+APS: Data for Action Learning in Primary Health Care

Argentina is an upper-middle-income country with a population of 47 million, most of whom live in large cities. Argentina has a fragmented and segmented health system, divided into three large sectors—the public, social security, and private sectors—as found in many Latin American countries. Approximately 17 million people (36%) in Argentina have no insurance and rely solely on the public health sector of each province or district. As a consequence, health disparities are widespread among districts. 

In 2004, Argentina started with a reform to expand universal health coverage for the uninsured. The SUMAR program is a public insurance program focused on transferring flows of financing to primary health care (PHC) centers  for preventive care services, while mandating the attainment of predefined quality standards for the services provided. SUMAR included maternal and child health services for eligible beneficiaries, consisting pregnant and lactating women, as well as uninsured children under six, uninsured children aged 6 to 9 years, uninsured youth aged 10 to 19 years and uninsured adults aged under 65, cancer prevention, sexual and reproductive health and prevention of noncommunicable diseases, as well as interventions to support the federal network for treating congenital heart disease. At the same time, SUMAR has results-based financing mechanisms at the provincial government and health care providers levels.

The program has established the importance of a results-based approach effective universal health coverage mostly focused on the poor and vulnerable population. However, despite the fact that this information has been collected for a long time, it is not used for decision-making at the point of care in the primary health care centers.

Therefore, the main challenge we will solve is not related to the lack of data: clinical and administrative data are available through the SUMAR primary care program, which includes 17 million people , a third of the Argentine population according to the last national census, cared for in more than 8,000 primary care clinics. 

The problem is about who are the end-users of this data. In other words, data are there, but available for managers at a central level but not for front-line workers who practice at a primary care setting where data can have a real impact on the health of the population. The fact that primary care centers do not know performance information means that they cannot manage their resources or plan data driven-strategies to improve the quality of care, satisfaction and access to health of their population in charge, thus compromising quality and widening health disparities. In conclusion, our challenge is how to transform data in information and intelligence to make appropriate decisions to improve PHC performance.

+APS is an interactive electronic tool that allows frontline workers and decision makers from the primary healthcare centers to view specific information from their patients and catchment area. It repurposes data that is currently being collected for the SUMAR program, including individual patient information. It also matches data from other secondary and context sources such as National statistics, household surveys that include socio demographic information. 

This is why we developed a tool aiming to customize the data that each clinic needs to improve its performance. Clinical and managerial data are deployed in a visually attractive dashboard with a georeferenced map, context information of the health area, and clinical and administrative data for each patient cared for by the clinic. Our solution allows each center to easily access to their population health-related information, showing performance indicators such as % of screening tests for cancer in population at risk, number of antenatal visits, health checkup in children and adolescents, or BP control visits, among many others. Having this info will increase awareness and allow the PHC team to develop data-driven strategies to improve outcomes on key performance indicators, as well as reaching more effectively the population at risk.  

Our tool offers a wide scope of data and information for the frontline workers as follows:

The dashboard allows viewing health information of a geographical area in different layers:

1. Context information: the values of multiple sociodemographic indicators of the selected area can be observed, at the lowest level of disaggregation available (in this case, the census fraction). Information is presented on the unemployment rate, illiteracy rate, percentage of children under 15 years of age, percentage of the population living in dwellings with insufficient access to basic services (water and sewage), percentage of the population living in dwellings, and percentage of population living in inadequate housing. The values of the deprivation factor can also be observed, elaborated from a Principal Components Analysis based on the indicators mentioned above. In our prototype, the primary source of these data was the National Census of Population, Households and Housing and the indicators are displayed in a choropleth map in which each polygon assumes a color in relation to the value of the indicator in a yellow-red color palette. A panel of historical birth and mortality indicators for a geographic area can also be observed in this dimension.

2. Areas of responsibility of health facilities: allows to define geographic areas by clicking on the same map that displays the socio-demographic characteristics, visualizing the geographic location of the health centers and hospitals in the area. The dashboard shows the main characteristics of the areas selected by the user (number of inhabitants, number of households, etc.).

3. Health center information: allows to view information related to each of the primary health centers. First, general information such as authorities and specialties can be seen. Secondly, indicators of the specific center can be observed, differentiated in two dimensions: health indicators (where the tracers of the Sumar program are observed) and managerial indicators. A nominalized list of health center users can also be explored. It should be noted that both the values of the health and management indicators, as well as the names and data associated with the patients, are fictitious data generated for the purposes of this prototype.

4. Patients: allows to view the geo-location of each of the patients in the primary health center and observe information on risk factors for each of them.

It is noteworthy that the information shown by the prototype is dependent on the availability of data from the selected geographic area. The dashboard contemplates the possibility of editing or expanding the information to be displayed.

On the other hand, the solution allows defining different user profiles. Access to the system can be done from the front-line worker, primary care center manager or area manager profiles. In this way, collaborative work between different levels of action will be favored.

The dashboard is developed in R and is viewed through a Shiny application, hosted on a web platform at https://iecs.shinyapps.io/MasA.... The use of R in combination with Shiny allows the deployment of this dashboard to be done through the free Shiny Server tool.

You can access the public repository of the code for this prototype at https://github.com/agsantoro/MasSaludDashboard

In addition to our initial proposal bridging +APS with the Sumar program data in Argentina, we are envisioning its scaling up in different low and middle income countries of Latin America and the world using other data sources such as DHIS2 (District Health Information 2), CHT (Community Health Toolkit), and OpenSRP, among other solutions. DHIS2 is an open source, web-based platform most commonly used as a health management information system (HMIS). Today, DHIS2 is the world’s largest HMIS platform, in use by 73 low and middle-income countries. Approximately 2.4 billion people live in countries where DHIS2 is used. Including NGO-based programs, DHIS2 is in use in more than 100 countries. DHIS2 software development is a global collaboration managed by the HISP Centre at the University of Oslo (UiO).

+APS will benefit the population of Argentina that rely only on public health coverage and lacks formal insurance. This includes 35% of the population, representing approximately 17 million people, of which 61% belong to the two lower quartiles of income. We currently know that these people are partially covered by the SUMAR program.

 +APS allows primary care centers to easily visualize the information they generate and use it to improve the quality of care and health standards.

An example of how this tool could benefit our target population is narrated in the pich presented by Camila Volij, a family doctor, in the video: “Last year Maria, a patient that lives in the catchment area of my primary care center, was diagnosed with widespread cervical cancer. Poor access to the PHC clinic and the pandemic, made her miss a great opportunity to be detected earlier on. When she came to visit me for the first time, it was already late.  Despite she had occasional visits to the PHC in the last 5 years; they were for urgencies seen by different providers.  Nobody noticed that Maria had not undertaken a single PAP smear in all this period.  I was devastated. If  we  had known, she would have been screened and detected on time to save her life.”

We are an interdisciplinary and multiprofessional team of primary care physicians, public health specialists, political, social and data scientists, with a major background in government and public service, non-governmental organizations, academic institutions and private organizations, with knowledge and expertise in the management of community-based primary care with vulnerable population.

IECS (from the Spanish acronym, Institute for Clinical Effectiveness and Health Policy) is a non-profit independent academic institution devoted to research, education and technical cooperation in healthcare. The Institute generates knowledge locally, regionally and globally, and aims to make a contribution that allows re-formulating the research agenda through works that reflect the priorities and health needs of those who live in low and middle-income countries.

The Center for Implementation and Innovation in Health Policies (CIIPS from the Spanish) - https://www.iecs.org.ar/en/ciips/ -  at the IECS was created in 2020 with the purpose of making a contribution to public debate and informed decision-making regarding health policies.

Through analysis and advice to governments, institutions and health organizations at the national, regional and international levels, from CIIPS we contribute with evidence to achieve more accessible, equitable and sustainable health systems.

CIIPS has developed numerous projects related to the current proposal. We created the Covid Dynamic Dashboard, an interactive display of epidemiological information on COVID-19 in Argentina, which feeds on data from the Integrated System of Argentine Health Information (SISA) published by the Ministry of Health. https://iecs.shinyapps.io/covid-argentina/   

Through the dashboard, it can be observed the incidence of the disease (new cases, accumulated, average of the last 7 days), the dynamics of the epidemic (effective number of reproduction -Rt-, percentages of variation between weeks), tests (determinations made and positivity), etc. The display allows selecting any of the 24 jurisdictions of Argentina or the entire country, and establishing comparisons between the selected areas. The system also allows downloading graphics in image format and tables in Excel format.

In 2020, the CIIPS and the Department of Economic and Health Technology Assessments of the IECS, had the support of the Inter-American Development Bank (IDB) to develop the project “Comprehensive Model of Preparation and Response of the Health Systems of Latin America and the Caribbean for estimate the impact of the expansion of COVID-19” - https://www.iecs.org.ar/modelocovid/ -. 

This project originated as a model to estimate the epidemiological impact and the preparedness and response of Latin American and Caribbean (LA&C) health systems to COVID 19. In early 2021, the IECS won a grant from the Strategic Advisory Group of Experts on Immunization (SAGE) of the World Health Organization to assess the impact of different vaccination strategies and their interaction with the rigor of public health and social measures (MSSP) for Argentina, Brazil, Chile, Colombia, Mexico and Peru. In the development stage, we extended the analysis of the epidemiological and health impact of vaccination to 27 countries in the region. In a second stage, we incorporated an economic evaluation, as a new layer of the epidemiological model, comparing different vaccination strategies with non-vaccination, keeping the MSSSP at intermediate levels of rigor in their application. This cost-effectiveness analysis was carried out in some selected countries: Argentina, Brazil, Chile, Colombia, Costa Rica and Mexico.

In 2022, the model has incorporated an estimation of the macro-economic impact of the pandemic during the year 2021 as part of the project "Integrated epidemiological and macro-economic modeling adapted and applied to answer policy questions in Argentina", with support from the IDB. The online version of the model, which incorporates all the features described, can be accessed at https://iecs.shinyapps.io/covid-model-v2/   

In 2021, we also provided expert support to the Plurinational State of Bolivia to strengthen the surveillance system and adapt the health system's preparedness and response of the health system to COVID19 epidemic.

Between September and December 2021, we have worked in the province of Mendoza, Argentina, to evaluate the impact of the use of Electronic Health Records and telemedicine programs on access to care for the population with exclusive public coverage and on the pandemic management. A quantitative analysis was carried out based on data of basic effective coverage and teleconsultations, complementing it with a qualitative analysis that allows understanding the context in which health care was provided to this population in the province.

Currently, we are working in collaboration with PAHO to generate the necessary knowledge, as well as the appropriate documents, and monitoring indicators so that the countries of the Region can adopt and share their experiences in the way of implementing the 8 guiding principles for the digital transformation of the health sector.

You can find more information about these and other projects at the following link: https://www.iecs.org.ar/en/ciips/proyectos-en-marcha/ 

The overarching goal of this challenge is to provide frontline workers and managers at the primary care setting with timely information to make evidence-based decisions and improve their performance. This data-driven action learning, a process for developing creative solutions in tackling complex problems, is key to make them aware of their population risks and needs.  In order to disseminate and scale-up our solution, we will need additional financial support. 

The SUMAR Program uses a financing model based on results in which the Nation transfers resources to the provinces based on the individual registration of the population; and the results of effective coverage and quality of care provided, measured from indicators.

Since the beginning of the program, this information has been collected from paper records, and transcribed into administrative databases, but is seldomly used for decision-making at the point of care. In addition, the data generated for the SUMAR program does not return to the primary care centers, so there is no information on the quality of care of the people who access it or of that management area of each primary care center. 

+APS allows health care centers to view and use their information at four levels: 1) by context information,  2) by area of responsibility of health facilities, 3) by health center, and 4) by patient. With +APS we will strengthen local management, the participation and protagonism of health teams, with the aim of improving decision-making based on evidence and generating a positive impact on the health of communities, transforming data into information for action.

The impact goals for the next year are improving the quality of care, access and satisfaction of the population that belongs to each primecare care center’s influential geographical area. This would lead to a reduction in the health gaps of the population. To achieve this impact goal, surveillance on the following indicators will be performed: increase the percentage of users who have a family doctor and an assigned primary health care team, increase the connectivity of health centers that do not have it, with a web shift available and increase the percentage of health workers with training.

For the year 2 onward, the impact goal is to improve health indicators such as the percentage of pregnant women receiving prenatal care, children and adolescents with health check-ups, the % of adults with colorectal cancer screening, the % of women with cervical cancer and breast cancer screening, % of type 2 diabetes control and blood pressure control among hypertensives. 

With the information provided by the dashboard, health care teams will be able to design and implement data-driven strategies according to the needs of their population and thus improve their KPI. As an example, decision makers of each primary health center can meet monthly with the health staff to monitor the indicators and jointly think of different strategies to improve their results (action learning).

Selected Key Performance indicators: Clinical (%)

1) Pregnant women receiving prenatal care

2) Children 0-9 years of age with health check-ups

3) Adolescents 10-19 years of age with health check-ups

4) Children with overweight or obesity

5) Adults with colorectal cancer screening

6) Women with cervical cancer screening

7) Women with breast cancer screening

8) Type 2 diabetes control

9) Blood pressure control among hypertensives

Selected Key Performance indicators: Management 

1) Users from the eligible population of the catchment area 

2) Users registered with a family doctor and a family health team

3) Connectivity bandwidth',

4) Use of an electronic medical record

5) Health workers receiving training

6) Number of workshops and training sessions

7) Use of an web-based scheduling system of scheduled visits for chronic care management

Starting from the problem of inequity in health in Argentina, we began to build a strategy to reduce these existing gaps and make primary health care more accessible, affordable, timely and of quality for all.

Activities

1. Main activity: To create a dashboard that integrates health data to monitor and evaluate primary health care performance indicators for front line workers

2. Target population: population of Argentina that has public health coverage

3. Dashboard creation: 

   1. Select a set of health and management key indicators that will allow decisions to be made to improve the performance of primary care centers.

   2. Deploy these indicators in a geo-reference visualization where they can be analyzed together with information on the social context and patients data in the center's catchment area.

   3. Develop an open source software tool that can be accessed in contexts of limited connectivity and low hardware availability.

Outputs

• Increase the number of primary care visits

• Improve georeferencing

• Increase the number of users who have a family doctor and an assigned primary health care team

• improve connectivity

• Apply web-based scheduling system

• Increase the number of centers that have electronic health records

• Increase the training of health workers

Short-term outcomes

• Improve blood pressure control among hypertensives

• Improve type 2 diabetes control

• Improve cancer screening

• Improve immunization in children

• antenatal visits before week 13

• Family planning

• Contraceptive consultations

Long-term outcomes

• Reduce health disparity

• Reduce morbidity from chronic non-communicable diseases

• Improve pregnancy outcome

It is an open source solution developed on the basis of free software such as R and Shiny. The dashboard for the visualization of indicators arising from primary information can be used both on personal computers and tablets and does not require hardware different from that of an ordinary home computer, making it easily accessible to front-line workers or managers of primary care centers.

On the other hand, the dashboard has been developed in highly versatile software for working with diverse data sources, of greater or lesser complexity. The primary information could be provided from a database (SQL Server, PostGreSQL, MySQL, etc.), from a web form, from a data management system, etc.

Front line workers of the primary health care centers collect the primary healthcare data for our solution. They collect clinical information in their paper (and sometimes electronic) health records, and transcribe key information into the electronic registry for the SUMAR program. This information is shared with the jurisdictional and national authorities for the incentive payment. Therefore, this is the information that will be repurposed for building the key performance dashboards within the interactive electronic tool.  

We have a multidisciplinary core team that integrates multiple visions and specialties. Family Physicians, Epidemiologists, Data science experts, Digital Health Experts, Psychologist, Political Scietists and Gender and Inclusion Experts are part of our team.

The intersection of experts‘ visions and expertise bring together the best capabilities to set the basis for the project implementation based on our premises of diversity, inclusion, equity, and people centeredness through a gender balanced team.

Our team develops and implements projects with an intersectional lens, always looking to contribute to improve access to quality healthcare in order to achieve people-centered universal health coverage. 

Community and users’ needs are leu for our work and all our projects include the analysis of all stakeholders’ points of views and needs. We develop efforts to achieve Inclusive Digital Health looking to leave no one behind in the digital age, which requires reaching populations in situations of greater social, economic, geographic, or cultural vulnerability, as well as those individuals and groups populations that are not digitally literate, encouraging the adoption of technologies as long as people decide and choose autonomously to use digital services.

Based on the Social Business Model CANVAS, we are focusing on the following drivers: 1) Customer segment: uninsured population enrolled in the Programa SUMAR, 2) Value proposition: to improve outputs, outcomes and impact in PHC performance for frontline workers, Channels: piloting, dissemination and scaling up in incremental stages; Customer Relationships: measurement of satisfaction  and other patient-centered outcomes; Revenue Streams: we don´t plan to have revenues since it is not a commercial initiative; Key Activities: monitoring & evaluation of PHC performance through a defined set of clinical and managerial indicators in each clinic.; Key Resources: we consider product (+APS tool), scope (PHC) and infrastructure (primary care clinics); Key Partnerships: we plan to engage for our program the Programa SUMAR, Argentine National Ministry of Health and the World Bank; Cost Structure: This is a high tech-low-cost device. All costs are well aligned with the key value propositions and scalable without important incremental costs. In addition to the development costs to fit the +APS in the scaling-up phase, we will need to equip PHC clinics with some other resources such as laptops and tablets. These additional resources will be provided by our partners.

We will pilot our tool +APS in a selected number of primary care clinics belonging to the Sumar Program to further scaling up after monitoring and evaluation on selected districts and the whole program at large. In this regard, we are planning to get the financial support for the scaling up phase from SUMAR and our National Minister of Health as well as the World Bank as its main  financial sponsor. This strategy will make usability, dissemination and scaling up of +APS  sustainable in the long term.

Since 2002, our institution conducts research studies, consultancy, and technical cooperation projects by working together with international organizations and agencies, governments, national departments and health departments, academic institutions, and health systems at a regional and global level. IECS is a WHO Collaborating Center in Health Technology Assessment (HTA), providing support to projects aimed at replicating WHO programs—regionally and internationally—by conducting research activities and consultancy to promote health development. We have collaborated with international entities and governments, such as the European Union, WHO, PAHO, the World Bank and Inter-American Development Bank (IDB), the Canadian International Development Research Center (IDRC), the US National Institute of Health (NIH), the Bill and Melinda Gates Foundation, and other public and private institutions, including pharmaceutical and technological companies.

Some examples are: 
TECHNICAL ASSISTANCE FOR SOCIALIZATION OF THE MATURITY ASSESSMENT TOOL IN THE ADOPTION OF ARTIFICIAL INTELLIGENCE IN ARGENTINA. Supported by: Central American Health Informatics Network (RECAINSA).
SUPPORT IN THE DEVELOPMENT OF THE WHO GUIDE FOR UNIQUE IDENTIFICATION IN HEALTH. Supported by: World Health Organization (WHO).
TECHNICAL SUPPORT FOR THE PREPARATION OF THE REPORT “HEALTH IN THE AMERICAS” (HIA 2022). Supported by: Pan American Health Organization (PAHO).
SCOPING STUDY ON SEXUAL, REPRODUCTIVE, AND MATERNAL HEALTH IN LATIN AMERICA AND THE CARIBBEAN. Supported by: International Development Research Center (IDRC).
ANALYSIS OF THE IMPACT OF COVID-19 VACCINES IN LAC: HEALTH AND COST-EFFECTIVENESS BASED ON EPIDEMIOLOGICAL MODELLING FOR 26 COUNTRIES. Supported by: Interamerican Development Bank (IBD)
EVALUATION AND CHALLENGES OF THE USE AND SCALING OF ELECTRONIC MEDICAL RECORDS AND TELEMEDICINE TO SUSTAIN ACCESS AND COVERAGE TO PRIMARY CARE SERVICES DURING THE COVID-19 PANDEMIC, IN MENDOZA, ARGENTINA. Supported by: Health Observatory – Group of Foundations and Companies (GDFE)
SUPPORT IN THE IMPLEMENTATION OF THE 8 GUIDING PRINCIPLES FOR THE DIGITAL TRANSFORMATION OF THE HEALTH SECTOR. Supported by: Pan American Health Organization (PAHO)
MODELING EPIDEMIOLOGICAL, SOCIAL AND ECONOMIC IMPACTS OF COVID-19 VACCINATION STRATEGIES. Supported by: World Health Organization
ELABORATION OF A COMMON REGISTRATION FORM (“PORT OF ENTRY”) FOR THE MEMBER STATES OF PROSUR FOR THE MANAGEMENT OF VIRAL TRANSMISSION OF SARS COV2. Supported by: Interamerican Development Bank (IBD)
PROVIDE SUPPORT TO HEALTH INFORMATION SYSTEMS FOR DECISION-MAKING REGARDING COVID IN THE PLURINATIONAL STATE OF BOLIVIA. Supported by: Interamerican Development Bank (IBD)
TECHNICAL SUPPORT FOR COVID-19 PREVENTION, PREPAREDNESS AND LOCAL RESPONSE IN 23 MUNICIPALITIES OF BUENOS AIRES PROVINCE, ARGENTINA. Supported by: 23 Municipalities of Buenos Aires Province, Argentina. 
COVID-19 HEALTH SYSTEM PREPAREDNESS AND RESPONSE IN LATIN AMERICA AND THE CARIBBEAN. Supported by: Interamerican Development Bank (IBD)
COVID-19 HEALTH SYSTEM PREPAREDNESS AND RESPONSE IN CORRIENTES PROVINCE, ARGENTINA. Supported by: Ministry of Public Health of Province of Corrientes.