Health systems, communicable diseases and integration

Abstract

The HIV/AIDS, tuberculosis and malaria pandemics pose substantial challenges globally and to health systems in the countries they affect. This demands an institutional approach that can integrate disease control programmes within health and social care systems. Whilst integration is intuitively appealing, evidence of its benefits remains uncertain and evaluation is beset by lack of a common understanding of what it involves. The aim of this paper is to better define integration in health systems relevant to communicable disease control. We conducted a critical review of published literature on concepts, definitions, and analytical and methodological approaches to integration as applied to health system responses to communicable disease. We found that integration is understood and pursued in many ways in different health systems. We identified a variety of typologies that relate to three fundamental questions associated with integration: (1) why is integration a goal (that is, what are the driving forces for integration); (2) what structures and/or functions at different levels of health system are affected by integration (or the lack of); and (3) how does integration influence interactions between health system components or stakeholders. The frameworks identified were evaluated in terms of these questions, as well as the extent to which they took account of health system characteristics, the wider contextual environment in which health systems sit, and the roles of key stakeholders. We did not find any one framework that explicitly addressed all of these three questions and therefore propose an analytical framework to help address these questions, building upon existing frameworks and extending our conceptualization of the 'how' of integration to identify a continuum of interactions that extends from no interactions, to partial integration that includes linkage and coordination, and ultimately to integration. We hope that our framework may provide a basis for future evaluations of the integration of programmes and health systems in the development of sustainable and effective responses to communicable diseases.

Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience

“…Even where broad analytical techniques are available, integration is complex and challenging to represent in quantitative terms. It can be best described as a continuum, progressing from linkages and service co-ordination to full integration of resources and services 21 25. New techniques, such as developing indices for integration, may provide a way forward.…”

“…New techniques, such as developing indices for integration, may provide a way forward. A recent study21 developed a scale of integration to enable cross-country comparisons of performance. Likewise, work is in progress on the Integra Initiativeii to develop an index of integration.…”

“…Although there has been some consensus recently in the field of sexual and reproductive health (SRH) on terminology,19 there remain several differing discourses on integration 12 20–23. The most common understanding relates to horizontal integration or integration at the point of service delivery; this can range from structured referrals to physical incorporation providing a one-stop approach 21. Integration can also be seen as part of a wider system of co-ordination at the policy and planning, human resources and financing levels, sometimes referred as linkages 19.…”

Integrating HIV services with other health services to improve care, retention and adherence

“…This report addresses the most common understanding of integration, relating to horizontal integration at the point of service delivery, although this mechanism can range from structured referrals to the physical incorporation of services within the same facility (Shigayeva et al 2010). In addition, integration can range in terms of how far services are fully integrated into the system .…”

The politics of tuberculosis and HIV service integration in Ghana

“…Depending on the prevailing contingencies, public health organisations (in this case, TB/HIV programmes) may determine the level at which they desire to integrate (Van de Ven et al, 2013); whether full segregation [no recognised connections, with programmes operating with different structures], linkages/referral system [unstructured relationship with ad-hoc interactions], coordination [goal-oriented activities enhanced by working together on joint activities, whilst retaining a programme's distinctive structures and functions], and full integration [changes in both programme structures and/or functions, leading to the establishment of common governance responsibilities, the pooling of funding, the merging of service delivery or the unifying of information systems, which leads to onestop-shop services for TB/HIV patients] (Shigayeva et al, 2010;Ansah et al, 2012). In this paper, we define integration as the combination of services such as diagnosis, treatment, data management/surveillance, financing and monitoring and evaluation that hitherto existed separately (Waddington and Egger, 2008).…”