By Susannah Mayhew (London School of Hygiene & Tropical Medicine) and Charlotte Warren (Population Council)
The UN’s World Population Day (11th July) calls attention to the need for the world to remember its commitments at the International Conference on Population and Development (ICPD) 25 years ago to make reproductive health and gender equity a reality for all. Further, they acknowledge that sexual and reproductive health (SRH) and gender equity are critical for the achievement of sustainable development goals. This means SRH, including HIV, must be seen as central to development and to universal health coverage and health systems strengthening goals.
Health Policy and Planning’s Supplement of November 2017 entitled ‘Integration for stronger health systems: lessons from integrating sexual and reproductive health and HIV services’, uniquely brings together learning from decades of research on integrating HIV, reproductive health and other primary-care services and a health systems lens on understanding health systems challenges and successes in delivering integrated care. We provide a collection of reviews, think pieces and primary data studies to bring systems processes, structures and “software” (its people) under the spotlight to learn lessons for achieving sustained integrated systems that can respond to the ever-changing and inter-connected health needs of diverse populations. Papers show that a key way of strengthening systems to meet ICPD commitments, and address broader sustainable development goals, is to build flexible integrated health systems.
Four key factors to scale-up ICPD
Existing siloed, programme-specific approaches to healthcare need to be transformed if ICPD commitments are to be met. 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. If ICPD progress is to be achieved, 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 and provide holistic SRH care.
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 SRH 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 the depth of learning from the SRH-HIV integration field for health systems strengthening. as the research in this supplement shows, a 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 this way, ICPD commitments to ensuring reproductive health and gender equity for all are more likely to be met.
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- Articles below
|· 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|
Image credit: Flynn Warren