Integration of Health Services: Theory and Practices

| February 1, 2012 | 0 Comments

Jacqueline Sherris, PhD is the Vice President of Global Programs at PATH (Program for Appropriate Technology in Health) and an Affiliate Assistant Professor in Global Health at the University of Washington School of Public Health.

Jeffrey Bernson, MPH, MPA is part of the Advisory Board fo Urgent Africa and a former intern for PATH.

In Seattle we often are fortunate enough to have access to a good health clinic or physician, where we can go for regular check-ups and screening tests, get necessary immunizations, address our reproductive health needs, get assessed and treated for many illnesses or injuries, and obtain referrals when we need care that the clinic does not provide. This kind of accessible, integrated care, with its focus on prevention, standard treatment for common health problems, and monitoring of chronic conditions is good for individuals, families, and communities.

Yet many people around the world face a much different health care picture. In developing countries particularly, access to health care is limited and services often are provided through vertically-organized programs. Immunizations are offered separately from reproductive health care, which in turn often is not integrated with HIV/AIDS care.

Malaria control programs often do not have the resources or capacity to address other very common infectious diseases that strike their target groups, for instance pneumonia, diarrhea, or even seasonal flu. And as populations in the developing world age and cancer, diabetes, and other non-communicable diseases become common, men and women living in developing countries have few opportunities to obtain necessary screening tests or receive information and services to help them combat these illnesses (WHO 2011).

To address these challenges, the global health community is increasingly focusing on how to provide client-centered integrated services to meet the health needs of men, women, and children, including in the lowest-resource settings (WHO 2008). While great successes have been achieved through vertical programming — notably in childhood immunizations, HIV/AIDS programming, and malaria control, — it is recognized that integration of health services can derive greater overall impact from health resources and systems.

Global health advocates, funders, and implementers see integration—including the use of a single encounter with a client to address multiple health or social concerns—as an important tool to better meet the needs of individuals and health systems.

Over the past year or two, PATH – an international non-profit organization headquartered in Seattle – has been considering how to design and evaluate integrated programs for greater impact, recognizing that integration can occur within communities, health organizations, broader health systems, and across sectors.

We have implemented integrated health projects in a number of countries, including combined HIV/AIDS and tuberculosis diagnosis and care in Tanzania, integrated care for HIV/AIDS and maternal and child health in Kenya, integrated interventions for diarrheal disease and child health in Vietnam, and a project linking agriculture and nutritional health in Kenya. This article describes our approach to health services integration and outlines the critical elements we consider when developing integrated programming.

Defining Integration

PATH defines health services integration as the organization, management, and delivery of a continuum of preventive and curative health services. We do this in accordance with patient and family needs over time and across different levels of the health system. Our definition builds on existing literature – including technical guidance from the World Health Organization – that describes integration as an approach rather than an end in itself. (WHO 2008)

PATH carefully weighs opportunities for integration in the places we work, knowing that integration is not always the best approach. We pose four questions as a starting point to assess whether integration is possible or desirable:

1. What type of service integration, if any, is needed? Answering this question addresses the appropriateness of integration in a particular context, including challenges and benefits.

2. To what extent should services be integrated? Answering this question requires and understanding of the specific services to integrate, and the timing, scope, and strategy for integrating them.

3. What steps are needed to establish and sustain high-quality integrated services? Answering this question involves understanding the necessary operational steps at the community, provider, facility, and health-system levels to support a program’s integration goals and objectives.

4. What information is needed to measure success and inform improvement, replication, or scale-up? Answering this question requires analysis of which indicators should be used to determine if integration is working to improve health services and outcomes.

A Conceptual Framework for Integration

Figure 1. PATH’s Approach to Integrated Health Services

Our conceptual framework for integration encompasses four levels of a country’s health structure— client-centered services at the community level, health operations planning at the organization or agency level, health system coordination at the national level, and intersectoral initiatives across development sectors. (PATH 2011)

• Client-centered services at the facility and community levels: Integrated programming must fit the needs of clients, including individuals and families, as well as the broader community. It may involve expanded clinic hours, more efficient referral systems, increased use of preventive and lifesaving technologies, and improved access to treatment services, drugs, or innovative interventions to enhance care.

• Operational elements at the health organization or agency levels: Integrating services often requires changes in how services are delivered by ministries of health, nongovernmental or local organizations, and private-sector agencies. Existing or new health system inputs (such as resources, time, money, or expertise) may need to be allocated differently to support planning, management, staffing, interpersonal communication, or the measurement of integrated services.

• Broader governance and capacity issues at the health system level: New levels of coordination or joint planning of the policies, processes, and infrastructure that make up a health system may be needed to deliver integrated services. Integration at this level often requires significant involvement and support from stakeholders, including donors, ministries of health, politicians, advocacy groups, the private sector, and nongovernmental organizations.

• Intersectoral coordination: Cross-sector integration may occur when, for example, a health system intersects with an educational system to administer vaccines through schools or with an agriculture program to address nutritional deficiencies. Integration across sectors requires engagement and commitment at multiple levels of the agencies involved. Figure 1 provides a graphic illustration of this conceptual framework.

Integrated Care in Kenya and Beyond

Working with partners in Kenya’s Western Province, PATH is helping integrate maternal and child health services with HIV/AIDS care and treatment. Previous to the integration effort, nearly all mothers in government hospital-based antenatal care programs were being tested for HIV, but only one quarter of those identified were being successfully enrolled in follow-up care and treatment offered though separate comprehensive care centers for HIV.

PATH focused was on developing more client centered services, and adjusting health operations to support integration of services (the central two elements of the conceptual framework illustrated in Figure 1). Maternal and child health clinics were used as the point of entry for a range of health services for both mothers and babies; HIV care and treatment were added to the existing services.

The shift to integrated services was associated with more HIV-positive mothers and babies being treated for their HIV disease, better compliance with drug treatment, early diagnosis and enhanced care for newborns, and improved opportunities for testing and treating spouses and other family members.

For instance, Western Province, officials report an 80-100 percent increase in the number of HIV-positive mothers enrolling in follow-up care and enhanced access to family planning services among these women.

Some of the key attributes that were considered during the shift to a more integrated approach included: building on shorter waiting times and improved quality of care in MCH clinics (health service organization), developing ongoing training and mentoring programs to link MCH and HIV providers (training, supervision), providing and tracking antiretroviral and other drugs through both MCH and HIV care centered (logistics), reaching out to men to build their support for their wives’ care (community outreach), and linking families with HIV/AIDS comprehensive care centers as they “graduate” from MCH care (referrals).

While much remains to be done to expand integrated care in Kenya – particularly in developing stronger tracking and monitoring tools to evaluate the impact of integration on health outcomes (an issue for many integrated health programs [Butta et al 2011]) – the results described here have been met with enthusiasm at the national level, and the MCH-HIV/AIDS integration model is being rolled out at a number of other locations country-wide.

Integrating services present challenges – and opportunities – on many levels. Consider the increasing burden of noncommunicable disease in low-resource settings, and the heath needs, for example, of poor, older women in developing countries. These women likely have survived various infectious diseases, as well as the threats of pregnancy and childbirth, and often have a key role in the social and economic health of their communities.

Yet they are at risk of cancer – particularly cervical and breast cancer. They have increasing incidence of diabetes and other risk factors for cardiovascular diseases. And they have a range of other health needs, including gynecological problems related to frequent childbearing.

The health systems that serve them must tackle the dual challenges of meeting ongoing infectious disease and maternal health challenges, and the noncommunicable disease threats needs of older women and men. As outlined in this article, considering how to achieve integration at various levels of the health structure, as well as how to manage specific changes in the organization of services, staffing, community outreach, logistics, etc., to support integration will be key to meeting these challenges.

Tags: , , , , ,

Category: Expert Submissions, Policy, Spring 2011

About the Author ()

Leave a Reply