2-4-6-8 Let's Use Platforms to Integrate_Hodgins_5.13.11
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2-4-6-8 Let's Use Platforms to Integrate_Hodgins_5.13.11
- 1. Integration What do we mean?
- 3. INTEGRATION
- 7. INTEGRATION of WHAT?
- 8. “[Combining] different kinds of services or operational programs to ensure and maximize collective outcomes. It would include referrals from one service to another, as well as services provided in the same setting or by the same provider.” Ensuring appropriate sequencing and coordination of elements of care; e.g. immediate post-delivery care for the mother and newborn, particularly in settings where the same health worker is responsible for both. Breaking down silos between different types of health workers or departments in a health facility (HF); improving collaboration within a HF or across levels of a HF (including referral linkages). Supermarket/ cafeteria type service delivery model, offering key services whenever the clinic is open rather than only at specific times of the week or month, allowing clients to get, for example, immunization and family planning (FP) services during the same clinic visit. Taking advantage of what was previously a one-intervention outreach contact to deliver additional interventions (‘one-stop’, ‘no-missed opportunities’; e.g. adding vitamin A supplement distribution to polio National Immunization Days (NIDS) or to routine immunization contact around 9 months of age). Piggy-backing (or coat-tail riding), taking advantage of an existing function as a platform to which a new intervention is added; linking an important but less-well-funded intervention to a better-funded program, e.g. pneumonia community case management (CCM) added to malaria CCM (funded under the President’s Malaria Initiative (PMI)). Placing a new technical intervention within an existing program. Using a service delivery contact to promote another service or to facilitate referral linkage, or to promote a particular behavior/ household practice (e.g. determine immunization status during sick child visit, and make referral to immunization service; nutrition or family planning counseling provided at the time infants are immunized). Taking advantage of other programs to elicit information: e.g. immunization contacts could be used to find out whether the infant slept under a bednet the previous night. Merging a function programmatically, e.g. ensuring that antenatal tetanus toxoid or intermittent presumptive treatment (in pregnancy) or HIV screening and PMTCT is fully incorporated into the antenatal program (including at level of provision of service). Using more polyvalent (rather than specialized) health workers. Incorporating content from several interventions/ program areas within a single tool (e.g. a family health card, health education job-aids for service providers, supervisory checklists covering multiple interventions/ program areas) De-verticalizing what has been a more specialized program, e.g. leprosy, STI, TB, PMTCT, … Mainstreaming systems functions previously managed on a vertical basis (e.g. supply chain for TB or HIV commodities, management information system (MIS) previously as a stand-alone for a particular technical area merged into a single comprehensive MIS). Institutionalizing elements of what has been a pilot initiative: e.g. changing Health MIS forms, adding new program commodities to Essential Medicines Lists; modifying routine supervisory checklists; modifying pre-service and in-service training curricula,… Consolidating/merging of management units; e.g. WHO has combined CAH and MPS into a new MCH division; MCHIP can be considered another such example. Harmonizing management/ administrative procedures across multiple programs (or among donors, e.g. under a Sector-Wide Approach arrangement). Improving coordination between units which remain distinct (e.g. expectation of HHS, State Dept, USAID, DoD, etc. with regard to health programming under PEPFAR, PMI, etc.; donors and host government). Linking health with non-health activities, e.g. income-generation, education, agriculture, environment, community development (e.g. as per Alma Ata-style Primary Health Care). Within a particular geographic area, consolidating services and facilities across multiple levels, (e.g. outreach, primary level, hospital level) or across types of service (e.g. social services, acute care, rehabilitory care, etc.) into a single coherent system. services management systems tools
- 9. > 2 + 2 4 ?
- 11. Plan/ decide Make Sense Sense Act
- 12. For further information, you can contact me at: shodgins@mchip.net visit us at: www.mchip.net follow us on:
Editor's Notes
- “Integration” is a popular word these days. But don’t you find it a bit frustrating sometimes trying to get a handle on what exactly is meant when you see or hear the word used?Over the next three days, we’ll be making a lot of use of this word and it could be helpful if from the outset we anticipate what could get us muddled and try to avoid that by specifying concepts and language a little more clearly.As you’ll see, in my comments over the next few minutes I’ll be focusing on the more general and abstract. When my colleagues here take over, they’ll be getting into the more particular and applied. So bear with me, if there doesn’t immediately seem to be a practical application to what I’m saying. I’m getting started in this way with a conviction that, to paraphraseKurt Lewin,“There’s nothing so practical as getting our concepts well nailed down.”
- When we think about implementing a program, an intervention, or a service we have a tendency to think of it in isolation. The logic of proposals, annual workplans and results reporting tends to encourage this.[CLICK] But in the real world any program, intervention or service is delivered within a specific context, and through and within very complicated systems,in which initiatives at one point in the system generally have consequences elsewhere.The word ‘integration’ gets used in a lot of different ways in global health workBut in general it is used in a way that can help remind us of these issues of context and embeddedness within systemsIt’s a good thing for us to be thinking that way; this can lead us in productive directions.
- At the same time, often we use the word ‘integration’ or ‘integrated’ in ways that end up not helping us so much.Two factors contribute to less productive use of the word.First – it means less than we imply that it does.
- The words “integration” or “to integrate” convey only an abstract general concept, without specific content.It really only means [CLICK, CLICK]To make whole.
- Here we have integrated HumptyI’d like to suggest that a second characteristic of these words that can get us into trouble is that they are value-laden.To make whole, to restore,To put (back) together, (therefore the happy Humpty)These are positive notions.So when we use the words “integration” or “integrate”, we are already implying that what we’re talking about must be a good thing.But we’re not necessarily on very solid ground to assume that more integration is always a good thing.
- What about ‘integrated locomotion’?[CLICK, CLICK]So we have words that are relatively content-free and general, but also value-laden. That being the case, we often see them used in a way that the meaning is not clear. And furthermore, they are used in a way that prejudges the outcome of the discussion at hand. So – these characteristics of the words create conditions favoring confusion. What’s the remedy?
- First, I would propose that we consistently recognize that floating on their own, ‘integration’ or ‘integrated’ convey very little content or meaning. They can become meaningful only when we specify…integration of what, and integrationinwhat sense.We need to make it clear what we’re talking about.Second, we need consistently to be alert to the implied value judgment, when we or others use these words.So, in global health, how do we use these words?Given what I’ve been saying, not surprisingly, we use them in a whole variety of ways.
- Here are some examplesDon’t try to read this list; if you’re interested I can send this to you, with other notes on integration.This is by no means an exhaustive list but it gives a good sense of the range of common uses in global health.All of these examples can be classified, falling into one or more of the following categories:CLICK - integrated servicesCLICK - integrated managementCLICK - integrated systems, and CLICK - integrated tools.… with the largest number falling into the category ‘integrated services’. Note that any particular initiative may involve several different processes to which the word ‘integrated’ could be applied, and these uses of the word could fall into more than one of these categories. So, while acknowledging that ‘integrated’ gets used in other ways in global health, let’s particularly focus on integrated service delivery.Let’s begin by remembering that when using the word ‘integrated’ to describe services, we need to guard against the implication that this is necessarily a good thing.
- I would propose that whenever we are considering integration of services, we routinely apply what I call the “2+2 test”. In the instance under consideration, does 2+2 equal more than 4?That is to say, with the change we are considering, what grounds are there to believe that the result will be better than in the less integrated condition? Do we expect to see greater overall health benefit? Or, do we expect to see greater efficiency, with regard to cost or time?To integrate or not – is a choice with regard to process. Selecting a more integrated option is of interest to us only if it results in a better outcome .The outcome we are particularly interested in, as public health professionals, is population-level health impact. Recall my question, “do we expect to see greater overallhealth benefit?” Because of categorical funding and the way programs and services are carved up and distributed among different units of government and agencies, generally we are held accountable for results measured only within the narrow interest of a particular program. But, again as public health professionals, we need to take a broader view. For any proposed service delivery arrangement, whether more or less integrated, we should be looking at overall health impact.
- An analogy from biology may be helpful here. Ecologic science describes 4 types of relationships when 2 organisms are in interaction with each other: commensalism: one benefits from the interaction, the other is unaffectedmutualism: both benefit from the interactioncompetition: both are harmed by the interactionparasitism: one benefits from the interaction and the other is harmedAs in nature, so in programs—efforts to integrate can produce a variety of possible outcomes. One cannot simply assume that all such combinations will result in happy outcomes all round (mutualism). Such linking or combining may produce worse results than implementing elements more independently (competition). Linking or combining may also have asymmetrical effects, improving some aspect of performance of one program or service but at the expense of undermining performance of another (parasitism). We can see hydraulics (where we pump up one thing as we suck down something else) rather than the desired halo effects.How do we increase the likelihood that our efforts will result in commensalism or, even better, mutualism?That is how do we ensure the best overall outcomes?We do so, first, by good planningAnticipating possible effects, not only for the particular interventions we are most interested in,but also for other interventions, programs or services that could be affected.And second, once we’re implementing, we need to rigorously monitor not only interventions of most interest to us, but also other interventions or services that could possibly be affected.What do we see with regard to actual performance?