By Martin Mckee and Dina Balabanova (London School of Hygiene & Tropical Medicine) and Fiona Leh Hoon Chuah and Helena Legido-Quigley (National University of Singapore)
Are integrated health systems more efficient and cost-saving or more even resilient than parallel, specialist systems? Much has been claimed for “integrated” approaches to health care but almost all research has looked at integration of services rather than the health system more broadly. Conversely, health systems research has not often looked at “integration” models, processes or case-studies using a health systems lens. This upcoming supplement discussing ‘Integration for stronger health systems: lessons from integrating sexual and reproductive health and HIV services’ brings together a range of papers that explore the health systems challenges, and successes, of delivering integrated services, drawing particular lessons from the rich experience of decades-long initiatives to integrate HIV services with reproductive health and other primary care services. 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.
This blog highlights two timely systematic reviews published ahead of the supplement, looking into:
- Health systems facilitators and barriers to the integration of HIV and chronic disease services: a systematic review
Getting it together: it makes sense to integrate HIV services with those for other chronic diseases
Health is now high on the global political agenda. When they signed up to the Sustainable Development Goals (SDGs), all world leaders committed to policies that would expand health coverage and improve outcomes. The tasks ahead varied. Those from low- and middle-income countries first had to mobilise the resources needed to expand coverage. Those in rich countries had to find ways to reorient services around people rather than, as was too often the case, institutional and administrative hierarchies. Time is not on their side. Growing, ageing populations, new opportunities to intervene and, in many country, growing pressure on resources mean that a major paradigm shift is needed.
Much attention is focusing on integration of services for people with different diseases and different needs. This makes sense, from many points of view. It offers scope to save time and resources, for those providing health care and those using it, for example if they can have all their needs met in a single facility, by a team that know them and understand their needs. It brings even greater benefits to those with multiple problems and complex illnesses, allowing the health care team to see the patient as a whole rather than, as is often the case, moving them from one silo to another, each defined by a different body system or disease. Yet, we still have many questions about how integrated programmes actually work and how to get the best results from them.
Yet while these questions are important, we’ve been asking a different one. Integration of care takes place within a health system, comprising ways of raising money, distributing it, training health workers, buying medicines, and much else. So we want to know what it is about health systems that either helps or hinders schemes to integrate services from achieving their full potential? Even the best designed model of integration may fail if there are weaknesses in the wider health system, such as weak infrastructure or dysfunctional management processes.
What did we find?
We systematically reviewed the available research that has looked at aspects of health systems that help or hinder integration of services for people living with HIV/AIDS and those with chronic non-communicable diseases that are increasing in many low- and middle-income countries. And of course, as more people infected with HIV survive, there are growing numbers of people with both, in part because AIDS and its treatments increase the risks of some chronic diseases. We found 150 papers, although 67% of them were from high-income countries.
We were able to confirm that aspects of health systems are often critical for the success of the integration. It 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 formal structures; informal relationships and trust are equally important.
As expected, effective integration requires health workers that are appropriately trained and incentivised health workers. However, it is also important that health workers are flexible in the roles that they can perform, where necessary going beyond their core areas of work. Having a ‘go-to’ person who can act as contact point for everyone involved can be very helpful. Staff perform best when they are supported by appropriate institutional structures and dedicated resources. All these things are made possible by managers and leaders committed to integrating services and overcoming difficulties. We also found that a positive, problem-solving culture, with a focus on the patient, their needs and personal circumstances made a difference, as does careful design of appropriate delivery models that can respond to patients’. This often involves working with families, communities and change agents outside the health system.
Mental Health and HIV Services
In another systematic review, we looked at the lessons learned from integrating services for HIV and mental illness. As with chronic noncommunicable diseases, there are strong clinical and organisational rationales for doing this. First, HIV, the accompanying opportunistic infections, and in some cases the side-effects of treatment can give rise to neurological damage and cognitive impairments. Second, some forms of mental illness, including depression and associated substance use disorders, may be associated with risky behaviours that promote transmission of HIV. Mental health problems can also jeopardise adherence to treatment, with major consequences for survival.
Given the strong linkages between these conditions, there are many examples of initiatives to bring the services together. We can group them into 3 broad categories, each with its own strengths and limitations.
- The first is integration on a single site, for what we might call “one-stop shopping“. It has many advantages for the patient but it can be difficult and expensive to bring all the necessary services together in a single place
- Another model involves building a network between health facilities and other providers, allowing people with complex problems to obtain access to those with the specialist knowledge needed to treat them. However, here the coordination can be very difficult with the risk of fragmentation of care
- The final model involves integrated care led by a case manager, with referral to specialists as needed. This also can be affected, but it requires very highly skilled case managers, who may be difficult to recruit and retain in health systems facing health worker shortages
Based on what we found, we are clear that integrated delivery of health services should start with the health system within which they are located, identifying what can help and what are the potential constraints. Integration is not a quick fix and involves willingness to allow for disruption in the short term and significant start-up costs. But above all, careful preparation is critical if we are to realise the potential that integrated programmes can bring.
The full supplement entitled Building integrated health systems: lessons from HIV & reproductive health integration will be published in Autumn 2017 in Health Policy and Planning.
Image credit: CDC Global