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Vasan A, Ellner A, Lawn SD, Gove S, Anatole M, Gupta N, Drobac P, Nicholson T, Seung K, Mabey DC, Farmer PE. Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI). BMC Med 2014; 12:6. [PMID: 24423387 PMCID: PMC3895758 DOI: 10.1186/1741-7015-12-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 12/17/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND More than three decades after the 1978 Declaration of Alma-Ata enshrined the goal of 'health for all', high-quality primary care services remain undelivered to the great majority of the world's poor. This failure to effectively reach the most vulnerable populations has been, in part, a failure to develop and implement appropriate and effective primary care delivery models. This paper examines a root cause of these failures, namely that the inability to achieve clear and practical consensus around the scope and aims of primary care may be contributing to ongoing operational inertia. The present work also examines integrated models of care as a strategy to move beyond conceptual dissonance in primary care and toward implementation. Finally, this paper examines the strengths and weaknesses of a particular model, the World Health Organization's Integrated Management of Adolescent and Adult Illness (IMAI), and its potential as a guidepost toward improving the quality of primary care delivery in poor settings. DISCUSSION Integration and integrated care may be an important approach in establishing a new paradigm of primary care delivery, though overall, current evidence is mixed. However, a number of successful specific examples illustrate the potential for clinical and service integration to positively impact patient care in primary care settings. One example deserving of further examination is the IMAI, developed by the World Health Organization as an operational model that integrates discrete vertical interventions into a comprehensive delivery system encompassing triage and screening, basic acute and chronic disease care, basic prevention and treatment services, and follow-up and referral guidelines. IMAI is an integrated model delivered at a single point-of-care using a standard approach to each patient based on the universal patient history and physical examination. The evidence base on IMAI is currently weak, but whether or not IMAI itself ultimately proves useful in advancing primary care delivery, it is these principles that should serve as the basis for developing a standard of integrated primary care delivery for adults and adolescents that can serve as the foundation for ongoing quality improvement. SUMMARY As integrated primary care is the standard of care in the developed world, so too must we move toward implementing integrated models of primary care delivery in poorer settings. Models such as IMAI are an important first step in this evolution. A robust and sustained commitment to innovation, research and quality improvement will be required if integrated primary care delivery is to become a reality in developing world.
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Affiliation(s)
- Ashwin Vasan
- Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
- Partners In Health, Kigali, Rwanda
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Medicine, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA
| | - Andrew Ellner
- Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA
| | - Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandy Gove
- IMAI-IMCI Alliance, San Francisco, CA, USA
| | - Manzi Anatole
- Partners In Health, Boston, MA, USA
- Partners In Health, Kigali, Rwanda
| | - Neil Gupta
- Partners In Health, Boston, MA, USA
- Partners In Health, Kigali, Rwanda
- Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA
| | - Peter Drobac
- Partners In Health, Boston, MA, USA
- Partners In Health, Kigali, Rwanda
- Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA
| | - Tom Nicholson
- Partners In Health, Boston, MA, USA
- Partners In Health, Kigali, Rwanda
| | - Kwonjune Seung
- Partners In Health, Boston, MA, USA
- Partners In Health, Kigali, Rwanda
- Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA
| | - David C Mabey
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Paul E Farmer
- Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
- Partners In Health, Kigali, Rwanda
- Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA
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Vasan A, Ellner A, Lawn SD, Gupta N, Anatole M, Drobac P, Nicholson T, Gove S, Seung K, Mabey D, Farmer P. Strengthening of primary-care delivery in the developing world: IMAI and the need for integrated models of care. LANCET GLOBAL HEALTH 2013; 1:e321-3. [PMID: 25104589 DOI: 10.1016/s2214-109x(13)70102-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ashwin Vasan
- Department of Medicine, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA; Partners In Health, Boston, MA, USA, and Rwanda; Program in Global Primary Care and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrew Ellner
- Program in Global Primary Care and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Neil Gupta
- Partners In Health, Boston, MA, USA, and Rwanda; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Peter Drobac
- Partners In Health, Boston, MA, USA, and Rwanda; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Sandy Gove
- IMAI-IMCI Alliance, former WHO IMAI Team Leader, WHO, Geneva, Switzerland
| | - Kwonjune Seung
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - David Mabey
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Farmer
- Partners In Health, Boston, MA, USA, and Rwanda; Program in Global Primary Care and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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