LESSONS LEARNT FROM THE CASE STUDIES ON INTEGRATED HEALTH SERVICES DELIVERY NETWORKS AND VERTICAL PROGRAMMES

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LESSONS LEARNT FROM THE CASE STUDIES ON
INTEGRATED HEALTH SERVICES DELIVERY NETWORKS AND
VERTICAL PROGRAMMES

• Edwin Vicente C. Bolastig, MD, MSc
• Consultant, PAHO/WHO
• 14th September 2010
• Rovanels Resort, Tobago

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2 Presentations

• Case Study on the Integration of HIV/AIDS
  Services in Trinidad and Tobago into Maternal,
  Newborn Child Health Services, as well as
  Sexual and Reproductive Health Services,
  including Family Planning (focused on Tobago
  findings)
• Experiences and Lessons Learned from Case Studies
  in the Region of the Americas

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Case Study on the Integration of HIV/AIDS
Services in Trinidad and Tobago into Maternal,
Newborn Child Health Services, as well as
Sexual and Reproductive Health Services,
including Family Planning

• Edwin Bolastig, Yoko Laurence and Karen Pierre
• Funded by
• Pan American Health Organization/ World Health
  Organization

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OBJECTIVES OF CASE STUDY

• To contribute to the body of work on health
  services integration
• To determine how vertical programs and Global
  Health Initiatives have impacted on the health
  system, and affected segmentation/fragmentation

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• TRINIDAD AND TOBAGO
• Southernmost Caribbean country
• Independence 1962 Republic 1976
• Parliamentary democracy
• Multi-ethnic population 1.3M
• Oil and gas-based economy
• GNI per capita (09)US 17,884
• 10-year GDP growth(99-08) 7.7
• Epidemiologic shift CNCDs over 60 of deaths

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CONTEXT

• First HIV case diagnosed in 1983
• 8th leading cause of death in 2004
• STI-HIV co-infection prevalence rate 42 (60 M
  40 F) (Buensuceso, 2008)
• HIV/AIDS cause enjoys strong political support
• World Bank loan, EU grant, CARICOM PANCAP,
  government, private sector funding

• SOCIAL DRIVERS
• Poverty and unemployment
• Gender inequality/domestic violence
• High mobility Caribbean diaspora
• Stigma and discrimination
• Multiple sex partners/Early initiation
• Substance abuse/unprotected sex
• (UNAIDS , 2005)

• ECONOMIC DRIVERS
• Inequitable income distribution
• Sex work due to poverty
• Rapid urbanisation
• Limited skills and poor socialisation
• Sex-oriented tourism
• (Camara, CAREC, 2002)

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BROAD SECTORAL CONTEXT

• 1986 National AIDS Programme
• 1993 Caribbean Charter on Health Promotion
• 1996 Health Sector Reform Programme (HSRP)
• National Health Promotion Plan
• 2001 Health Promotion Council Directorate of
  Health Promotion and Public Health
• 2004 National AIDS Coordinating Committee
  (NACC)
• 2005 Vision 2020
• 2006 MOH Corporate Plan (2006-2009)

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SEGMENTATION/FRAGMENTATION

• Decentralisation of health service delivery to
  RHAs with the exception of Vertical Programmes
  and Services
• Fragmented human resource management
• Dual employment system
• Information and medical records management
  largely manual
• Unstructured referral system

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HIV INTEGRATION INITIATIVES

• Integration with Maternal and Child Health -
  PMTCT
• Integration with STI and Family Planning - VCT
• Integration with Population Programme - PITC
• Integration with Chronic Disease Care
• Tobago Health Promotion Clinic (THPC)
• Integration of Treatment with Prevention San
  Fernando General Hospital
• Integration of Information Systems for HIV/AIDS
• TERIDA Project

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• Description of the Process of Integration of
  HIV/AIDS services in Trinidad and Tobago using
  PAHOs Framework on Integrated Health Services
  Delivery Networks (IHSDN)

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• The covered population/territory is defined and
  there is broad knowledge of its health needs and
  preferences, which determine the services
  provided by the system.
• HIV Prevalence 1.5 of Population (generalised
  epidemic)
• Perception that high-risk groups are well-defined
  but targeted prevention not happening
• In Tobago, youths targeted but not MSM or sex
  workers

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• 2. An extensive offer of health facilities and
  services, which include public health services,
  health promotion, disease prevention, timely
  diagnosis and treatment, rehabilitation, and
  palliative care, all under a single
  organizational umbrella.
• Tobago Health Promotion Clinic (THPC) Dr Noel
• behaviour modification, social services, housing,
  religious/pastoral services, mental health,
  substance abuse, mobile services, nutrition,
  dental referral, etc.

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• A first level of care that acts as the de facto
  gateway to the system, integrates and coordinates
  health care, and meets most of the populations
  health needs.
• Tobago Health Promotion Clinic (THPC) is the
  gateway into the system

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• 4. Specialist services delivered in the most
  appropriate place, preferably non-hospital
  settings.
• Pregnant women referred to THPC
• Baby treated at paediatric ward in TRH
• One (1) HIV specialist in Tobago for adults but
  none for paediatric care

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• 5. Coordination of care mechanisms exist
  throughout the entire continuum of services.
• A full and integrated coordination of care
  mechanism is compromised due to
• A lack of feedback to and from TPHC
• Ineffective utilisation and training of personnel
  within organisations.

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• 6. Health care centered on the person, the
  family, and the community/territory.
• Health professionals from the health centres and
  THPC sometimes go out to the community to do
  testing via the Mobile Clinics at football games
  or all-fours clubs.
• THPC has a programme that provides support to
  discordant couples, allowing these couples to
  have children who eventually turn out to be
  negative
• No prevention programme for at risk families

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• 7. A single, participatory governance system for
  the entire IDS.
• National Strategic Plan for HIV/AIDS is monitored
  by the NACC under the Office of the Prime
  Minister), while implementation of the Health
  Sector Plan is monitored by the Ministry of
  Health through HACU.
• In Tobago, THPC falls under the Tobago House of
  Assembly (THA) Tobago HIV/AIDS Coordinating
  Committee (THACC) serves as the link between NACC
  and THA

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• 8. Integrated management of administrative and
  clinical support systems.
• Disparate administrative and clinical support
  systems are not managed in an integrated manner
• At THPC, administrative and clinical support
  addressed by some administrative staff but
  everyone working at clinic can provide support
  services if necessary

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• 9. Sufficient, competent human resources,
  committed to the system.
• Human resources for the THPC are considered
  insufficient given the comprehensive nature of
  the clinic in terms of HIV and chronic disease
  treatment, which has caused the clinic to grow
  continuously since its inception.
• Only 16 of required staff of 27

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• 10. An integrated information system that links
  all members of the IDS.
• Figure 1 TERIDA
• IT System Diagram
• Tobago not included
• in pilot project

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• 11. Adequate financing and financial incentives
  aligned with the goals of the system.
• 2 schools of thought in terms of adequacy of
  financing
• There is enough funding for HIV/AIDS, the problem
  is effective utilization and despite huge
  investments, there is no reduction of HIV in the
  general population.
• Financing could never be enough as progress is
  made in diagnosis and treatment, new techniques,
  equipment and drugs emerge in the market.

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• 12. Broad intersectoral action.
• Collaboration between THPC and support groups
  like TAS, OASIS and others
• THACC is known for engaging the community through
  the village councils in the implementation of
  HIV-related projects.
• Corporate sponsorships but discrimination happens
  in the workplace

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EMERGING MODELS

• Three (3) Emerging Models of Integration
• Standalone outpatient HIV/AIDS clinic integrated
  with chronic disease care (Tobago Health
  Promotion Clinic)
• Hospital-based HIV/AIDS testing and treatment
  centres adult paediatric (San Fernando
  General Hospital)
• Satellite network of multi-tiered hospital based
  and outpatient health facilities

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MODEL 1 Stand Alone
ADVANTAGES/STRENGTHS GAPS/WEAKNESSES
By associating HIV/AIDS with other chronic diseases, stigma and discrimination may be minimised Unique branding strategy associating comprehensive approach with quality care Well-organised manual record-keeping transitioning to a paperless information system Multi-tasking of health workers Triaging according to purpose of visit (counselling and testing, pick-up of ARVs, consults, etc.) to avoid long queues and waiting times Community outreach activities (home visits) ensures good follow-up/ return rates Weak linkage with health centres doing counselling and testing Referrals have to be made to the Scarborough General Hospital for treatment of paediatric patients and to the OB/GYN Ward for pregnant women Inconspicuous location not all potential clients are aware of the clinic site (Conversely, could be an advantage too)
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MODEL 2 Hospital Based Testing and Treatment
ADVANTAGES/STRENGTHS GAPS/WEAKNESSES
Simulates one-stop shop for services (STI, HIV/AIDS testing, counselling and treatment, maternal and child care, etc.) in a single health facility/ compound Weak community outreach services Link to family planning services missing Hospital-based care is known to be generally more expensive than out-patient care
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MODEL 3 Multi-tiered Satellite Network
ADVANTAGES/STRENGTHS GAPS/WEAKNESSES
Hand-holding approach to referral of patients to other health facilities Assurance of a wide range of services Relatively good feedback being received from facilities where patients were referred to Patients being lost in the process of referring to another health facility Patients being lost to follow-up Longer time spent in securing appointments and attending clinics Travel and opportunity costs of attending multiple clinic schedules
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FINANCING Total TTD 253.5 million
1 USD 6.29 TTD
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BENEFITS

• Programmes institutionalisation of PMTCT
  integration of VCT with SRH free ARVs
• Resources - high levels of funding for HIV/AIDS
  also used for MCH, STIs and FP
• Processes - shift from a programme approach to
  institutionalisation of interventions
• Intermediate products build capacity of
  committed health personnel
• Outcomes increased HIV testing among mothers
  improved efficiency in some areas community
  outreach

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TWO SCHOOLS OF THOUGHT ON INTEGRATION

• Strengthening of services as pre-requisite to
  integration vs.
• Integration as means to improve services

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LESSONS LEARNT

• Facilitating factors
• Role of advocates and champions in the health
  system
• Perception of strong political support from
  government
• Health promotion (high risk groups and wider
  population)
• Service delivery decentralisation (RHAs)
• Increased resources for HIV/AIDS
• Expanded role of civil society knowledge
  broker

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LESSONS LEARNT

• Hindering Factors
• Structural and support services
• inadequate infrastructure, human resource
  shortages, weak reporting and referral systems
• Socio-cultural
• breach of confidentiality, SD,
  territorialism, lack of accountability
• Policy and legal environment
• lacks policy framework for zero tolerance to
  SD, non-adherence to protocols/SOPs

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AREAS FOR IMPROVEMENT

• Socio-cultural
• Health workforce
• Service delivery
• Systems interventions
• Policy and legal environment

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CONCLUSIONS

• Resources for HIV/AIDS supported integration of
  HIV services with other health programmes such as
  Maternal and Child Health
• GHIs did not seem to have undermined national
  planning and policy development process
• Integration process aligned with national
  priorities, along existing mechanisms for
  coordination

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Experiences and Lessons Learned in the Region of
the Americas Case Studies
Regional Advisory Meeting Integrated Health
Services Networks and Vertical Programs Cusco,
Peru 11 and 12 November 2009
Hernán Montenegro and Caroline Ramagem Area of
Health Systems and Services PAHO/WHO
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Integration Initiatives in LAC
Country Initiative
Argentina Law creating the Integrated Federal Health System
Bolivia Municipal Intercultural Family and Community Health Networks and Network of Services
Brazil Better Health The Right of All 2008-2011
Chile Health Care Networks Based on Primary Care
El Salvador Law creating the National Health System
Guatemala Coordinated Health Care Model
Mexico Functional Integration of the Health System
Peru Guidelines for forming networks
Dominican Republic Regional Health Services Network Model
Trinidad and Tobago Experience of the Eastern Regional Health Authority
Uruguay Integrated National Health System
Venezuela Health Network of the Metropolitan District of Caracas
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Summary of Case Studies Lima Workshop, 9
November 2009
Country Type of Case Type of Case
Country Integrated health services networks (2 topical 3 general 5) Integration of vertical programs (6)
Brazil Care for women and children Mãe Curitibana (Curitiba, Paraná) Urgent/emergency care (Northern Macroregion, Minas Gerais) HIV/AIDS (National)
Chile Ñuble Health Service Metropolitan Health Services Children Chile Grows With You (National)
Guatemala Ministry of Public Health and Social Welfare and Guatemalan Social Security Institute (Department of Escuintla)
Colombia Tuberculosis (National)
Peru HIV/AIDS (National)
Dominican Republic HIV/AIDS (National)
Trinidad and Tobago HIV/AIDS (National)
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FACILITATING FACTORS AND BARRIERS
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FACILITATING FACTORS

• Political commitment and backing
• Availability of financial resources
• Leadership of health authorities and service
  managers
• Decentralization and flexibility of local
  management
• Alignment of financial and non-financial
  incentives
• Culture of collaboration and teamwork
• Active participation of stakeholders

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STRUCTURAL BARRIERS

• Segmentation and weakness of health systems
• Reforms of the 1980s and 1990s
• Privatization of insurance
• Differentiated service portfolios
• Provider competition
• Diversification and instability of labor regimes
• Regressive cost-recovery schemes

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STRUCTURAL BARRIERS

• Powerful opposing Interest groups
• Specialists and super-specialists
• Private insurers and social security
• Pharmaceutical industry, supply industry, etc.
• External financing modalities (Global Health
  Initiatives)

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NON-STRUCTURAL BARRIERS

• Deficiencies in information, monitoring, and
  evaluation systems
• Management weaknesses

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• Thank you!