Starfield’s 4Cs of NCD management in primary healthcare: a conceptual framework development from a case study of 19 countries

Care coordination

Care coordination is a tenet that ensures PHC providers are well-linked to other essential services across levels of care and beyond the healthcare system. In most countries, there were no designated care coordinators. Instead, nurses or social workers usually double up as care coordinators, often viewed as a form of task-shifting when PHC providers operate in a multidisciplinary team.25 However, to ensure smooth care coordination in a resource-poor setting that necessitates task shifting, investment into training and the establishment of designated care workflows is paramount to ensure optimal patient care and to avoid role strain and overload. This is particularly crucial in an ever-evolving healthcare landscape with an increasing NCD burden. In most countries, patients (usually stable) can transition across levels of care and between facilities. The liaison between care entities is facilitated by having an interoperable IT system that allows providers at all care entities to have a bird’s eye view of a patient’s medical history, augmenting the coordination of care and enabling providers to transfer patient data across care echelons, especially when patients are discharged from tertiary to the PHC level.26 This will be particularly salient in health systems that employ private PHC providers to co-manage patients with NCD with specialists in the hospital setting.27 However, we must acknowledge that digitalised platforms may not be accessible to all populations, and resources, including IT infrastructure, might not be available for widespread implementation in certain settings.28

By breaking down the 4Cs into subthemes, the framework provides PHC providers, policymakers and researchers with greater clarity on the components of each C, enabling targeted and actionable changes. This iteratively developed conceptual framework, derived from global country examples, helps countries prioritise subaspects, identify specific limitations and understand the necessary infrastructure and financing required to optimise their existing healthcare systems. Overall, the conceptual framework shows the extent of collaboration required across PHC providers and multiple levels of care in synergistically leveraging on multiple dimensions to successfully meet the needs of PHC providers and patients with NCDs, with them at the nexus.

While most aspects of the PHC systems that were reviewed has shown some high-level semblance of Starfield’s 4Cs of PHC, there is much left to be done. We need to leverage this window of opportunity that presents itself post-COVID-19 and ride on the wave that places PHC at the core of a health system by recognising that PHC can confer multifold benefits through protecting population health writ large during peacetime and health crises.29 In the paragraphs below, we outline various arguments that extend beyond the scope of PHC and into the broader health system, as shown by the overarching themes that encapsulate the 4Cs of the PHC system. This is illustrated in the outer rim of our framework.

From a centralised perspective, national frameworks and policies are fundamental towards pivoting the strategic direction of policy development and implementation. They emphasise PHC’s role in addressing the 4Cs towards robust NCD management, restructuring various resources and integrating multiple levels of care digitally and physically. National health organisations need to ensure transparency and accountability in the provision of fiscal incentives and financial co-payments. The overarching governance and leadership buttresses the foundation on which subsequent levels of the 4Cs and their subthemes can be built.

The recent COVID-19 pandemic has shown how healthcare emergencies can rapidly destabilise health systems, highlighting the importance of emergency preparedness. To prevent the neglect of non-emergent conditions such as NCDs in future healthcare emergencies, countries explored in this study have since established emergency responder funds, taskforces, workflows and clinical guidelines to ensure rapid response to such emergencies while prioritising existing healthcare demands. Immunisation and infectious disease control, information systems activities, development of best practice guidelines, quality assurance and evaluation strengthen existing healthcare systems to better serve current patients while ensuring preparedness to weather future healthcare emergencies such as the COVID-19 pandemic. Yet, the pandemic also contributed to innovative strategies, such as the advent of digital applications and the rapid training and deployment of village volunteers and social workers to overcome geographical barriers in the delivery of care.30 31 In the non-emergent setting, these strategies should continue to be leveraged for the delivery of NCD care while increasing their competencies in emergency response.

The COVID-19 pandemic has also shown the severe impact of underinvesting in healthcare workers. In reality, every country faces a shortage of healthcare workers, and the shortfall is only projected to worsen.32 In LMICs, health inequities at the PHC level are exacerbated by chronic underfunding and healthcare workers preferring to work in non-rural settings, further straining existing PHC facilities.33 Thus, governments can introduce task shifting, harnessing non-clinical staff such as community health workers to provide basic NCD-related services. This must be coupled with the necessary training and accreditation for PHC providers to manage cases normally managed at higher care levels or by specialists.15 More importantly, steps need to be expeditiously undertaken to prevent healthcare worker burnout, improve remuneration and protect the well-being and welfare of healthcare workers to ensure healthcare provider retention and competent service delivery.34 Several countries have implemented policies to improve manpower retention, such as special allowances for those working in rural areas, fixed-term rotation of health staff at districts and communes, development of open feedback and communication channels and employee recognition and rewards. Furthermore, the planning and forecasting of human resources are included in such policies, particularly in the face of the ageing population and emergency preparedness. Such efforts would pave the way towards ensuring that the PHC sector has adequate human resources to provide quality NCD services and respond to shocks to the system. But for such aspirations to materialise, sustainable investments that are accountable and equitable need to flow to frontline primary care facilities while employing cost-effective strategic purchasing tools to ensure medical resources, both human and material, are adequate to anchor PHC as the epicentre of the health system.14 35

Bidirectional policy development and implementation are predicated on community engagement and empowerment. Social participation in implementing certain PHC policies which have been co-created can help make these policies more durable and palatable in the long run.36 This can be done by a multidisciplinary team at the primary care level that may also comprise volunteers or community health workers, as seen in the context of Thailand, to serve as a link between the health system and the community. This can also serve as a means to cultivate trust between system and population. Furthermore, chronic disease management and screening services should be integrated to serve current patients with NCD and to connect patients with high NCD risk to the healthcare system, such that they receive preventive healthcare and lifestyle advice much earlier. In countries facing manpower constraints and geographical inaccessibility, preventive health and public health ventures such as community engagement and empowerment can be conducted through digital means. Such measures should be integrated into the larger healthcare landscape and national frameworks to ensure equitable delivery of healthcare services and to ensure continued NCD care in the event of future healthcare emergencies.

Crucially, even as we place increased emphasis on PHC for NCD management, secondary and tertiary care must not be neglected.37 Higher levels of care are still required to manage more complex and severe cases of NCDs. In a health system, PHC and higher levels of care need to work in concert through integrated models of service delivery, which also includes unified and commensurate financial mechanisms for all providers to deliver equitable and optimal care for patients with NCD in a collaborative fashion.38 The integration can also involve co-engineered care models between providers across care interfaces and the community so that integrated programmes assimilate the expectations of all stakeholders and reduce any unintended consequences.

The various themes and subthemes illustrated in this study provide countries with a multidimensional outlook in boosting the comprehensiveness and competencies of their healthcare systems, showing the interconnections between the 4Cs and their respective subthemes and the necessity of factoring in the concepts in the outer rim of our framework in ensuring integration and coordination of PHC with the larger healthcare system. To ensure the sustainability and resilience of NCD management in the face of uncertainties, all themes and subthemes need to be evaluated and factored in parallel into future policy decision-making.

To generalise from these convergent streams of thought and action, continuing disparities in health conditions between and within countries must be addressed by employing a whole-of-systems approach that focuses on equity and sustainability, such that individual and collective action at all levels can be relevant and mutually reinforcing. We have also summarised the priority recommendations based on the key themes and subthemes in the conceptual framework in box 5.

This paper also acknowledges that the subsets of themes that emerge are not exhaustible and the major subthemes can percolate across the 4Cs of primary care. In addition, the subthemes are constrained by the data collected from the respective countries and might not be generalisable to all healthcare systems. As there are only case studies for two African countries, there remains an under-representation of analysis from that continent that requires further analysis going forward. The next step will be to deploy this framework and evaluate how primary care systems perform in the aspects derived in this study.