requires establishing targets, monitoring performance against those targets, and implementing and adapting improvement efforts. Sharing data with staff as part of a continuous quality-improvement cycle allows countries to move away from inspection and punitive arrangements to a culture of problem solving and active collaboration among providers, supervisors, and team members (PHCPI 2018). A variety of performance measurement and management tools is available to help with this process (Hall 2019; Kane 2012; Necochea and Bossemeyer 2005).4,5

Extending care into the community to address health disparities

With the support of CHWs, the PHC team offers care that extends beyond the static clinic into communities. Proactive frontline strategies can help address disparities in health outcomes by supporting basic health

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education and promotion; offering nutritional coaching and supplementation; identifying subclinical illness; and helping sustain adherence to treatment, among other strategies. In Brazil, community heath agents are each assigned about 150 households for monthly visits, during which they offer health promotion and support basic health care (Macinko and Harris 2015). In Costa Rica, CHWs within broader multidisciplinary teams calculate risk scores for individual households in their catchment areas; these scores are used to determine the frequency of future in-person visits (Pesec et al. 2017). South Africa’s ward-based outreach teams (WBOTs) likewise consist of a nurse team manager and five to six CHWs, all linked to a fixed primary health center, who conduct health promotion, active case finding, and doorstep care within communities. Preliminary reviews of the program have shown significant increases in measles immunization coverage and reductions in severe diarrhea cases in regions served by outreach teams, although formal evaluations are still needed (Assegaai, Reagon, and Schneider 2018).6 In an uncontrolled study in peri-urban Mali, daily door-to-door case detection by CHWs appeared to help double the early treatment of malaria, nearly halve the rate of febrile illnesses, and reduce under-five mortality (Johnson et al. 2018). Pilot studies also support the feasibility (although not necessarily cost-effectiveness) of proactive screening strategies for chronic and more complex diseases—for example, stroke detection in Karachi, Pakistan (Khan et al. 2015); cancer in New Delhi, India (Shridhar et al. 2015); and cardiovascular disease risk across four LMICs (Gaziano et al. 2015), often led by CHWs.

Increasingly, active outreach strategies can be supported by mobile health (mHealth) applications, helping identify chronic conditions even when qualified personnel are unavailable—and potentially helping increase the cost-effectiveness of active case finding strategies. In South Africa, for example, CHWs deployed a smartphone-based application (hearScreenTM) to identify adults and children with hearing deficits, subsequently referring them for specialist attention (Hussein et al. 2016). In Madagascar, a cervical cancer screening program used smartphones to take snapshots of the cervix and email the images to remotely located specialists (Catarino et al. 2015). Such strategies have high upside potential in urbanizing centers, where mobile phones are common and network coverage is strong, but current evidence is largely limited to small-scale pilot and efficacy studies (Ettinger et al. 2016; Peiris et al. 2014).

Marginalized communities, or individuals facing potential diagnosis of a stigmatized disease, may be more likely to receive needed care when they can access health services directly within their communities, or

even within their own homes. In Nigeria, for example, men who have sex with men (MSM) were nine times more likely to accept HIV testing and counseling if the service was directly offered by a member of the same community versus referral to a health center; the uptake was 21 times more likely among injection drug users (Adebajo et al. 2015). Even for the general population, systematic review evidence suggests that uptake of HIV testing and counseling services is far higher in community-based settings than within health facilities (Sulat et al. 2018). Increasingly, health services can also target the virtual communities where marginalized populations congregate. In urban China, for example, men who have sex with men volunteers identified members of the MSM community through their profiles on gay social networking sites and recruited them to testing and counseling services via chat rooms, instant messages, and emails (Zou et al. 2013). Internet-based outreach is still in its infancy within LMICS, and scale-up will require careful consideration of the privacy, rights, and safety of marginalized populations.

The COVID-19 pandemic has highlighted the importance of proactive community-based care and case management as a supplement to traditional, facility-based treatment, particularly in the context of limited inpatient capacity for COVID-19 patients and the importance of self-isolation to limit transmission potential. In the United States, the Cambridge Health Alliance (CHA) created multidisciplinary “community management teams” for the remote management of high-risk COVID-19 patients (in addition to primary care teams for patients at low or normal risk); the teams check in with the patients regularly by phone or teleconsultation “at points in the disease process associated with significant changes in clinical course, including four, seven, and 10 days after symptom onset. Patients at highest risk receive calls daily, sometimes multiple times a day. This triage process reserves the respiratory clinic for severely ill patients who have developed dyspnea, or shortness of breath, and enabled CHA to manage most patients without hospitalization” (Schweich 2020). In a small sample of patients, the model was estimated to avert almost one-half of hospitalizations (John, Zallman, and Blau 2020). In the Republic of Korea, where individuals who have been exposed to COVID-19 are asked to self-quarantine for two weeks, self-isolation is facilitated by deliveries of food and sanitation supplies, plus twice-daily check-ins from a dedicated case officer (Genries 2020). In Vietnam, whose successful COVID-19 response has been widely recognized, the local health station and village health workers played an essential role in raising community awareness about COVID-19 prevention; they also took on contact tracing and self-isolation monitoring on top of their routine responsibilities (Nguyen et al. 2020).

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Empanelment and accountability

The empanelment process assigns a defined catchment population to a single, cohesive multidisciplinary care team. This process, in turn, creates a natural structure for accountability; the care team can be held accountable for the patient experience and health outcomes of the empaneled population. The focus on whole-population outcomes, versus patient experience among care seekers alone, reinforces an equity orientation; PHC teams are held accountable for their ability to engage, educate, and improve health outcomes, even among individuals or families who may feel reluctant or unempowered to seek care, including the poorest households and other marginalized populations. Care teams can be held accountable at all levels—by the populations they serve, by their peers and colleagues within the care team itself, and by payers and regulators at the regional or national level.

Within this general principle—that the care team should be accountable for the experience and outcomes of the empaneled populations—many different accountability mechanisms are available. These mechanisms can be modularly combined in various permutations to reinforce accountability at different levels and from different directions.

First, timely data collection and benchmarking can increase PHC professionals’ and managers’ awareness and understanding of their own performance, empowering them to make better decisions. Providing insights into peers’ performance through benchmarking can further inspire emulation and positive reinforcement. In Costa Rica, for example, the Evaluación de la Prestación de Servicios de Salud (EPSS) offers a standardized benchmarking process across different health areas for dimensions of access, continuity, effectiveness, efficiency, and user satisfaction. PHC managers are assessed against targets and the performance of their peers, making them more accountable for their performance. To foster continuous quality improvements, performance targets are slightly increased each year, while health areas in the lowest quintile are required to develop remediation plans (PHCPI n.d.).

Second, public reporting on how different providers perform can help communities hold care teams accountable; they may also induce positive changes in health worker performance to protect their reputations or to attract additional patients (if empanelment is on a choice or opt-in basis). Rigorous studies of public reporting systems are mostly limited to high-income settings, but systematic review evidence suggests that they are associated with consistent and significant reductions in overall mortality (Campanella et al. 2016). With increasing mobile phone and internet access, web-based quality databases may be more applicable in middle-income countries; for a low-tech solution, performance