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Third Expert Consultation on Positive Synergies between Health Systems

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

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Third Expert Consultation on Positive Synergies between Health Systems

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  1. 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 The Global Fund to Fight AIDS, Tuberculosis and Malaria Dr Soji Adeyi Coordinator, Public Health Programs The World Bank

  2. 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

  3. 8,274 6,723 excluded I. Title scanning 1,551 1,046 excluded II. Abstract scanning 387 i.e. program evaluations, descriptions, reviews, uncontrolled studies 118 30 not available* 44 14 III. Full text scanning 88 18 excluded 26 IV. Quality assessment 12

  4. Results

  5. Key Results • Limited evidence for or against integration • Nature and extent of integration varies • Shaped by the context

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

  7. Key variables affecting the nature and extent of integration The Problem being addressed The Intervention The Adoption System Health System Factors The Broad Context Atun, Ohiri, Adeyi, 2008

  8. Theoretical Framework for Analysis Broad Context Health System Characteristics Adoption System Intervention Problem Broad Context

  9. The Problem Necessity and Urgency Burden Economic and social consequences Perceived and real Social Narrative Transmission dynamics

  10. The Intervention Complexity Scalability Simpler to more complex* Replicability Standardisability * See next slide

  11. Intervention: simple versus complex Single episode Less complex Multiple elements Few elements More complex Multiple episodes Atun and Kyratsis 2007

  12. Intervention: simple versus complex Few stakeholders Less complex Multiple levels Few levels More complex Multiple stakeholders Atun and Kyratsis 2007

  13. Intervention: simple versus complex User engagement lower Less complex Behaviour dominates Technology dominates More complex User engagement higher Atun and Kyratsis 2007

  14. The Adoption System Receptivity Individual & organisational Political economy Incentives agency/provider/user incentive alignment Legitimacy Cognitive Technical Normative Economic

  15. 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

  16. The Context Sustainability Opportunity Fiscal space Overall and health sector specific Frailty Critical events Synergy Technology / innovation

  17. The Context Opportunity Desirability

  18. The Context Opportunity Desirability Critical events Visibility Synergy Technology / innovation Political economy Socio-cultural factors

  19. Analysing the extent and nature of integration

  20. Single Dular - India Onchocerciasis - Uganda Nutrition - Peru, etc. FP/MCH - Matlab, Bangladesh STD - Mbofana FP; STD - Lafort Many Few FP/MCH - Pakistan - LHWP FP/MCH - Nepal (Tuladhar) Malaria - Colombia Dengue - Cuba Leprosy - India, Sri Lanka Schistosomiasis - Brazil, Burundi, Cameroon, China, Saudi Arabia, Uganda HIV/AIDS - Haiti ICDS IMCI Mental health - Whetten Substance abuse - Friedmann Multiple Intervention Complexity Intervention frequency/number of episodes Intervention elements

  21. Fully integrated Most to all outcomes Partially integrated Mixed outcomes No outcomes Not integrated ? ? Unknown Unknown Extent of Integration and Success as documented in studies

  22. Integration into Critical Health System Functions Governance Accountability Reporting Performance management Financing Pooling Provider payment methods Planning Needs assessment Priority setting Resource allocation

  23. Integration into Critical Health System Functions Organization and Service Delivery Structural Human resources, shared infrastructure Operational integration Procurement Supply chain management Care pathways / guidelines Referral and counter-referral systems Monitoring and Evaluation Data collection -- routine and surveys Data analysis Demand Generation Financial incentives – e.g. CCT, insurance Population interventions – e.g. education and promotion

  24. Extent of integration & success as documented in studies Governance Service delivery Monitoring & Evaluation Success Demand generation Planning Finance Dengue ? Cuba (ToledoRomani2007) Malaria Colombia (Rojas2001)

  25. Extent of integration & success as documented in studies Governance Service delivery Success Monitoring & Evaluation Demand generation Planning Finance Schistosomiasis control ? ? ? Brazil (Filho1992) ? ? ? ? Burundi (Engels1993,1995) Cameroon (Bausch1995,Cline1996) China (Sleigh1998) ? Saudi Arabia (Ageel 1997) ? ? Uganda (Kabatereine 2006) ?

  26. Extent of integration & success as documented in studies Stewardship/Governance Service delivery Success Monitoring & Evaluation Demand generation Planning Finance Leprosy India (Rao 2002, Thakar 2003) ? ? Sri-Lanka (Kasturiaratchi 2002)

  27. Extent of integration & success as documented in studies Governance Service delivery Success Monitoring & Evaluation Demand generation Planning Finance Nutrition Peru Bangladesh (Hossain2005) ? ? Various (Deitchler2004) ?

  28. Extent of integration & success as documented in studies Governance Service delivery Success Monitoring & Evaluation Demand generation Planning Finance Child health & development IMCI* ICDS - India (Agarwal2000, Kapil1999) ? ? ? Dular - India (Dubowitz2007)

  29. Extent of integration & success as documented in studies Governance Service delivery Success Monitoring & Evaluation Demand generation Planning Finance Family Planning services Bangladesh – FPHSP (Philips1984, de Graff 1986) ? ? ? ? ? Pakistan – LHWP (Douthwaite 2005) ? ? ? ? Nepal (Tuladhar 1982)

  30. Extent of integration & success as documented in studies Stewardship/Governance Service delivery Success Monitoring & Evaluation Demand generation Planning Finance HIV/AIDS & STD services ? ? ? Haiti (Peck 2003)

  31. Conclusions • Limited evidence for or against integration • 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 • Context matters: complex adaptive systems at play • Limited research and robust evidence base to guide decisions • Reductionist approaches counterproductive: aim to design programmes that are ‘context sensitive’ and ‘fit for purpose’

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