Advanced Practice Nursing: A Strategy for Achieving Universal Health Coverage and Universal Access to Health

ABSTRACT Objective: to examine advanced practice nursing (APN) roles internationally to inform role development in Latin America and the Caribbean to support universal health coverage and universal access to health. Method: we examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universal health coverage and access to health. Results: given evidence of their effectiveness in many countries, APN roles are ideally suited as part of a primary health care workforce strategy in Latin America to enhance universal health coverage and access to health. Brazil, Chile, Colombia, and Mexico are well positioned to build this workforce. Role implementation barriers include lack of role clarity, legislation/regulation, education, funding, and physician resistance. Strong nursing leadership to align APN roles with policy priorities, and to work in partnership with primary care providers and policy makers is needed for successful role implementation. Conclusions: given the diversity of contexts across nations, it is important to systematically assess country and population health needs to introduce the most appropriate complement and mix of APN roles and inform implementation. Successful APN role introduction in Latin America and the Caribbean could provide a roadmap for similar roles in other low/middle income countries.


Introduction
Along with the development of stronger health systems in which primary health care is paramount, improved access to health and universal health coverage are recognized priorities for improving global health (1)(2) .
Following 60 plus years of global development, there is heightened recognition of advanced practice nurses and their impact on increased access to primary health care and improved quality of care and health outcomes (3)(4) .
At the intersection of primary health care and advanced practice nurses as two global phenomena is the concept of human resources for health. An adequate supply and appropriate mix of health care providers is critical to achieve the global agenda for health and advanced practice nurses are an essential component of country level health human resources (5)(6) . Advanced practice nursing (APN) roles are at an early stage of development in Latin American countries (7) . Thus, there is tremendous opportunity to leverage these roles to achieve goals for access to health, universal health coverage and primary health care reform in these countries.

Objectives
The purpose of this article is to examine what is known about the deployment and impact of APN roles internationally and to use this evidence to provide recommendations for developing these roles in Latin American countries to achieve universal health coverage and universal access to health.

Method
We examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universal health coverage and access to health. The examination of APN roles was limited to the clinical nurse specialist (CNS) and the nurse practitioner (NP).
The article begins with a summary of the WHO's (2) goals for universal health coverage and universal access to health in relation to primary health care and  2. equitable access to these services, regardless of social circumstances, without risk of financial hardship (2) . The right to health is an inherent value of universal health coverage. According to Margaret Chan, Director of the WHO (8) , universal health coverage, grounded in the delivery of integrated primary health care services, may provide the single most powerful tool for improving global health. The United Nations (9) has reaffirmed its commitment to universal health coverage in new sustainability goals for 2030.
Although much progress has been made in Latin American countries to improve health care and implement varied financial models for universal health coverage, equitable access to health and essential primary health care remains elusive for millions of people in the region (10)(11)(12)(13)(14) . There are pressing needs to improve access to primary health care in rural communities and for services to improve health outcomes related to maternal and child mortality, infectious diseases, and aging. Augmented health promotion, prevention and management services are needed to reduce the burden and mortality associated with chronic conditions, especially for mental health, cancer, cardiovascular disease and diabetes.
Recognition of the need to strengthen primary health care worldwide dates back to the Declaration of Alma-Ata in 1978 and has been reinforced in subsequent policies such as the WHO Resolution WHA62.12 (1) .
However, it is only recently through two policy events that the need and opportunity to develop APN roles for primary health care in Latin America were formally identified. In August 2013, the WHO 2008-2012 progress report on nursing and midwifery (15) emphasized the need to develop specialized nursing and APN roles with the core competencies to meet population health and health services needs in revitalized primary health care systems. PAHO echoed this recommendation with Resolution CD 52.R13 to include advanced practices nurses as one part of an overall strategy to increase the primary health care workforce in Latin America (12) . Over www.eerp.usp.br/rlae the past two years nursing leaders from Latin America and the Caribbean have begun to explore strategies to support APN role development in their countries (7,(16)(17)(18)(19) .

Types of advanced practice nursing roles
The International Council of Nurses (ICN), defines an advanced practice nurse as a "registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which she/ he is credentialed to practice. A master's degree is recommended for entry level" (20) . Clinical practice anesthetist (24) . Of these role titles, CNS and NP are the most common (25)(26) . Regardless of the type, common systems improvement such as providing leadership and education and promoting evidence-based practice (27) .
Nurse practitioners have an expanded scope of practice that usually includes advanced health assessment, illness and injury prevention and therapeutic management and tend to spend more of their time providing direct patient care (22) .

Global deployment and use of advanced practice nursing roles
The States, Canada, United Kingdom and Australia (25) .
In the last decade there has been further expansion of APN roles, especially in high income countries in Europe, Africa, Asia and the Middle East (29)(30)(31)(32) . There are few reports of APN role development in low and middle income countries.
Improving health outcomes and increasing access to health care in rural and remote communities and for vulnerable populations (e.g., homeless, mental health, drug addiction) in urban communities have been initial drivers for the introduction of NPs in primary health care settings (33)(34) . Initially, CNSs were introduced to keep pace with advances in treatment and technology and the increased complexity of nursing care for specialized populations in acute care settings (35) . More recently, CNSs and NPs are also being deployed internationally to a broad range of community, long-term care and acute care settings as catalysts for improving health outcomes and quality of care and innovation to deliver more sustainable models of health care (12,15,25,(36)(37)(38)(39)(40) .  (16,19,(24)(25)(50)(51) . In relation to role clarity, nursing leaders from Latin America and the Caribbean identify a general lack of awareness and understanding of APN roles within the nursing profession and amongst health care policy decision-makers within governments (16) . At the political and policy level, a shared challenge across all countries has been legislative barriers to define, legitimize and facilitate regulation of nurses with expanded scopes of practice.
There is also need to strengthen nursing education in Latin America to improve access to standardized, high quality programs including those specific to APN (16)(17)42) .
There Other challenges for introducing APN roles for primary health care in most Latin American countries is a general shortage of nurses and a high proportion of technically trained nurses (e.g., nursing aides) compared to degree prepared professional nurses in the workforce to draw on for further development (11,13,16,42,53) . There is also limited focus on community or primary health care

coverage and access to health
Universal health coverage is dependent on adequate financing which is difficult to achieve for all countries, but especially those with low and middle incomes, due to rising health care costs. In Latin America and the Caribbean, inadequate financing of universal health coverage in some countries has contributed to a mix of public and private insurance plans, high outof-pocket expenses and inequitable access to timely and high quality care for the unemployed, poor and vulnerable populations (10) . Improved financing to provide comprehensive universal health coverage is an important issue for the region, where over 25% or 130 million people live in chronic poverty (54) .
One strategy is to offset the costs of financing universal health care coverage by gaining efficiency in health care. The WHO has provided ten recommendations for reducing the 40% of health care spending that is wasted through inefficiency (55) . At least five of these shorter hospital lengths of stay and reduced hospital readmissions for the elderly and patients transitioning from hospital to home (40,(56)(57)(58) ; fewer tests and reduced clinic, physician and emergency department visits for cancer patients (59) ; and lower consultation costs for patients in primary care (3)(4) .
Relevant to appropriate staff mix, as substitutes for other providers (usually physicians) to address workforce shortages, CNSs and NPs achieve equal or better health outcomes and satisfaction with care in inpatient and outpatient settings and for transitional care (3,38,40,56,(59)(60) . These same systematic reviews also demonstrate the benefits of the complementary addition of CNS and NP roles to health care teams to improve patient health outcomes, satisfaction with care and quality of care. In studies of team-based models of primary health care, the addition of an NP increases access to health promotion and prevention services to meet community needs (61)(62)(63) and improves the quality of care for chronic disease management (64) .
Other studies indicate that CNSs help support the development of a motivated workforce by promoting staff satisfaction (65) and facilitating the recruitment and retention of high quality nurses (66) . They also reduce errors and suboptimal care by promoting patient safety and preventing complications (58,(67)(68) and lower the use of inefficient or ineffective health care interventions by promoting provider and patient uptake of best practices (69)(70) .
Compared to usual care, CNSs and NPs also improve access to health by achieving better health outcomes for a broad range of patient populations in varied practice settings. Older adults receiving APN care in ambulatory care for dementia or chronic heart failure or those in long term care settings have reduced mortality rates and improved health outcomes related to depression, aggressive behavior, incontinence, and pressure ulcers (36,57) . In primary care and in ambulatory care settings, NP care for patients with chronic conditions such as heart disease, hypertension, and diabetes results in better indicators of disease control such as lower blood pressure, reduced serum cholesterol levels, and reduced glycated hemoglobin (3)(4) . CNS outpatient care is associated with improved mental health for patients with psychiatric problems, better disease control and quality of life for patients with heart failure, and reduced symptoms of disease activity for patients with arthritis (38) .
CNS transitional care also permits earlier hospital discharge of high risk patient populations (cancer, pregnancy, older adults, heart failure, neonates) while at the same time achieving equivalent or better health outcomes (40) . Examples of improved outcomes include increased survival for patients with advanced cancer or heart failure and improved immunization rates for very low birth weight infants (40) . Similar findings of equal or better health outcomes for NP transitional care compared to usual care have been demonstrated for patients undergoing gynecological surgery and those with complex conditions, asthma, or myocardial infarction (56) . Across these studies, aspects of CNS

Caribbean countries
If the process is done well, the introduction of APN roles in Latin America and the Caribbean could provide a roadmap or template for introducing these roles in low and middle income countries where few such roles exist. To achieve optimal impact for improving universal health coverage and access to health, a systematic approach to APN role introduction is required to determine patient populations and communities with unmet health and health service needs and where the greatest gains in health outcomes, health care efficiency and health systems improvement can be made (55) . Such The framework also applies principles for effective health human resource planning to determine the type of APN role, the optimal complement and mix of other health care providers, and how the role will interact with other health care team members to achieve identified goals and related outcomes (73) . Due to the diversity of health systems, funding arrangements, human resources, and population health needs it will be important for each country in the Latin American and Caribbean region to conduct its own systematic process for prioritizing and defining the APN role or roles to be introduced (11) .
Given the overall shortage of nursing and other provider roles in primary health care in most countries, it will be important to consider the introduction of APN roles within the context of creating a primary health care workforce (74)(75) .  (5) . APN leadership is also required to advocate for policies to support nursing practice in new care delivery models providing a better balance between health promotion and prevention and disease-focused care (11,75) . APN leadership can also be used to support healthy workplace environments for nurses and other health care providers. Leadership strategies may include managing and developing interprofessional teams, promoting effective interprofessional team work, and supporting the developing of health professionals and community health workers (77)(78) .
The PEPPA framework also integrates planning steps to identify potential barriers and optimize enablers to effective APN role implementation related to stakeholder and APN education, recruitment and retention, and health care policies including legislation and regulation (71) .  and other providers is also essential for effective role implementation (5) .
As outlined above, there are a multitude of systematic reviews of the international literature, predominately from high income countries, confirming that CNSs and NPs are safe and effective health care providers. Within the context of APN role introduction in Latin America and the Caribbean, research and the use of other evaluation methods will be required to ensure the effective use, optimal implementation and long-term sustainability of these roles. A major challenge in some Latin American countries is the lack of good baseline workforce and health care system data to inform the introduction and design of APN roles and to support subsequent evaluations (41) . To address country decision-making needs for better and more contextually relevant data, the PEPPA framework has been enhanced to provide detailed guidance for APN role evaluation (79) .