Third Expert Consultation onPositive Synergies between Health Systems
and Global Health Initiatives2-3 October, WHO HQ, Geneva
Professor Rifat AtunDirector, Strategy, Policy and Performance ClusterThe Global Fund to Fight AIDS, Tuberculosis and Malaria
Evidence on Integration of Programmatic Interventions with Health Systems
Dr Soji AdeyiCoordinator, Public Health ProgramsThe World Bank
Integration of programmatic interventions into health systems
• Longstanding debate with polarisation of views– Binary -- reductionist arguments
• Three short ‘reviews’ to date
Our Study: • Systematic review using Cochrane criteria to identify
the nature of evidence ‘for or against integration’• Wider systematic review with broader range of study
types that did not meet Cochrane inclusion criteria
8,274
1,551
118
88
26
6,723 excluded
1,046 excluded
387i.e. program evaluations, descriptions, reviews, uncontrolled studies 30 not available*
18 excluded
44
I. Title scanning
II. Abstract scanning
III. Full text scanning
IV. Quality assessment
12
14
ResultsProgramme Intervention Outcome
IMCI (Adam 2005, Arifeen 2004, Bryce 2005, Armstrong Schellenberg 2004)
Multi-country CBA in 12 countries Integration of IMCI in services in vs. routine care
Improved case management, quality of care and under-5 mortality. Costs lower
PRISM-E (Bartels 2004, Krahn 2006, Oslin 2006)
Integrated delivery of mental health and/or substance abuse services for elderly in PHC setting
Improved patient engagement
Substance abuse & PHC (Weisner 2001, Willenbring 1999
Substance abuse treatment with integrated medical treatment of substance abuse-related co-morbidities
Improved abstinence. Cost effective
Mental health provision in PHC (Gater 1997, Watts 2007)
Depression and schizophrenia treatment integrated into PHC
Improved access and treatment, resources more effectively used
Key Results
• Limited evidence for or against integration
• Nature and extent of integration varies– Shaped by the context
Analysing and understanding the extent and nature of integration
The extended review (n=55)
Atun, Ohiri, Adeyi, 2008
Key variables affecting the nature and extent of integration
1. The Problem being addressed
2. The Intervention
3. The Adoption System
4. Health System Factors
5. The Broad Context
Theoretical Framework for Analysis
InterventionAdoption
System
Broad Context
Broad Context
Health System Characteristics
Problem
The Problem
• Necessity and Urgency • Burden– Economic and social
consequences
• Perceived and real• Social Narrative
• Transmission dynamics
The Intervention
• Complexity
• Scalability
• Simpler to more complex*
• Replicability• Standardisability
* See next slide
Intervention: simple versus complex
Single episode
Multiple episodes
Few elements
Multipleelements
Less complex
More complex
Atun and Kyratsis 2007
Intervention: simple versus complex
Few stakeholders
Multiple stakeholders
Few levels
Multiplelevels
Less complex
More complex
Atun and Kyratsis 2007
Intervention: simple versus complex
User engagement lower
User engagement higher
Technologydominates
Less complex
More complex
Atun and Kyratsis 2007
Behaviourdominates
The Adoption System
• Receptivity • Individual & organisational
• Political economy
• Incentives– agency/provider/user incentive
alignment
• Legitimacy– Cognitive
– Technical
– Normative
– Economic
Health System Characteristics
• Feasibility
• Desirability
• Governance• Financing • Provider payment methods• Planning• Organization and Service
Delivery • M&E system• Demand Generation
• Political economy• Socio-cultural factors
The Context
• Sustainability
• Opportunity
• Fiscal space– Overall and health sector
specific
• Frailty
• Critical events• Synergy• Technology / innovation
The Context
• Opportunity
• Desirability
The Context
• Opportunity
• Desirability
• Critical events– Visibility
• Synergy• Technology / innovation
• Political economy• Socio-cultural factors
Analysing the extent and nature of integration
Intervention Complexity
Few Many
Single
Multiple
Dengue - Cuba Malaria - Colombia
Schistosomiasis - Brazil, Burundi, Cameroon, China, Saudi Arabia, Uganda
Leprosy - India, Sri Lanka
Onchocerciasis - Uganda
Nutrition - Peru, etc.
IMCIICDS
Dular - India
FP/MCH - Matlab, Bangladesh
FP/MCH - Pakistan - LHWPFP/MCH - Nepal (Tuladhar)
HIV/AIDS - Haiti
STD - Mbofana
FP; STD - Lafort
Mental health - WhettenSubstance abuse - Friedmann
Intervention
elements
Intervention frequency/number of episodes
Extent of Integration and Success as documented in studies
Fully integrated
Partially integrated
Not integrated
? Unknown
Most to all outcomes
Mixed outcomes
No outcomes
? Unknown
Integration into Critical Health System Functions
1. Governance– Accountability – Reporting– Performance management
2. Financing– Pooling– Provider payment methods
3. Planning– Needs assessment– Priority setting – Resource allocation
Integration into Critical Health System Functions
4. Organization and Service Delivery– Structural
• Human resources, shared infrastructure– Operational integration
• Procurement • Supply chain management• Care pathways / guidelines• Referral and counter-referral systems
5. Monitoring and Evaluation– Data collection -- routine and surveys– Data analysis
6. Demand Generation– Financial incentives – e.g. CCT, insurance– Population interventions – e.g. education and promotion
Extent of integration & success as documented in studies
Success
Cuba (ToledoRomani2007)
Colombia (Rojas2001)Malaria
Dengue
Service deliv
ery
Finance
Governance
Demand generatio
n
Monitorin
g & E
valuation
?
Planning
Extent of integration & success as documented in studies
Success
Service d
elivery
Finance
Governance
Demand g
eneratio
n
Monitorin
g & E
valuatio
n
Planning
Schistosomiasis control
Burundi (Engels1993,1995)
Cameroon (Bausch1995,Cline1996)
China (Sleigh1998)
Saudi Arabia (Ageel 1997)
Brazil (Filho1992)
?
?
?
?
?
?
?
?
?
?
?
Uganda (Kabatereine 2006)
Extent of integration & success as documented in studies
Success
Service d
elivery
Finance
Steward
ship/G
overnance
Demand g
eneratio
n
Monitorin
g & E
valuatio
n
Planning
India (Rao 2002, Thakar 2003)
Leprosy
Sri-Lanka (Kasturiaratchi 2002)
??
Extent of integration & success as documented in studies
Success
Service d
elivery
Finance
Governance
Demand g
eneratio
n
Monitorin
g & E
valuatio
n
Planning
Peru
Nutrition
Bangladesh (Hossain2005) ??
Various (Deitchler2004) ?
Extent of integration & success as documented in studies
Success
Service d
elivery
Finance
Governance
Demand g
eneratio
n
Monitorin
g & E
valuatio
n
Planning
IMCI*
ICDS - India (Agarwal2000, Kapil1999)
Child health & development
Dular - India (Dubowitz2007)
?
?
?
Extent of integration & success as documented in studies
Success
Service d
elivery
Finance
Governance
Demand g
eneratio
n
Monitorin
g & E
valuatio
n
Planning
Bangladesh – FPHSP (Philips1984, de Graff 1986)
Pakistan – LHWP (Douthwaite 2005)
Family Planning services
Nepal (Tuladhar 1982)
?
?
?
?
?
?
?
?
?
Extent of integration & success as documented in studies
Success
Service d
elivery
Finance
Steward
ship/G
overnance
Demand g
eneratio
n
Monitorin
g & E
valuatio
n
Planning
Haiti (Peck 2003)
HIV/AIDS & STD services
? ??
Conclusions
1. Limited evidence for or against integration
2. Extent and nature of integration varies• Shaped by the problem addressed, interaction of the intervention,
the adoption system, health system characteristics and broader contextual factors
3. Context matters: complex adaptive systems at play
4. Limited research and robust evidence base to guide decisions
5. Reductionist approaches counterproductive: aim to design programmes that are ‘context sensitive’ and ‘fit for purpose’
