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Third Expert Consultation on Positive Synergies between Health Systems and Global Health Initiatives 2-3 October, WHO HQ, Geneva. Evidence on Integration of Programmatic Interventions with Health Systems. Professor Rifat Atun Director, Strategy, Policy and Performance Cluster - PowerPoint PPT Presentation

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  • Third Expert Consultation onPositive Synergies between Health Systems and Global Health Initiatives2-3 October, WHO HQ, GenevaProfessor Rifat AtunDirector, Strategy, Policy and Performance ClusterThe Global Fund to Fight AIDS, Tuberculosis and MalariaEvidence 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 viewsBinary -- reductionist argumentsThree short reviews to date

    Our Study: Systematic review using Cochrane criteria to identify the nature of evidence for or against integrationWider systematic review with broader range of study types that did not meet Cochrane inclusion criteria

  • Results

  • Key ResultsLimited evidence for or against integrationNature and extent of integration variesShaped by the context

  • Analysing and understanding the extent and nature of integrationThe extended review (n=55)

  • Atun, Ohiri, Adeyi, 2008Key variables affecting the nature and extent of integrationThe Problem being addressed The InterventionThe Adoption SystemHealth System FactorsThe Broad Context

  • Theoretical Framework for AnalysisInterventionAdoption SystemBroad ContextBroad ContextHealth System CharacteristicsProblem

  • The ProblemNecessity and UrgencyBurdenEconomic and social consequencesPerceived and realSocial NarrativeTransmission dynamics

  • The InterventionComplexity

    Scalability

    Simpler to more complex*

    ReplicabilityStandardisability* See next slide

  • Intervention: simple versus complex Single episodeMultiple episodesFew elementsMultipleelementsLess complexMore complexAtun and Kyratsis 2007

  • Intervention: simple versus complex Few stakeholdersMultiple stakeholdersFew levelsMultiplelevelsLess complexMore complexAtun and Kyratsis 2007

  • Intervention: simple versus complex User engagement lowerUser engagement higherTechnologydominatesLess complexMore complexAtun and Kyratsis 2007Behaviourdominates

  • The Adoption SystemReceptivityIndividual & organisational

    Political economyIncentivesagency/provider/user incentive alignmentLegitimacyCognitiveTechnical NormativeEconomic

  • Health System CharacteristicsFeasibility

    DesirabilityGovernanceFinancing Provider payment methodsPlanningOrganization and Service Delivery M&E systemDemand Generation

    Political economySocio-cultural factors

  • The ContextSustainability

    OpportunityFiscal spaceOverall and health sector specificFrailty

    Critical eventsSynergyTechnology / innovation

  • The ContextOpportunity

    Desirability

  • The ContextOpportunity

    DesirabilityCritical eventsVisibilitySynergyTechnology / innovation

    Political economySocio-cultural factors

  • Analysing the extent and nature of integration

  • Intervention ComplexityIntervention elementsIntervention frequency/number of episodes

  • Extent of Integration and Success as documented in studies

  • Integration into Critical Health System Functions GovernanceAccountability ReportingPerformance managementFinancingPoolingProvider payment methodsPlanningNeeds assessmentPriority setting Resource allocation

  • Integration into Critical Health System FunctionsOrganization and Service DeliveryStructuralHuman resources, shared infrastructureOperational integrationProcurement Supply chain managementCare pathways / guidelinesReferral and counter-referral systemsMonitoring and EvaluationData collection -- routine and surveysData analysisDemand GenerationFinancial incentives e.g. CCT, insurancePopulation interventions e.g. education and promotion

  • Extent of integration & success as documented in studiesSuccessCuba (ToledoRomani2007)Colombia (Rojas2001)MalariaDengueService deliveryFinanceGovernanceDemand generationMonitoring & Evaluation?Planning

  • Extent of integration & success as documented in studiesSuccessService deliveryFinanceGovernanceDemand generationMonitoring & EvaluationPlanningSchistosomiasis controlBurundi (Engels1993,1995)Cameroon (Bausch1995,Cline1996)China (Sleigh1998)Saudi Arabia (Ageel 1997)Brazil (Filho1992)???????????Uganda (Kabatereine 2006)

  • Extent of integration & success as documented in studiesSuccessService deliveryFinanceStewardship/GovernanceDemand generationMonitoring & EvaluationPlanningIndia (Rao 2002, Thakar 2003)LeprosySri-Lanka (Kasturiaratchi 2002)??

  • Extent of integration & success as documented in studiesSuccessService deliveryFinanceGovernanceDemand generationMonitoring & EvaluationPlanningPeruNutritionBangladesh (Hossain2005)??Various (Deitchler2004)?

  • Extent of integration & success as documented in studiesSuccessService deliveryFinanceGovernanceDemand generationMonitoring & EvaluationPlanningIMCI*ICDS - India (Agarwal2000, Kapil1999)Child health & developmentDular - India (Dubowitz2007)???

  • Extent of integration & success as documented in studiesSuccessService deliveryFinanceGovernanceDemand generationMonitoring & EvaluationPlanningBangladesh FPHSP (Philips1984, de Graff 1986)Pakistan LHWP (Douthwaite 2005)Family Planning servicesNepal (Tuladhar 1982)?????????

  • Extent of integration & success as documented in studiesSuccessService deliveryFinanceStewardship/GovernanceDemand generationMonitoring & EvaluationPlanningHaiti (Peck 2003)HIV/AIDS & STD services???

  • ConclusionsLimited evidence for or against integrationExtent and nature of integration variesShaped by the problem addressed, interaction of the intervention, the adoption system, health system characteristics and broader contextual factorsContext matters: complex adaptive systems at playLimited research and robust evidence base to guide decisionsReductionist approaches counterproductive: aim to design programmes that are context sensitive and fit for purpose

    *

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