By Jonathan Hopkins (Independent Consultant, formerly, International Planned Parenthood Federation) and Susannah Mayhew (London School of Hygiene & Tropical Medicine)
The Sustainable Development Goals – the 17 global goals for bringing about sustainable development by 2030 – will not be reached unless there is an interconnected, multisectoral approach to development in general and health specifically through more people-centred, more integrated health systems. The ability to provide joined-up packages of services to meet changing health needs is essential, especially as health needs are going to change significantly in the coming 50 years with increased life expectancies, aging populations and the disease burden shift from infectious to chronic diseases as well as climate change altering patterns of vector-borne diseases. Health systems need to adapt to these changing needs.
Integration research in a new Supplement in Health Policy and Planning entitled ‘Integration for stronger health systems: lessons from integrating sexual and reproductive health and HIV services’, shows that a key way of being resilient to change and difficult conditions is building flexible integrated health systems.
Four key factors
Existing siloed, disease specific approaches to healthcare need to be transformed. In order to do this, we highlight four key factors that appear as a common theme within the papers in the Supplement:
- Invest in the health workforce: Structural integration (i.e. infrastructure/training etc.) is not sufficient for integrated service delivery; rather sensitive management of staff to nurture and support their agency in decision making, team-working and load-sharing is critical to being able to work flexibly to meet the challenges that face providers each day.
These findings highlight the need for health systems to support healthcare workers to promote a supportive enabling environment that can facilitate provision of integrated health services. (Mudzengi et al; Mayhew et al; Siapka et al; Mutemwa et al).
- Scaling up integrated service delivery requires a system wide, not an adhoc approach: Just focusing on integration at the service delivery level or even the health system level ignores how health policies and strategies influence service delivery. Key policies and strategies therefore need to be integrated with others that have mutual activities and targets to normalise integration throughout the health system. (Mounier-Jack et al; Watts et al; Mudzengi et al; Mayhew et al).
- Encourage effective collaboration and coordination: Integrated service delivery is more likely to succeed where health systems encourage effective collaboration and coordination within and between teams, and between staff and patients. It is not just about formal systems and service structures; informal relationships and trust are equally important. Having a ‘go-to’ person who can act as a contact point for everyone involved was also found to be helpful. Critically, a positive, problem-solving culture, with a focus on the patient, their needs and personal circumstances made a difference, as did careful design of appropriate delivery models that can respond to patients’ needs. (Chuah et al; Mayhew et al; Mutemwa et al).
- Political will: Lessons from sexual and reproductive health and HIV integration experience points to the need for strong political will to establish clear governance structures with a key role for civil society in holding governments and government agencies accountable for rights-based action on health. It is not only structures, policies and resources that must be linked but the people within the sector or system must also be motivated and enabled to make connections beyond their usual field (and sector) of operation. Thus, a flexible, multi-sectoral approach is essential – especially as the progressive realization of the right to health depends on the development of enabling environments to support the structural linkages for planning and service-delivery across sectors which requires political will and strong leadership. (Hopkins et al; Warren et al).
The papers in this Supplement clearly illustrate that any focus on integrating health services needs to include a broader systems-wide, people-centred approach if it is to be both successful and sustainable.
In context of the Sustainable Development Goals, which recognise the interconnectedness of sectors, the ability to provide joined-up packages of services to meet changing health – and development – needs becomes increasingly relevant. Health systems need to adapt to the changing needs of populations; a people-centred integrated approach – as the research in this supplement shows – is a key way of ensuring health system resilience in years to come.
Papers within this supplement
- EDITORIAL (Mayhew): Building integrated health systems: lessons from HIV and reproductive health integration
- COMMENTARY (Mounier-Jack et al): Integrated care: learning between high-income, and low- and middle-income country health systems
- REVIEW (Watts et al): Health systems facilitators and barriers to the integration of HIV and chronic disease services: a systematic review
- REVIEW ((Chuah et al): Interventions and approaches to integrating HIV and mental health services: a systematic review
- ORIGINAL MANUSCRIPT (Mudzengi et al): The patient costs of care for those with TB and HIV: A cross-sectional study from South Africa
- ORIGINAL MANUSCRIPT (Hopkins et al): How linked are national HIV and SRHR strategies? A review of SRHR and HIV strategies in 60 countries
- ORIGINAL MANUSCRIPT (Mayhew et al): Numbers, systems, people: how interactions influence integration. Insights from case studies of HIV and reproductive health services delivery in Kenya
- ORIGINAL MANUSCRIPT (Siapka et al): Impact of integration of sexual and reproductive health services on consultation duration times: results from the Integra Initiative
- ORIGINAL MANUSCRIPT (Mutemwa et al): Does service integration improve technical quality of care in low-resource settings? An evaluation of a model integrating HIV care into family planning services in Kenya
- COMMENTARY (Warren et al): Health systems and the SDGs: lessons from a joint HIV and sexual and reproductive health and rights response