Integration of priority population, health and nutrition interventions into health systems: systematic review

Group-based trajectory models of integrated vaccine delivery and equity in low- and middle-income countries

BACKGROUND

Integrated vaccine delivery - the linkage of routine vaccination with provision of other essential health services - is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes.

METHODS

We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership.

RESULTS

We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage.

CONCLUSIONS

Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration.

Perspectives of Dietary Assessment in Human Health and Disease

Diet and human health have a complex set of relationships, so it is crucial to identify the cause-effects paths and their management. Diet is crucial for maintaining health (prevention) and unhealthy diets or diet components can cause disease in the long term (non-communicable disease) but also in the short term (foodborne diseases). The present paper aims to provide a synthesis of current research in the field of dietary assessment in health and disease as an introduction to the special issue on "Dietary Assessment and Human Health and Disease". Dietary assessment, continuously evolving in terms of methodology and tools, provides the core information basis for all the studies where it is necessary to disentangle the relationship between diet and human health and disease. Estimating dietary patterns allows for assessing dietary quality, adequacy, exposure, and environmental impact in nutritional surveillance so on the one hand, providing information for further clinical studies and on another hand, helping the policy to design tailored interventions considering individual and planetary health, considering that planetary health is crucial for individual health too, as the SARS-CoV-2 (COVID-19) pandemic has taught. Overall, dietary assessment should be a core component in One-Health-based initiatives to tackle public health nutrition issues.

Integrating HIV services and other health services: A systematic review and meta-analysis

BACKGROUND

Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.

METHODS AND FINDINGS

We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.

CONCLUSIONS

Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.

One country's journey to interoperability: Tanzania's experience developing and implementing a national health information exchange

BACKGROUND

Robust, flexible, and integrated health information (HIS) systems are essential to achieving national and international goals in health and development. Such systems are still uncommon in most low and middle income countries. This article describes a first-phase activity in Tanzania to integrate the country's vertical health management information system with the help of an interoperability layer that enables cross-program data exchange.

METHODS

From 2014 to 2019, the Tanzanian government and partners implemented a five-step procedure based on the "Mind the GAPS" (governance, architecture, program management, and standards) framework and using both proprietary and open-source tools. In collaboration with multiple stakeholders, the team developed the system to address major data challenges via four fully documented "use case scenarios" addressing data exchange among hospitals, between services and the supply chain, across digital data systems, and within the supply chain reporting system. This work included developing the architecture for health system data exchange, putting a middleware interoperability layer in place to facilitate the exchange, and training to support use of the system and the data it generates.

RESULTS

Tanzania successfully completed the five-step procedure for all four use cases. Data exchange is currently enabled among 15 separate information systems, and has resulted in improved data availability and significant time savings. The government has adopted the health information exchange within the national strategy for health care information, and the system is being operated and managed by Tanzanian officials.

CONCLUSION

Developing an integrated HIS requires a significant time investment; but ultimately benefit both programs and patients. Tanzania's experience may interest countries that are developing their HIS programs.

Factors supporting the implementation of integrated care between physical and mental health services: an integrative review

In Australia and internationally there is a strong policy commitment to the redesign of health services toward integrated physical and mental health care. When executed well, integrated care has been demonstrated to improve the access to, clinical outcomes from, and quality of care while reducing overtreatment and duplication. Despite the demonstrated effectiveness and promise of integrated care, exactly how integrated care is best achieved remains less clear. The aim of this review study was to identify factors that support the implementation of integrated care between physical and mental health services. An integrative review was conducted following the framework developed by Whittemore and Knafl, with quantitative and qualitative evidence systematically considered. To identify studies, Medline, PubMed, PsychINFO, CINAHL were searched for the period from 2003 to 2018, and reference lists of included studies and review articles were examined. Nineteen studies were included. Synthesis of study findings identified seven key factors supporting the implementation of integrated care between physical and mental health services: (a) adequate resourcing, (b) shared values, (c) effective communication, (d) information technology (IT) infrastructure, (e) flexible administrative organizations, (f) role clarity and accountability, and (g) staff engagement and training. There was little theoretical development in included studies, with little insight into the contextual factors or underlying mechanism required to support the implementation of integrated care initiatives. This review identified a set of inter-related barriers and facilitators which, if addressed, can improve the implementation and sustainability of truly integrated care.

Prevalence and determinants of incomplete or not at all vaccination among children aged 12-36 months in Dabat and Gondar districts, northwest of Ethiopia: findings from the primary health care project

OBJECTIVE

Ethiopia is one of the Africa's signatory countries for implementation of the primary healthcare strategy including immunisation. In Ethiopia, however, 16% of child death is due to vaccine-preventable disease. Thus, this study aimed to assess the prevalence and determinants of incomplete or not at all vaccination among children aged 12-36 months in Dabat and Gondar districts, Northwest Ethiopia.

STUDY DESIGN

The study is community-based cross-sectional study.

STUDY SETTING

Dabat and Gondar Zuria districts, Northwest Ethiopia.

PARTICIPANTS

Mothers/caregivers with children aged 12-36 months were enrolled in the study. Participants were randomly selected through systematic sampling and a total of 603 participants were included in the analysis.

METHODS

A binary logistic regression analysis was done. In the multivariable logistic regression analysis, a p value of <0.05 and adjusted OR (AOR) with 95% CI were used to identify statistically associated factors with incomplete or not at all vaccination.

OUTCOMES

Incomplete or not at all vaccination.

RESULTS

The prevalence of incomplete or not at all vaccinated children was 23.10% (95% CI 16.50 to 29.70). The multivariable analysis revealed that the odds of incomplete or not at all vaccination were higher among mothers who had no antenatal care (ANC) visit (AOR: 1.81, 95% CI 1.21 to 4.03) and no postnatal care (PNC) visit (AOR=1.52, 95% CI 1.05 to 2.25).

CONCLUSIONS

In the study area, nearly one-fourth of children are incompletely or not at all vaccinated. Our finding suggests that ANC and PNC visits are key determinants of incomplete or not at all vaccination. Thus, in low-resource settings like Ethiopia, the health system approaches to improved ANC and PNC services should be intensified with more effective advice on child immunisation to reduce vaccine preventable disease.

Perceived impacts as narrated by service users and providers on practice, policy and mental health system following the implementation of the mhGAP-IG using the TEAM model in a rural setting in Makueni County, Kenya: a qualitative approach

Background

A team approach is key to reduction of the mental health treatment gap. It requires collaborative effort of all formal and informal community based service providers and the consumers of the services. Qualitative evaluations of such an approach add value to the quantitative evaluations.

Methods

A qualitative study was conducted among 205 participants. These were grouped into a total of 19 focus group discussions for community health workers (CHW), traditional healers (TH), faith healers (FH) and patients. For nurses and clinical officers we held 10 key informant interviews and three key informant discussions. We aimed to document personal perceptions as expressed in narratives on mental health following a community based application of the WHO mental health treatment Gap-intervention guideline (mhGAP-IG) using the TEAM model. We also aimed to document how the narratives corroborated key findings on the quantitative wing of the TEAM model.

Results

There were three categories of perceptions: (i) patient-related, (ii) health provider-related and, (iii) health system related. The patient related narratives were linked to improvement in their mental and physical health, increased mental health awareness, change in lifestyle and behavior, enhanced social functioning and an increase in family productivity. Health provider perceptions were related to job satisfaction, capacity building and increased interest in mental health training. Mental health system related narratives included effectiveness and efficiency in service delivery and increase in number of referrals at the primary health care facilities.

Conclusion

The TEAM is a feasible model for the implementation of the mhGAP-IG. It led to positive perceptions and narratives by service provides and service consumers. The qualitative findings corroborated the quantitative findings of TEAM.

Strengthening integration of family planning with HIV/AIDS and other services: experience from three Kenyan cities

Background

Kenya has made remarkable progress in integrating a range of reproductive health services with HIV/AIDS services over the past decade. This study describes a sub-set of outcomes from the Bill & Melinda Gates Foundation (BMGF)-funded Jhpiego-led Kenya Urban Reproductive Health Initiative (Tupange) Project (2010–2015), specifically addressing strengthening family planning (FP) integration with a range of primary care services including HIV testing and counselling, HIV care services, and maternal, newborn and child care.

Methods

A cross-sectional study was conducted between August and October 2013 in the cities of Mombasa, Nairobi and Kisumu in Kenya to assess the level of FP integration across six other service delivery areas (antenatal care clinic, maternity wards, postnatal care clinic, child welfare clinic, HIV testing and counseling (HTC) clinics, HIV/AIDS services in comprehensive care clinics). The variables of interest were level of integration, provider knowledge, and provider skills. Routine program monitoring data on workload was utilized for sampling, with additional data collected and analyzed from twenty health facilities selected for this study, along with client exit interviews. Descriptive analysis and Chi-square/ Fishers Exact tests were done to explore relationships between variables of interest.

Results

Integration of FP occurred in all the five service areas to varying degrees. Service provider FP knowledge in four service delivery areas (HTC clinic, antenatal clinic, postnatal clinic, and child welfare clinic) increased with increasing levels of integration. Forty-seven percent of the clients reported that time spent accessing FP services in the HTC clinic was reasonable. However, no FP knowledge was reported from service providers in HIV/AIDS comprehensive care clinics in all levels of integration despite observed provision of counseling and referral for FP services.

Conclusions

Integration of FP services in other primary care service areas including HTC clinic can be enhanced through targeted interventions at the facility. A holistic approach to address service providers’ capacity and attitudes, ensuring FP commodity security, and creating a supportive environment to accommodate service integration is necessary and recommended. Additional studies are necessary to identify ways of enhancing FP integration, particularly with HIV/AIDS care services.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0715-8) contains supplementary material, which is available to authorized users.

Characteristics of successful integrated family planning and maternal and child health services: Findings from a mixed-method, descriptive evaluation

Background: Most postpartum women in low- and middle-income countries want to delay or avoid future pregnancies but are not using modern contraception. One promising strategy for increasing the use of postpartum family planning (PPFP) is integration with maternal, newborn and child health (MNCH) services. However, there is limited evidence on effective service integration strategies. We examine facilitators of and barriers to effective PPFP integration in MNCH services in Kenya and India.  

Methods: We conducted a cross-sectional, mixed-method study in two counties in Kenya and two states in India. Data collection included surveying 215 MNCH clients and surveying or interviewing 82 health care providers and managers in 15 health facilities across the four sites. We analyzed data from each country separately. First, we analyzed quantitative data to assess the extent to which PPFP was integrated within MNCH services at each facility. Then we analyzed qualitative data and synthesized findings from both data sources to identify characteristics of well and poorly integrated facilities.

Results: PPFP integration success varied by service delivery area, health facility, and country. Issues influencing the extent of integration included availability of physical space for PPFP services, health workforce composition and capacity, family planning commodities availability, duration and nature of support provided.

Conclusions: Although integration level varied between health facilities, factors enabling and hindering PPFP integration were similar in India and Kenya. Better measures are needed to verify whether services are integrated as prescribed by national policies.

Access to hypertension care and services in primary health-care settings in Vietnam: a systematic narrative review of existing literature

Background: Health care in Vietnam is challenged by a high burden of hypertension (HTN). Since 2000, several interventions were implemented to manage HTN; it is not clear what is the status of patient access to HTN care. Objective: This article aims to perform a systematic narrative review of the available evidence on access to HTN care and services in primary health-care settings in Vietnam. Methods: Search engines were used to identify relevant records of scientific and grey literature. Data from selected articles were analysed using standardised spreadsheets and MaxQDA and following a framework synthesis methodology. Results: There has been increasing interest in research and policy concerning the burden of HTN in Vietnam, covering many aspects of access to treatment at the primary health-care level. Vietnam's National HTN Programme is managed as a vertical programme and its services integrated into the network of primary health-care facilities across the public sector in selected provinces. The Programme financed population-wide screening campaigns for the early detection of HTN among people above 40 years of age. There was no information on the acceptability of HTN health services, especially regarding the interaction between patients and health professionals. In general, articles reported good availability of medication, but problems in accessing them included: fragmentation and lack of consistency in prescribing medication between different levels and short timespans for dispensing medication at primary health-care facilities. There was limited information related to the cost and economic impact of HTN treatment. Treatment adherence among hypertensive patients based on four studies did not exceed 70%. Conclusions: Although the Vietnamese health-care system has taken steps to accommodate some of the needs of HTN patients, it is crucial to scale-up interventions that allow for regular, systematic, and integrated care, especially at the lowest levels of care.

IMCI and ETAT integration at a primary healthcare facility in Malawi: a human factors approach

BACKGROUND

Integrated Management of Childhood Illness (IMCI) and Emergency Triage, Assessment and Treatment (ETAT) are guidelines developed by the World Health Organization to reach targets for reducing under-5 mortality. They were set out in the Millennium Development Goals. Each guideline was established separately so the purpose of this study was to understand how these systems have been integrated in a primary care setting and identify barriers and facilitators to this integration using a systems approach.

METHOD

Interviews were carried out with members of staff of different levels within a primary healthcare clinic in Malawi. Along with observations from the clinic this provided a well-rounded view of the running of the clinic. This data was then analysed using the SEIPS 2.0 work systems framework. The work system elements specified in this model were used to identify and categorise themes that influenced the clinic's efficiency.

RESULTS

A process map of the flow of patients through the clinic was created, showing the tasks undertaken and the interactions between staff and patients. In their interviews, staff identified several organisational elements that served as barriers to the implementation of care. They included workload, available resources, ineffective time management, delegation of roles and adaptation of care. In terms of the external environment there was a lack of clarity over the two sets of guidelines and how they were to be integrated which was a key barrier to the process. Under the heading of tools and technology a lack of guideline copies was identified as a barrier. However, the health passport system and other forms of recording were highlighted as being important facilitators. Other issues highlighted were the lack of transport provided, challenges regarding teamwork and attitudes of members of staff, patient factors such as their beliefs and regard for the care and education provided by the clinic.

CONCLUSIONS

This study provides the first information on the challenges and issues involved in combining IMCI and ETAT and identified a number of barriers. These barriers included a lack of resources, staff training and heavy workload. This provided areas to work on in order to improve implementation.

Integration of postpartum care into child health and immunization services in Burkina Faso: findings from a cross-sectional study

BACKGROUND

The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH).

METHODS

We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 (N = 757) and in 2014 (N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6-10 and during weeks 6-8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention.

RESULTS

The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6-10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration.

CONCLUSION

Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results.

Integration of antenatal care services with health programmes in low- and middle-income countries: systematic review

Background

Antenatal care (ANC) presents a potentially valuable platform for integrated delivery of additional health services for pregnant women–services that are vital to reduce the persistently high rates of maternal and neonatal mortality in low– and middle–income countries (LMICs). However, there is limited evidence on the impact of integrating health services with ANC to guide policy. This review assesses the impact of integration of postnatal and other health services with ANC on health services uptake and utilisation, health outcomes and user experience of care in LMICs.

Methods

Cochrane Library, MEDLINE, Embase, CINAHL Plus, POPLINE and Global Health were searched for studies that compared integrated models for delivery of postnatal and other health services with ANC to non–integrated models. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organisation of Care (EPOC) criteria and the Newcastle–Ottawa Scale, depending on the study design. Due to high heterogeneity no meta–analysis could be conducted. Results are presented narratively.

Findings

12 studies were included in the review. Limited evidence, with moderate– to high–risk of bias, suggests that integrated service delivery results in improved uptake of essential health services for women, earlier initiation of treatment, and better health outcomes. Women also reported improved satisfaction with integrated services.

Conclusions

The reported evidence is largely based on non–randomised studies with poor generalizability, and therefore offers very limited policy guidance. More rigorously conducted and geographically diverse studies are needed to better ascertain and quantify the health and economic benefits of integrating health services with ANC.

Development and implementation of Models of Care for musculoskeletal conditions in middle-income and low-income Asian countries

This chapter discusses the challenges faced in the development and implementation of musculoskeletal (MSK) Models of Care (MoCs) in middle-income and low-income countries in Asia and outlines the components of an effective MoC for MSK conditions. Case studies of four such countries (The Philippines, Malaysia, Bangladesh and Myanmar) are presented, and their unique implementation issues are discussed. The success experienced in one high-income country (Singapore) is also described as a comparison. The Community Oriented Program for Control of Rheumatic Diseases (COPCORD) project and the role of Asia Pacific League of Associations for Rheumatology (APLAR), a professional body supporting MoC initiatives in this region, are also discussed. The experience and lessons learned from these case studies can provide useful information to guide the implementation of future MSK MoC initiatives in other middle-income and low-income countries.

A cross-sectional mixed study of the opportunity to improve maternal postpartum care in reproductive, maternal, newborn, and child health services in the Kaya health district of Burkina Faso

OBJECTIVE

To propose a rationale to improve maternal postpartum care in reproductive, maternal, newborn, and child health (RMNCH) services.

METHODS

We conducted a cross-sectional mixed study in the Kaya health district in Burkina Faso based on two data collection exercises conducted between December 2012 and May 2013. A household survey of 757 mothers in their first year after delivery was processed. It was complemented with a qualitative analysis using in-depth interviews with key informants, focus group discussions with mothers, and participant observation.

RESULTS

Postpartum services showed serious weaknesses. Overall, 52% (n=384) of mothers did not receive any maternal postpartum care; however among them, 47% (n= 349) received infant postpartum care.

CONCLUSION

We suggest the integration of maternal postpartum care in RMNCH services as a key step to improving postpartum care. The intervention would require the overcoming of challenges related to the quality and cost of services, and to reaching the poor populations with low education and a high parity.

The Complexity of Health Service Integration: A Review of Reviews

BACKGROUND

The aim of health service integration is to provide a sustainable and integrated health system that better meets the needs of the end user. Yet, definitions of health service integration, methods for integrating health services, and expected outcomes are varied. This review was commissioned by Queensland Health, the government department responsible for health service delivery in Queensland, Australia, to inform efforts to integrate their mental health services. This review reports on the characteristics, reported outcomes, and design quality of studies included in systematic reviews of health service integration research.

METHOD

The review was developed by systematically searching nine electronic databases to find peer-reviewed Australian and international systematic reviews with a focus on health service integration. Reviews were included if they were in the English language and published between 2000 and 2015. A standardized assessment tool was used to analyze the study design quality of included reviews. Data relating to the integration types, methods, and reported outcomes of integration were synthesized.

RESULTS

Seventeen publications met the inclusion criteria. Eleven (65%) reviews were published during the past 5 years, which may indicate a trend for increased awareness of the need for service integration. The majority of reviews were published by researchers in the UK (8/47%), USA (3/18%), and Australia (3/18%). Included reviews focused on a variety of integration types, including integrated care pathways, governance models, integration of interventions, collaborative/integrated care models, and integration of different types of health care. Most (53%) of the reviews reported on the cost-effectiveness of service integration, e.g., positive results, no effect, or inconclusive. Only one of the reviews reported on the importance of consumer involvement. The overall design of 70% of the reviews was high, 18% medium, and 12% low.

CONCLUSION

There is no "one size fits all" approach to health service integration. Instead, this literature review highlighted the complexity of service integration, which in most primary studies involved a range of strategies. Rigorous assessments of cost-effectiveness and reporting on consumer involvement are required in future research.

Understanding factors that influence the integration of acute malnutrition interventions into the national health system in Niger

Since 2007 to address a high burden, integration of acute malnutrition has been promoted in Niger. This paper studies factors that influenced the integration process of acute malnutrition into the Niger national health system.We used qualitative methods of observation, key informant interviews and focus group discussions at national level, two districts and nine communities selected through convenience sampling, as well as document review. A framework approach constructed around the problem, intervention, adoption system, health system characteristics and broad context guided the analysis. Data were recorded on paper, transcribed in a descriptive record, coded by themes deduced by building on the framework and triangulated for comprehensiveness.Key facilitating factors identified were knowledge and recognition of the problem helped by accurate information; effectiveness of decentralized continuity of care; compatibility with goals, support and involvement of health actors; and leadership for aligning policies and partnerships and mobilizing resources within a favourable political context driven by multisectoral development goals. Key hindering factors identified were not fully understanding severity, causes and consequences of the problem; limited utilization and trust in health interventions; high workload, and health worker turnover and attrition; and high dependence on financial and technical support based on short-term emergency funding within a context of high demographic pressure.The study uncovered influencing factors of integrating acute malnutrition into the national health system and their complex dynamics and relationships. It elicited the need for goal-oriented strategies and alignment of health actors to achieve sustainability, and systems thinking to understand pathways that foster integration. We recommend that context-specific learning of integrating acute malnutrition may expand to include causal modelling and scenario testing to inform strategy designs. The method may also be applied to monitor progress of integrating nutrition by the multisectoral nutrition plan to guide change.

Medical Expenditure for Chronic Diseases in Mexico: The Case of Selected Diagnoses Treated by the Largest Care Providers

BACKGROUND

Chronic diseases (CD) are a public health emergency in Mexico. Despite concern regarding the financial burden of CDs in the country, economic studies have focused only on diabetes, hypertension, and cancer. Furthermore, these estimated financial burdens were based on hypothetical epidemiology models or ideal healthcare scenarios. The present study estimates the annual expenditure per patient and the financial burden for the nine most prevalent CDs, excluding cancer, for each of the two largest public health providers in the country: the Ministry of Health (MoH) and the Mexican Institute of Social Security (IMSS).

METHODS

Using the Mexican National Health and Nutrition Survey 2012 (ENSANUT) as the main source of data, health services consumption related to CDs was obtained from patient reports. Unit costs for each provided health service (e.g. consultation, drugs, hospitalization) were obtained from official reports. Prevalence data was obtained from the published literature. Annual expenditure due to health services consumption was calculated by multiplying the quantity of services consumed by the unit cost of each health service.

RESULTS

The most expensive CD in both health institutions was chronic kidney disease (CKD), with an annual unit cost for MoH per patient of US$ 8,966 while for IMSS the expenditure was US$ 9,091. Four CDs (CKD, arterial hypertension, type 2 diabetes, and chronic ischemic heart disease) accounted for 88% of the total CDs financial burden (US$ 1.42 billion) in MoH and 85% (US$ 3.96 billion) in IMSS. The financial burden of the nine CDs analyzed represents 8% and 25% of the total annual MoH and IMSS health expenditure, respectively.

CONCLUSIONS/SIGNIFICANCE

The financial burden from the nine most prevalent CDs, excluding cancer, is already high in Mexico. This finding by itself argues for the need to improve health promotion and disease detection, diagnosis, and treatment to ensure CD primary and secondary prevention. If the status quo remains, the financial burden could be higher.

The role of global traditional and complementary systems of medicine in treating mental health problems

Traditional and complementary systems of medicine (TCM) encompass a broad range of practices which are commonly embedded within contextual cultural milieu, reflecting community beliefs, experiences, religion and spirituality. Evidence from across the world, especially from low- and middle-income countries (LMIC), suggests that TCM is commonly used by a large number of persons with mental illness. Even though some overlap exists between the diagnostic approaches of TCM and conventional biomedicine (CB), there are major differences, largely reflecting differences in the understanding of the nature and etiology of mental disorders. However, treatment modalities employed by providers of TCM may sometimes fail to meet common understandings of human rights and humane care. Still, there are possibilities for collaboration between TCM and CB in the care of persons with mental illness. Research is required to clearly delineate the boundaries of such collaboration and to test its effectiveness in bringing about improved patient outcomes.

Short structured general mental health in service training programme in Kenya improves patient health and social outcomes but not detection of mental health problems - a pragmatic cluster randomised controlled trial

TRIAL DESIGN

A pragmatic cluster randomised controlled trial.

METHODS

PARTICIPANTS

Clusters were primary health care clinics on the Ministry of Health list. Clients were eligible if they were aged 18 and over.

INTERVENTIONS

Two members of staff from each intervention clinic received the training programme. Clients in both intervention and control clinics subsequently received normal routine care from their health workers.

OBJECTIVE

To examine the impact of a mental health inservice training on routine detection of mental disorder in the clinics and on client outcomes.

OUTCOMES

The primary outcome was the rate of accurate routine clinic detection of mental disorder and the secondary outcome was client recovery over a twelve week follow up period. Randomisation: clinics were randomised to intervention and control groups using a table of random numbers. Blinding: researchers and clients were blind to group assignment.

RESULTS

Numbers randomised: 49 and 50 clinics were assigned to intervention and control groups respectively. 12 GHQ positive clients per clinic were identified for follow up. Numbers analysed: 468 and 478 clients were followed up for three months in intervention and control groups respectively.

OUTCOME

At twelve weeks after training of the intervention group, the rate of accurate routine clinic detection of mental disorder was greater than 0 in 5% versus 0% of the intervention and control groups respectively, in both the intention to treat analysis (p = 0.50) and the per protocol analysis (p =0.50). Standardised effect sizes for client improvement were 0.34 (95% CI = (0.01,0.68)) for the General Health Questionnaire, 0.39 ((95% CI = (0.22, 0.61)) for the EQ and 0.49 (95% CI = (0.11,0.87)) for WHODAS (using ITT analysis); and 0.43 (95% CI = (0.09,0.76)) for the GHQ, 0.44 (95% CI = (0.22,0.65)) for the EQ and 0.58 (95% CI = (0.18,0.97)) for WHODAS (using per protocol analysis).

HARMS

None identified.

CONCLUSION

The training programme did not result in significantly improved recorded diagnostic rates of mental disorders in the routine clinic consultation register, but did have significant effects on patient outcomes in routine clinical practice.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Register ISRCTN53515024.

A systematic approach to the planning, implementation, monitoring, and evaluation of integrated health services

Background

Because of the current emphasis and enthusiasm focused on integration of health systems, there is a risk of piling resources into integrated strategies without the necessary systems in place to monitor their progress adequately or to measure impact, and to learn from these efforts. The rush to intervene without adequate monitoring and evaluation will continue to result in a weak evidence base for decision making and resource allocation. Program planning and implementation are inextricability linked to monitoring and evaluation. Country level guidance is needed to identify country-specific integrated strategies, thereby increasing country ownership.

Discussion

This paper focuses on integrated health services but takes into account how health services are influenced by the health system, managed by programs, and made up of interventions. We apply the principles in existing comprehensive monitoring and evaluation (M&E) frameworks in order to outline a systematic approach to the M&E of integration for the country level. The approach is grounded by first defining the country-specific health challenges that integration is intended to affect. Priority points of contact for care can directly influence health, and essential packages of integration for all major client presentations need to be defined. Logic models are necessary to outline the plausible causal pathways and define the inputs, roles and responsibilities, indicators, and data sources across the health system. Finally, we recommend improvements to the health information system and in data use to ensure that data are available to inform decisions, because changes in the M&E function to make it more integrated will also facilitate integration in the service delivery, planning, and governance components.

Summary

This approach described in the paper is the ideal, but its application at the country level can help reveal gaps and guide decisions related to what health services to prioritize for integration, help plan for how to strengthen systems to support health services, and ultimately establish an evidence base to inform investments in health care. More experience is needed to understand if the approach is feasible; similarly, more emphasis is needed on documenting the process of designing and implemented integrated interventions at the national level.

Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya

BACKGROUND

A cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact on the health, disability and quality of life of clients, despite a severe shortage of medicines in the clinics (Jenkins et al. Submitted 2012). As focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems (Sharfritz and Roberts. Health Transit Rev 4:81-85, 1994), the experiences of the participating clients were explored through qualitative focus group discussions in order to better understand the potential reasons for the improved outcomes in the intervention group.

METHODS

Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 clients from the intervention group clinics where staff had received the training programme, and 10 clients from the control group where staff had not received the training during the earlier randomised controlled trial.

RESULTS

These focus group discussions suggest that the clients in the intervention group noticed and appreciated enhanced communication, diagnostic and counselling skills in their respective health workers, whereas clients in the control group were aware of the lack of these skills. Confidentiality emerged from the discussions as a significant client concern in relation to the volunteer cadre of community health workers, whose only training comes from their respective primary care health workers.

CONCLUSION

Enhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcomes for clients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed.

TRIAL REGISTRATION

ISRCTN 53515024.

The effects of Global Fund financing on health governance in Brazil

Objectives

The impact of donors, such as national government (bi-lateral), private sector, and individual financial (philanthropic) contributions, on domestic health policies of developing nations has been the subject of scholarly discourse. Little is known, however, about the impact of global financial initiatives, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, on policies and health governance of countries receiving funding from such initiatives.

Methods

This study employs a qualitative methodological design based on a single case study: Brazil. Analysis at national, inter-governmental and community levels is based on in-depth interviews with the Global Fund and the Brazilian Ministry of Health and civil societal activists. Primary research is complemented with information from printed media, reports, journal articles, and books, which were used to deepen our analysis while providing supporting evidence.

Results

Our analysis suggests that in Brazil, Global Fund financing has helped to positively transform health governance at three tiers of analysis: the national-level, inter-governmental-level, and community-level. At the national-level, Global Fund financing has helped to increased political attention and commitment to relatively neglected diseases, such as tuberculosis, while harmonizing intra-bureaucratic relationships; at the inter-governmental-level, Global Fund financing has motivated the National Tuberculosis Programme to strengthen its ties with state and municipal health departments, and non-governmental organisations (NGOs); while at the community-level, the Global Fund’s financing of civil societal institutions has encouraged the emergence of new civic movements, participation, and the creation of new municipal participatory institutions designed to monitor the disbursement of funds for Global Fund grants.

Conclusions

Global Fund financing can help deepen health governance at multiple levels. Future work will need to explore how the financing of civil society by the Global Fund and other donors influence policy agenda-setting and institutional innovations for increased civic participation in health governance and accountability to citizens.