Integrated Care Programmes: Inaugural Conference
"Making People-centred Integrated Care a Reality"
The Printworks, Dublin Castle, Republic of Ireland
6th October 2015
People-centred Integrated
Care Strategy – Irish Launch
Hernan Montenegro, MD, MPH
Coordinator
Services Organization and Clinical Interventions Unit
Service Delivery and Safety Department
World Health Organization
Content
• Global context and health system challenges
• WHO policy directions
• WHO strategy on integrated, people-centred
health services (IPCHS)
• Lessons learned on implementation of IPCHS:
– Context
– Content
– Processes
– Actors
The changing global context:
challenges and opportunities
Ageing
Innovation
Climate change
Globalization
Rising costs
NCDs
Citizen voice
Urbanization
Source: WHO Global Health Observatory Data Repository, 2015
One view of the challenge: millions miss out on
needed health services
Percentage of Skill Birth Attendants
0
20
40
60
80
100
Q1, Q5 and Average - 22
0
10
20
30
Q5
Q1
Average
Source: Latest available DHS for each country (excl. CIS countries)
40
50
•
•
•
HAI pooled prevalence: 15·5 per 100 patients [95% CI 12·6–18·9]) was much higher than
proportions reported from Europe & the USA.
Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per
1000 patient-days (95% CI 36·7–59·1), at least 3 times as high as densities reported from the USA.
Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100
surgical procedures), strikingly higher than proportions recorded in developed countries.
"The burden of health-care-associated
infection in developing countries is high."
Source: Allegranzi et al. Lancet. 2011 Jan 15;377(9761):228-41.
Millions more suffer financially
when they use health services
EMR
AFR
EUR
SEA
AMR
WPR
impoverishment
catastrophic
-
30
60
Number of people (million)
90
Model of Care: Continuity of Care
Section I.3: PHC Model of Care: Continuity of Care
%
3.1 Respondents Responses, in Percent
50
40
30
20
10
0
3.1.1
Never
3.1.2
Almost never
3.1.3
Sometimes
3.1.1 Are patients seen by the same provider (doctor/
health team) whenever they consult?
3.1.2 Is there an appointment and follow-up system,
including arranging home visits by the health team?
3.1.3 Is assigning people from a geographical area to
lists or registries with a specific PHC provider or
provider group encouraged?
3.1.4
Usually
3.1.5
Always
3.1.4 Does a good referral and counter-referral
system based on case complexity normally function
for patients?
3.1.5 Is there a policy that enables ensuring that
PHC facilities are regularly covered by physicians or
nurses?
Ongoing challenges for health
Lack of coordination
Coordination Of Care, Medical Errors, And Safety Among Sicker Adults In Eleven Countries, 2011
Percent of respondents who:
Experienced coordination gaps in past 2 years
Test results/
Specialist lacked
records not
Key
medical history or
available at
information
regular doctor not
appointment or
not shared
informed about
duplicate tests
among
specialist care
Country ordered
providers
AUS
19%
12%
19%
CAN
25
14
18
FRA
20
13
37
GER
16
23
35
NETH
18
15
17
NZ
15
12
12
NOR
22
19
25
SWE
16
18
20
SWI
11
10
9
UK
13
7
6
US
27
17
18
Any gap
36%
40
53
56
37
30
43
39
23
20
42
Experienced
gaps in
hospital/surgery
discharge
planning
55%
50
73
61
66
51
71
67
48
26
29
Reported
regular doctor
seemed
uninformed
about hospital/
surgery care
18%
19
15
17
9
19
18
35
15
11
12
Experienced
medical,
medication,
or lab error
19%
21
13
16
20
22
25
20
9
8
22
Reported
pharmacist
or doctor did
not review
prescription
s in past year
34%
28
58
29
41
31
62
55
25
16
28
SOURCE adapted from 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults In Eleven Countries
% of hospitalized patients according to
most appropriate site of care
51%
Primary care
49%
Non-primary care
PAHO, 2004
WHO AFRO, 2012
Strengthening a global commitment to
people centred integrated health
services delivery
People-centred
and integrated
health services
in the NUKA
health system,
Alaska, USA
Case
management in
Torbay, UK
Promoting
HIV/AIDS literacy
in Angola
Integrated health
care networks in
Brazil
Integrated health
care networks in
Chile
Social
participation in
Tupiza, Bolivia
Shared
accountability
contract for
population
health
outcomes,
Kinzigtal,
Germany
Promoting
service
coordination in
Lithuania
Integrated care
in South Karelia,
Finland
What are the
experiences to date?
Integrating
HIV/AIDS and
TB in Mali
Mobilizing
communities to
reduce maternal
and neonatal
deaths in Malawi
Family medicine
in Thailand as
part of UHC
Balanced
scorecard to
promote
accountability,
Afghanistan
Integrating
traditional and
complementary
medicine in Asia
Communityowned primary
care networks in
Mali
Success
Lessons from implementation:
challenges to achieve sustainability and scale
t1
t2
t3
Time (years)
Project’s duration
Source: Adapted from Amelung et al. 2014, Transform Proposal
1
Project failure
2
Slow death
3
Struggling projects
4
Sustainable projects
5
Scaling up
6
System transformation
Defining people-centred
integrated health services delivery
People-centred
health services
People-centred health services are an approach to care that
consciously adopts the perspectives of individuals, families and
communities, and sees them as participants as well as
beneficiaries of trusted health systems that respond to their needs
and preferences in humane and holistic ways. It requires that
people have the education and support they need to make
decisions and participate in their own care. It is organized around
the health needs and expectations of people rather than diseases.
Integrated health services are health services that are
managed and delivered in a way that ensures people receive a
continuum of health promotion, disease prevention, diagnosis,
treatment, disease management, rehabilitation and palliative
care services, at the different levels and sites of care within the
health system, and according to their needs, throughout their life
course.
Integrated
health services
Improved
access to care
for marginalized
groups
Reduced
unplanned
hospitalizations
Increased
ability to selfmanage
Shared
decision-making
Shift in the
balance of care,
allocating
resources
closer to needs
What outcomes
have been achieved?
Increased
access to care
Greater
community
influence & better
relationships with
care providers that
build awareness
and trust
Improved
health literacy
Workforce role
enhancement
Reduced
perinatal and
neonatal mortality
Reduced
costs
Increased
health coverage
Greater community
engagement &
participatory
representation
Better
coordination
of care
Greater
quality of care
IPCHS: Key challenges on evidence
• Multiple definitions of IPCHS
• Evidence gaps:
– Most research focused on:
• Relatively narrowly-defined interventions in support of IPCHS
• Treatment and diagnosis
• Adult and elderly care
– Less research on:
• Broader approaches in support of IPCHS
• Health promotion, prevention, long-term care, rehabilitation and palliative
care
• Other life stages such as childhood
•
•
•
•
Evidence mainly derived from advanced economy settings
Most times mixed results or without changes in health outcomes
Outcomes are highly context-specific
Policies and strategies need to be evidence-informed rather than
evidence-based
• Need more implementation research and sound evaluation
A framework for people-centred
integrated health services delivery
One size does not fit all
© World Health Organization 2015
Country Settings
Fragile & Post-conflict:
Low Income:
- Special needs of refugees & displaced people
- Specific health needs resulting from conflict
- Increase in CDs due to disruption of water & sanitation services
- Security issues
- Unstable governance & weak institutional capacity
- Damaged infrastructure
- Acute shortages of HWF and other essential supplies
Non-functioning delivery system
- High dependency from external assistance & financing
- Low Life Expectancy, high burden of CDs & malnutrition
- High reliance on O-O-P contributions & regressive public health spending
- Low public health expenditure as % of GDP
- Poor governance & weak institutional capacity
- Shortages of infrastructure, HRH and other essential supplies
- Poorly developed delivery system & predominance of vertical programs
- Majority of existing services provided by NGOs & informal providers
- Poor information systems and lack of performance assessment
- High dependency from external assistance & financing
- Inequities that affect the most vulnerable
population groups
- Quality of care issues, including medicines
- Fragmented care
-Inefficient use of existing resources
- Insufficient participation
High Income:
Medium Income:
- High Life Expectancy, predominance of NCDs & mental health problems
- Aged population
- Medium Life Expectancy, double burden of disease: NCDs & CDs, mental
health, injuries
- Multi-morbidity
- High reliance on O-O-P contributions & regressive public health spending
- Need for chronic care
- Low public health expenditure as % of GDP
- High levels of public health spending & low levels of O-O-P contributions
- Poorly organized delivery system with overreliance on vertical programs
- High levels of public service provision
- Poor information systems and lack of performance assessment
Alignment between national health policies,
strategies and plans and the IPCHS strategy
Analysis by income level
Overall proportion of countries whose national
Policies, strategies and plans are aligned
with the global strategy on IPCHS
Analysis by WHO Region
The way forward: five strategic directions
© World Health Organization 2015
Strategic Goals and Objectives
1
Empowering and
engaging people
1.1 Empowering and
engaging individuals
and families
1.2 Empowering and
engaging
communities
1.3 Reaching the
underserved &
marginalized
2
Strengthening
governance and
accountability
2.1 Bolstering
participatory
governance
2.2 Enhancing
mutual
accountability
3
Reorienting the
model of care
3.1 Defining service
priorities based on
life-course needs
and preferences
3.2 Revaluing
promotion,
prevention and
public health
3.3 Building strong
primary care-based
systems
3.4 Shifting towards
more outpatient
and ambulatory care
3.5 Innovating and
incorporating new
technologies
4
Coordinating
services
4.1 Coordinating
care for individuals
4.2 Coordinating
health programmes
and providers
4.3 Coordinating
across sectors
5
Creating an
enabling
environment
5.1 Strengthening
leadership and
management for
change
5.2 Striving for
quality
improvement and
safety
5.3 Reorienting the
health workforce
5.4 Aligning
regulatory
frameworks
5.5 Reforming
payment systems
Next steps: parallel processes in
the development of the strategy
Strategy consultation
Implementation support
May
2015
Public consultation
June
2015
Consultation with WHO Regional
Offices
Development of web-platform &
launch (summertime 2015)
Supporting demonstration sites
2016
World Health Assembly
Fostering partnerships
Developing tools for monitoring &
evaluation
© World Health Organization 2015
TRANSFORM – HORIZON 2020 (EU FUNDING)
From successful pilot projects to at-scale implementation. Leadership and management for transformational change towards
integrated health and social care systems
The process is not simple, not linear
Idealized
Idealised planning processes
 It is not only the "plan“- the
process is important!
5 year plan
GHI
 … but the process is usually
messy…
 Inclusive policy dialogue is
key
partn
ers
Annual
Review
Annual
Review
Annual
Review
Bottom-up participatory
planning cycle
CSO
CSO
NGO
NGO
Real-life
Real-life planning processes
→ Facilitation of policy
dialogue
Private
sector
5 year plan
Lobbies
CSO
Government plan
partners
Elections
Political
priorities
Program
mes
Civil service
reform
Operational
plan disease x
Annual
Review
Framework for analyzing the
implementation of health care reform
Context
Players
individuals
Groups
Content
Processes
Walt & Gibson 1994
Lessons learnt from: Context
 High priority within the whole of government political agenda
 Right political timing
 Part of broader sectoral and/or social protection reforms
 Embedded in national health policy & strategy supported by
changes in legislation and regulation
 Linked to higher goals such as achieving UHC, high quality of care,
patience experience and/or addressing chronic care
 Greater availability and dedicated resources
 Strategies are politically feasible and adapted to local context
 When implemented in the context of stronger health systems with
less structural problems
Service delivery in the value chain
Sources: WHR 2000; WHO 2007 “Everybody’s business”; IHP+ 2011 “Common M&E framework”; van Olmen et.al. 2010 “Analysing HS to
make them stronger”
Lessons learnt: Content
 Common vision, shared values and a clear narrative for change
that is easily understood
 Sound implementation plan with clear goals, measurable
objectives, and defined roles and responsibilities
 Institutional capacity and dedicated resources for reform
 Strong communications and public relations strategies
 Multiple policy instruments targeting different levels of system
 Balanced top-down and bottom-up approaches
 Coherence across all reform policies and strategies
 Focus on clinical integration and clinical leadership
 Alignment of financial incentives
Policy instruments and
intervention levels
Information &
Exhortation
Society
Legal &
Regulation
Community
Building
Capacity of
others
Family
Person
UHC with High Quality,
Integrated People-centred
Services
National
Context
Direct
Provider(s)
Bureaucratic
Reforms
Health
Facility
Taxes &
Subsidies
Provider Network
Service
Provision
System
Financing &
Contracting
Global &
Regional
Context
Lessons learnt: Processes
 Processes are complex, difficult and long-term
 Sustained political will, leadership and policy direction over time
 Build from existing structures and strengths
 Different speeds depending on political context: "big-bang" versus
gradual, incremental
 Experiment and test innovative approaches, allow for failure
 Take advantage of low hanging fruits and demonstrate early gains
through measurable results
 Use demonstration sites and spread knowledge gains
Lessons learnt: Actors
 Patients, users, and service providers should be involved in all stages
of reform
 Support from the public and strategic alliances
 Quality interpersonal and inter-institutional relations, including:
willingness to change, trust, credibility, appreciation, and sense of
belonging
 Close gap between policy makers, managers, providers and users
through spaces for open dialogue and exchanges
CONTACT INFORMATION
Services Delivery and Safety Department
World Health Organization
Avenue Appia 20
CH-1211, Geneva 27
Switzerland
For more information on health services delivery visit
http://www.who.int/servicedeliverysafety/areas/peoplecentred-care/en/