Clearing the Global Health Fog

Rifat Atun

Description

A longstanding debate on health system organization relates to the benefits of integrating programs that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration arguing relative merits of each approach. Recently, the debate has been rekindled due to substantial rises in externally-funded programs for priority health, nutrition, and population (HNP) interventions and an increase in international efforts aimed at health system strengthening.
However, all too frequently these arguments have not been based on hard evidence. In this book we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of integration of targeted health programs that emphasize specific interventions into critical health systems functions; (ii) how the integration or non-integration of health programs into critical health systems functions in different contexts have influenced program success; and (iii) how contextual factors have affected the extent to which these programs were integrated into critical health systems functions.
The findings provide a new synthesis of evidence to inform the debate on health systems and targeted interventions. In practice a rich mix of solutions exists. While the discussion on the relative merits of integrating health interventions will no doubt continue, discussions should move away from the highly-reductionist approach that has polarized this debate.

Informations

• Publié par: world-bank-publications
• Publié le: 26 mars 2009
• Nombre de lectures: 23
• EAN13: 9780821379363
• Langue: English

Extrait

W O R L D B A N K W O R K I N G P A P E R N O . 1 6 6

Clearing the Global Health Fog A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions

Rifat Atun Thyra de Jongh Federica V. Secci Kelechi Ohiri Olusoji Adeyi

V H P R I O R I T I E S T O O L S S Y S T E M S N R E C A I N T E R V E N T I O N R I L E I U V E T G L C T I N H H O R I Z O N T A L R C C I A C L I E E V I D E N C E T D A T A S T U D I E S E I L P I P O P U L A T I O N P D O G M A F L N R N R A O G L O B A L T D I A G O N A L A S Y C O V E R A G E H

THE WORLD BANK

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Clearing the Global Health Fog

W O R L D B A N K W O R K I N G P A P E R N O .

Rifat Atun Thyra de Jongh Federica V. Secci Kelechi Ohiri Olusoji Adeyi

A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions

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Copyright © 2009 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First Printing: March 2009

ank’ ork to the s w is paper therefore ally-edited texts. dily available. e of the author(s) construction and xecutive Directors in this work. The p in this work do ny territory or the ing portions or all national Bank for n of its work and nd a request with d Drive, Danvers, . ld be addressed to , DC 20433, USA,

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

L IST OF F IGURES 1. Flow Chart Representing the Selection Process for Studies Included in the Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2. The Extent and Nature of Integration by Targeted Health Intervention and Intervention Success as Reported in the Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 iii

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Contents

Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 7

5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

B. Summary of the Included Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

A. Search Strategy and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

2. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The Conceptual Framework for Analysing Integration of Targeted Health Interventions into Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Outcomes Reported in the Studies Analyzed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 The Extent and Nature of Integration of Health Interventions into Critical Health Systems Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 The Extent of Intervention Success in the Studies Analyzed . . . . . . . . . . . . . . . . . . . 18 How the Context Influences the Extent and Nature of Integration . . . . . . . . . . . . . 19

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3 L IST OF T ABLES 1. Critical Health Systems Functions and Elements of Integration . . . . . . . . . . . . . . . . . . 5

C. Contextual Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

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Acknowledgments

T a he n  d w e o n r t k i  t p l r e o d g “ r I a n m te  g u r n a d ti e o r n p  i o n f n  i H n e g a t lt h h is   S p y a st p e er m  s w  a a s n i d n  i P ti ri at o e ri d t  y a  n H d e f a u lt n h d , e N d u b t y r  i t t h io e n W a o n r d l  d P B o a p n u k - lation Interventions.” Preparation of the paper was co-funded in a collaborative exercise by the Center for Health Management at Imperial College London and the World Bank. In that context the authors acknowledge consultations with a number of colleagues during an international consultation hosted by the World Bank in May 2008, and comments from several reviewers who helped to improve the manuscript. The reviewers were Tom Novotny (Professor, University of California, San Francisco) and Richard Coker (Reader, London School of Hygiene & Tropical Medicine). Sylvia Robles reviewed the initial version of a Cochrane Review, which was an earlier step in this exercise. Logan Brenzel and Peter Berman commented on the conceptual framework on which the paper is based. Sonalini Khetrapal provided comments on an earlier version of the paper and Inas Ellaham helped with formatting. The authors alone are responsible for the contents of the paper. About the authors: Rifat Atun, MBBS, MBA, FRCGP, FFPH. Professor of International Health Manage- ment, Imperial College, London. E-mail: [e-mail] Thyra de Jongh, MSc, DIC, PhD. Researcher, Centre for Health Management, Impe- rial College London. E-mail: [e-mail] Federica V. Secci, MSc. Doctoral Researcher, Centre for Health Management, Imperial College London. E-mail: [e-mail] Kelechi Ohiri, MD, MPH, MS. Health Specialist in the Human Development Network of the World Bank. E-mail: [e-mail] Olusoji Adeyi, MD, DrPH, MBA. Coordinator of Public Health Programs in the Human Development Network of the World Bank. E-mail: [e-mail] Cover design: concept by Olusoji Adeyi, text by Olusoji Adeyi and Sonalini Khetrapal, graphics by Stuart K. Tucker.

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Acquired Immune Deficiency Syndrome Bangladesh Integrated Nutrition Project Community Working Groups Expanded Program for Immunization Cochrane Effective Practice and Organisation of Care Group Family Planning Human Immunodeficiency Virus International Center for Diarrheal Disease Research, Bangladesh India Integrated Child Development Services Integrated Management of Childhood Illness Lady Health Worker Program Monitoring and Evaluation Maternal and Child Health Primary Health Care Pulse Polio Immunization Tuberculosis United Nations Children’s Fund United States Agency for International Development Voluntary Counselling and Testing World Health Organization

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AIDS BINP CWG EPI EPOC FP HIV ICDDR,B IDCS IMCI LHWP M&E MCH PHC PPI TB UNICEF USAID VCT WHO

Acronyms and Abbreviations

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Summary

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l ing debate on he s to benefits of integrating A h o e n al g t s h t  a p n r d ogramsthatemph a a l s t i h z  e s s y p st e e ci m fi s c  i o n r t g e a r n v i e z n a t t i i o o n n s r i e n l t a o t  e mainstreamhealthsystems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration argu- ing the relative merits of each approach. Recently, the debate has been rekindled due to sub- stantial increases in externally funded programs for priority health, nutrition and population interventions and enhanced international efforts aimed at health systems strengthening. However, all too frequently these arguments have not been based on hard evidence. In this paper we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of integration of targeted health programs that emphasize specific interventions into critical health systems functions (defined in the Methodology Section), (ii) how the integration or non-integration of health programs into critical health systems functions in different contexts have influenced program success, (iii) how contextual factors have affected the extent to which these programs were integrated into critical health systems functions. We use a new conceptual framework to guide the analysis. The review evaluates peer-reviewed studies that focus on health interventions, and which have been introduced on a regional or national scale. The debate on health interventions has tended to narrowly focus on vertical or inte- grated descriptors . However, our analysis shows this to be a false dichotomy as few inter- ventions are purely vertical (single-disease oriented) or horizontal (fully integrated into mainstream functions) health system. As this review shows, in practice the nature of the problem, the interventions to address these and the adoption and assimilation of health interventions in health systems vary greatly in different contexts, as does success. The purpose, nature, speed and the extent of integration also vary—in part, dependent on the intervention complexity, the health sys- tem characteristics and the contextual factors. There are few instances where there is full integration of a health intervention or where an intervention is completely non-integrated. Instead, there exists a highly heterogeneous picture both for the nature and also for the extent of integration. The review suggests that the evidence base for integration versus targeted health pro- gramming is very limited. As success was measured in different ways (for example, in terms of varied programmatic goals related to efficiency, effectiveness, or equity), analysis and drawing lessons from this is further complicated. Perhaps the modesty of evidence creates the context for strong opinions for or against integration in global health. We have attempted to show that in practice the dichotomy between integrated and non-integrated (traditionally described as vertical and horizontal) is not rigid. Health systems combine both non-integrated and integrated interventions, but the balance of these interventions varies considerably. Our findings suggest that the purpose, nature and extent of integra- tion vary enormously between interventions and in countries, creating a rich mosaic of local solutions to address emergent problems. We found rare instances of full integration but a wide range of instances where health interventions are integrated into one or more critical health system functions. Further, it is important to note that in many countries that ix

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simultaneously have applied multiple health interventions, the nature of integration for these interventions varies and different degrees of integration for the same critical health system function co-exist. The findings provide new synthesis of evidence to inform the debate on health systems and targeted interventions. Given the highly varied contexts and adoption systems that reflect local nuances, different health system capacities and the range of problems being addressed, it is not surprising that in practice a rich mix of solutions exist. While the dis- cussion on the relative merits of integrating health interventions will no doubt continue, discussions should move away from the highly reductionist approach that has polarized this debate. Future efforts are best spent on generating and learning from useful evidence.

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