Transfer of the idea of the Managed Clinical

Network into less advanced settings

~ Tarry Asoka4th World Congress on Integrated Care

23 – 25 November 2016TSB BANK ARENA, WELLINGTON

NEW ZEALAND

Introduction• Presentation based on research (Asoka, 2016) to

explore: Feasibility of Managed Clinical Networks(MCN) in Nigeria

– possibility as ‘collaborative service delivery’ approach in developing country setting

• Model of integrated care – a form of governance health service, operate alongside or intermingle productively with bureaucratic or market forms of governance

• Being tried in economically advanced nations – USA, Australia, UK etc.

Asoka, T. (2016) Feasibility of Managed Clinical Networks in Nigeria: a case of policy transfer to less advanced settings. (Doctoral thesis) Keele: Keele University, UK

Managed Clinical Networks: ‘linked groups of health professionals and

organisations from primary, secondary, and tertiary care working in a co-ordinated

manner, unconstrained by existing professional and [organisational] boundaries to ensure equitable provision of high quality

effective services’ (Scottish Executive, 2002).

Attractiveness of idea of MCN in less advanced locations: - potential benefits of inter-organisational networks over

hierarchies and markets in delivering care that is integrated across time, settings and providers

(i) service integration that leads to better health outcomes for patients

(ii) efficient use of health resources, especially scarce human resources for health

(iii) increase patient satisfaction with the health services

Despite repeated calls by WHO - for the adoption of clinical networks in resource poor countries, the feasibility of the network model of service in this setting is not proven.

To assess feasibility: - study conducted in Nigeria in service area where team-based collaboration is particularly likely – HIV/AIDS:

a) a strong identity and therefore clearly bounded, b) high social interaction within the community of

professionals, who arec) despite potential organisational barriers,

collaborative in attitude

Fundamental research questions: (i) What might be the conditions that mean that the

idea of the MCN is doable in Nigeria? (ii) Will the idea of the MCN survive and thrive when it

arrives?

Methods Case Study – HIV/AIDS Service

delivery in Rivers State, Nigeria - One of 36 States

- Population 5.2 million- Two sites: Ahoada & Bori, supported by The Global Fund

with Anti-retroviral drugs & coordination budget

- Multiple data sources: semi-structured interviews, review

of documents & reports, detailed observations, policy

& institutional analysis- Theory of Change: how idea of

MCN can implement change - Findings verified against

theoretical perspectives & evidence based practice

Findings & Analysis• HIV/AIDS service delivery in Nigeria:- operates in difficult health system - complex

institutional arrangement that tends to resist change - involves various agencies & multiple layers of

resource flows, policy & administrative coordination above service delivery level

• Formation of HIV/AIDS Programme Clusters:- Each cluster arrived through incentives provided by

The Global Fund (supported by national policy) to adopt an ‘Integrated Cluster Model’ for service provision

- Though prior to this, health professionals working in the HIV/AIDS in each location voluntarily attempted joint working

• HIV/AIDS Programme Cluster activities: - HIV/AIDS related services jointly working together to

increase number of people receiving anti-retroviral treatment in respective locality;

- holds monthly meetings, as main forum for taking decisions for service integration ;

- receives funding from The Global Fund - drugs & some money for coordination. Other activities funded by regular budget

• HIV/AIDS Programme Cluster governance:- Each cluster led by coordinator, secretary & treasurer - But Programme Manager of The Global Fund at each

site, acting as a facilitator tends to hold each cluster by force of purpose to deliver expected cluster results

• HIV/AIDS Programme Cluster outcome: Each cluster:

- developed & maintained well-defined relationships among specific HIV/AIDS programme interventions undertaken by several primary care facilities, hospital units, & community-based organisations

- Exhibited remarkable degree of relational practice, i.e. multiplicity of the links, volume of exchange, level of goodwill within groups, reliability & trust among members.

- delivered comprehensive services for HIV & AIDS patients at their respective locations without repeated registration, procedures, waiting periods & other administrative barriers.

- adopted a slightly different approach, but both delivered similar results, i.e. number of persons on anti-retroviral drugs

Table 1 - Main differences between Ahoada and Bori HIV

Programme Clusters

S/No Themes Ahoada HIV/AIDS Programme Cluster

Bori HIV/AIDS Programme Cluster

1. Cluster Leadership – ART Focal Person

Medical Doctor Laboratory Scientist

2. Frequency of Meetings Less frequent – there were no meetings in some months of the year

More frequent – meetings took place nearly every month in the year

3. Report of Partner Activities in the Minutes of the Meetings

More systematic – with space allocated for each and every member in the cluster

Less systematic – though tend to cover issues from all partners in the cluster

4. Membership Representation More than the prescribed number of HCT Units, and OVC, HBC, support groups are represented

Support Group and individual volunteers tend to cover the work of OVC, and HBC groups, as none was available.

5. Physically identifiable HIV clinic at base hospital

None – HIV patients are seen in regular clinics

Yes – HIV Clinic located in a building called the ‘White House’

6. Integration with routine clinical services at base hospital

A lot more integrated – HIV patients are seen by the same set of clinical staff as others with other medical conditions

Supernumerary clinical staff mainly Medical Doctors, Pharmacists and counsellors are brought in to run the HIV Clinic

7. Social activities other than core cluster business

None Celebration and gifts for special occasions - Send Off (Send-Forth), Weddings etc.

8. Level of engagement with Global Fund Managers

Less hands on – maintained a facilitator role

More engaged – more of supervisory than facilitation

Emerging Issues:- Each of the HIV/AIDS Programme Clusters is considered to

be ‘equivalent’ to the idea of the MCN since they: (a) have mandate to integrate HIV/AIDS services; (b) having an identity with central authority; (c) have resources made available for collective use that

benefits all.

- Thus HIV/AIDS Programme Clusters exhibited features largely supportive of collaborative service delivery

- Sustainability is unclear - existing institutional arrangements (legal framework, administrative processes/procedures & funding) in Nigeria challenged

- But possible to overcome institutional hostilities by undertaking specific policy reforms, based on a Theory of Change (Figure 1)

Discussion & Conclusion

Key insights:• strong indicators that the idea of the MCN in Nigeria

can work - structural and socio-metric characteristics of HIV/AIDS

Programme Clusters as networks- demonstrated the fact of collaboration as the

organising logic

• possible to ‘explicitly construct’ networks or collaborations in order to achieve a desired objective in areas with limited experience

• likely that networking and collaborative activities aimed at combating service fragmentation through clinical networks is capable of being used universally

Critical Success Factors:(i) Programme funding - resources made available by The Global Fund for HIV/AIDS responsible for formation of clusters & relationships observed

(ii) Some common basis for collaboration- prior, general mandates & other policy incentives from

Government to collaborate- recognition in centres of power of the disease (HIV/AIDS) as a

‘wicked problem’, requiring collective action - actors adopt collaborative practices as pragmatic approach to

tackling ‘difficult problems’ that share similar features as ‘wicked problems

- pre-existing ties - individual professionals & health facilities keen on streamlining service provision for HIV/AIDS patients

- CBOs providing supportive services invited to link up with ART sites, in order to maintain care continuum

- advocacy processes of ‘people living with HIV’ that demand integrated care for their members

(iii) Convener with authority & resources- presence of project managers of The Global Fund

compelled the network participants to be jointly accountable for the network results

(iv) Capacity for systematic collaboration - HIV/AIDS Programme Cluster seen as a well-

articulated system of collaborative relationships (not just emergent or partial connections)

(v) Joint production- value is produced through joint production, though task coordination & some self-interested collaborative exchanges was mode of operation of HIV/AIDS Programme Clusters

Take Home Messages: • the idea of the MCN is considered to be

‘operationally doable’ in this context (Nigeria), & therefore ‘technically’ transferable.

• ability of collaborating partners to sustain the clusters without reforming the institutional context is not clear – since ‘cluster model’ challenges exiting institutional arrangements in Nigeria.

• transferability (in practice to developing country setting) does not mean ‘spread’, ‘change in policy’ or ‘institutionalisation’

• But questions on sustainability remain, for example: - Is the drug fund required? - Is that funding just as catalyst? - Can it be changed or removed without damage to

the integrated care arrangement? - Or does everything fall apart? Etc.

• Further research is recommended:- ‘How’ and ‘Why’ the idea of the managed clinical network, as an alternative means of service integration, might be implemented in an institutional context that is characterised by a mix of modes of governance (hierarchy and markets) typical of developing nations, and the possibility of ‘sustainable transfer’ into this environment.