The impact of alternative care integration strategies on Health Care Networks’ performance in different Latin American health systems

Final Report Summary - EQUITY-LA II (The impact of alternative care integration strategies on Health Care Networks’ performance in different Latin American health systems)

Executive Summary:
Health services fragmentation is one of the main obstacles to attain effective health care outcomes in many healthcare systems around the world, and particularly in Latin American countries, leading to difficulties in access to care, poor technical quality, discontinuity of care and inefficiencies in the use of scarce resources. These weaknesses are most evident in the care of patients with chronic conditions that require the coordination of multiple health professionals and care settings. This is also an important challenge in Latin America (LA) and is a consequence of the demographic and epidemiological transitions occurring in there.
In response to this challenge, a wide range of strategies to improve care integration have been promoted primarily in high income countries, but also in some middle and low-income countries. However, they are usually designed in advance and not adapted to the local context, a common approach in the implementation science area that is increasingly criticized for its lack of effectiveness in terms of adoption and sustainability over time. In contrast, more collaborative and bottom-up approach, such as participatory action research (PAR) are gaining attention within mainstream health services research because it has been used effectively to bridge the gap between evidence and practice and to facilitate the change in industry or education. The effectiveness of the PAR method lies in the involvement of the practitioners in the process, including decision-making, which firstly lends greater relevance and validity to interventions designed to resolve common practical problems in their working day, and secondly creates more interest and positive feedback for the changes being instituted. However, its application in healthcare organizations is scarce and little is known about the factors of success or failure, sustainability and applicability of the intervention to other contexts.
In this particular environment of disjointed and fragmented care coupled with the increasing prevalence of chronic conditions and limited effectiveness of many of the implemented interventions; the policy challenge is to explore avenues to lead to joined up thinking regarding care integration taking into account local priorities, processes and perspectives which would lead to more satisfactory outcomes.

The general objective of the project is to evaluate the effectiveness of various care integration strategies in improving coordination and quality of care, using a participatory action research approach, in integrated healthcare networks in different health systems of Latin America: Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. Evidence provided on best practices of care integration should inform the development of policies conducive to better quality health care and contribute to the effectiveness of Latin American healthcare systems and other contexts, including those of European countries.

To achieve the study aim, the project adopted an innovative quasi-experimental design (a control before and after design), using a participatory action research approach (involving professionals, managers, policy makers and users), which allow to evaluate integrated care interventions under “natural” conditions. Study areas were two integrated public healthcare network in each country (intervention and control). First a base-line was established on IHN performance on care coordination and continuity of care (using qualitative and quantitative research methods), a relevant problem that had not been analysed comprehensively in the countries involved so far. It was followed by the design and implementation of care integration strategies using a participatory action research (PAR) process and focusing on chronic conditions. In the third phase, their effectiveness and the implementation process was evaluated. Intra-country and cross country analysis of results were performed.

Results of the based-line study showed poor performance of IHN regarding care coordination and continuity of care in all studied networks. With some differences between countries, doctors reported limited care coordination, mainly in the transfer of information and communication for the follow-up of patients, and to lesser extent inappropriate referrals and disagreement over treatments. Associated factors to coordination related to employment, organization and interaction between doctors. In this respect, one of the most relevant findings is the association between SC doctors’ frequent use of reply letters and interactional factors: knowing the PC doctors personally, trusting in their clinical skills, and recognizing their role as coordinators of patient care across levels. Similarly, with differences between countries, the results showed that chronic patients perceived significant discontinuities in the exchange of clinical information between the PC and SC doctors and to a lesser degree, limited care coherence, indicating the need for improvement in coordination between levels,

In each intervention network, through a PAR process led by the Local Steering Committee, that started with the return of baseline results and covered the selection of problems and interventions; their design and adjustment, interventions were implemented to improve communication and clinical agreement between PC and SC doctors. Results of the process evaluation revealed that contextual factors, the PAR process and the intervention’s content were determinants in their successful implementation, interacting across time. It also reveals that when certain contextual elements converge –alignment with policy, institutional support– a correctly carried out PAR process in terms of time, method and levels of participation can turn into a factor of motivation and cohesion determining the adoption of interventions.. The qualitative evaluation reinforced the importance of mutual adjustment mechanisms, such as joint meetings, as strategies in improving interpersonal factors, encouraging mutual knowledge and positive attitudes towards collaboration. Moreover, the interventions institutionalization and consolidation of leadership were essential for their sustainability

The evaluation of the interventions effectiveness showed improvements in intermediate results (personal knowledge and trust between doctors of different care levels) and final care coordination results (agreement over treatments prescribed by the other care level and perception of coordination). Similarly, improvements were reported by patients, regarding continuity of information and clinical management across care levels. In both cases, there were differences among countries.
Study results demonstrate the relevance of developing bottom-up strategies which are sustainable and transferable to other contexts as long as its participative method is maintained. Although further evaluations are required after longer implementation time to establish the interventions´ full impact, in all countries the project had a number of positive side effects: some of the developed interventions have been institutionalized and integrated into IHN planning and the “Equity working method” adopted as a method for improving the quality of care in the network; in some cases, the interventions have incorporated in national or local policies/actions, and other IHNs have initiated similar processes adopting the design, methods and tools of the project.

The Equity LA II project has allowed for a deepening of the understanding of integrated care, providing evidence-based context-tailored strategies for better informed policy decisions and identifying best practices in the implementation of PAR-based interventions. It has developed methods and tools to implement and evaluate care integration interventions that are sustainable, replicable and already included in policies. It developed and applied frameworks and tools to evaluate the performance on IHN on care coordination and continuity. It has largely contributed to capacity building in health services research, policy makers and health professionals’ knowledge and skills, with a critical mass (more than 1000 trained) in the field of integration of care and interventions and methods to improve it. The PAR method implemented contributed to the establishment of a different form of collaboration between universities and health services found of mutual benefit and transferable to other research projects. Finally, the findings contribute to improve performance of healthcare services and to promote sustainable and efficient healthcare systems.

Project Context and Objectives:
Health services fragmentation is one of the main obstacles to attain effective health care outcomes in many Latin American countries, leading to difficulties in access to care, poor technical quality, discontinuity of care and inefficiencies in the use of scarce resources. These weaknesses are most evident in the care of patients with chronic conditions that require the coordination of multiple health professionals and care settings. This is also an important challenge in Latin America (LA) and is a consequence of the demographic and epidemiological transitions occurring in there. Population groups most seriously affected by healthcare fragmentation include those living in large urban slums, rural inhabitants, and indigenous populations.

In this particular environment of disjointed and fragmented care coupled with the increasing prevalence of chronic conditions; the policy challenge is to explore avenues to lead to joined up thinking regarding care integration which would lead to more satisfactory outcomes. Many countries have promoted the development of integrated healthcare networks (IHN), defined as a network of organisations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the health status and outcomes of the population served. Theoretically, integration of healthcare delivery should contribute to more efficient, equitable and higher quality health services. The advantages of care coordination go beyond reducing costs and encompasses patients’ access to appropriate levels of care; improvements in quality of care; and thus contributes to overall effectiveness of the health system.

The results of previous Equity-LA, identified numerous barriers to access healthcare services in the IHNs of Colombia and Brazil, suggesting failures in IHN policy implementation. A number of these issues were related to deficiencies in the coordination between primary and secondary care and quality of care, related to IHN’s internal factors such as lack of communication among healthcare professionals, insufficient coordination mechanisms, poor response capacity of primary care and limited compliance of clinical standards as defined by national and international guidelines; as well as external factors such as lack of a policy to promote care coordination in IHN at national level. Similar evidence from other Latin American health systems was limited. While the problems in coordination and quality of care indicated a poor IHN performance and the need for developing and testing useful and feasible strategies to provide evidence on best practices in care integration to help policy-makers to enhance health services networks results, the gap in the research on IHN, further highlights the need for extending the analysis to different types of health systems. This study focuses on both.

Care coordination is defined here as the harmonious connection of the different services needed to provide care to a patient throughout the care continuum in order to achieve a common objective without conflicts. Care integration is considered the highest degree of coordination. Continuity, on the other hand, is related to how patients’ experience the coordination of services received. Most available literature on care coordination generally refers to two interrelated types of care coordination: clinical information and clinical management coordination. Information coordination or the transfer and use of the patient clinical information needed to coordinate activities between providers. Coordination of clinical management is the provision of care in a sequential and complementary way, within a healthcare plan which is shared by the different services and healthcare levels involved.

Continuity of care, on the other hand, relates to how individual patients experience coordination of services, namely the result of coordination from the patient’s viewpoint, and it is defined as the degree to which patients experience care over time as coherent and linked. Three types of continuity are defined, a) of information: the patients’ perceptions of the availability, use and interpretation of information on past events in order to provide care which is appropriate to their current circumstances, b) of clinical management, the patients’ perceptions that they are receiving the different services in a coordinated, complementary and unduplicated way and of relation, the patients’ perceptions of an ongoing, therapeutic relationship with one or more providers.
Finally, quality of care is related to clinical outcomes or practices equal to or higher than accepted standards, minimum waste and costs within legal and policy requirements and a satisfied patient experience. Poor quality care is understood as outcomes, costs or experiences below accepted standards and norms. Poor process quality refers to provider actions or omissions that are likely to result in poor outcomes or that diverge from accepted good practice. Available evidence and theory suggest that the lack of coordination is the feature of organizational practice that has the highest direct and significant effect on patient outcome and costs8, being the common cause of poor quality. Recent research in high income countries indicates that failures in the coordination of care are common in healthcare organizations, suggesting that an appropriate and necessary way to address quality improvement is to advance in care coordination.

Care integration is dependent on the local context – that is, opportunities and costs depend on the particular healthcare system and its settings. Thus, interventions to improve the performance of IHN might be required at policy level, for example health services plans and payment systems, or at the organisational level, in which case interventions may range from those that aim to introduce organisational changes to those developing a tool for integrating patients’ information or combining coordination mechanisms in disease management programmes.

National governments and international organisms, such as the Pan American Health Organisation (PAHO), have made considerable efforts and displayed a growing interest in developing IHN. However, questions concerning best practices in care integration for the Latin American context and what structural and organizational reforms would be required to make IHN and their regulatory instances more effective remain unexplored.
IHN are not an aim in themselves but a means to improve coordination of care and hence, care continuity, quality and efficiency. In this sense, IHN are in different degrees of evolution. This is also the case in the six Latin American countries participating in the study - Colombia, Brazil, Chile, Mexico, Argentina and Uruguay - which represent different types of healthcare systems. In all of them, national laws regarding the configuration of the health system, also provide a framework for the development of IHN. Although the models vary, they have health systems that are segmented by population groups according to socioeconomic or employment status with a public subsystem and a private one. The public sector is financed by social security contributions and/or taxes. It encompasses at least one subsystem dependent on the ministry of health, decentralized to different levels of government (departments/provinces and/or municipalities) and is generally aimed at the lower income population and/or those without social security. This study is focused on the public subsystem. The proportion of covered population – estimated from the figures of enrollees to the public subsystem under study or to the other subsystems - varies depending on the country: in Chile (FONASA) and Brazil (SUS) it is higher, with 73% and 75% respectively, in Mexico (Health Department/public health insurance) 58.4%, in Uruguay (ASSE) 36%, in Argentina (provincial and municipal health departments) 36%, and in Colombia 53.7%, taking into account that these services provide care for the uninsured population and those enrolled in the subsidized scheme.
These public healthcare subsystems have important similarities. They have national policies or programs fostering the integrated healthcare networks, with diverse degrees of ambition and specificities. Healthcare provision is organized in networks of providers, mainly public (except in Colombia), but also private (except in Mexico). In all six countries, the norms envisage health care organized by levels of complexity, with PC as the entry point and coordinator of patient care and SC care in a supporting role, requiring a referral from PC for access to the specialist. However, some studies show dysfunctions in this model: the use of emergencies as a regular source of care and direct access to the specialist, which seems to indicate that, in addition to access barriers, there is limited coordination of care between levels.
Organisations are using many types of interventions to improve coordination, but there is very little evidence of their effectiveness. There is a need to develop more quasi-experimental research in order to develop theory about how a coordination change is best made and to include participants’ preferences which may be important for influencing their motivation and attitudes. Aspects that can be further promoted by a participatory action research approach PAR) that focuses on learning, success and action, by involving a collaborative approach. Its strength lies in generating solutions to practical problems and implies the involvement of all stakeholders. It contributes to raise the relevance of research, its credibility and social validity. In addition, the involvement of stakeholders allows for the bottom-up emergence of strategies, considered the most effective, and which has important implications for the sustainability of interventions. The adoption of an action research approach contributes to bridging the theory - practice gap. By drawing on professionals' experience, it can generate findings that are more meaningful and useful to them.

The results of the research, which builds upon those of Equity-LA, will support national and international decision makers by providing evidence of best practices in care integration in different types of health systems in Latin America, with particular reference to chronic diseases (diabetes, hypertension, and chronic obstructive pulmonary disease-). It contributes to advancing the state of the art by producing new knowledge on the impact of integrated healthcare networks reforms with respect to their objectives for care coordination and quality of care. The project achieved this by expanding the scope of the research in Colombia and Brazil and by incorporating other Latin American countries, which are Chile, Mexico, Argentina and Uruguay, thus representing a large array of health systems and IHNs.

Research policy goal: To contribute to the improvement of the effectiveness, efficiency and equity of Latin American healthcare systems by providing evidence on best practices of care integration, which will be translated into effective policies for varied social, political and economic contexts.

General objective

To evaluate the effectiveness of various care integration strategies in improving coordination and quality of care in IHN in different healthcare systems in Latin America.

Specific objectives

a) To analyse the integrated healthcare networks’ (IHN) performance with respect to coordination and quality of care in different healthcare systems in Latin America and associated factors in each particular context.
b) To design, implement and benchmark a set of organisational interventions aimed at improving care coordination and quality in different IHN in Latin America, with a focus on health workers and chronic care management
c) To test the effectiveness and limitations of the various interventions in improving coordination and quality of care in IHN and to identify the factors that determine their applicability in different contexts.
d) To develop tools to translate evidence on best practice of integration of care into innovative and effective policies for a better organisation of IHN in Latin America

In order to achieve the objectives the research applied a quasi-experimental design within a participatory and multidisciplinary action research framework. Participatory action research principles support the development of effective and sustainable care integration strategies by increasing relevance of research and improving its credibility and social validity. To achieve the active participation of relevant stakeholders of the selected IHNs throughout the research process, a local steering committee was set up at the beginning of the research process in each country, representing all the stakeholders involved in the IHN (healthcare professionals, managers, users, local policymakers and researchers). This committee took part in all the project phases and was in charge of the selection, design and implementation of interventions. Equity LA II research applied a quasi-experimental design (a controlled before and after design), First a base-line was establish on IHN performance on care coordination and continuity (using qualitative and quantitative research methods. It was followed by design and implementation of care integration strategies through a participatory process and then by the evaluation of its effectiveness. For this, two public IHNs were selected in each participant country, one intervention and one control. They met the following selection criteria: a) provision of a continuum of services including at least primary and secondary care; b) provision of services to a defined population; c) provision of care mainly to urban slums; d) willingness to participate and implement designed interventions; and e) leadership with the authority to implement the designed strategies.

In Argentina, The study took place in the municipal IHN in Rosario, which is organized in 3 care levels, according to complexity. It comprises 51 primary care centres, 3 general hospitals, a maternity centre, an integrated emergency services and 2 tertiary hospitals. Two sub-networks were selected to participate in the study: Northeast/North Districts (intervention), and the sub-network (control). In Brazil. The IHNs of the municipalities of Caruaru (intervention) and Recife (control) were selected, The Caruaru municipal IHN comprises 63 primary care units and 19 specialized care centres. In Recife participated, the DS III micro-regions 3.2 and 3.3 and DS VII, which gather 25 primary care centres and 14 specialized care centres. In Chile, two health services network of the Metropolitan Region were selected: the North Metropolitan Health District (Intervention) and the South Metropolitan Health District (control). The North Metropolitan Health District IHN comprises 60 primary care centres, a general hospital, a paediatric hospital, psychiatric hospital and a communal hospital. The South Metropolitan Health District IHN also integrates 60 primary care facilities and a hospital. Colombia, in Bogota, two of the 4 Health Secretary District IHNs participated: the IHN South-West (intervention) and the IHN South (control). The intervention sub-network comprised 17 primary health care centres, 6 second level hospitals, and a third level hospital. The control sub-network comprises 14 primary care centres; 6 second level hospitals, and a third level hospital. Mexico. Both intervention and control IHNs belong to the State of Veracruz and cover the population without social security. The intervention IHN in the municipality of Xalapa comprises a regional hospital, a third level hospital, 3 Units of Medical Specialties (UNEME) and 7 primary care centres. The control IHN in the municipality of Veracruz, comprises a general hospital, a third level hospital and 15 primary care centres. In Uruguay, the participant IHNs belong to the West Region. The intervention IHN comprised the Departments of Rio Negro and Colonia and the control INH was constituted by the departments of Florida, San José and Flores. The first level of care is provided through urban and rural policlinics and the second level through hospitals and auxiliary centres. The intervention IHN includes 48 centres of first and second level while the control IHN includes 50.

The project contributed to FP7 topic Research on health systems and services in low- and middle- income countries (HEALTH.2012.3.4) addressing policy-makers needs’ by providing evidence on best practices in integration of health care, that take into account relevant contextual factors necessary for their transferability, with particular reference to chronic diseases (Diabetes, COPD and other). The research has also developed methods and tools to develop, implement and evaluate care integration interventions, together with theoretical frameworks, as well as tools to evaluate the performance of IHN on care coordination and continuity. In addition it has largely contributed to capacity building in health services research, policy makers and health professionals’ knowledge and skills in the field of integration of care and interventions and methods to improve it.

Project Results:
This section includes the project main results separated into three main parts, according to the phases of the project, subdivided into different chapters. First, main results of the baseline study (2015) regarding IHN performance healthcare coordination and continuity, applying both qualitative and quantitative methods, are described comparatively and for each participant country. Secondly, the design of the interventions and its implementation process in the intervention networks (INs) is detailed. The third part, and last 3 chapters describes the results of the comparative cross-country analyses on: a) of the implementation process; b) changes in clinical coordination; and c) changes in care continuity.

1. IHN performance on care coordination and continuity: results of the base line
This section presents main results of the base-line study on clinical coordination (health professional’s viewpoint) and care continuity (users viewpoint) in the healthcare networks.

1.1. Limited care coordination across levels of care
To establish the baseline in 2015, a survey was conducted applying the COORDENA questionnaire to primary care (PC) and secondary care (SC) doctors working in the two public healthcare networks (intervention (IN) and control (CN); 348 doctors per country) to measure their experiences of coordination of information, coordination of clinical management and general perception of clinical coordination and the influencing factors. The knowledge and use of coordination mechanisms was also assessed. The survey was complemented with a qualitative study with network professionals (health managers, health and administrative professionals) on clinical coordination across care levels was also performed.

The cross-country analysis, showed that with some differences between countries, doctors generally reported limited clinical coordination, mainly in the transfer of information (coordination of information), but also in the coordination of clinical management specifically in the communication for the patients follow-up and access to SC for referred patients, especially in the case of PC doctors and, to a lesser degree, inappropriate clinical referrals and disagreement over treatments, in the case of SC doctors. General perception of clinical coordination between doctors of both care levels was limited, particularly in Brazil, Chile and Mexico. These results were associated to various factors related to working conditions, interaction between the professionals and attitude. Moreover, the results highlighted the limited implementation of a model based on PC as coordinator, with some differences between contexts.

Regarding knowledge of coordination mechanisms, the knowledge and use of the referral and reply letter (RRL) was high in all the analysed networks and countries (40.0% Brazil to 79.4% Mexico). Knowledge of discharge report was also over the 50% in all the networks and countries. However, there was greater variability in the use of discharge reports (23% Brazil to 60% Uruguay). Knowledge of clinical management coordination mechanisms was limited, especially among SC doctors. It is noteworthy, however, that adherence to clinical guidelines was high among those who knew them (83.1% Mexico to 96.8% Brazil), while participation in joint meetings varied widely (23.7% Chile to 76.2% Brazil). The difficulties reported in the use/participation of the mechanisms were related to both structural and organizational factors.

Results of the qualitative study, in all countries, showed difficulties in coordinating patient care among PC doctors and specialists and their consequences on quality of care. One of the main problems concerned the limited exchange of clinical information, especially by specialists, which made it difficult to diagnose and indicate the appropriate treatment of referred patients. As suggestions to improve clinical coordination emerged the clear definition of clinical roles of each care level, appropriate medical training, and the implementation of coordination mechanisms based on feedback among professionals which, in addition to improving consistency of care, patients follow-up and quality of care, favour mutual knowledge and trust between doctors of different care levels.

Within countries, some differences were also established between the studied networks:

Argentina. Results were similar in both networks. In relation to coordination of information only 30% of the doctors reported a frequent exchange of clinical information. Regarding coordination of clinical management: the repetition of tests performed in the other care level and contradictions and/or duplications in the treatments that PC and SC doctors prescribe did not emerge as problem. Majority of SC doctors reported that PC doctors refer patients to SC level when necessary, but only around 30% reported that SC doctors refer patients to PC for follow-up. Half of doctors reported that SC doctors make recommendations to PC doctors for patients´ follow-up, and that PC doctors consult the specialists with any queries they have about patients´ follow-up. Only 20% of doctors of both networks considered that the patient care was coordinated across levels. The RRL, discharge report and the institutional telephone were the three most well-known coordination mechanisms (>80%) in both networks. Results of the qualitative study a number of difficulties emerged in the transfer of information between care levels and insufficient coordination of clinical management, specifically discrepancies in the diagnostic criteria and over the treatments were described, with consequences for quality of care.

Brazil. Results differed between networks. Regarding coordination of information, between 16.7% in the IN to 32.3% in the CN of doctors reported exchanging information with the other care level. In relation to the coordination of clinical management, the percentage of doctors who agreed with the treatments prescribed by doctors from the other care level was lower in SC (between 17.9% in CN to 37.7% in the IN). Repetition of tests already performed in the other care level was reported by approximately the 20% of doctors of both networks. A small proportion of doctors perceived that patient care was coordinated across levels (IN 12.8%; CN 8.7%). Regarding coordination mechanisms, the RRL was the better known mechanism in both networks (61%), followed by the discharge report (55%) and the shared clinical guidelines (33%). Results of the qualitative study highlighted the insufficient exchange of clinical information between care levels and limited coordination of clinical management, specifically problems in consistency of care due to limited sharing of clinical objectives, duplication of tests and treatments, unnecessary referrals and limited patients follow-up across levels of care.

Chile. Results were similar between both networks. Results showed low levels of exchange of clinical information between doctors of both care levels (10%), and of coordination of clinical management, around the 65% reported that PC doctor referred patients to SC when it was necessary, and less than 20% reported contraindications and/or duplications of the treatments prescribed by the other care level. Regarding patients’ follow-up, around the 55% of doctors reported that SC referred the patient to PC for follow-up, and only around the 12% considered that PC consulted the SC doctors with any query about the patients’ follow-up. The general perception of patient care coordination was also low (<15%). The use of coordination mechanisms was limited, especially of the discharge report (information mechanisms) (52%) and for the participation in the joint clinical meetings (clinical management mechanisms) (15%), indicating insufficient interactions and feedback between doctors of both care levels. In qualitative study, professionals from both networks indicated difficulties of coordination between care levels relating to the transfer of information, especially the information from SC level to PC doctors and also the coordination of clinical management, with important limitations in access to secondary care, problems of patient follow-up, identifying problems in the consistency of care.

Colombia. Results were similar in both networks. Regarding coordination of information the reported exchange of information across care levels was under the 50%. Concerning coordination of clinical management, in both networks, less than 35% of doctors reported duplication of tests performed in the other care level. More than 50% reported disagreement over the treatments prescribed by the other care level. An overall low general perception of clinical coordination (<25%) was reported by doctors of both networks. Regarding knowledge and use of clinical coordination mechanisms, in both networks, the level of knowledge of information mechanisms (referral and reply letters (RRL) and discharge report) was very high (>90%), while it was very limited that of clinical management mechanisms (shared clinical guidelines and joint meetings) (<20%). The coordination mechanism used with the greatest frequency was the RRL (88%), followed by the discharge report (48%). Results of the qualitative study showed that although there were difficulties in the two types of clinical coordination, difficulties in coordination of clinical management were the most important -lack of agreement among professionals, insufficient patients follow-up, restriction of access to SC-, followed by problems in coordination of information.

Mexico. Results were similar for both networks, except for the general perception of clinical coordination. More than 50% of doctors of both networks reported limited exchange clinical information with the other care level. Regarding the coordination of clinical management, more than half of doctors of both networks reported that PC referred the patients when necessary, repeating the tests performed at the other care level, agreeing over the treatments, and the existence of contraindications and/or duplications in the treatments. General perception of clinical coordination across levels differed by networks, being higher among CN (IN 9%; CN 18%). The better known coordination mechanisms were the RRL (>90%) in both networks, followed by the discharge report (>80%). Qualitative results were similar for both networks, describing limited exchange of clinical information. Regarding coordination of clinical management, limited follow up across levels, due to lack of feedback from SC to PC, together with inadequate and delayed referrals to SC were also mentioned. In general, professionals or both networks considered that there was limited clinical coordination between care levels.

Uruguay. Results were similar across both networks. Less than 40% of doctors of both networks declared to exchange clinical information with the other care level. Regarding coordination of clinical management, more than 70% of the doctors in both networks considered that PC doctors refer the patients when necessary but also declared that they did not always agree over the treatment prescribed by doctors of the other care level. However, less than 20% of the doctors referred that they repeat the tests already performed by the other care level and a similar proportion of the doctors declared that there were contradiction and/or duplications in the treatments prescribed by the other care level. General perception of clinical coordination across levels was around 80% in both networks. A scant knowledge and use of RRL was observed (<60%), and a very low knowledge and participation in joint meetings (13%). The qualitative study with professionals of both networks revealed problems of clinical coordination between the care levels that were related to a fragmented healthcare organization and to a professional culture focused on the SC and not considering PC as the responsible of patients follow-up.

In short, these results indicated that there was limited coordination across care levels in all study networks. In general, results of coordination of information and coordination of clinical management were similar between the networks in all countries, except for Brazil were some differences were observed. The results highlighted the need to strengthen the provision model based on primary care as coordinator, and to address key aspects for the integration of the healthcare networks: the definition of the roles of each care level, the implementation of feedback mechanisms to improve clinical coordination and quality of care but also to favour mutual trust and knowledge between the professionals. Finally, the improvement of working conditions would be helpful to increase professionals´ time and willingness to get involve in clinical coordination activities.

1.2. Limited continuity of care across levels
This study provided evidence on a little explored phenomenon in Latin America, continuity of care across levels focusing in patients with chronic diseases. Continuity of care (CC) is defined as the degree to which the patient experiences care over time as coherent and linked, and is the result of care coordination. Three interrelated types can be distinguished: continuity of information, continuity of clinical management and continuity of relation. While the first two types can be analysed intra or inter levels of care, the third can only be analysed intra-level.
To establish the baseline of continuity across levels of care in 2015, a survey was conducted to users of the IHN services, with at least a chronic condition using the CCAENA© questionnaire in face-to-face interviews, following its adaptation to the different contexts of the participating countries. The final sample was around 400 patients per network (IN, CN) and country. In addition, a qualitative study was carried out by means of interviews to patients with Diabetes, COPD and other chronic conditions and in some cases, also their carers.
Main results of the baseline study on continuity of care in patients with chronic conditions are presented summarising the cross-country analysis regarding the experience and perception of continuity of care in the six countries, then, the most important findings in each country providing additional comparison between the intervention network (IN) and control network (CN) when deemed necessary.
The cross-country analysis In general, patients from the six countries reported experiencing discontinuities of care in the transition from primary care (PC) to secondary care (SC) that were mainly related to cross-level follow up, accessibility between levels and limited transfer of information. For instance, patients from the six countries reported having experienced long waiting times, mainly in the transition from PC to SC doctor, limited back referral from SC and low use of the clinical report across levels of care, although with different levels depending on the country.
Regarding the perception of continuity of care across levels, chronic patients had worse perception of continuity of information and accessibility to SC than that of care coherence. However, there were important difference among countries. Higher levels of continuity of information were perceived in Uruguay, while in Argentina, patients perceived higher care coherence. Moreover, patients in the six countries perceived significant discontinuities in access to SC following referral by a PC doctor. The study of factors associated with the perception of continuity of care in all six countries revealed that improving continuity of care between levels for chronic patients entails strengthening their relational continuity with both the PC and SC doctor.
Finally, the results of the qualitative studies found that patients consistently identified lack of communication and of mechanisms for the transfer of clinical information as important factors constraining the continuity of care across levels. Moreover, important differences across patients’ experiences regarding continuity of clinical management, accessibility to care levels and the factors associated to continuity of care emerged.
Within countries, some differences were also established between the studied networks:

In Argentina, patients experienced discontinuity of clinical information across levels of care, mostly referred to limited awareness of PC and SC doctors of the indications given by the other level. Patients also perceived higher awareness of PC doctor on the diagnosis treatment and recommendations given by the specialists (60.0%). Concerning clinical management continuity, a great majority (>90%) of patients in both networks declared being referred to SC by the PC doctor. Regarding care coherence across levels of care, patients perceived high levels of agreement on diagnosis and treatments and collaboration between PC and SC doctors. Additionally, regarding factors associated to continuity of care, patients expressed trust on PC and SC professional ability (>80.0%). The results of the qualitative study showed that chronic patients from both networks considered that there was clinical agreement between doctors of different levels of care regarding treatments and diagnostic tests. Moreover, patients perceived that the follow-up was responsibility of the primary care doctors, and described a strong bond, but also with the specialists based on their capacity for resolving complex pathologies or recurrent episodes,
In Brazil, patients from both networks reported high levels of discontinuity of care. Regarding clinical information, patients reported lack of PC doctor’s awareness of their clinical history, treatment and recommendations given by SC doctor. Likewise, patients perceived lack of awareness of SC doctors of the diagnosis, treatment and recommendations given by the PC doctor (82.7%). With regard to clinical management continuity, patients reported high levels of agreement (>70%) between PC and SC doctor. In addition, long waiting times to consultation with both levels of care and difficulties in access to consultation with the specialist were reported. Finally, regarding the main factors associated to continuity of care was trust in PC (89.7%) and SC (87.2%) doctors. The results of the qualitative study provided in-depth information on the factors influencing continuity of care, among others, patients highlighted the difficulties particularly in the arrangement of specialist’s visits, leading to having to pay for private consultations, jeopardising the family income.
In Chile, the results showed limited levels of the different types of continuity of care, with important implications for quality of care in both networks. Regarding continuity of information, patients reported low awareness of both PC and SC doctors regarding the diagnosis, treatment and recommendations given by the other level. Likewise, patients perceived low continuity of clinical management, regarding consistency of care and accessibility between care levels. Consistently, patients in both networks reported that the referrals across levels of care did not respond to their follow-up needs. Factors associated to continuity of care were high levels of agreement between PC and SC doctors (IN: 71.5% and CN: 61.8%) and of trust in their professional abilities (IN: 72.6% and CN: 79.1%). The results of the qualitative study found that patients perceived as main problems the lack of collaboration of professionals of the different levels of care; and serious limitations in accessing adequate care – especially in SC. According to the participants, the latter led to a deterioration of their health.

In Colombia, patients’ reported the lack of awareness of SC doctors regarding their clinical record with PC doctor in both IN (73.9%) and CN (71.8%). Concerning continuity of clinical management, there was a low perception of agreement of SC doctors with the diagnosis, treatment and recommendations given by the PC doctor. Patients also perceived low levels of collaboration between PC and SC to solve their health problems. Regarding factors associated to continuity of care, more than 85% of patients referred trust on PC doctors’ professional abilities and the great majority (>90) reported to attend to their regular source of attention. According to the results of the qualitative study, patients related the absence of mechanisms to transfer clinical information to a shift of this responsibility to them, and to the prescription of medicines without enough clinical evidence.
In Mexico, differences were found in the perception and experience of continuity of health care across dimensions. On the one hand, patients perceived discontinuity in the transfer of clinical information, particularly in the IN where more than a half (55.2%) of patients perceived that PC doctors were not aware of the diagnosis, treatment and recommendations given by the specialist, and also most of SC doctors (62.5%). On the other hand, regarding experienced continuity of care management, patients reported high levels of accessibility across levels of care in both, the IN (84.5%) and CN (96.8%). According to qualitative results, factors related to the health system such as restricted coverage of the Seguro Popular and payment- for-services affected the accessibility between levels of care. Other identified factors related to services were deficits in service supply, instability of physicians, lack of training and problems in the relationships between physicians of the different levels and with the patients.
In Uruguay, patients from both networks perceived high levels of continuity of clinical information mainly in PC doctors’ awareness of the instructions given by the specialist (88.4%). The most outstanding finding refers to continuity of clinical management, regarding care coherence and accessibility across levels of care. Regarding care coherence, patients reported that PC doctor did not repeat medical exams already made by SC doctor, while the majority (>90%) referred that accessibility across care levels was positive. Finally, according to the results of the qualitative study patients identified themselves as responsible of securing the coordination across levels of care in order to compensate the deficiencies in the transfer of clinical information and the administrative management.
In short, in the base-line study, the need for improving continuity of care in patients with chronic conditions, emerged as a priority in all six countries. Although differences between networks emerged from the analysis, patients consistently reported high experience and perception of discontinuity of care across levels. The analysis of the associated factors showed that organizational factors rather than individual factors, are consistently associated with the perception of continuity of care and care coherence in all countries. Consequently, this study support the importance of strengthening the coordination of clinical information, and relational continuity to improve continuity of care of patients with chronic conditions and quality of care.
2. Intervention design in each country through a PAR process

The participatory action research process started in each of all participant countries with the creation of a Local steering committee (LSC) to lead the design and implementation process. It was made up of managers from different care levels in the network, and in some cases also health professionals, together with the research team in the role of facilitator (capacity building, systematization, monitoring and feedback). The LSC was expanded in Chile to include new stakeholders, while it showed a high turnover in Argentina, Colombia and Mexico.
In the first phase, the baseline study, evidence was produced on care coordination in the networks which was then presented to and discussed with the professionals; this process was particularly extensive in Chile, Colombia and Mexico (aprox. 200 participants). In the second phase, an inter-level professional platform (PP) was created with those interested in taking action, with which the baseline study results were problematized and interventions were chosen. The Professional Platform consisted of approximately 15 participants - in Mexico, 31, divided into two groups (according to working hours). Although the number of participants increased with the time and there was also some rotation. Most were doctors, although in some cases, other health professionals, administrative staff or middle managers also participated. In Chile and Colombia, a problematization and preliminary selection of interventions in each centre was also carried out, as a previous step to the final selection with the PP and LSC, while in the rest of the countries it was only carried out with the latter. The interventions’ selection took into account the interventions for the improvement of clinical coordination suggested by the professionals at the baseline or during the dissemination of results, previous experiences in the network, or in other contexts, and international evidence. To select the interventions, consensus techniques and / or prioritization matrix were also applied.
In the second phase, the interventions were designed and implemented through three types of process: 1) in Colombia, Brazil and Mexico, two PAR cycles: i) a short initial design by the PP and/or LSC (3 months) followed by implementation and ii) adjustment and implementation (5 months); 2) in Chile, long design with greater participation on the part of inter-level working groups and LSC, in several cycles of action-reflection, with pilot tests and implementation (10 months); and 3) in Argentina and Uruguay, open design to be agreed with the PP and subsequent implementation (7 - 10 months). However, some phases of the intervention were not implemented in Argentina; and in Uruguay, the research team was responsible for carrying out some intervention design activities due to problems in the functioning of the PP.
Regarding the difficulties faced during the process of designing the interventions, the main obstacle identified was the limited participation of SC doctors, attributed to the difficulty of freeing time to participate in the meetings. This affected both the process of return of results, and the operation of the Professional Platforms. Despite having the formal institutional support (health secretariat / CCL / network directors / centres), only in Chile, it seems to be resolved through prior scheduling and reconfirmation of meetings. In Brazil, Mexico, and Colombia, the participation of professionals was encouraged with an academic accreditation. The geographical distance between the intervention network services - and therefore between the members of the Platform-, and with the research team influenced the correct functioning of the PP in Uruguay, which was attempted to address maintaining an online communication.
On the other hand, the political cycle interfered the process of the design of the interventions in Brazil, Mexico and Colombia. This caused a delay in carrying out activities and the breach of the agreements reached due to the lack of government activity during the election period and the constant rotation of the LSC members. The change of government meant the replacement of some of the LSC members in Brazil and Mexico.
The main selected problems in all countries were lack of communication between PC an SC doctors regarding the patient care and clinical disagreement were. Three types of interventions were implemented to improve communication and agreement between PC and SC doctors in the clinical management of patients (problems selected): joint meetings between PC and SC doctors to discuss clinical cases and/or ongoing training, in person in Brazil, Colombia and Mexico and online in Chile, where other health professionals also participated; offline virtual consultations between PC and SC doctors, by email in Brazil, and via a digital platform in Mexico; the drawing up and implementation of shared care guidelines in Argentina and Brazil; a multi-component strategy to promote the use of referral and counter-referral forms in Uruguay. In Chile, moreover, an induction program was developed in order to foster a common identity and shared vision in the healthcare network. The interventions were not only aimed at the professionals of the platform (PP), but in many cases it was intended to involve all the PCs of the network, the specialists and other professionals related to the care of this type of patients.
The contents of the designed interventions are briefly described below.
Argentina. The selected intervention was the development of a hypertension and diabetes shared care guideline (“Acuerdo de gestión clínica de HTA y DM”). Its main objectives were to identify obstacles and areas for improvement in the process of care for patients with hypertension and diabetes in the sub network’s health care service through joint meetings of professionals from both PC and SC care levels and to draw up a of shared care guidelines for treatment of hypertension and diabetes chronic patients, covering the required resources and pathways for its implementation in the healthcare network.

Accordingly, the drawing up of the shared care guidelines was performed in two phases:
a) Characterization of diabetes and hypertension patient’s itinerary across care levels through clinical record review (February – November 2016). During this phase of the intervention’s design, the research team reviewed national and international guidelines and regulations of hypertension and diabetes, in order to build a guide (worksheet) to systematize the information of the selected clinical records. Once this document was ready, research team members along with professionals from both care levels, proceeded to review the clinical records, identifying obstacles in patient attention.
b) Joint meetings for building a diabetes and hypertension patient care agreement (December 2016 – November 2017). Joint meetings consisted on the discussion of clinical cases that were previously selected by PC professionals. After identifying the main obstacles, members from the LSC and the PP, along with the research team and SC physicians, discussed possible items to incorporate to the shared guideline, resulting in 3 components: Primary Care Centre/clinical hospitalization - Primary Care Centre/Cardiology – Primary Care Centre/Endocrinology.

Chile.Two interventions were selected a) Joint virtual clinical conferences, and b) Induction program for working in network for physicians, other professionals, and staff.
a) Joint virtual clinical conferences between PC and SC. The intervention aimed at improving inter-level communication and exchange, fostering mutual knowledge, trust and care agreement across care levels. The intervention consisted of synchronous virtual meetings between professionals from different care levels. The meetings were coordinated by San José Hospital, with the support from the LSC. During these meetings, the participating teams updated diagnostic and referral protocols, and the PC teams presented cases, analyzed procedures, and solved questions. The platform was complemented by a WhatsApp group, which helped improve the exchange of information Meetings were held every two weeks and lasted between 90 and 120 minutes.
b) Induction program for working in network. The intervention aim was to inform healthcare professionals about available coordination mechanisms between care levels, health services portfolio, medication guide, and other relevant information. Additionally, the program sought to facilitate the exchange of information and improve personal linkage among professionals to support administrative coordination between care levels. It consisted of a program of activities and informative graphic and audiovisual dossier on the network for physicians and other healthcare professionals. A relevant contribution of the program were the cross-level bidirectional visits between PC centers and the San José Hospital.
Colombia. The selected intervention was joint meetings between PC and SC doctors with two components: the discussion of clinical cases and continuous medical training, based on reflexive methods (RM). The main objective of the interventions was to improve clinical management coordination between PC and SC doctors by improving communication, collaboration and agreement over diagnosis and treatment of chronic patients. Two modalities were designed: joint meetings with PP doctors, and replica meetings addressed to PC doctors in the network. Both types of sessions were held monthly. Although joint meetings involved mainly PC and SC doctors, some sessions involved other healthcare professionals from the IHN.

1) Join meetings of PP doctors lasted 4 hours. A PC professional was responsible for the clinical case to be discussed. This involved the selection and preparation of the clinical case, its presentation, emphasising disagreements and communication failures in its clinical management. The intervention facilitator (an internist) promoted the discussion, solving participants’ doubts and helping to establish care agreements. The facilitator also introduced the topic to be discussed during the continuous medical training, along with the objectives and activities. Those responsible for conducting the training session used the pedagogic strategy. Healthcare staff had 1 working hour per month for preparing the session.

2) Replica meetings lasted 2 hours. They were conducted by the facilitator (internist) and a member of the PP (a PC doctor). They contemplated the socialization of the discussed cases and lessons learned in the PP meetings.

Brazil, The intervention had three different components: a) Diabetes shared care guidelines; b) Asynchronous virtual consultations in mental health via email between PC doctors and psychiatrists; c) Discussion of clinical cases in mental health between PC teams and psychiatrists. The main objectives of the intervention were: 1) To stimulate the knowledge exchange between PC and SC physicians; 2) To improve the quality of information shared between PC and SC physicians; 3) To promote formal communication mechanisms adapted to professionals’ needs; 4) To improve the clinical adequacy of referrals for SC; 5) To contribute to establishing a coherent and timely health care flow.

a) The development of the diabetes shared care guidelines two place in two phases: first, joint meetings to discuss clinical cases between the doctors of AP and AE were conducted and then, a number of meetings to draw up the shared care guidelines, in which members of the network management were also incorporated. b) Concerning the asynchronous virtual consultation in Mental Health, meetings were held to design the tool. A standardized format was designed, with the minimum information to be sent by the PC doctor (administrative data, clinical history, medical tests and referral reason). The number of potential consultations per doctor was unlimited and the maximum response time for SC doctor reply, 8 days, whereby a weekly working shift was allocated for their reply. The discussion of clinical cases in mental health were conducted through clinical sessions in PC units with professionals of both care levels.

Mexico. The selected interventions were a) virtual communication system between care levels and b) joint training sessions (the latter designed during the second implementation cycle).
a) The online communication system aimed at improving direct communication (clinical information exchange) between PC and SC doctors, helping to coordinate patients’ care and referral through a direct and asynchronous channel accessible through computer equipment. It had three functions: i) consultations between PC and SC doctors (by filling out a form with detailed information on the patient), ii) documents consultation (Clinical practice guidelines and Official Mexican standards), and iii) feedback from the referral and reply letters received (by direct message to the sender). A standardized format was designed with the minimum information to be sent by the PC doctor: administrative data, clinical history, medical tests and referral reason. The number of consultations per doctor were unlimited, and the maximum response time for SC doctor replying was 3 days.
b) The joint training sessions, based on discussion of clinical cases in maternal and perinatal care and chronic diseases, aimed at improving clinical agreement and the adequacy of the referrals and communication across care levels. PC doctors were trained through 8-hour seminars for 3 consecutive days, by an intervention facilitator (an gynecologist).

Uruguay. A multi-component strategy was selected to promote the use of referral and reply letters (RRL). The strategy consisted of three components: a) a flowchart for the use of RRL by different levels of care; b) development of a standardized format – multi-copy form, with the minimum data to be provided on the patient (administrative, clinical, referral reason and recommendations for follow-up) -, and a guideline for the use of RRL that contains the roles and responsibilities of the different actors involved. The implementation plan designated the members of the PP responsible for the implementation of the intervention in their healthcare units. Their tasks were to deliver and control the material in the healthcare units, inform doctors and other professionals of the strategy, and monitor the use of RRL. A dossier was left at each healthcare unit containing information on: the Equity LA II project, the intervention, the bibliography on referral and counter-referral letters and its impact on care coordination, guidelines for the intervention implementation and monitoring and its evaluation criteria. Users of PC could only be referred to SC using the intervention’s referral and counter-referral form: an original copy remained in PC clinical history, and copies 2 and 3 were submitted to SC to schedule an appointment with the doctor. Then, patients returned to PC with the counter-referral while the other remained in SC clinical history. The monitoring device allowed for the verification of the continuity of this process, identifying possible disruptions in the healthcare circuit; the contents of the referral and counter-referral letter allowed for the evaluation of the relevance of the information; and the number and quality of referrals and counter-referrals enabled to measure the degree of adherence to the process by both doctors and patients.

In short, the design of the interventions through PAR processes were conducted with different levels and type of participation according to country and stage of the process. In Chile, the PAR process was more flexible, iterative and co-learning type, while in Colombia and Mexico the process was more planned, and including Uruguay, cooperative type. The type of PAR process carried out may have influenced the results and sustainability of the intervention. In most countries, there were obstacles to maintaining the levels of participation: time constraints of professionals, in line with other PAR studies, and political changes, related to the weak governance of the healthcare systems in the region. The interventions selected by the professionals, mostly based on mutual adjustment or direct feedback between healthcare professionals, aimed at improving communication and mutual knowledge between levels of care, in contrast to the type of top-down interventions that are usually implemented in health services to improve coordination between care levels.

3. Evaluation of the interventions implementation process

The level of participation in the interventions was higher among PC doctors, particularly in those with longer duration, attendance at joint meetings in Colombia (76% over 16 months) and frequent use of shared care guidelines in Brazil (96.7% over 21 months); and lower among SC doctors (except for virtual clinical conferences in Chile, where more specialists participated as the intervention did not focus on a specific disease). By contrast, the number of asynchronous virtual consultations in Brazil and Mexico, the frequent use of referral forms in Uruguay, and attendance at joint meetings in mental health in Brazil were low. Joint meetings in Chile, Colombia and Mexico, and shared care guidelines in Brazil had a higher penetration (percentage with knowledge of the intervention) among the PC doctors of network.

Regarding factors that influenced the implementation of interventions, the participants identified factors related to the context, the PAR process and the content of the interventions, which were determinant for their implementation. The factors, which differed according to experience, interacted between them over the course of time. Firstly, the institutional support providing the necessary resources, together with professionals’ and managers’ willingness to participate, emerge as key contextual factors which in turn are influenced by factors of the system (alignment with public policies and the political cycle with directives rotation), of the IHNs (lack of time due to work overload and inadequate working conditions) and of individual nature (lack of knowledge and mutual mistrust). Secondly, characteristics of the PAR process –participation, flexibility, consensual decision making-, the leadership of the LSC and the facilitating role of the research team, boosted institutional support and professionals’ motivation during the implementation of the interventions.

According to results as perceived by informants, joint meetings between care levels were the interventions that showed bigger impact on clinical coordination, especially in Chile, Colombia and Mexico –through the improvement of direct communication between PC and SC doctors, clinical agreement and the adequacy of the referrals–. Impact of joint meetings on the factors that influence professionals’ coordination and training was also identified, although limited to the professional specialities that took part in the study. Cross-level visits in Chile also contributed to the improvement of coordination between care levels. Regarding virtual consultations (Brazil and Mexico) and referral and counter-referral forms (Uruguay), informants identified few contributions to care coordination, due to their limited use among professionals. The PAR process also contributed to improve factors that influence care coordination (problem awareness, professionals’ and managers’ willingness to participate and coordinate themselves), showing different intensities in each country.

In all countries the project had a number of positive side effects. For example: 1) the intervention has been incorporated in national or local policies/actions (e.g. Chile, example of good practice in the national policy documents of 2018/2019; México, the intervention has been incorporated in the state policy as main strategy to reduce maternal mortality and has been implemented to the entire State of Veracruz (more than 2.102 PC doctors trained); 2) the intervention has triggered the implementation of other interventions to improve the functioning of the IHN in the six countries; 4) the “Equity working method” has been adopted as a method for improving the quality of care in the IN; 5) Other IHNs have initiated similar processes adopting the design, methods and tools of the project.

The interventions are considered to be sustainable in time –especially virtual consultations in Chile, as they have been integrated into IHN planning–, as well as transferable to other contexts. However, threats related to government changes and lack of institutional support are also perceived. The elements identified as essential for the sustainability of the interventions are their institutionalization and the identification/consolidation of leaderships that can go on with the implementation of the interventions. Informants also considered that the implementation of the PAR methodology, the willingness of managers and professionals, as well as the institutional support and leadership throughout the implementation; are essential for the transferability of the interventions to other contexts.

In conclusion, the study provides evidence on the influence of factors of context and process in the implementation of PAR interventions to improve care coordination across levels, and their interaction across time. It also reveals that when certain contextual elements converge –alignment with policy, institutional support– a correctly carried out PAR process in terms of time, method and levels of participation can turn into a factor of motivation and cohesion determining the adoption of interventions. The findings also reveal the importance of mechanisms based on mutual adjustment processes to coordinate clinical care across primary and secondary care. Specifically, mechanisms that create spaces for direct communication, such as joint meetings, emerge as useful strategies for improving interpersonal relationships, thus encouraging mutual knowledge and positive attitudes towards collaboration. Their institutionalization and the identification/consolidation of leaderships that can go on with the implementation of the interventions are the elements identified as essential for the sustainability and applicability of the interventions

4. Results on the effectiveness of the interventions on care coordination: cross-country analysis

All interventions, developed through the PAR process, were implemented aiming at improving clinical coordination between care levels. To assess the effectiveness of interventions, the evaluation survey was conducted in 2017 among PC and SC doctors of the participating healthcare networks using the COORDENA questionnaire. Some additional questions were included regarding the intervention implementation. Despite intervention periods relatively short (the longest around 12-month) some improvements in clinical coordination between care levels, and coherent with the interventions’ objectives, were observed in all intervention networks (IN).

Regarding intermediate results, that is, changes in influencing factors, interactional factors –knowledge between doctors of both care levels– increased significantly in the INs of Brazil (2015: 13.6%; 2017: 22.3%; p<0.05) and Colombia (2015: 3.9%; 2017: 10.2%; p<0.05) (p<0.05); and –trust on the other care level (2015: 56.6%; 2017: 69%; p<0.05) and identification of PC doctors as coordinators of patients care across care levels (2015: 59.3%; 2017: 74%; p<0.01)– rose in Brazil. Organizational factors –manager’s support to clinical coordination–, increased significantly in the IN of Mexico –managers of PC (2015: 19%; 2017: 34.8%; p<0.01) and SC (2015: 21.4%; 2017: 32.7%; p<0.01) healthcare settings facilitate clinical coordination–. Regarding final results, that is clinical coordination, improvements in care consistency items were observed: agreement over treatments prescribed by doctors of the other care level significantly increased in the INs of Brazil (2015: 46.1%; 2017: 56.7%; p<0.05) Colombia (2015: 40.9%; 2017: 53.3%; p<0.05) and Uruguay (2015: 42.1%; 2017: 57.4%; p<0.01); SC referrals to PC for patient´s follow-up (2015: 51.1%; 2017: 63%); PC doctor´s doubts consultations to SC (2015: 6,5%; 2017: 13.3%; p<0.05) were greater in the Mexican IN; and SC recommendations for patient follow-up was greater in the Chilean IN (2015: 39.9%; 2017: 53.9%; p<0.05) (p<0.05). General perception of clinical coordination between care levels increased in the INs of Brazil (2015: 9%; 2017: 18.1%; p<0.05) Colombia (2015: 25.5%; 2017: 35.7%; p<0.05) and Mexico (2015: 8.7%; 2017: 22.3%; p<0.01).

This is the first study evaluating the effectiveness of health services PAR based interventions to improve clinical coordination between care levels. Improvements in intermediate and final clinical coordination results were observed in the INs of all countries after the implementation of the interventions. There were some differences between countries, with more changes in the interactional factors in Brazil, while changes in consistency of care and patients follow-up were observed in all the INs and, in the general perception of clinical coordination in the INs of Brazil, Colombia and Mexico. Reduced implementation time and some process and context factors may have limited the interventions´ impact. New measurement are needed after longer implementation time to establish the interventions´ full impact, as other improvements were observed that did not achieve statistical significance.

5. Results on the effectiveness of the interventions on care continuity: cross-country analysis

The evaluation survey was conducted in 2017 to assess the effectiveness of the interventions from the chronic patient’s viewpoint, using the CCAENA questionnaire. Some specific additional questions were included in Mexico and Uruguay. A sample of around 400 patients with at least a chronic condition and that had used two levels of care in the six months previous to the survey was selected in each network

The experience and perception of continuity of care across levels increased, with difference among countries. The most outstanding changes occurred in continuity of clinical information in Brazil in the reported transfer of clinical information between PC and SC doctors, followed by improvements in Mexico, Chile, and Uruguay, and to lesser extent in Colombia. Regarding clinical management continuity, Brazil, Chile and Uruguay reported an increase in care coherence across levels of care, while only Chile reported improvements in doctors’ agreement. The findings are consistent with the objectives of the interventions implemented in each country, which have as their main objective to improve collaboration among doctors across levels of care. Likewise, the differences and lesser perception and experience of continuity across countries may be understood in the frame of the particular contextual and implementation process factors.
Regarding the experience of clinical information continuity, there was an increase in patients of the IN network that reported that the PC doctor knew beforehand the instructions given by the SC doctor (2015: 34.8%; 2017: 56.2%; p-value <0.01) in Brazil. Moreover, patients in Chile reported an improvement in SC doctor delivering a clinical report for the PC doctor (2015: 38.6%; 2017: 53.9%; p-value <0.01). Likewise, there was an increase in patients reporting that PC doctors delivered a clinical report to SC doctors in Brazil (2015: 54.9%; 2017: 72.0%; p-value <0.01) and Chile (2015: 59.1%; 2017: 64.9%; p-value <0.05). An increase was also observed in Chile regarding SC doctors knowing beforehand about the patient’s clinical record (2015: 14.5%; 2017: 35.6%; p-value <0.01) and SC doctors being aware beforehand of the reason why the PC doctor referred the patient for consultation (2015: 17.1%; 2017: 40.4%; p-value <0.01). Regarding patient’s perception of continuity of information across levels of care, more patients perceived that PC doctors were aware of the diagnosis, treatment and recommendations given by SC in Brazil (2015: 37.6%; 2017: 50.2%; p-value <0.01) and Mexico (2015: 44.6%; 2017: 52.9%; p-value <0.01). In Mexico an increase was observed in patients’ perception of PC doctors asking about consultations held with SC (2015: 67.9%; 2017: 69.2%; p-value <0.01) and also in SC doctors’ awareness of the diagnostic, treatment and recommendations given by the PC doctor (2015: 36.5%; 2017: 49.4%; p-value <0.01).
Regarding the patient’s experience of clinical management continuity, the percentage of patients declaring that there was no repetition of medical exams already made by the SC doctor increased in the IN of Uruguay (2015: 61.1%; 2017: 73.6%; p-value <0.05). The experience of being referred by the PC doctor to the SC doctor increased in Brazil (2015: 75.7%; 2017: 91.6%; p-value <0.01) and Chile (2015: 80.5%; 2017: 89.7%; p-value <0.05). Regarding the perception of clinical management continuity between care levels, improvements in care coherence were observed in patients’ perception of being sent by the PC doctor to the SC doctor whenever needed increased in Chile (2015: 73.5%; 2017: 78.4%; p-value <0.01); and Uruguay (2015: 92.4%; 2017: 95.5%; p-value <0.01).
Other changes, although non statistically significant, were observed in the IN in Chile, regarding patient’s perception of information exchange in: PC doctors asks about any consultations the patient had in SC; SC doctor knows about the patient’s treatment before he/she explains it; SC doctor is aware of patient’s clinical record; and SC doctor knows the reason of consultation beforehand. Likewise, it improved in other countries. In Colombia, concerning no repetition of medical exams already made by the SC doctor. In Uruguay, regarding PC and SC doctors collaboration to solve patients’ health problems.
This analysis allowed knowing the degree to which patients with chronic conditions perceived and experienced the effectiveness of the implemented strategies on continuity of care, while considering contextual factors influencing the selected continuity outcomes. Policies strengthened the implemented interventions in Brazil, but changes in the organizational model in Colombia may have an unfavourable influence over patients’ perception experience of continuity of care in spite of implemented interventions. While further analysis is needed, the results are of interest of policy makers interested on enhancing continuity of care across care levels in patients with chronic conditions in diverse setting. These results adds evidence that strengthen previous evaluations of the effectiveness of PAR interventions.

Potential Impact:

1. Strategic impact
The project addressed the objective of the FP7 Health Cooperation Work Programme: health for Specific Cooperation Actions (SICA) of supporting research to improve the efficiency and effectiveness of health systems in low and middle income countries, focusing on the two areas of the call: health systems/health services research and strengthening research capacity building in terms of human resource. It aimed to contribute to the strengthening of health systems increasing the quality of care and performance of health services, by addressing an area of high interest, but so far little explored: the integration of healthcare.

1.1. Contributions to the expected impacts of the FP7 cooperation work programme in health
The project focused on the HEALTH.2012.3.4-1 topic “Research on health systems and services in low-and middle income countries”. It aimed to contribute to the expected impacts of the topic by developing, implementing and testing a set of interventions to improve care coordination, continuity and quality in six Latin American countries, using a quasi-experimental design, within a participatory and multidisciplinary action research framework.
Firstly, in response to policy makers’ needs it contributed to empower national and regional decision-makers in middle income countries in the planning, management and organisation of health systems; by: a) providing robust evidence on best practices to improve the integration of health services that will contribute to the strengthening health systems, b) involving key stakeholders in the process of research from the beginning of the project; c) developing tools based on best practices of disseminating information to non-academic public, to allow the evidence to be translated into healthcare integration policies conducive to more effective health systems and higher quality health services.
Secondly, it contributed to capacity building in at least three domains: 1) strengthening research capacity in the field of health systems/health services research by establishing EU-LA and South-South cooperation links and specific training of junior researchers 2) health professional knowledge and skills on clinical coordination and quality of patient care through in-service training programmes and involvement in action research activities. 3) incorporating in pre-graduate and post-graduate training for health professionals of involved institutions teaching on adequate strategies to improve coordination of care in networks, particularly for chronic elderly patients.
Equity-LA II built upon the results of Equity-LA, which explored access to the care continuum in IHNs of Colombia and Brazil and identified important barriers to care coordination, expanded the scope of the research in Colombia and Brazil and incorporated four new countries to represent a larger array of health systems and IHN. It aimed at improving the organisation of health service delivery (HEALTH.2012.3.2.1) by providing information on best practices of integration between primary and secondary care and on the effect of new organisational approaches on quality of care, in different healthcare contexts also relevant for EU healthcare systems.
The Equity LA II project has allowed for a deepening of the understanding of integrated care, providing evidence-based strategies for better informed policy decisions and identifying best practices in the implementation of PAR-based interventions and the contextual factors that affect it. The findings contribute to improve performance of healthcare services by deepening the evidence regarding IHNs, providing effective and context-tailored strategies, focusing on chronic conditions and finally, promoting sustainable and efficient healthcare systems. In doing so, the project also contributed to the Innovation Union Pilot Partnership on Active and Healthy Ageing goals since the evidence on best practices of care integration is particularly relevant for the management of chronic diseases highly prevalent among the elderly. By providing effective strategies, adapted to the context, it contributes to improve coordination allowing for a better life quality for the elderly.

1.2. Contribution to evidence for policies, strategies, practices and interventions to improve integration of care in Latin American countries
Calls for a better integration of healthcare networks, as a means to address equity, efficiency and quality, appeared worldwide. In response, many countries in Latin America, and around the world, with different types of health systems have issued policies fostering the introduction of integrated healthcare networks. However, there is practically no evidence on the effectiveness of available interventions targeted to improve integration of care, and their results on coordination and quality of care, within the context of low and middle-income countries.
By using a quasi-experimental design, this research has helped to fill the evidence gap to support health policy making by providing the first available evidence on best practices of care integration in the region. Evidence was produced combining qualitative and quantitative methods for analysing the performance of IHN and evaluating the effectiveness of the PAR developed interventions; conducting intra- and cross-country comparisons to compare care integration practices in different health systems and generating robust evidence for their transferability.
The participation of six Latin American countries, with different healthcare systems and different development of their healthcare networks contributed to a better understanding of the link between the context of the health systems and the development degree of healthcare networks on the one hand, and the different interventions and their outcomes, on the other.
By designing, implementing and evaluating the interventions developed through a PAR process (involving professionals, managers, policy makers and users) it provided evidence on best practice for integrated care interventions under “natural” conditions. The evaluation of the implemented interventions, and particularly, the joint meetings between primary and secondary care professionals were effective in improving on the one hand, intermediate results, that is factors influencing integration (such as motivation, knowledge, communication and trust among the professionals and managers of the different care levels) key for the effectiveness and sustainability of interventions over time. On the other hand, the interventions contributed to improve care coherence, adequacy of referral and care opportunity across levels of care, and to improve primary care effectiveness and chronic patients’ control. Moreover, all interventions, but particularly joint meetings, proved to be an innovative, easy to implement and affordable, key features for its replicability.
The wide disseminating of information to the general public or audiences who have little to no knowledge of the subject matter, Equity-LA II contributed to empower national and regional decision makers to better translate knowledge, empirical and operational data into policies and planning conducive to more effective health systems and services, through better integrated healthcare networks.

1.3 Contribution to strengthened research capacity of involved institutions
The development of research capacity in the participant countries represented an important project component, encompassing two aspects: generation/consolidation of new areas of research and skills.
Healthcare integration is a priority area for health systems development and research but was not much developed in Latin America research institutions. Equity-LA II provided an opportunity to consolidate the capacity developed in Equity LA participants’ institutions and to expand it to the new participants. This has enabled them to identify priority issues on integration of care, quality and IHN; to carry out research in areas identified as priority research areas in health system development. They have developed abilities in applying different research approaches and methods (participatory action research; qualitative and quantitative methods); and getting evidence into policy and practice, contributing to developing a basis for enhanced knowledge-development in their countries.
The project brought together participants with different complementary fields of expertise (researchers, health professional, policy makers) and developed the research capacity, among others, building upon previous Equity-LA experience. New participants benefited from the knowledge and experience of the previous research experience on integration of care; while old participants benefited from new participants complementary knowledge and skills, such as, health workers training and gender analysis.
In addition to developing the project as a team, a training plan was designed and implemented to develop the necessary research skills of participants (based on an initial needs analysis), which was later adapted to emerging needs. This included workshops on research methods and tools; joint work among the teams, in order to share knowledge and skills (in Latin America and also in Europe) and specific training and close monitoring of younger research fellows by senior researchers in each country team. Junior researchers participated in the international workshops. Moreover, some juniors and one senior researcher had the opportunity to pursue formal academic training in the framework of the project (masters or PhD studies).
Throughout the project, 11 International Workshops have been carried out, with the participation of researchers, members of the LSC and PP, 65 monthly teleconferences for the joint development and adaptation of research instruments, exchange of experiences and collective construction of the knowledge, and a cycle of experiences in care integration in the studied healthcare networks, and other contexts, relevant to the intervention design process.
The strong capacity building component of the project has contributed to increase the skills and knowledge not only of health professional, managers and policy makers, but also all members of the research team, and in particular the junior research assistants. In doing so it has contributed to create a sustainable research landscape for health systems and services research, particularly in the areas of integration and quality of healthcare, in the participating countries. Integration of care has become a line of research, and framework, methods and tools incorporated in different courses.
1.4 Contribution to improved skills and motivation of health workforce
Equity-LA II focused on testing healthcare integration strategies at the micro-level that according to available evidence, seemed to be the most effective in enhancing collaboration across care levels. The introduction of these integration strategies needed a) to adopt a bottom up approach where health professionals play a central role in introducing the changes and b) to be based on human resources training.
The improvement of health workers skills and increasing their motivation was at the core of the project. The interventions to improve care integration were developed based on a participatory action-research (PAR) process, whereby health professionals were involved in all phases (selection, design, implementation, monitoring, adapting and evaluation). Moreover, the core of the interventions introduced (aimed at improving coordination and care quality) addressed their identified training needs. These included, the development or/and improvement and use of clinical coordination mechanisms (mainly joint clinical sessions, but also virtual consultations, shared care pathways, (back)referral system, among others.
The PAR method developed (participatory, reflexive, flexible, consensual decision-making and methodological rigor) has been key to the success in the implementation of the interventions. Previous research had shown that very often, evidence-based interventions are not effective in “natural” healthcare settings because of the difficulties of altering clinician’s behavior or implementing organizational change. The developed PAR method promoted, on one side, the interest and motivation of healthcare professionals to participate in the interventions and change their practice, and on the other side, communication, knowledge and trust among the participating healthcare professionals and managers of the different care levels, which is one of the main barriers to care integration. Both factors were found key for the effectiveness and sustainability of interventions over time.
These parallel actions, and the involved training, contributed to increase motivation among healthcare workers, while improving their performance and skills. Moreover, the project has produced evidence on best practices to train and motivate healthcare workers and improve quality of care. Around 1000 health professionals have been directly involved in the design and implementation of the interventions, making up a relevant critical mass for the improvement of the health services. All interventions contained some training component, either because the intervention was aimed at the continuing education of health professionals (e.g. joint training meetings), or because the use of the intervention required the prior training of professionals (e.g. virtual communication system between levels, or shared care guidelines). The joint meetings, in particular, allowed to improve the training of participating PC doctors - making them referents in their units - and demanded the updating of the specialists who acted as facilitators. This, in turn, contributed to improving the management of patients by the PC doctor (more appropriate diagnosis and treatment), and the adequacy of referral to secondary care. Participants in Colombia and Mexico highlighted the unusual nature of these medical training spaces in the network. And in Chile, its greater regularity and scope - related to its online character - than the existing ones.
Additionally, and through the link with universities, undergraduate and post-graduate public health training for health professionals has incorporated teaching on adequate strategies to improve coordination of care in networks, particularly for chronic elderly patients, and when possible the participating IHNs personnel is contributing to the training. Moreover, the theoretical framework developed by the project has been applied to other areas, such as mental health, in the research conducive to master or PhD training.

1.5. Contribution to building networks
The research brought together a diverse range of interest groups and stakeholders concerned with health sector organisation at local, national and international levels, civil society groups, organized users of health services and health providers. It is expected that collaborative links established in each country and between countries will continue after completion of this project. Around 15,000 people (researchers, health professionals and managers, users and policy makers) have been directly involved in project. However, beneficiaries (health services users, doctors and other health professional of the intervention areas that might benefit even if not directly involved in the research process) are over 4,500,000 people.
The established links together with the capacity built and the PAR method implemented increases the probability of the further implementation of evidence-based policies, strategies and interventions to improve the integration of care and the quality of the health services. Moreover, Equity-LA II provided the opportunity to consolidate and expand the networks already established, that involve policy makers, civil society, and international experts and networks (enhancing also the work developed during the Equity-LA project).
1.6. Contribution towards achieving Millennium Development Goals
Achieving health-related Millennium Development Goals (MDGs) crucially depends on people having access to healthcare to meet their health needs. Thus, in Latin America and the Caribbean there is an urgent need to improve access to quality healthcare services as a condition for achieving the MDGs. Although the Latin American countries differ in terms of health situation relating to Millennium Development Goals, they face common challenges to meet the commitments undertaken: a faster progress towards a substantial reduction in health inequalities, progress with respect to universal health-care coverage under social protection schemes and an improvement of the quality of resource allocation. With this aim, the PAHO highlights among the guiding principles for health policy: improving equity and extension of social protection in health; strengthening health systems capacity to respond to the needs of the population, among others, by building-up a network of services to make the universal right to health a reality, and ensuring continuity of care between different levels and subsystems of the health system.
1.7. Contributions to national research agendas
The research addressed priority interests on the national research agenda of the six Latin American countries involved. Argentina, Brazil, Colombia, Chile, Mexico and Uruguay were listed as International Co-operation Participants Countries (ICPC) in the Annex 1 of the FP7 Cooperation work programme and include in their national programmes and policies, research on integrated care. The participation of these countries with their different types of health systems (and subsystems) ensured a combination of public-private in the provision; and different types of integrated healthcare networks.
The research addressed an important lack of knowledge regarding the effectiveness of the introduction of integration interventions in improving coordination and continuity of care and the factors that influence it, which constituted a priority research area in all involved countries.

1.8. Contribution of the European and international approach
Policy lessons are also relevant to EU countries. The project produced robust evidence on a problem relevant to all health systems around the world, including Europe, limited integration of the health care, and provided a framework and validated research methods and tools to identification of strategies to improve. It has achieved scientific excellence by bringing together international, multi-disciplinary institutions, thanks to the European-Latin American collaboration, as was already shown in the previous Equity-LA project. On the one hand, it allowed cross-countries comparisons to establish relevant factors for different health systems and care settings, to benchmark interventions and to establish best practices. On the other hand, it allowed us building upon the European experiences of integration and research, among others, through the involvement of the European participants in other related research projects.
The European and multidisciplinary approach brought together existing knowledge on integration of health services and participatory action research from expert institutions in Europe and Latin America (health systems of the EU reflect values of universal access to good healthcare, solidarity and equity). The exchange between participants contributed to maximise expertise and shared learning to generate new knowledge on integration of health services based upon innovative research approach and instruments; to build capacity and network, to get research into practice and to develop practical guidelines to strengthen evidence-based policies to improve quality care and effectiveness of health system.

2. Steps taken to bring about the expected impacts

To bring about these impacts, the following steps were undertaken:
I) Production of scientific evidence on effective interventions aimed at improving care integration

The project has produced new evidence and research methodologies on care integration, such as:
1. Robust evidence on two priority areas for any health system, including those of European countries: integration of health care and implementation research. This relevant problem- limited integration of health care- had not been analysed comprehensively and systematically in the countries involved so far. Primary data were collected in the six Latin American countries –first surveys at all to be conducted among doctors and users in Latin America to evaluate clinical coordination and continuity across levels of care. By designing, implementing and evaluating integrated care interventions through the PAR process (involving professionals, managers, policy makers and users) it provided evidence on best practice for integrated care interventions under “natural” conditions. Moreover, the quasi-experimental design of the research allowed for the evaluation of the effectiveness of the interventions.
In short, new knowledge has been produced on the effectiveness of specific interventions to improve care integration; the performance of IHN relating to care coordination, continuity, and quality of care, particularly relating to chronic diseases; how contextual factors relating to health systems and healthcare settings influence these results; how content, context and process influence the effectiveness of integration strategies in improving care coordination, continuity and quality, in different health systems and healthcare settings; and, particularly in the field of chronic conditions.

2. Evidence for policy development to promote the emergence of better quality and better performing healthcare providers that will benefit national efforts to improve healthcare organisation and effectiveness in the health sector.
Policy recommendations have been put forth
• to adjust and further develop policies, strategies and mechanisms currently used to progress towards integrated healthcare
• to develop strategies to introduce mechanisms that increase coordination of institutions providing healthcare, especially those aiming at coordinating primary and secondary care levels. This will contribute to a better-coordinated and more efficient healthcare delivery.
• to implement strategies for coordinating healthcare that take into account the identification, by all actors involved, of critical factors that influence care coordination, continuity and quality of care. This is intended to improve the performance of coordination mechanisms in place, or to generate new alternatives seeking consensual solutions.
• to implement interventions through a PAR process, bearing in mind at the research planning stage what factors may have a bearing on the process and identify strategies to address them, for example: agreements on creating working groups and protecting professionals’ time, the involvement of managers, flexibility to adapt the “soft core” of interventions to changes in institutional priorities, roles and types of participants, time, resources and efforts required to install the PAR process in the organization.
• to incorporate PAR features into the care coordination interventions to be implemented: mutual adaptation, critical reflection on own practice geared towards action, feedback, and a facilitator with knowledge of the method.
• to develop better strategies to ensure that the views and experiences of users relating to continuity of care are taken into account;
• to set up or improve training programmes directed at strengthening management skills to support integration in the health system.

3. Development of health services management know how and research instruments to analyse and monitor factors and actors influencing health services performance.
To improve health systems regulation and to make health services work better, policy makers and health providers must invest in efforts to measure systems’ performance and to inform the public on it. Information about the performance of providers is essential to preserve the healthcare system and to protect citizen’s rights. On the other hand, integration of health services is a process that takes time and it is essential to learn from IHNs performance evaluation throughout the process.
This research project has significantly contributed to efforts providing validated theoretical framework, methods, tools and standards to evaluate the performance of integrated healthcare: at network level in terms of care coordination and continuity of care, and at intervention level in terms of effectiveness. The final aim is to assist governments (in their stewardship role) in their attempts to develop effective ways of not only measuring system performance, but also in using this knowledge to improve health systems’ performance.
The performance evaluation framework and standards was derived from the following principles,
establish measurable goals on coordination and continuity of care based; include measures based on process variable with a focus on sub-populations, including those at higher risk, with particular attention to chronic patients, ensure data availability and quality; ensure patients’ perspective is included in the framework and measures; provide reports that are comprehensible and meaningful to targeted audiences at different levels

Specific methods, measures and strategies were developed in the following areas: a) clinical management and information coordination across levels of care b) information and clinical management continuity across and within levels of care and relation continuity intra level of care. A theoretical framework was developed for the evaluation of the interventions, taking into account not only the results, but also the process and context that contributed to these results.
In addition, a conceptual framework for the replicability of interventions and the IAP method in other contexts is being developed. This framework is based on the identification of factors related to the context and process that influenced the implementation of these interventions, as well as the most effective strategies that should be used to address them.

The framework and measures developed provided validated tools for measuring health organisations’ performance; to be used, for example, by health authorities or purcharsing agencies to support the evaluation of healthcare provision; in benchmarking initiatives to compare results among providers; by the providers themselves to identify problems and solutions. Those methods and tools could be applied to any health system; including those in Europe (some have already been adapted in Europe, by the research team and other research groups). For example, the COORDENA questionnaire has been already adapted and applied in the Spanish National Health System in Catalonia, by the research team (pilot experience published at WHO Europe journal: Public Health Panorama).

II) Enhancement of research cooperation links to promote excellence

In order to conduct this research, it was necessary to develop strong scientific partnerships on the basis of mutual interest, to generate and exchange the knowledge needed to provide a scientific basis to improve their health systems. This was achieved by:

• The research design. In the way it has been designed (participatory action research), the research contributed to research ownership by Latin American countries, establishing links between them, and with the European countries. The project contributed to sustainable development and to strong North- South collaborative links. The international collaboration should persist following the project culmination and in the short-term by the development of a new research proposal that builds upon the research results and, to seek new funding by EC research programme.
• Improving the research capabilities of participant universities, research and healthcare institutions in the field of health systems research and health policy analysis in the six Latin American participant countries. Not only by training and research experience, but also by establishing collaborative links within and among the different participating institutions in involved countries. Particular emphasis was put on improving capabilities to getting research results into policy and practice. This evolved into an international community of junior and senior researchers of the six countries of Latin America and the two of Europe, “a community of practice”, that goes beyond the borders with an astonishing degree of solidarity, collaboration and cooperation, very promising for future projects.
• Interacting throughout the research process. The project enhanced the collaboration between participating research institutions, health service providers, policy makers, and civil society organisations involved in the project. To this result the different participation devices (national scientific committee, local steering committee and professionals’ platforms) were particularly relevant.
• Involvement, from the beginning, of policy makers and other relevant stakeholders, such as health managers and professionals, academics, users, in the research process of diagnosis and identification of problems and solutions in IHNs, that was crucial to implement the interventions and to getting results into policy and practice. The PAR method implemented contributed to the establishment of a different form of collaboration between universities and health services found of mutual benefit and transferable to other research projects. Each Latin American partner worked together with a public healthcare network using the PAR approach to design and implement ways to improve clinical coordination across levels of care and hence the quality of services. So that they see an immediate benefit.
• Fostering social ownership of project generated knowledge. This was achieved, in addition to PAR process involving key social actors, through the wide dissemination of results using materials and means appropriate to different audiences (including, meetings, workshops, round tables, short reports, scientific papers, conferences, etc) and through the integration of research results and methods into health services and academic training programmes.
• Contributing to further development of collaborating links between European and Latin American countries and within both groups, leading to opportunities for future scientific and technological collaboration. The involvement of PAHO and the coordination with other networks guarantee the dissemination of the results beyond the involved countries.
• The participation of the international and national scientific committees contributed to the scientific excellence of the research process and at the same time to the dissemination of results.
• The gender mainstreaming strategy adopted by the Commission formed the basis for integrating the gender dimension in the project. Gender equality and the empowerment of women was addressed in two ways: during the research process, encouraging gender balance in all committees as well as among researchers, data collectors and analysts; and contributing to improved understanding of gender issues regarding coordination and continuity of care. Women were majority within the teams and PI (5 out of 8 PI)

III) Utilization of the evidence produced by the research (Equity LA II) into policy and practice: GRIPP

In order to get an impact on health systems performance, special emphasis has been put throughout the project on getting research results into practice. All participating Latin American research teams held long-standing collaboration links with their respective Ministries and/or Secretaries of Health. In addition, to the intrinsic participatory nature of the project, a strategy was developed to enhance health research utilization into policy-making. From the beginning research results and project-related news were posted in the project webpage for a wider dissemination and a number of dissemination activities implemented.

The developed PAR method promoted, on one side, the interest and motivation of healthcare professionals to participate in the interventions and change their practice, and on the other side, communication, knowledge and trust among the participating healthcare professionals and managers of the different care levels, which is one of the main barriers to care integration. Both factors have been found key for the effectiveness and sustainability of interventions over time.
The interventions have been widely institutionalized in the networks of most participating countries: In Chile, the annual programming of on-line joint meetings extended to almost all medical specialties and to all primary care areas and the LSC is becoming a permanent cross-level coordination committee in the network, under the new management; in Colombia, the intervention has been incorporated to the continuous education program; in Mexico, it was incorporated as the main strategy to reduce the maternal mortality at the state level; in Brazil, it is part of the Health Secretariat strategy to improve quality of care; in Uruguay, it has become a reference for the new information system.
Policy brief and report on best practices were developed to help policy makers to better translate knowledge, empirical and operational data into policies and planning conducive to more effective health systems and services, through the improvement in care integration using a model based on PAR.

Potential users of project results include the European Commission, Health Ministries and Public Health institutes of Members States, international, national and local policy makers and other stakeholders and NGO which support health sector policies aimed at improving integration of care and quality of services. Finally, it is expected that project results will be used by scholars to enhance understanding of the relationship between integrated care and the overall health sector organization and development in middle income countries. Most researchers involved in the project have academic tasks and are using the generated knowledge in their training courses, where possible involving IHNs personnel.

In addition, a number of substantial results regarding the impact of the project on policy and practice can be described already:
a) The intervention has been incorporated into national or local policies/actions (e.g. Chile, example of good practices in the Ministry of Health national policy documents of 2018, 2019 and 2020; México, the intervention was incorporated in the State policy as main strategy to reduce the maternal mortality and was implemented in the entire State of Veracruz (more than 2.102 PC doctors trained): In Brazil, it is part of the Health Secretariat strategy to improve quality of care, and was presented as a case of good practices at the National Coucil of Municipal Health Secretaries; in Uruguay, it has become a reference for the new information system and new coordination devices.
b) The intervention triggered the implementation of other interventions to improve the functioning of the networks. For example, in Argentina contributed to reactivate meeting spaces for professional from different levels of care or in Mexico, the referral system was revised and updated.
c) The “Equity working method” was adopted as a method for improving the quality of care in the intervention networks. In Brazil, for example, for the development of care guide focusing in other pathologies.
d) Other healthcare networks have initiated similar processes adopting the design, methods and tools of the project. In Chile, the control network is initiating the same process. In Colombia, another district in Bogotá is introducing implemented. In Mexico the intervention was introduced in other areas,
d) In Uruguay, the project is considered as a model and resource for international cooperation.

3. Dissemination of research results

Workpackage 5 was dedicated to knowledge management, with a strategy for dissemination of results of the Equity LA II project. This included different mechanisms involving all stakeholders, in order to promote greater public engagement an dialogue.

I. Management of knowledge

Different dissemination strategies have been carried out throughout the Equity LA II project, in order to assure that project results got to relevant stakeholders and served to society’s interest. In this sense, project results and learnings – gathered in guidelines, reports and research papers- were made widely available by disseminating them in all relevant areas.

A number of activities for the dissemination management of newly generated knowledge were developed detailed in Section A (Template A2) of this final report.

a) Round tables/seminars were held periodically in the six participant Latin American countries to discuss preliminary results and to bring together researchers and a variety of local and national stakeholders and other interest groups. (policy makers, managers, and civil society organisations).
b) Meetings and workshops with professionals, managers of health services and relevant authorities, (with brief summary reports) around key findings as a tool for improving integrated care delivery
c) Building networks of key contacts among relevant organizations (academic, governmental, non-governmental, civil society, etc.) in the six participant countries and international agencies, such as the Pan American Health Organization (PAHO/WHO), and coordinating with already established networks.
d) Public seminars held regularly in all participant countries, allowing for discussion of project’s progress with relevant actors (such as researchers, health professionals platform, local steering committee members, health professionals from the participant IHNs, managers and local political representatives, users).
e) Participation in regional and/or international meetings/conferences concerned with health sector organisation and policy, to disseminate methods and findings for comparative research in other countries, relevant to International agencies and other governments.
f) Short reports and open access research papers summarizing main project learnings and results in peer-reviewed journals. These publications contributed to fil a knowledge gap on the subject and helped disseminating project results to the academic community (published papers are listed in project deliverable 6.6).
g) Best practices report on care integration, and a policy guideline for national and international policy makers have been produced, to ensure that results inform policy making. These guidelines include findings and recommendations on care integration interventions and PAR processes. (project deliverables 6.4 and 6.5).
h) The research results have been integrated into capacity building processes in research and training (in related areas) within health services, universities and research institutions involved
i) The International Conference held in Santiago de Chile between 26th-27th June 2019. This conference gathered more than a hundred participants from Latin America and Europe. Final results of the research were presented and debated by public health specialists, policy makers and PAHO representatives.

List of Websites:
1. Project website
A specific project website has been set up: http://www.equity-la.eu/en/. This website includes general information about the project such as research objectives, methods, working plan and beneficiaries, as well as past and ongoing dissemination activities (seminars, conferences, publications, etc.). Furthermore, the news section informs about upcoming events and recent publications. Its content is available in English, Spanish and Portuguese.

2. Contact Details
Consorci de Salut i Social de Catalunya (CSC)
Health Policy Research Unit
Av. Tibidabo, 21; 08022 Barcelona; Spain
www.consorci.org
Project coordinator and Principal Investigator: M. Luisa Vázquez (mlvazquez@consorci.org)

Prins Leopold Instituut voor Tropische Geneeskunde (ITM)
Nationalestraat 155; 2000 Antwerp; Belgium
www.itg.be
Principal Investigator: Bruno Marchal (BMarchal@itg.be)

Colegio Mayor de Nuestra Señora del Rosario (Urosario)
Escuela de Medicina y Ciencias de Salud
Carrera 24, No. 63 C – 69; 11001 Bogotá D.C.; Colombia
www.urosario.edu.co
Principal Investigator: Amparo Mogollón (amparo.mogollon@urosario.edu.co)

Instituto de Medicina Integral Prof. Fernando Figueira
Research Group for Evaluation of Health Care of the IMIP (GEAS/IMIP)
Rua dos Coelhos | 300 Boa Vista - Recife - PE - Brasil
http://www1.imip.org.br/imip/home/index.html
Principal Investigator: Isabella Chagas Samico (isabella@imip.org.br)

Universidad de Chile
Community Health Program of the School of Public Health Dr. Salvador Allende Gossens
Av. Libertador Bernardo O'Higgins, 1058, Santiago de Chile, Chile
http://www.saludpublica.uchile.cl/
Principal Investigator: Pamela Eguiguren (peguiguren@u.uchile.cl)

Universidad Veracruzana
Institute of Public Health
Lomas del Estadios, S/N, Colonia Zona Universitaria, Xalapa, Veracruz, 91000, Mexico
https://www.uv.mx/isp/
Principal Investigator: Edit Romero Rodriguez (edrodriguez@uv.mx)

Universidad Nacional de Rosario
Center of Interdisciplinary Studies
Maipú, 1065, Rosario, Argentina
https://cei.unr.edu.ar/
Principal Investigator: Mario Rovere (roveremarior@gmail.com)

Universidad de la República
Faculty of Nursing
Jaime Sibils, 2810, Montevideo, Uruguay
https://www.fenf.edu.uy/
Principal Investigator: Fernando Bertolotto (fbertolotto@fenf.edu.uy)

Final Report Summary - EQUITY-LA II (The impact of alternative care integration strategies on Health Care Networks’ performance in different Latin American health systems)

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