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Integration as a Health Systems Strengthening Intervention: Case Studies from Senegal and Malawi


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Webinar presentation by Elizabeth Sutherland, PhD; Daniel Glazier, MPA, PMP; and Heidi W. Reynolds, MPH, PhD.

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Integration as a Health Systems Strengthening Intervention: Case Studies from Senegal and Malawi

  1. 1. Systems Strengthening Intervention: Case Studies from Senegal and Malawi Elizabeth Sutherland, PhD Daniel Glazier, MPA, PMP Heidi W. Reynolds, MPH, PhD MEASURE Evaluation 30 September 201 5
  2. 2. What do we mean by. . Integration - Organization, coordination, and management of multiple activities and TGSOUTCGS. .. (WHO HIV, FP/ RH, MNCH Technical Working Group, March 2011) Integrated health services - Clients receive a continuum of services according to their needs (WHO, 2008) - For this study: two or more health services available to clients (e. g., maternal and newborn health, reproductive health/ family planning, HIV, malaria, etc. )
  3. 3. Integration background - Evidence of feasibility, acceptability, and improved service quality and uptake - Increasing evidence on health outcomes and of cost effectiveness - Employed as a strategy to extend care services in contexts with limited resources - Lacking shared experiences about planning, implementing, monitoring and evaluating integrated strategies See, for example: Spaulding et al. , AIDS, 2009; Lindegren et al. , Cochrane, 2012; Reynolds & Sutherland, BMC Health Serv Res, 2013; Shade et al. , AIDS, 2013; Wilcher et al. , AIDS, 2013
  4. 4. « Funding projects focused on integration ~ Convening meetings, working groups and task forces -= Sponsoring literature reviews I 1; 6 Publishing in peer—reviewed literature ~ Issuing guidance ~ Developing a results framework and indicators GHI p - n . /nt 00/9 5 egrayon _ 30:9,» on 6%, "7 the H 85/”)
  5. 5. Results Framework for the Integration Principle IMPACT Sustained improvements in health status HEALTH OUTCOMES Outcomes of integration contribute to GHI targets for HN/ AIDS, TB, malaria, Nl'Ds, maternal mortality, family planning. child mortality, and nutrition INTEGRATION OUTCOMES “Added Value" of Srriart Integration (Benefits/ Results) Coverage and Access Aoceptability Responsiveness/ Quality Efficiency Uptake (Use) - Improved availability of - Improved client satisfaction o Increased readiness of services - Cost savings/ Improved o Improved uptake of services, e. g., one-stop shop , More gam; ly, ¢,_, me, .ed are to meet client needs resource use integated services - lnaeased coverage of , ,mp, wed , e[enu~°n in am - Appmpriate followup - Reduced duplication - Improved use of services ef‘ectx've interventions _ Impwved hemh_see. dng . Remged rmsged 999°, -u, nme, of efforts along the continuum - Expanded access of beha-50,»; at high-iolurne contact points - Improved functioning o Improved patient care, e. g., services per client Contact . community engagemem of health system ART initiation, Ell’), etc. Coherent Service Integration‘ ‘Service integration of proven - integrated manuals, guidesnob aids on site effiGd°'” '. Me"eMi°M' 9'9" - Preventing mother-to-child - Services organrzed within facilities to meet different client needs: Uangmimm (PMTCT) single client (e. g., F? and AIIC) or multiple clients (e. g., rnothers and infants) (,4 . . - Linkages across facility and community-based care; effective referrals ' 4 . Minimum package of essential services available - Efforts to support a continuum of care and ensure principle of "no missed opportunity in service provision“ INTEGRATION INPUTS Policy and Governance Health Systems Functions Planning and Management Demand Creation and - Policymakers, managers, and - HMIS-Integrate surveillance, when interventions for Healthy Behaviors donors guppon integration M&E, and information systems populations overlap: _ Inwgrae behavior change - Financing and resource - l~lRH—Adapt HR functions, - Joint planning for multiple cornrnunication campaigns 3“°C35°" ‘° '05‘? imegratiori management systems, and tools programs . pqeam, g, eh, ._-50,; 3,, pmmgwd in ' °°<°"‘”‘“3°d '““‘“°“‘ ‘° '°“°r im°9'“'°" - Consolidate adriiinistrarion combination, e. g., nutntion and PP - Policy and guidelines for - Cross-training and task shifting management and staff across , game“ (0 beam, seek, -"9 3,? integrated service delrvery _ Medial ‘Kh_ub°nt°(y and programs for smart integradon , dd, .e. _<, ed fin cwmmwd and logistics systems are linked o Pool/ share resources across integrated fashion disease-specific programs
  6. 6. : | ‘vI/ :5 ', I.I: . . _l*1{ (I : ,.': ::. ‘:V Number of maternal, newborn, and child I 1' -r- s»: °a"el7. health service delivery points that have ‘m ‘. i'l, I=l%'Z I": integrated at least one other type of service (coverage and access) Number of clients who have received two or more services during a single visit to a service delivery point (uptake) USG Global Health Principles M&E Guide http: //www. cpc. unc. edu/ measure/ publications/ ms—14—85
  7. 7. Approach to ntegration 1. Begin with the 2. Identify 3. Define and test end in mind. common primary interventions for Define the public points of contact integrated service health problem. for care. delivery packages. Planning & Implementation Monitoring & Evaluation 5. Improve the 6. Use data in health information 4. Create a theory- decision making. system. Collect the driven logic model. right data.
  8. 8. Reading the last page Results will show: - Increased coverage of integrated services - Reported improvements in care use and health outcomes - Improvements (and room for improvement) to health system functions to support integrated health services - Health information systems do not support the M&E of the integrated intervention
  9. 9. Case studies: background and aims - Conducted high-level 10 country assessment (May- Dec 2013) - Chose Malawi and Senegal as cases for in-depth study (Sept-Oct 2014) - To understand countries’ expenences implementing integrated health services and necessary health system changes, including health information systems
  10. 10. ntegration in Malawi - To improve health outcomes among women of childbearing age and children under age 5 - Developed essential health service package - Implemented in antenatal and under-5 clinics in all Ministry of Health facilities in the country - Extended to the community through health surveillance assistants - Includes HIV, nutrition, malaria, maternity care, growth monitoring, and family planning services
  11. 11. Integration in Senegal - To improve maternal and child health - Developed minimum package of services - Implemented in rural areas through renovation of case de santé (health hut) system and by a cadre of community volunteers - Includes prenatal care, growth monitoring, immunization, HIV testing, family planning, malaria diagnosis and treatment, hygiene
  12. 12. Case study methods - Document review (e. g., operational plans, strategies) - Qualitative and quantitative data collection at all levels - Secondary data analysis of Service Provision Assessment (SPA) (Senegal)
  13. 13. Study sites Senegal Nkflamfi 39 community sites, 48 health huts, and 48 health centers in 8 health districts in 2 regions (Kaolack and Louga) 10 randomly chosen MOH facilities with ANC and under-5 clinics in Central Region, Malawi
  14. 14. Study participants J 23 principal actors at the national, regional, and district levels 13 M&E staff from MOH and lPs 48 providers at health posts 96 providers at the health hut/ community 1,050 female clients ages 18-49 attending health activities at community sites 16 principal actors at the national, district, and zonal levels 11 M&E staff from MOH and lPs 75 providers from health facilities 3 focus group discussions with Health Surveillance Assistants in the community 383 under-5 clinic clients (all female, ages 18-49) 379 antenatal care clinic clients (all female, ages 18-49)
  15. 15. Result themes 3. Effective evidence based interventions integrated at points of contact for care 1. Major causes of 2. Common primary mortality and points of contact for morbidity. care Planning & Implementation Monitoring & Evaluation 4. Health s stem . 5. Health . . V 6. Use data in . . interventions by information systems, . . logic model inputs, tool, indicators to measure inte ration outputs’ outcomes 3 ' and health impacts. program decision making.
  16. 16. Results Framework for the Integration Principle IMPACI’ Sustained inipmvements in health status HEALTH OUTCOMES Outcomes of integration contribute to GHI targets for HIV/ AIDS. TB. malaria. NTDS. maternal mortality, family planning. diild mortality, and nutrinm INTEGRATION OUTCOMES Coverage and Access Acceptability . Improved i‘aiI1brIl"y‘ of . Imprvi .4 cl-em satisfaction M-i<e1.e s . ane»4ov st-no . Niaelamilyrteflkeied can . Increased towuge oi eiitttm -itemnoe-is Elplnded mt»; oi 5e1‘t'I(€$ pt: ti-mt cnnlxl . unpvvsea rexennovi In cm . lnlprv-Ed healtli-seevmg behmuis . (ommunity eomumit Coherent Service Integration‘ . Inugiatod mamuiz. gu-new, » aid: on rite . Service: ovganrmd mmm IIUIIUQE to meet miiemtt tlm-z needs singte ci-ecu ie g . FF and MIC) or Moiuple cinema it 9 , momei-5 ma uiiuiuy . Linkage: xm/ . hnlrty and ccrnmunlty mm tut, elfeune Ieferut: Q . Minimum package of rzeritxal rnwces autism . more to motion a coiiumum or one and «tune Drlnuple oi “no missed opportunity In emu Dim-won” INTEGRATION OUTPUTS es» INTEGRATION INPUTS Policy and Governance . Polvtvmalnevn. manages. and omen . uwort integutm . rum»; and moan allocation In lozter int. -yam-I . Deceiiualized lurrcuons . natty and guidelines in: integrated 5efl'K( dpiwcrv Health Systems Functions . HMIS-Integrate surveillance. met, an information systems . HRH-Adda! an iuntuam. management systems. 3M1 tools to loner mtegnnon . (rossruairiing ma tut shilling . Medl€llKQ<l1'LIDOVil0'y mi IDgLxv(: system; are linked Responsiveness/ Quality . inaeasea renal-e: s oi aemtcs to meet (Item meat - lbvrovhale follow-09 . mat-tea nu; -'4d nppaumue It Nah-voiuvu to-auzt wine “Added Value" of Smart Integration (Benefits/ Resuls) Efficiency . (on smng. »/imarme-1 mute we . We-Soced Qlbllcatlofl oi aim . Imuvvvfd lulnctvoiiing of health NSKQKVI Uptake (Use) . imam-a upme at mtegazea services . lmptmed use oi 5ef‘(e; along the coiilmuum . impvoted oat-mt an-. e g ART MIUIKIKI. Elli, ex: 'SerVi<e Integration of woven elficxious interventions. e g . p. ... nung maths! to-(mid Krammisziofl IPMYCTI Demand Creation and Healthy Behaviors ’‘’‘’‘‘'‘‘‘°’‘‘ ‘’'‘''‘°: - Integrate iseiumr ciunge . )oml puma»; fni muinpie Kuvimunicaoori tunpaigu: P"°§’3'"5 - Health behavior: are promoted In . Conroéidake aanxmslrinon combiiiztron. e g , mltn'Jon and PP rnanagernettt no staff mm; “M, H, ,_, ,., , ,6,“ , , P'°! ’3"'“ I9’ "NIH mteguucri aadrr-sad In coovmnaled and . riooiianm re, -ources xrm: mtegrazeo mm-on abuse somix pvogianis Planning and Management when -itenrentions to: I outputs, outcomes 3. Effective evidence based interventions integrated at points of contact for care 4. Health sysem interventions by logic model inputs, and health impacts.
  17. 17. " 1 ~- s. -~. I. , -akuoi-on I r K. I T A N z A N I A . .2 - .2 ’ s Rugrohl l , . / Mziu ‘ / " -/4 ( '3 .1 mt , » ‘ 3. fl “"’ c-, “. ,_, . / Mzfmb . .. _ A z A M a i A X 3 (A ‘-S I ,7 I )EM. REH " ‘i OFTHE B Nkhonloon. _ 9°~e9i I ‘raw 1 t, _. . _< , MALAWI -_. T-¥LM’t= h‘nii. osuank I " olilookoy _/ ,v ll-"° °. ,¢, ,.Baz. MOZAMBIQUE / //T "“ , FMan9oclio‘_ . /’ -, "°"°" ) ‘~ gzomuao <1 ' I , usaka/ /I. -.) / .BIan. tyie J ‘, - _ WV’ gotilkwaxa} / C. ~’ 0 so ioomi ) _ (I L . -. - " 1' ZIMBABWE T~, - , I- , ° 5°‘°°'°" rzfi). -. .190 ' lralm Upama Khatri, MPH Mary Freyder, MPH Elizabeth Sutherland, PhD MEASURE Evaluation ’m’, A V 7 ‘E . i"§: sIi; E FROM THE AMERICAN PEOPLE P E P F R Evaluation
  18. 18. = i I’ g. - 1. l l ‘ef~L! —- I l I (will is) ) )- l 7 , 7 7 -- 7 . 3. 7 a7 7 7 I77 . 7 __ 7 ,7 ,7 7 7 , ' *5 4 Identified focus on matemal and child health needs Articulated in National 6 Health Sector Strategic It " Plan (2o11.2o1e) l ’ g Objective to reduce = ~ matemal, newbom, and 2“ ’ child morbidity and mortality
  19. 19. .rl 1;, ii, si : ,.. ;' v ', ;_j~ r ', '—. ’ ' l, ' I. u"~, ,-l :1. ‘I 1; ll '— 5‘ é ill‘ fl ll _l ; _l. .l} Isl 3’: -Sf» J « Health facilities - Antenatal care (ANC) ’ : - Under5 - Maternity - HIV - Outpatient ~ Health Surveillance Assistants as community-facility link v I‘-. ' ’ . .. ..— __ . Photo: Abbie Trayler-Smith / Oxfam
  20. 20. package - Developed package of essential services corresponding to health priorities - Such as: growth monitoring, nutritional supplementation, dx and tx of malaria, prenatal care, beds nets, PMTCT, vaccinations, facility deliveries, family planning, HIV - Interventions integrated at the point of contact and across the continuum of care
  21. 21. Essential inte-7 ration 7- uts - Integration is National Po| icy—Hea| th Sector Strategic Plan, nationally supported EHP - Integration is financed through the public health sector and also supported through extemal donor funding - Human resources support for integration - Training (universallytracked) - Supportive supen/ ision (86.1% of providers inten/ iewed) - Community-facility link in HSAs
  22. 22. Essential inte» ration in o uts - Decentralization: Commodities, service implementation and staffing managed by facilities and districts - Integrated planning and management: also decentralized and occurs at all levels (district, regional, and national) - planning is weakest at national level “I/ Wiaz‘ We are doing is you get counseled and come ibrARTs in the very same clinic. . . But in other clinics where we have problems of structures they will be met and counseled by another person (referraIs). ” -District Health Official
  23. 23. Coherent service delive - Integration is occurring in facilities and in the community Client Outcome Under 5 Clients Received Referral none none Satisfied with services 91.3% 90.8% received Received more than 42.1% 64.6% one service Left without a hoped 12.1% 7.9% for service
  24. 24. 100 ~ 90 " 80 70 60 50 “ANC ‘it Under 5 30 — 20 10
  25. 25. uts and outcomes of Client and provider satisfaction Stigma Efficiency Demonstrated increase C in service uptake and access
  26. 26. Monitoring and evaluation - Health information systems not currently integrated - 2 of 3 global integration outcome indicators piloted deemed useful and relevant - 2 NGO partners and 1 district reported collecting similar indicators - No national or coordinated effort to collect and report on integration "Monitoring has not been integrated. When you go to the facility you see that there are several registers. . . .there is a family planning register, a matemity register, and the like. Those ones do not capture the sen/ ices in an integrated manner” -Key infonnant from NGO partner
  27. 27. Dagnna. ll? ml” 0 Loc dc P°d°" |25 km . t_ ' . St OUIS Gums Scncgalu , Rrvcr . Mnuim r Diourbcl Ungucm , ’ ‘Thics Bakel- Mboul‘. SENEGAL Kidrin. K3°l3Cl'< T.1mbacou. nda Falemeul ' , ,/ "K . RJVCI Baniul , Mfg _/ < ' 4-‘ Gambia I . " y , K‘ 1 . 3;§nom DCasamance 9 River Ziguinc OI’ _ _ , _ V_ Kcdcu ou , .._ / « § 1. . 1-, n The C“"'“"‘ Ngk 0 '4" "2-tmbia . " ” K050 ‘' Bissau Nor. Park GLJIEX ©<. .;, .“: ,1K. ,.-- Daniel Glazier, MPA, PMP Heidi W. Reynolds, MPH, PhD MEASURE Evaluation A ~ . « ’ 9?? ‘ FROM THE AMERICAN PEOPLE P E P F R Evaluation
  28. 28. xii‘ Data—identified matemal and child health needs Articulated in National Health Development Plan (201 4-1 8) Objective to reduce matemal, newbom, and child morbidity and mortality - . . fr _> ’ V. _ ‘K’ ’I--‘ — -V . “'_--'7 Rx, ‘ ‘V " "Q ’, ,. 1 1 _l -%nw—-rm. . Al . H, 3‘ . .~: ' . , V
  29. 29. Common oints of contact ‘ . .g‘. ¥¥f‘, ,, ‘. '.. ' : . - Health huts (case de santé) - Community sites - Volunteer team consisting of: - Community health worker (agent santé communautaire) - Bajenu gox - Home care provider (dispensateur de soins a domicile) - Matrone - Relais
  30. 30. interventions Developed package of essential services POPAEN corresponding to health priorities - Such as: prenatal care, growth monitoring, dx and tx of malaria, hygiene and, handwashing, immunization, HIV testing, family planning - Interventions are integrated at the point of contact and across the continuum of care
  31. 31. .. W t. .. -‘ _, l L , 7, _w_> _ r_! _. «, t_u; _J ! , u ‘C: , I _. ..‘, l; 1 _A, .._ Poligrz National Community Health Policy, a framework for the strategic plan Decentralized functions: Improved central-regional- district-community coordination and planning a Human resources: Strengthened technical capacities of community agents through training, job supports 2 of providers interviewed reported having received training to provide integrated services [study data]
  32. 32. Essential inteo ration to uts (cont’d) Sugn/ ision: conducted regularly, but still an area for inten/ ention O Commodities: “Push model” has improved stockouts, but challenges remain (e. g., ACT) 81% of health huts and 85% of health pasts received an external supervisory visit in the last 6 months [2012-13 SPA] "Some supplies have for years experienced ruptures, blockages at the community level, due to credit problems of the districts. ” —Study informant
  33. 33. [ . ,. 4 ' ", ,.. _ , _ lf? ‘ ' . ,_ .2 I. x , :.. .“. ,;. L. ‘W; M, ‘; " V f, . . ... : F. :~3t= ~:: iee-t _l_, i i .1 l 1 I » I _u_r _V [_ . ti Financing and resource allocation Main sources: GoS, technical partners, and clients who pay Increased responsibility of local leaders for planning, budgeting, and financing implementation Women’s and local community groups facilitated local involvement with implementers Still there are financial shortfalls: ”The state has not changed in its handling of resources, it pays after services are provided. ... unlike the partner who puts resources in place, people perform and are held accountable. ” — Study informant V) '. ~:-l. f‘_l? s-: ea: it2:sii‘: :
  34. 34. Essential Inteo ration o uts (cont’d) - Cost structure - Cost to clients reduced through credit system, mutual health organization, package of services free for children under 5 - Cost policies inconsistently applied at health posts - Revenue generation for health posts can be a problem "Health posts are suffering. ..| t takes them a long time before they break even [financia| ly]” — Study informant 22% of health huts do not provide services to those who cannot pay [2012-13 SPA]
  35. 35. Essential Inte- ratjon lnpgyg (cont’d) Demand creation and health education - Conducted through community agents and activities Implementation of multiple strategies, including targeting men
  36. 36. Coherent service inte - ration «ma Received 2 or more services on the day of . . 9% interview Visited health hut in last month 14% Received 2 or more services at health hut 15? (of those visited) 0 Received referral in last month 5% Unmet service needs in last month 11%
  37. 37. Coherent service inte - ration «ma Vaccination for infants Growth monitoring Curative services (under 5) Family planning Prenatal care All posts and health centers, with one exception, had at least two services available. 100% 100% 100% 98% 98% 93% 98% 97% 94% 59% 66% 71% 51% 63% 31%
  38. 38. Inte ration outcomes Reported observed improvements due to integration: - Birth registration of newborns - Acquisition and transmission of knowledge by community workers - Availability of qualified personnel to provide services - Adherence to advice - Timely access to health services - Access to essential care and medications
  39. 39. ”Health personnel more adequately meet the needs of clients, through better structuring of the availability of services, standardization, and strengthening collaboration between the different actors. ” ”. ..drastic reduction of pandemics such as malaria with net use, the management of diarrhea with ORS/ zinc is popular, and nutrition for children under five years. ” ”Women no longer are hiding their pregnancy as was the case before. ... the woman is ready to stay three days after birth in the structure, which was not the case. ”
  40. 40. M&E stems for inte ration At the health hut, more than 18 registers that could be filled out on daily, weekly, monthly basis Volunteers have their own tools Data submitted to PSSC II and head nurse at health post quarterly Monthly partner self assessment meetings Quarterly data coordination and use meetings Integrated supenrision checklist grid verifies package of senrices available Used in indicator “Number and percent of health huts oli'en'ng a minimum package of services”
  41. 41. Malawi and Senegal Both cases: - Identified and targeted priority health outcomes - Implemented a minimum/ essential health package of evidence based services - Increased availability of multiple services at single point of contact - Harnessed collective ownership among donors and other partners for national—| ed strategic plans - Implemented HR, organizational/ management, and commodity strategies
  42. 42. Malawi and Senegal Both cases: - Exhibit perceived health improvements due to integration - Revealed perceived positive externalities [e. g., reduction of stigma (Malawi) and increased access by women and male partner support (Senegal)]
  43. 43. Malawi and Senegal Challenges - Lack of harmonization in implementation and M&E across donors, implementing partners, and ministries - Persisting weaknesses related to human resources, supervision, commodity supplies, and organizational capacity - Limited financial and geographic access remains
  44. 44. Malawi and Seneal: health - Existing systems support monitoring program outputs and vertical disease outcomes - Collection of indicators to capture integration outcomes not currently a priority - The addition of integration outcome indicators can: - Help validate the proposed program impact pathway - Reveal successes and challenges in integration implementation and improve programing - Provide more evidence of integration effectiveness for global learning - Indicators exist and can be tailored to measure expected integration outcomes
  45. 45. Acknowledgments Senegal Members of the USG | nter_ Ministere de la Santé et de agency Integration Principle l’ACtl°“ Soclale (M5/*5) TWG Global Research and Advocacy Group (GRAG) USA”) Mission Staff in Chi| dFund International Senegal and Malawi and the PSSC ll consortium _m, m Malawi ~~-—“‘5"L*“. .5:" 7 §; .". ‘l; ‘.. i.= - Ministry of Health Malawi The UNC Project Malawi 'W°'fiIFlGI'—Gl SSDl—Services Project
  46. 46. I _. y - What are your program’s reasons for implementing an integrated approach? - What are your experiences with integrated service delivery at scale? - What were the interventions in the health systems functions to support integrated service delivery? - What adjustments and improvements to monitoring and evaluation and health information systems were made? What information did you collect to assess integration? o Are you getting the information you need from your integrated program? ~ What information about integrated programs do you still need?
  47. 47. For a copy of these reports, visit: www. cpc. unc. edu/ measure/ publications/ fs-15-139-en MEASURE Evaluation is funded by the U. S. Agency for International Development (USAID) under terms of Cooperative Agreement AID-OAA-L-14-00004 and implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International, John Snow, lnc. , Management Sciences for Health, Palladium Group, and Tulane University. The views expressed in this presentation do not necessarily reflect the views of USAID or the United States government. '1:"1:"1t.1L' "I; -"'. -.. E.1.l. J.l'. °_‘; -‘: “.-. ]l. .l*. '.. l.. ..l" -‘r”“; I.3:t. i;I. i:f. i'l,