This document discusses the U.S. Global Health Initiative's work on integrating global health services. It provides an overview of GHI and the Integration Working Group, which is developing tools to measure integration principles. The working group has defined integration and identified evidence gaps. It is developing a results framework, global indicators, and illustrative measures. The learning agenda will evaluate integrated service delivery models in countries and assess the value added of integration compared to standard care.

1. U.S.
Global
Health
Initiative
Global Health Initiative
Principle on Integration
CORE Group Spring Meeting
Baltimore, April 23, 2013
GHI Integration Working Group

2. U.S.
Global
Health
Initiative
Presentation Outline
• Overview of GHI
• Purpose of Integration workgroup
• Progress to date
• Next steps

3. U.S.
Global
Health
Initiative
GHI – overview
3

4. U.S.
Global
Health
Initiative
GHI Integration Workgroup
• USG Interagency workgroups for all GHI Principles
formed in Aug 2012 (members from USAID, OGAC and
CDC).
• Tasked to develop guidance for countries to use to
measure and evaluate the principles
• Deliverables: results framework, global indicators and
illustrative indicators
• Integration workgroup provided with funding to develop a
―learning agenda‖ to further the evidence base on
integrated service delivery
• In process of collecting feedback on products from
countries, implementing partners and other stakeholders

5. U.S.
Global
Health
Initiative
GHI Integration Progress
• Definition of Integration:
….The organization, coordination, and management of
multiple activities and resources to ensure the delivery of
more efficient and coherent services in relation to cost,
output, impact, and use…. )
• Summarized findings from USAID Cochrane Reviews
2010
• Evidence on Integration is limited by lack of rigorous
studies
(operational feasibility of measuring is complex-
most services are along a continuum of integration)
• Developing Integration Scoping Tool
• Developing illustrative integration measures – by core
outcomes

6. U.S.
Global
Health
Initiative
Key Issues Considered for Developing the Results
Framework, Indicators and Learning Agenda
• Integration is not an ―intervention‖- RF not typical so
inputs, outputs and outcomes vary by country and
context
• Significant overlap with other principles, e.g. HSS &
gender; integration best conceived as an
approach/lens
• Results Framework and Indicators should go beyond
specific service delivery interventions (e.g. Nutrition
and HIV, MCH/FP, TB/HIV)
• Learning agenda should focus on what countries
need to make strategic decisions about scaling up
integration
– provide evidence on how and when does integration
affect key outcomes
– what integration models work and under what
conditions?

7. Outcomes of Integration contribute to GHI targets for HIV/AIDS, TB, Malaria,
NTDs, Maternal Mortality, Family Planning, Child Mortality and Nutrition
Coherent 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 “no
missed opportunity in service provision”
Policy and Governance
Demand Creation and
Healthy Behaviors
Planning and
Management
Health System Functions
• Policy Makers, Managers and
Donors support integration
• Financing and resource allocation
to foster integration
• Decentralized functions
• Policy and Guidelines for Integrated
Service Delivery
• HMIS-Integrate surveillance, M&E
and Information Systems
• HRH- Adapt HR functions,
management systems and tools to
foster integration
• Cross training and task shifting
• Medical Tech- Laboratory and
logistics systems are linked
When interventions for populations
overlap;:
• Joint Planning for multiple programs
• Consolidate administration
management, and staff across
programs for smart integration
• Pool/share resources across disease
specific programs
• Integrate Behavior Change
communication campaigns
• Health behaviors are
promoted in combination e.g.
Nutrition and FP
• Barriers to health seeking are
addressed in coordinated and
integrated fashion
*Service Integration of proven
efficacious interventions e.g.
• Preventing Mother-to-Child
Transmission (PMTCT)
Coverage and Access Acceptability
“Added value” of Smart Integration ( Benefits/Results)
• Improved availability of
services e.g. one stop shop
• Increased coverage of
effective interventions
• Expanded access of
services per client contact
• Improved client satisfaction
• More family centered care
• Improved retention in care
• Improved health seeking
• behaviors
• Community engagement
• Cost savings/Improved
resource use
• Reduced duplication of
efforts
• Improved functioning of
health system
• Increased readiness of
services to meet client needs
• Appropriate follow up
• Reduced missed
opportunities at high volume
contact points
Responsiveness / Quality Efficiency Uptake (Use)
• Improved uptake of
integrated services
• Improved use of services
along the continuum
• Improved patient care- e.g.
ART initiation, EID etc.
Integration Inputs
Integration Outcomes
Health Outcomes
SustainedImpact Sustained Improvements in Health Status
Integration Outputs

8. U.S.
Global
Health
Initiative
GHI Indicators
• The USG GHI Integration TWG tasked with
developing up to 3 Global Indicators that
map to the Integration RF
• Illustrative indicators are a resource for
countries to monitor their integration efforts at
the country level and do not need to be
reported

9. U.S.
Global
Health
Initiative
Learning Agenda Overview
Goal: to assist Missions and host countries to plan,
design, monitor and evaluate integrated services
Obj 1: understand current state of integrated
service delivery models in a number of countries
and the drivers & factors facilitating choice of model
and interventions.
Obj 2: understand how well interventions map to
RF and document strengths, weaknesses, gaps of
M&E systems.
Obj 3: identify country specific eval opportunities
and study designs (for phase 2)
Year 1 funding provided to MEASURE Evaluation
(Year 2 TBD).

10. U.S.
Global
Health
Initiative
Learning Agenda—Question 1
What is the current experience of countries in
implementing integrated health services?
Identify ―best bets, best buys‖
– Which services when integrated or bundled and under
what circumstances seem to be the most efficient and
which are better left not integrated?
– What types of models of integrated services (e.g. one
stop shop model; co-location of services; referral models)
are appropriate in various contexts and for different types
of service delivery platforms (e.g. community-based
services; clinic services)?
– Is there a ―tipping point‖ where adding extra services
might actually be more harmful than beneficial?
Approach: Conduct survey and case studies in a sample of GHI
countries to document their experience implementing integrated
services over the last 3-4 years.

11. U.S.
Global
Health
Initiative
Learning Agenda—Question 2
What is the value-added of integrated service delivery
compared with community standards of care?
Outcomes to measure:
• Coverage and access
• Client acceptability
• Responsiveness and quality
• Efficiency
• Service use and uptake
• Equity
Approach: Case studies and impact eval in
selected countries.

12. U.S.
Global
Health
Initiative
Contact Information:
• Kristin Saarlas, ScD, MPH
Evaluation Advisor
Office of Policy, Programs, and Planning (P3)
Bureau for Global Health, USAID/Washington
mobile: 571-345-5463; email: ksaarlas@usaid.gov
• Rushna Ravji, MD, MPH, MS
Health Team Leader, Asia and the Middle East
Bureau for Global Health, USAID/Washington
mobile: 202-538-3358; email: rravji@usaid.gov

13. U.S.
Global
Health
Initiative
Thank You