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Health care for chronic diseases in rural Tanzania

Mwangome, M.N.

2016

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citation for published version (APA)

Mwangome, M. N. (2016). Health care for chronic diseases in rural Tanzania: Including non-communicable diseases in primary care towards health for all.

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Chapter 2

dŚĞŽƌĞƟĐĂůĐŽŶĐĞƉƚƐ

33

ŚĂƉƚĞƌϮdŚĞŽƌĞƟĐĂůĐŽŶĐĞƉƚƐ

dŚŝƐĐŚĂƉƚĞƌƉƌĞƐĞŶƚƐƚŚĞƚŚĞŽƌĞƟĐĂůĐŽŶĐĞƉƚƐƵƐĞĚƚŽĐŽŶĐĞƉƚƵĂůŝnjĞƚŚĞƌĞƐĞĂƌĐŚĚĞƐĐƌŝďĞĚ in this thesis. First, it presents the concept of health care services, which is one element of the six building blocks of a health system and encompasses health care for chronic diseases, which is the focus of this thesis. Then the chapter elaborates on the concepts of primary care and primary health care because this thesis focuses on service provision and use at the ƉƌŝŵĂƌLJĐĂƌĞůĞǀĞů͘dŚĞĚĞƐĐƌŝƉƟŽŶƐŝŶŚĂƉƚĞƌϭŝŶĚŝĐĂƚĞƚŚĂƚdĂŶnjĂŶŝĂŶƌƵƌĂůƉŽƉƵůĂƟŽŶƐ ĂƌĞůĂƌŐĞůLJƐĞƌǀĞĚďLJƉƌŝŵĂƌLJĐĂƌĞĨĂĐŝůŝƟĞƐͶŝ͘Ğ͘ĚŝƐƉĞŶƐĂƌŝĞƐĂŶĚŚĞĂůƚŚĐĞŶƚƌĞƐ͘WƌŝŵĂƌLJ ŚĞĂůƚŚ ĐĂƌĞ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ t,K͛Ɛ ĞĐůĂƌĂƟŽŶ ŽĨ ůŵĂͲƚĂ ;ϭϵϳϴͿ͕ ĞŵƉŚĂƐŝnjĞƐ ƚŚĞ ĞŶŐĂŐĞŵĞŶƚŽĨĐŽŵŵƵŶŝƟĞƐŝŶŚĞĂůƚŚĐĂƌĞƐĞƌǀŝĐĞƐ͘ŶƵŶĚĞƌƐƚĂŶĚŝŶŐŽĨƚŚĞĐŽŶĐĞƉƚŽĨ primary health care is, therefore, necessary to address the aim of this thesis, given that ŵŽƐƚĐĂƌĞĨŽƌĐŚƌŽŶŝĐĚŝƐĞĂƐĞƐƚĂŬĞƐƉůĂĐĞŝŶĐŽŵŵƵŶŝƟĞƐƌĂƚŚĞƌƚŚĂŶĂƚŚĞĂůƚŚĨĂĐŝůŝƟĞƐ͘ dŚĞĐŚĂƉƚĞƌĞŶĚƐǁŝƚŚĂĚĞƐĐƌŝƉƟŽŶŽĨĂĨƌĂŵĞǁŽƌŬƌĞůĂƚĞĚƚŽƚŚĞŽƌŐĂŶŝnjĂƟŽŶŽĨĐŚƌŽŶŝĐ ŚĞĂůƚŚĐĂƌĞ͕ĞƐƉĞĐŝĂůůLJĂƚƉƌŝŵĂƌLJĐĂƌĞůĞǀĞů͕ƚŽĂĐŚŝĞǀĞĨĂǀŽƵƌĂďůĞƉĂƟĞŶƚŽƵƚĐŽŵĞƐ͘dŚŝƐ ĨƌĂŵĞǁŽƌŬŝƐƌĞůĞǀĂŶƚƚŽƚŚŝƐƚŚĞƐŝƐ͛ƐĂŝŵŽĨŝŶĨŽƌŵŝŶŐƚŚĞĚĞƐŝŐŶŽĨĐŚƌŽŶŝĐŚĞĂůƚŚĐĂƌĞŝŶ ƌƵƌĂůƐĞƫŶŐƐŝŶŽƌĚĞƌƚŽĂƩĂŝŶĨĂǀŽƵƌĂďůĞƉĂƟĞŶƚŽƵƚĐŽŵĞƐ͘ Ϯ͘ϭdŚĞĐŽŶĐĞƉƚƐŽĨŚĞĂůƚŚĐĂƌĞƐĞƌǀŝĐĞƐ͕ƉƌŝŵĂƌLJĐĂƌĞĂŶĚƉƌŝŵĂƌLJŚĞĂůƚŚĐĂƌĞ

This thesis will focus on care and treatment services, especially at primary care level. The t,KĚĞĮŶĞƐŐŽŽĚŚĞĂůƚŚƐĞƌǀŝĐĞƐĂƐƚŚŽƐĞ͞ǁŚŝĐŚĚĞůŝǀĞƌĞīĞĐƟǀĞ͕ƐĂĨĞ͕ƋƵĂůŝƚLJƉĞƌƐŽŶĂů ĂŶĚŶŽŶͲƉĞƌƐŽŶĂůŚĞĂůƚŚŝŶƚĞƌǀĞŶƟŽŶƐƚŽƚŚŽƐĞƚŚĂƚŶĞĞĚƚŚĞŵ͕ǁŚĞŶĂŶĚǁŚĞƌĞŶĞĞĚĞĚ͕ ǁŝƚŚ ŵŝŶŝŵƵŵ ǁĂƐƚĞ ŽĨ ƌĞƐŽƵƌĐĞƐ͟ ;ϭͿ͘ ,ĞĂůƚŚ ƐĞƌǀŝĐĞƐ ĂůƐŽ ĞŶĐŽŵƉĂƐƐ Ă ĐŽŶƟŶƵƵŵ ŽĨ ƐĞƌǀŝĐĞƐ ĨƌŽŵ ƉƌŝŵĂƌLJ ƉƌĞǀĞŶƟŽŶ ƚŽ ĐĂƌĞ ĂŶĚ ƚƌĞĂƚŵĞŶƚ ĂŶĚ ƌĞŚĂďŝůŝƚĂƟǀĞ ƐĞƌǀŝĐĞƐ͘ ǀŝĚĞŶĐĞŝŶĚŝĐĂƟŶŐƚŚĂƚƉƌŝŵĂƌLJĐĂƌĞĐĂŶĚĞůŝǀĞƌďĞƩĞƌŚĞĂůƚŚŽƵƚĐŽŵĞƐĂƚŵƵĐŚůŽǁĞƌ cost is robust (2). Primary care can be considered both a product of the health system as well as a level of health care. As a product, primary care consists of the kind of basic care ĂŶĚ ƐĞƌǀŝĐĞƐ ƚŚĂƚ ĂƌĞ ƉƌŽǀŝĚĞĚ ƚŽ ƉĞŽƉůĞ ĂŶĚ ĐŽŵŵƵŶŝƟĞƐ ǁŚĞŶ ƚŚĞLJ ĮƌƐƚ ĐŽŶƚĂĐƚ ƚŚĞ health care system with a health problem. As a level, primary care is that health service level at which primary care is delivered (3). Primary care providers include those providing ƐĞƌǀŝĐĞƐŝŶƉƵďůŝĐƉƌŝŵĂƌLJĐĂƌĞĨĂĐŝůŝƟĞƐ͕ŝŶƉƌŝƐŽŶƐĂŶĚƚŚĞŵŝůŝƚĂƌLJŽƌŝŶƉƌŝǀĂƚĞƐĞƌǀŝĐĞƐĂƚ ƚŚĞĐŽŵŵƵŶŝƚLJůĞǀĞů;ϰͿ͘dŚĞĨƵŶĐƟŽŶƐŽĨƉƌŝŵĂƌLJĐĂƌĞŚĂǀĞďĞĞŶĚĞƐĐƌŝďĞĚĂƐƉƌŽǀŝĚŝŶŐ ĂĐĐĞƐƐ͕ĐŽŶƟŶƵŝƚLJĂŶĚĐŽŽƌĚŝŶĂƟŽŶŽĨŚĞĂůƚŚĐĂƌĞ;ϱͿ͕ǁŚŝĐŚĐŽǀĞƌƚŚĞŶĞĞĚƐĨŽƌƉƌŝŵĂƌLJ care of chronic diseases as well.

• universal access and coverage on the basis of need; • commitment to health equity;

ͻĐŽŵŵƵŶŝƚLJƉĂƌƟĐŝƉĂƟŽŶ͖ĂŶĚ ͻŝŶƚĞƌͲƐĞĐƚŽƌĂůĐŽůůĂďŽƌĂƟŽŶŝŶŚĞĂůƚŚ͘

Recently, the WHO has brought back the focus on primary care because of the need for health systems to be more responsive to the challenges of a changing and globalized world ;ϴͿ͘dŚĞĨŽĐƵƐŝƐŽŶŚĂǀŝŶŐƚŚĞǁŚŽůĞƐƉĞĐƚƌƵŵŽĨŚĞĂůƚŚƐĞƌǀŝĐĞƐͶŝ͘Ğ͘ŚĞĂůƚŚƉƌŽŵŽƟŽŶ ĂŶĚĚŝƐĞĂƐĞƉƌĞǀĞŶƟŽŶ͕ƚƌĞĂƚŵĞŶƚĂŶĚƌĞŚĂďŝůŝƚĂƟŽŶƐĞƌǀŝĐĞƐͶƚŽďĞƉƌŽǀŝĚĞĚŝŶƉƌŝŵĂƌLJ ĐĂƌĞ ƐĞƫŶŐƐ ŝŶ Ă ǁĂLJ ƚŚĂƚ ŝƐ ƐĂĨĞ͕ ĞīĞĐƟǀĞ ĂŶĚ ƐŽĐŝĂůůLJ ĂĐĐĞƉƚĂďůĞ͘ dŽ ĂĐŚŝĞǀĞ ƚŚŝƐ͕ ƉĞŽƉůĞ ŵƵƐƚ ďĞ ƉƵƚ ĮƌƐƚ Ͷ ŵĞĂŶŝŶŐ ƐĞƌǀŝĐĞ ƵƐĞƌƐ ĂŶĚ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞƌƐ ;ϴͿ͘ dŚĞ ĚŝƐƟŶĐƟǀĞĨĞĂƚƵƌĞƐŽĨƌĞƐƉŽŶƐŝǀĞƉƌŝŵĂƌLJĐĂƌĞĂƌĞďĞŝŶŐĞīĞĐƟǀĞĂŶĚƐĂĨĞ͕ƉĞƌƐŽŶͲĐĞŶƚƌĞĚ͕ ĐŽŵƉƌĞŚĞŶƐŝǀĞĂŶĚŝŶƚĞŐƌĂƚĞĚ͕ĂďůĞƚŽƉƌŽǀŝĚĞĐŽŶƟŶƵŝƚLJŽĨĐĂƌĞ͕ĂŶĚĂďůĞƚŽƉƌŽǀŝĚĞĂ regular and trusted provider (8).

Ϯ͘Ϯ͘ŽŶĐĞƉƚƵĂůĨƌĂŵĞǁŽƌŬĨŽƌƚŚĞƚŚĞƐŝƐ

dŚĞŽƌĞƟĐĂůĐŽŶĐĞƉƚƐ 35  ϯϲ  

&ŝŐƵƌĞϭ͘/ůůƵƐƚƌĂƚŝŶŐƚŚĞ/ĨƌĂŵĞǁŽƌŬ



^ŽƵƌĐĞ͗t,KϮϬϬϮ;ϴϴͿ

ŽƉĞƌĂƚŝŶŐĂƚƚŚĞŵĂĐƌŽůĞǀĞůŽĨĂƉŽƐŝƚŝǀĞƉŽůŝĐLJĞŶǀŝƌŽŶŵĞŶƚ;ϲͿ͘&ŽƌƚŚĞŝŶǀĞƐƚŝŐĂƚŝŽŶŽĨ

ƐĞƌǀŝĐĞƉƌŽǀŝƐŝŽŶĨŽƌĐŚƌŽŶŝĐĚŝƐĞĂƐĞƐ͕ƚŚĞƐƚƌƵĐƚƵƌĞŽĨƚŚĞĨƌĂŵĞǁŽƌŬƐĞĞŵƐƐƵĨĨŝĐŝĞŶƚŝŶ

ŵĂƉƉŝŶŐŽƵƚƚŚĞĂĐƚŽƌƐĂŶĚƚŚĞŝƌƌŽůĞƐŝŶĐŚƌŽŶŝĐĐĂƌĞĂŶĚǁĂƐ͕ƚŚĞƌĞĨŽƌĞ͕ĂĚŽƉƚĞĚƚŽŐƵŝĚĞƚŚĞ

ƐƚƌƵĐƚƵƌĞŽĨƚŚŝƐƚŚĞƐŝƐ͘dŚĞ/ĨƌĂŵĞǁŽƌŬŝƐĂůƐŽŐƵŝĚĞĚďLJĂƐĞƚŽĨƉƌŝŶĐŝƉůĞƐ͕ĞĂĐŚŽĨǁŚŝĐŚ

ŝƐĨƵŶĚĂŵĞŶƚĂůƚŽƚŚĞŵŝĐƌŽ͕ŵĞƐŽĂŶĚŵĂĐƌŽůĞǀĞůƐŽĨƚŚĞŚĞĂůƚŚĐĂƌĞƐLJƐƚĞŵ͘dŚĞƉƌŝŶĐŝƉůĞƐ

ĂƌĞ͗ĞǀŝĚĞŶĐĞͲďĂƐĞĚĚĞĐŝƐŝŽŶͲŵĂŬŝŶŐŝŶƉŽůŝĐLJŵĂŬŝŶŐ͕ƐĞƌǀŝĐĞƉůĂŶŶŝŶŐĂŶĚĐůŝŶŝĐĂů

ŵĂŶĂŐĞŵĞŶƚ͖ĂĨŽĐƵƐŽŶƉƌŽŵŽƚŝŶŐƚŚĞŚĞĂůƚŚŽĨĂĚĞĨŝŶĞĚƉŽƉƵůĂƚŝŽŶƚŽŵŝŶŝŵŝnjĞĐŽƐƚƐ͖Ă

ƉƌĞǀĞŶƚŝŽŶĨŽĐƵƐ͕ǁŚŝĐŚŝŶĐůƵĚĞƐƉƌĞǀĞŶƚŝŽŶŽĨĐŽŵƉůŝĐĂƚŝŽŶƐ͖ĂƋƵĂůŝƚLJĨŽĐƵƐ͖ŝŶƚĞŐƌĂƚŝŽŶĂƚ

ƉŽůŝĐLJĂŶĚƐĞƌǀŝĐĞůĞǀĞůƐ͖ĂŶĚĨůĞdžŝďŝůŝƚLJĂŶĚĂĚĂƉƚĂďŝůŝƚLJǁŝƚŚĐŚĂŶŐŝŶŐĐŽŶƚĞdžƚƐ;ϲͿ͘/ŶĚĞƐŝŐŶŝŶŐ

&ŝŐƵƌĞϭ͘/ůůƵƐƚƌĂƟŶŐƚŚĞ/ĨƌĂŵĞǁŽƌŬ ^ŽƵƌĐĞ͗WHO 2002 (88) ŽƉĞƌĂƟŶŐĂƚƚŚĞŵĂĐƌŽůĞǀĞůŽĨĂƉŽƐŝƟǀĞƉŽůŝĐLJĞŶǀŝƌŽŶŵĞŶƚ;ϲͿ͘&ŽƌƚŚĞŝŶǀĞƐƟŐĂƟŽŶŽĨ ƐĞƌǀŝĐĞƉƌŽǀŝƐŝŽŶĨŽƌĐŚƌŽŶŝĐĚŝƐĞĂƐĞƐ͕ƚŚĞƐƚƌƵĐƚƵƌĞŽĨƚŚĞĨƌĂŵĞǁŽƌŬƐĞĞŵƐƐƵĸĐŝĞŶƚŝŶ mapping out the actors and their roles in chronic care and was, therefore, adopted to guide the structure of this thesis. The ICCC framework is also guided by a set of principles, each of which is fundamental to the micro, meso and macro levels of the health care system. The principles are: evidence-based decision-making in policymaking, service planning and clinical ŵĂŶĂŐĞŵĞŶƚ͖ĂĨŽĐƵƐŽŶƉƌŽŵŽƟŶŐƚŚĞŚĞĂůƚŚŽĨĂĚĞĮŶĞĚƉŽƉƵůĂƟŽŶƚŽŵŝŶŝŵŝnjĞĐŽƐƚƐ͖ ĂƉƌĞǀĞŶƟŽŶĨŽĐƵƐ͕ǁŚŝĐŚŝŶĐůƵĚĞƐƉƌĞǀĞŶƟŽŶŽĨĐŽŵƉůŝĐĂƟŽŶƐ͖ĂƋƵĂůŝƚLJĨŽĐƵƐ͖ŝŶƚĞŐƌĂƟŽŶ ĂƚƉŽůŝĐLJĂŶĚƐĞƌǀŝĐĞůĞǀĞůƐ͖ĂŶĚŇĞdžŝďŝůŝƚLJĂŶĚĂĚĂƉƚĂďŝůŝƚLJǁŝƚŚĐŚĂŶŐŝŶŐĐŽŶƚĞdžƚƐ;ϲͿ͘/Ŷ designing a chronic health care delivery model, it is important to consider these principles ĂƐŵƵĐŚĂƐƉŽƐƐŝďůĞ͘dŚĞůĂƐƚƉƌŝŶĐŝƉůĞ;ŇĞdžŝďŝůŝƚLJĂŶĚĂĚĂƉƚĂďŝůŝƚLJͿŝƐĞƐƉĞĐŝĂůůLJĐƌƵĐŝĂůŝŶƚŚĂƚ ĂƐŝƚĂůůŽǁƐƚŚĞƚĂŝůŽƌŝŶŐŽĨƚŚĞŵŽĚĞůĂĐĐŽƌĚŝŶŐƚŽĐŽŶƚĞdžƚƵĂůƌĞĂůŝƟĞƐ͕ǁŚŝĐŚŝƐŝŵƉŽƌƚĂŶƚ because the aim of the thesis is to inform the design of future chronic care delivery. The ICCC micro level

this thesis are referred to as the front-line actors in chronic disease care. It recognizes the essence of engaging people in health care as advocated by Edgman (2013) and by the WHO through the people-centred approach to health care (15, 16). These authors emphasize that ƚŚĞĞŶŐĂŐĞŵĞŶƚŽĨƉĞŽƉůĞ;ƉĂƟĞŶƚƐ͕ĨĂŵŝůŝĞƐĂŶĚƚŚĞĐŽŵŵƵŶŝƚLJͿŝŶŚĞĂůƚŚĐĂƌĞĐŽƵůĚďĞ ƚŚĞƐŽůƵƟŽŶĨŽƌŝŵƉƌŽǀŝŶŐŚĞĂůƚŚŽƵƚĐŽŵĞƐ;ϭϱͲϭϳͿ͘

Given that disease control is one of the main desired outcomes for chronic care, it is important ƚŽƵŶĚĞƌƐƚĂŶĚŚŽǁƉƌŝŵĂƌLJĐĂƌĞĨŽƌĐŚƌŽŶŝĐĚŝƐĞĂƐĞƐĂīĞĐƚƐĂĐŚŝĞǀĞŵĞŶƚŽĨĚŝƐĞĂƐĞĐŽŶƚƌŽů͘ dŚĞƉĂƟĞŶƚ͕ĂƐƚŚĞĞǀĞŶƚƵĂůƐƵďũĞĐƚŽĨĐŚƌŽŶŝĐĐĂƌĞ͕ŝƐĞdžƉĞĐƚĞĚƚŽĂĚŚĞƌĞƚŽĂĚǀŝƐĞĚĐĂƌĞ ƉƌĂĐƟĐĞƐƚŽďƌŝŶŐĂďŽƵƚƚŚŝƐĐŽŶƚƌŽů;ϭϴͿ͘ĞƐŝĚĞƐĂĚŚĞƌĞŶĐĞŽĨƉĂƟĞŶƚƐ͕ŚŽǁǁĞůůƚŚĞĨƌŽŶƚͲ ůŝŶĞĂĐƚŽƌƐĂƌĞƉƌĞƉĂƌĞĚ͕ŵŽƟǀĂƚĞĚŽƌŝŶĨŽƌŵĞĚĂďŽƵƚƚŚĞĚŝƐĞĂƐĞĂŶĚŝƚƐŵĂŶĂŐĞŵĞŶƚĂŶĚ how they interact with each other determine how well the disease will be controlled (6). >ŝƚĞƌĂƚƵƌĞƐŚŽǁƐƚŚĂƚŝŶĨŽƌŵŝŶŐƉĂƟĞŶƚƐĂŶĚƚŚĞŝƌĨĂŵŝůŝĞƐĂďŽƵƚƚŚĞĐŚƌŽŶŝĐĚŝƐĞĂƐĞĂŶĚŝƚƐ ĐĂƌĞ͖ƉƌĞƉĂƌŝŶŐƚŚĞŵǁŝƚŚďĞŚĂǀŝŽƵƌĂůƐŬŝůůƐƚŽƐĞůĨͲŵĂŶĂŐĞƚŚĞĐŽŶĚŝƟŽŶ͖ĂŶĚŵŽƟǀĂƟŶŐ ƚŚĞŵƚŽĞŶƐƵƌĞƚŚĂƚƚŚĞƉĂƟĞŶƚĐŚĂŶŐĞƐůŝĨĞƐƚLJůĞĂŶĚĂĚŚĞƌĞƐƚŽƚƌĞĂƚŵĞŶƚĐĂŶďĞĂĐŚŝĞǀĞĚ ƚŚƌŽƵŐŚ ĐŽŶƚĞdžƚͲƌĞůĞǀĂŶƚ ĂŶĚ ƐƚƌƵĐƚƵƌĞĚ ĞĚƵĐĂƟŽŶ ƉƌŽŐƌĂŵŵĞƐ ƚŚĂƚ ĂƌĞ ĚĞƐŝŐŶĞĚ ƚŽ ĞŵƉŽǁĞƌĂŶĚŝŵƉĂƌƚƐŬŝůůƐƚŽƉĂƟĞŶƚƐ͕ƚŚĞŝƌĨĂŵŝůŝĞƐŽƌĐůŽƐĞĐŽŵŵƵŶŝƚLJŵĞŵďĞƌƐ;ϭϵ͕ϮϬͿ͘ ŽŵŵƵŶŝƚLJƉĂƌƚŶĞƌƐĂƚƚŚŝƐůĞǀĞůĂƌĞƚŚŽƐĞŝŶǀŽůǀĞĚŝŶĚŝƌĞĐƚƉĂƟĞŶƚƐƵƉƉŽƌƚĂŶĚĐĂƌĞ͕ƐƵĐŚ ĂƐĐŽŵŵƵŶŝƚLJŚĞĂůƚŚǁŽƌŬĞƌĐĂĚƌĞƐ͘dŚĞŝƌƉƌĞƉĂƌĂƟŽŶƚŽĐŽŶƚƌŝďƵƚĞƚŽĐŚƌŽŶŝĐĐĂƌĞŝŶǀŽůǀĞƐ ƚƌĂŝŶŝŶŐĂŶĚƚŚĞƉƌŽǀŝƐŝŽŶŽĨƌĞƐŽƵƌĐĞƐƚŽĨĂĐŝůŝƚĂƚĞƉĂƟĞŶƚĂŶĚĨĂŵŝůLJƐƵƉƉŽƌƚ;ϲͿ͘,ĞĂůƚŚ care providers can be informed and prepared for their tasks in chronic disease management through training to improve their knowledge and skills (21). The ICCC framework describes ƚŚĞ ŽƌŐĂŶŝnjĂƟŽŶ ŽĨ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ŝŶƚŽ ƚĞĂŵƐ ŽĨ ĚŝīĞƌĞŶƚ ĐĂĚƌĞƐ ŽĨ ƉƌŽǀŝĚĞƌƐ ĂƐ one modality of preparing them for chronic care (6). It considers the triad to be working ŽƉƟŵĂůůLJǁŚĞŶƉĂƟĞŶƚƐĂŶĚƚŚĞŝƌĨĂŵŝůLJƌĞƉŽƌƚĨĞĞůŝŶŐĐĂƉĂďůĞŽĨĐĂƌŝŶŐĨŽƌƚŚĞĚŝƐĞĂƐĞ͕ supported by their community and health care providers to self-manage, and empowered to make decisions about their care (6).

The ICCC meso level

dŚĞŽƌĞƟĐĂůĐŽŶĐĞƉƚƐ

37

ĂŶĚϱͿƚŽƐƵƉƉŽƌƚƉĂƟĞŶƚƐ͛ƐĞůĨͲŵĂŶĂŐĞŵĞŶƚ;ϲͿ͘hŶĚĞƌƐƚĂŶĚŝŶŐƚŚĞŽƉĞƌĂƟŽŶƐŽĨƚŚĞƐĞĮǀĞ ĨƵŶĐƟŽŶƐ͕ŚŽǁƚŚĞLJŝŶŇƵĞŶĐĞĞĂĐŚŽƚŚĞƌĂƚƉƌŝŵĂƌLJĐĂƌĞĨĂĐŝůŝƟĞƐĂŶĚŚŽǁƚŚĞŚĞĂůƚŚĐĂƌĞ ŽƌŐĂŶŝnjĂƟŽŶĐŽŽƉĞƌĂƚĞƐǁŝƚŚƚŚĞĐŽŵŵƵŶŝƚLJĐĂŶƐŚŽǁƚŚĞĚLJŶĂŵŝĐƐŽĨƐƵƉƉŽƌƚĨŽƌƚŚĞƚƌŝĂĚ of front-line actors in care for chronic diseases.

The ICCC macro level

References ϭ͘ tŽƌůĚ ,ĞĂůƚŚ KƌŐĂŶŝnjĂƟŽŶ͘ ǀĞƌLJďŽĚLJ͛Ɛ ďƵƐŝŶĞƐƐͲͲƐƚƌĞŶŐƚŚĞŶŝŶŐ ŚĞĂůƚŚ ƐLJƐƚĞŵƐ ƚŽ ŝŵƉƌŽǀĞ ŚĞĂůƚŚ ŽƵƚĐŽŵĞƐ͗ t,K͛Ɛ ĨƌĂŵĞǁŽƌŬ ĨŽƌ ĂĐƟŽŶ͘ ϮϬϬϳ͘ǀĂŝůĂďůĞ ĨƌŽŵ ŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ŝŶƚͬ ŚĞĂůƚŚƐLJƐƚĞŵƐͬƐƚƌĂƚĞŐLJͬĞǀĞƌLJďŽĚLJƐͺďƵƐŝŶĞƐƐ͘ƉĚĨ΀ŝƚĞĚϭϭth _{Mar 2016]} Ϯ͘ tŽƌůĚ,ĞĂůƚŚKƌŐĂŶŝnjĂƟŽŶ͘WĂĐŬĂŐĞŽĨĞƐƐĞŶƟĂůŶŽŶĐŽŵŵƵŶŝĐĂďůĞ;WEͿĚŝƐĞĂƐĞŝŶƚĞƌǀĞŶƟŽŶƐ ĨŽƌ ƉƌŝŵĂƌLJ ŚĞĂůƚŚ ĐĂƌĞ ŝŶ ůŽǁͲƌĞƐŽƵƌĐĞ ƐĞƫŶŐƐ͘ ϮϬϭϬ͘ ǀĂŝůĂďůĞ ĨƌŽŵ ŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ ŝŶƚͬŶŵŚͬƉƵďůŝĐĂƟŽŶƐͬĞƐƐĞŶƟĂůͺŶĐĚͺŝŶƚĞƌǀĞŶƟŽŶƐͺůƌͺƐĞƫŶŐƐ͘ƉĚĨ ΀ŝƚĞĚ ϯϬth _{Mar 2016].} ϯ͘ DƵůĚŽŽŶ ><͕ ,ŽŐŐ t͕ ĂŶĚ >ĞǀŝƩ D͘ WƌŝŵĂƌLJ ĐĂƌĞ ;WͿ ĂŶĚ ƉƌŝŵĂƌLJ ŚĞĂůƚŚ ĐĂƌĞ ;W,Ϳ͘ tŚĂƚ ŝƐ ƚŚĞ ĚŝīĞƌĞŶĐĞ͍ ĂŶ : WƵďůŝĐ ,ĞĂůƚŚ͘ ϮϬϬϲ͖ ϵϳ;ϱͿ͗ϰϬϵͲϭϭ͘ ƉƵď ϮϬϬϲͬϭϭͬϮϰ͘

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ƉƌŝŵĂƌLJĐĂƌĞ͘ƵůůĞƟŶŽĨƚŚĞtŽƌůĚ,ĞĂůƚŚKƌŐĂŶŝnjĂƟŽŶ͘ϮϬϭϬ͖ϴϴ;ϭϮͿ͗ϵϰϯͲϴ͘

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ŐůŽďĂůƌĞƉŽƌƚ͘ 2002.

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ĂƌĞ͕ůŵĂͲƚĂ͕h^^Z͕ϲͲϭϮ^ĞƉƚĞŵďĞƌϭϵϳϴ͘ϭϵϳϴ͘ǀĂŝůĂďůĞĨƌŽŵǁǁǁ͘ǁŚŽ͘ŝŶƚͬͬ͘͘͘ĂůŵĂĂƚĂͺ ĚĞĐůĂƌĂƟŽŶͺĞŶ͘ƉĚĨ͘΀ŝƚĞĚϮϵth _{Mar 2016]} ϴ͘ tŽƌůĚ,ĞĂůƚŚKƌŐĂŶŝnjĂƟŽŶ͘dŚĞǁŽƌůĚŚĞĂůƚŚƌĞƉŽƌƚϮϬϬϴ͗ƉƌŝŵĂƌLJŚĞĂůƚŚĐĂƌĞŶŽǁŵŽƌĞƚŚĂŶ ĞǀĞƌ͘ϮϬϬϴ͘ǀĂŝůĂďůĞĨƌŽŵŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ŝŶƚͬǁŚƌͬϮϬϬϴͬĞŶͬ͘΀ŝƚĞĚϭϴƚŚ&ĞďϮϬϭϲ΁ ϵ͘ tĂŐŶĞƌ,͕ƵƐƟŶd͕ĂŶĚsŽŶ<ŽƌīD͘KƌŐĂŶŝnjŝŶŐĐĂƌĞĨŽƌƉĂƟĞŶƚƐǁŝƚŚĐŚƌŽŶŝĐŝůůŶĞƐƐ͘The Milbank Quarterly. 1996:511-44. 10. Bodenheimer T. /ŶƚĞƌǀĞŶƟŽŶƐƚŽŝŵƉƌŽǀĞĐŚƌŽŶŝĐŝůůŶĞƐƐĐĂƌĞ͗ĞǀĂůƵĂƟŶŐƚŚĞŝƌĞīĞĐƟǀĞŶĞƐƐ͘ Disease Management. 2003; 6(2):63-71. ϭϭ͘ ^ŝŵŝŶĞƌŝŽ>D͕WŝĂƩ'͕ŵĞƌƐŽŶ^͕ZƵƉƉĞƌƚ<͕^ĂƵůD͕^ŽůĂŶŽ&͕ĞƚĂů͘ĞƉůŽLJŝŶŐƚŚĞĐŚƌŽŶŝĐĐĂƌĞ ŵŽĚĞůƚŽŝŵƉůĞŵĞŶƚĂŶĚƐƵƐƚĂŝŶĚŝĂďĞƚĞƐƐĞůĨͲŵĂŶĂŐĞŵĞŶƚƚƌĂŝŶŝŶŐƉƌŽŐƌĂŵƐ͘ The Diabetes Educator. 2006; 32(2):253-60. ϭϮ͘ ƉƉŝŶŐͲ:ŽƌĚĂŶ :͕ WƌƵŝƩ ^͕ ĞŶŐŽĂ Z͕ ĂŶĚ tĂŐŶĞƌ ͘ /ŵƉƌŽǀŝŶŐ ƚŚĞ ƋƵĂůŝƚLJ ŽĨ ŚĞĂůƚŚ ĐĂƌĞ ĨŽƌ

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^͕DĂƌŝŶͲ>ŝŶŬ͕hŶĚĞƌŚŝůů>͕ŽƩƐ͕ZĂǀĞŶƐĚĂůĞ͕ĞƚĂů͘dŚĞĞdžƉĂŶĚĞĚŚƌŽŶŝĐĂƌĞDŽĚĞů͗ĂŶ

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ϭϯ͘ ^ƚƌĂƩŽŶ /D͕ ĚůĞƌ /͕ EĞŝů ,t͕ DĂƩŚĞǁƐ Z͕ DĂŶůĞLJ ^͕ Ƶůů ͕ Ğƚ Ăů͘ ƐƐŽĐŝĂƟŽŶ ŽĨ

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