Global Health Initiative Principle on Integration_4.23.13


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  • Not sure how many people are already familiar with GHI, brief overviewVarious WG formed around the themes to identify programmatic themes, address M&E issues. Our work focuses on integration.
  • Here is the context, this may look familiar.
  • Keep this slide.Working to develop guidance, RF, indicators and in our group, we have specific learning agenda for this topic.
  • Integration paper is on the GHI website, encourage people to check it out.Integration Scoping Tool – details are in the paper. Table 1 is in this paper, helps to get people to think through where they are with integration in their country. How far along is the country, without judgment/value placed on how questions are answered. Mainly to get programs/missions thinking about possibility of integration, “walk through” integration issues. Not yet implemented in a lot of places and there may efforts to implement/”pilot” in the future. “Readiness to integrate”. Please check it out. Series of questions under different domains (ex, policy) and questions about resources/consolidation/management of integrated service delivery (ex, facility based, community based services).
  • Not an intervention – not trying to identify the results of a specific intervention and how input/process/outputs lead to outcomes. Integration is a means of service delivery for interventions we may already know about in terms of results. So RF looks very different. Learning agenda purpose is to support countries in making decisions about which services should be integrated, how to assess opportunities for integration and identify promising approaches.
  • Coherent service integration addresses systems/policy.Added value of integration is in purple text – these outcomes are thought to be broadly applicable to any context/country.Very open to feedback.
  • A lot of pushback from MERG last week about recommending global indicators. REVISE – looking at potential to develop indicators and working with different groups to see what is feasible (ex, UNAIDS MERG).There is the possibilityUSG Missions will report Global indicators to Washington as part of routine reporting once indicators are field-tested and finalized.Indicator development process:Indicators are guided by the Integration Results Framework finalized in October 2012January 2013: Review of grey literature and indicator databases/compendiums to identify existing indicators/metrics for integrationFeb 2013: Update to and input from M&E stakeholder’s during the BGH CA’s M&E TWG meetingMarch 2013: Streamlining, prioritizing and crafting indicator language to develop draft list of global and illustrative indicators for field input
  • Potential countries include:EthiopiaKenyaTanzaniaRwandaMozambiqueSenegalGhanaLiberiaCambodiaPakistanIndonesiaNepalBangledeshCountries selected because they are GHI programs,have either current or new integration projects—represent a range of progress and models. Most are integrating with HIV but not all
  • Global Health Initiative Principle on Integration_4.23.13

    1. 1. U.S.GlobalHealthInitiativeGlobal Health InitiativePrinciple on IntegrationCORE Group Spring MeetingBaltimore, April 23, 2013GHI Integration Working Group
    2. 2. U.S.GlobalHealthInitiativePresentation Outline• Overview of GHI• Purpose of Integration workgroup• Progress to date• Next steps
    3. 3. U.S.GlobalHealthInitiativeGHI – overview3
    4. 4. U.S.GlobalHealthInitiativeGHI Integration Workgroup• USG Interagency workgroups for all GHI Principlesformed in Aug 2012 (members from USAID, OGAC andCDC).• Tasked to develop guidance for countries to use tomeasure and evaluate the principles• Deliverables: results framework, global indicators andillustrative indicators• Integration workgroup provided with funding to develop a―learning agenda‖ to further the evidence base onintegrated service delivery• In process of collecting feedback on products fromcountries, implementing partners and other stakeholders
    5. 5. U.S.GlobalHealthInitiativeGHI Integration Progress• Definition of Integration:….The organization, coordination, and management ofmultiple activities and resources to ensure the delivery ofmore efficient and coherent services in relation to cost,output, impact, and use…. )• Summarized findings from USAID Cochrane Reviews2010• Evidence on Integration is limited by lack of rigorousstudies(operational feasibility of measuring is complex-most services are along a continuum of integration)• Developing Integration Scoping Tool• Developing illustrative integration measures – by coreoutcomes
    6. 6. U.S.GlobalHealthInitiativeKey Issues Considered for Developing the ResultsFramework, Indicators and Learning Agenda• Integration is not an ―intervention‖- RF not typical soinputs, outputs and outcomes vary by country andcontext• Significant overlap with other principles, e.g. HSS &gender; integration best conceived as anapproach/lens• Results Framework and Indicators should go beyondspecific service delivery interventions (e.g. Nutritionand HIV, MCH/FP, TB/HIV)• Learning agenda should focus on what countriesneed to make strategic decisions about scaling upintegration– provide evidence on how and when does integrationaffect key outcomes– what integration models work and under whatconditions?
    7. 7. Outcomes of Integration contribute to GHI targets for HIV/AIDS, TB, Malaria,NTDs, Maternal Mortality, Family Planning, Child Mortality and NutritionCoherent Service Integration*• Integrated Manuals, guides / job aids on site• Services organized within facilities to meet different client needs e.g.single client (FP & ANC) or multiple clients (e.g. mothers & infants)• Linkages across facility-community based care ; Effective referrals• Minimum package of essential services available• Efforts to support a continuum of care and ensure principle of “nomissed opportunity in service provision”Policy and GovernanceDemand Creation andHealthy BehaviorsPlanning andManagementHealth System Functions• Policy Makers, Managers andDonors support integration• Financing and resource allocationto foster integration• Decentralized functions• Policy and Guidelines for IntegratedService Delivery• HMIS-Integrate surveillance, M&Eand Information Systems• HRH- Adapt HR functions,management systems and tools tofoster integration• Cross training and task shifting• Medical Tech- Laboratory andlogistics systems are linkedWhen interventions for populationsoverlap;:• Joint Planning for multiple programs• Consolidate administrationmanagement, and staff acrossprograms for smart integration• Pool/share resources across diseasespecific programs• Integrate Behavior Changecommunication campaigns• Health behaviors arepromoted in combination e.g.Nutrition and FP• Barriers to health seeking areaddressed in coordinated andintegrated fashion*Service Integration of provenefficacious interventions e.g.• Preventing Mother-to-ChildTransmission (PMTCT)Coverage and Access Acceptability“Added value” of Smart Integration ( Benefits/Results)• Improved availability ofservices e.g. one stop shop• Increased coverage ofeffective interventions• Expanded access ofservices per client contact• Improved client satisfaction• More family centered care• Improved retention in care• Improved health seeking• behaviors• Community engagement• Cost savings/Improvedresource use• Reduced duplication ofefforts• Improved functioning ofhealth system• Increased readiness ofservices to meet client needs• Appropriate follow up• Reduced missedopportunities at high volumecontact pointsResponsiveness / Quality Efficiency Uptake (Use)• Improved uptake ofintegrated services• Improved use of servicesalong the continuum• Improved patient care- e.g.ART initiation, EID etc.Integration InputsIntegration OutcomesHealth OutcomesSustainedImpact Sustained Improvements in Health StatusIntegration Outputs
    8. 8. U.S.GlobalHealthInitiativeGHI Indicators• The USG GHI Integration TWG tasked withdeveloping up to 3 Global Indicators thatmap to the Integration RF• Illustrative indicators are a resource forcountries to monitor their integration efforts atthe country level and do not need to bereported
    9. 9. U.S.GlobalHealthInitiativeLearning Agenda OverviewGoal: to assist Missions and host countries to plan,design, monitor and evaluate integrated servicesObj 1: understand current state of integratedservice delivery models in a number of countriesand the drivers & factors facilitating choice of modeland interventions.Obj 2: understand how well interventions map toRF and document strengths, weaknesses, gaps ofM&E systems.Obj 3: identify country specific eval opportunitiesand study designs (for phase 2)Year 1 funding provided to MEASURE Evaluation(Year 2 TBD).
    10. 10. U.S.GlobalHealthInitiativeLearning Agenda—Question 1What is the current experience of countries inimplementing integrated health services?Identify ―best bets, best buys‖– Which services when integrated or bundled and underwhat circumstances seem to be the most efficient andwhich are better left not integrated?– What types of models of integrated services (e.g. onestop shop model; co-location of services; referral models)are appropriate in various contexts and for different typesof service delivery platforms (e.g. community-basedservices; clinic services)?– Is there a ―tipping point‖ where adding extra servicesmight actually be more harmful than beneficial?Approach: Conduct survey and case studies in a sample of GHIcountries to document their experience implementing integratedservices over the last 3-4 years.
    11. 11. U.S.GlobalHealthInitiativeLearning Agenda—Question 2What is the value-added of integrated service deliverycompared with community standards of care?Outcomes to measure:• Coverage and access• Client acceptability• Responsiveness and quality• Efficiency• Service use and uptake• EquityApproach: Case studies and impact eval inselected countries.
    12. 12. U.S.GlobalHealthInitiativeContact Information:• Kristin Saarlas, ScD, MPHEvaluation AdvisorOffice of Policy, Programs, and Planning (P3)Bureau for Global Health, USAID/Washingtonmobile: 571-345-5463; email:• Rushna Ravji, MD, MPH, MSHealth Team Leader, Asia and the Middle EastBureau for Global Health, USAID/Washingtonmobile: 202-538-3358; email:
    13. 13. U.S.GlobalHealthInitiativeThank You