Title: Development and evaluation of a targeted, integrated, coherent and people-centred approach to the management of Multiple Long-Term Conditions (MLTC-M) in South African primary healthcare
Funder: Department of Health and Social Care

Abstract: Against the background of 1) rising multiple long-term conditions &ndash; multimorbidity (MLTC-M) in low- and middle-income countries (LMICs) as a result of unplanned urbanization and the globalization of unhealthy lifestyles; as well as 2) historically fragile, vertically organized organised health systems that are ill-equipped to deal with MLTC-M, this body of research addresses a critical overarching research aim: To produce evidence-based scalable solutions for care, treatment and support systems for people living with MLTC-M in LMICs so as to enhance their health and well-being. The research will be conducted across two diverse provinces in South Africa. This country provides an opportune setting for this research given: 1) A high burden of all three MLTC-M disease clusters (mental disorders as well as communicable and non-communicable diseases); 2) Widely used functional public primary care system; and 3) Policy reforms that provide an enabling policy environment. These include reducing health inequities through the introduction of National Health Insurance, and re-engineering of primary health care to promote horizontal programming and strengthening of person- and people-centredness. The overarching research aim will be achieved through six interlinking work packages (WPs) that will run in parallel throughout the 4 year funding cycle: WP1: Epidemiological analysis of existing large data bases to identify the most common configurations of MLTC-M that should be targeted, and their determinants, health service utilisation and outcomes. WP 2: Strengthening community and patient engagement representing interests from all three condition clusters in MLTC-M advocacy and networking who will interface with work packages 3-6 to ensure empowered stakeholder driven outputs. WP3: With stakeholder input from WP 2, development of new MLTC-M clinical decision and patient support tools addressing the most common MLTC-M configurations, as well as accompanying training curricula and support materials for providers to promote efficiencies, reduce MLTC-M care burden, and promote activated self-managing patients. WP4: Conduct formative evaluation to identify systems barriers and facilitators to MLTC-M care, co-develop and iteratively strengthen with key stakeholders feasible and scalable health systems strengthening implementation strategies that will enable and support implementation of MLTC-M care at scale. WP5: Conduct a type 2 hybrid trial and process evaluation to test the efficacy of the combined tools (WP3) and implementation strategies (WP4) in public sector primary care clinics in the two study sites. WP6: Development of an Implementation for Impact model to estimate the health gains, cost-effectiveness and resources need to scale-up the co-produced evidence-based MLTC-M toolkit in South Africa. At the end of the 4-year funding cycle, the project will provide the following outputs: Clinical and systems strengthening implementation strategies for implementation at scale in South Africa and adaptation and testing in other contexts; Policy recommendations on how to best to organise and resource the healthcare system to maximise the benefits and minimise risks for people with MLTC-M

Lay abstract: Multimorbidity is the experience of living with more than one long-term condition &ndash; like HIV, diabetes, depression. In South Africa, we have large epidemics of all three, and others, like TB and hypertension, but are unsure how commonly they occur together and in what combinations. Coping with multimorbidity is difficult for people with several conditions and their health workers because healthcare is usually provided separately for each condition and treatment is complex. In South Africa health workers use PACK (Practical Approach to Care Kit) &ndash; a compilation of clinical policies and guidelines &ndash; to help them decide how to manage their patients. PACK standardises an approach to long-term care, but when there is more than one condition, the number of different components to check is overwhelming, making decisions difficult about what to prioritise and leaving little space for patients to share their health concerns. This research aims to develop and test a solution. We will examine health information of over 10 million people to identify the commonest patterns of multimorbidity. We shall use this information to improve PACK. We shall design practical methods to get this guidance used in everyday care in the clinic and at home, tackling issues that might prevent it. This will form a package to strengthen the health system called PACK Multimorbidity . We will test this in 32 clinics involving 360 health workers and 1600 people with multimorbidity. We will examine a range of outcomes including patients functioning, living expenses, treatment success, clinic and hospital visits and patients and health workers experience. This will help to strengthen PACK Multimorbidity and inform policymakers of likely costs and benefits if adopted country-wide. Throughout we will work closely with those affected by multimorbidity &ndash; health service managers, health workers and importantly people with multimorbidity and representatives of their communities. We shall do this by convening various groups to inform the design of PACK Multimorbidity and the research, to contribute the concerns of people with multimorbidity and help consider how best to tackle the issues that make challenge improving multimorbidity care. Keen to avoid losing the interest and skills such involvement might generate among patient representatives, we plan to form an Advocacy Academy to become multimorbidity champions who can contribute to civil society organisations beyond the project. To reach health system leaders and other researchers in the fields of multimorbidity and health systems strengthening, we will use policy briefs, publications and presentations at academic and health service meetings. We shall also share our experiences with other countries using PACK including Ethiopia and Brazil. This will ensure our learnings can spread to where multimorbidity is a growing challenge for health systems, health workers, patients and their communities.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: METABOLIC AND ENDOCRINE;INFECTION;MENTAL HEALTH;CARDIOVASCULAR