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

Against the background of 1) rising multiple long-term conditions – 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