LESSONS LEARNT FROM THE CASE
STUDIES ON INTEGRATED HEALTH
SERVICES DELIVERY NETWORKS
AND VERTICAL PROGRAMMES
Edwin Vicente C. Bolastig, MD, MSc
Consultant, PAHO/WHO
14th September 2010
Rovanel’s Resort, Tobago
2 Presentations:
• Case Study on the Integration of
HIV/AIDS Services in Trinidad and Tobago into
Maternal, Newborn & Child Health Services,
as well as Sexual and Reproductive Health
Services, including Family Planning (focused
on Tobago findings)
• Experiences and Lessons Learned from Case
Studies in the Region of the Americas
2
Case Study on the Integration of
HIV/AIDS Services in Trinidad and Tobago
into Maternal, Newborn & Child Health
Services, as well as Sexual and Reproductive
Health Services, including Family Planning
Edwin Bolastig, Yoko Laurence and Karen Pierre
Funded by:
Pan American Health Organization/ World Health
Organization
OBJECTIVES OF CASE STUDY
• To contribute to the body of work on
health services integration
• To determine: “how vertical
programs and Global Health
Initiatives have impacted on the
health system, and affected
segmentation/fragmentation”
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TRINIDAD AND TOBAGO:
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Southernmost Caribbean country
Independence 1962; Republic 1976
Parliamentary democracy
Multi-ethnic population: 1.3M
Oil and gas-based economy
GNI per capita (09):US$ 17,884
10-year GDP growth(99-08): 7.7%
Epidemiologic shift: CNCDs over
60% of deaths
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CONTEXT
• First HIV case diagnosed in 1983
• 8th leading cause of death in 2004
• STI-HIV co-infection prevalence rate: 42% (60% M ; 40% F)
(Buensuceso, 2008)
• HIV/AIDS cause enjoys strong political support
• World Bank loan, EU grant, CARICOM PANCAP, government,
private sector funding
SOCIAL DRIVERS:
• Poverty and unemployment
• Gender inequality/domestic violence
• High mobility: Caribbean diaspora
• Stigma and discrimination
• Multiple sex partners/Early initiation
• Substance abuse/unprotected sex
(UNAIDS , 2005)
ECONOMIC DRIVERS:
• Inequitable income distribution
• Sex work due to poverty
• Rapid urbanisation
• Limited skills and poor socialisation
• Sex-oriented tourism
(Camara, CAREC, 2002)
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BROAD SECTORAL CONTEXT
• 1986 – National AIDS Programme
• 1993 – Caribbean Charter on Health Promotion
• 1996 – Health Sector Reform Programme (HSRP)
National Health Promotion Plan
• 2001 – Health Promotion Council; Directorate of
Health Promotion and Public Health
• 2004 – National AIDS Coordinating Committee (NACC)
• 2005 – Vision 2020
• 2006 – MOH Corporate Plan (2006-2009)
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SEGMENTATION/FRAGMENTATION
• Decentralisation of health service delivery to
RHAs with the exception of Vertical
Programmes and Services
• Fragmented human resource management
• Dual employment system
• Information and medical records management
largely manual
• Unstructured referral system
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HIV INTEGRATION INITIATIVES
• Integration with Maternal and Child Health PMTCT
• Integration with STI and Family Planning - VCT
• Integration with Population Programme - PITC
• Integration with Chronic Disease Care
– Tobago Health Promotion Clinic (THPC)
• Integration of Treatment with Prevention – San
Fernando General Hospital
• Integration of Information Systems for HIV/AIDS
– TERIDA Project
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Description of the Process of Integration
of HIV/AIDS services in Trinidad and
Tobago using PAHO’s Framework on
Integrated Health Services Delivery
Networks (IHSDN)
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1. The covered population/territory is defined
and there is broad knowledge of its health
needs and preferences, which determine the
services provided by the system.
• HIV Prevalence: 1.5% of Population
(generalised epidemic)
• Perception that high-risk groups are welldefined but targeted prevention not
happening
• In Tobago, youths targeted but not MSM or
sex workers
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2. An extensive offer of health facilities and
services, which include public health services,
health promotion, disease prevention, timely
diagnosis and treatment, rehabilitation, and
palliative care, all under a single
organizational umbrella.
• Tobago Health Promotion Clinic (THPC) – Dr
Noel
– behaviour modification, social services, housing,
religious/pastoral services, mental health,
substance abuse, mobile services, nutrition,
dental referral, etc.
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3. A first level of care that acts as the de facto
gateway to the system, integrates and
coordinates health care, and meets most of
the population’s health needs.
• Tobago Health Promotion Clinic (THPC) is the
gateway into the system
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4. Specialist services delivered in the most
appropriate place, preferably non-hospital
settings.
• Pregnant women referred to THPC
• Baby treated at paediatric ward in TRH
• One (1) HIV specialist in Tobago for adults but
none for paediatric care
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5. Coordination of care mechanisms exist
throughout the entire continuum of services.
• A full and integrated coordination of care
mechanism is compromised due to:
– A lack of feedback to and from TPHC
– Ineffective utilisation and training of personnel
within organisations.
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6. Health care centered on the person, the
family, and the community/territory.
• Health professionals from the health centres
and THPC sometimes go out to the
community to do testing via the Mobile Clinics
at football games or all-fours clubs.
• THPC has a programme that provides support
to discordant couples, allowing these couples
to have children who eventually turn out to be
negative
• No prevention programme for at risk families
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7. A single, participatory governance system for
the entire IDS.
• National Strategic Plan for HIV/AIDS is
monitored by the NACC under the Office of
the Prime Minister), while implementation of
the Health Sector Plan is monitored by the
Ministry of Health through HACU.
• In Tobago, THPC falls under the Tobago House
of Assembly (THA); Tobago HIV/AIDS
Coordinating Committee (THACC) serves as
the link between NACC and THA
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8. Integrated management of administrative
and clinical support systems.
• Disparate administrative and clinical support
systems are not managed in an integrated
manner
• At THPC, administrative and clinical support
addressed by some administrative staff but
everyone working at clinic can provide
support services if necessary
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9. Sufficient, competent human resources,
committed to the system.
• Human resources for the THPC are considered
insufficient given the comprehensive nature of
the clinic in terms of HIV and chronic disease
treatment, which has caused the clinic to grow
continuously since its inception.
• Only 16 of required staff of 27
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10. An integrated information system that links
all members of the IDS.
Trinidad & Tobago
HIV/AIDS Web-based Information System
Figure 1: TERIDA –
IT System Diagram
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Expansion to other
Stakeholders:
Tobago GH & clinics
Mt. Hope Pediatric ward
PoSGH clinics
Sangre Grande GH
Others
MRF
(Medical
Research Foundation)
HIV/AIDS
Ward, SFGH
Cellma
(CMS)
Cellma
(CMS)
QPCC&C
North
Cellma
(CMS)
NACC
Health Metrics 3D
(BI)
Internet
QPCC&C
South
Cellma
(CMS)
• Tobago not included
in pilot project
TPHL
M/Lab
IT Dept
MoH
NBTS
Blade Server
Health Exchange
Platform
Blood Bank e-Progresa
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NSU
Health Metrics 3D
(BI)
Forsys (PHR-EMR)
X4H
Oracle DB
Application Software
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·
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Cellma: Clinical Management System (CMS)
M/LAB: Laboratory Information System
HM3D: Business Intelligence suite (BI)
Forsys: Patient Health Records (PHR)
E-Progresa: Blood bank management System
Health Exchange Integration Platform Hub
X4H: Expert System for Health
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11. Adequate financing and financial incentives
aligned with the goals of the system.
• 2 schools of thought in terms of adequacy of
financing:
– There is enough funding for HIV/AIDS, the
problem is effective utilization and despite huge
investments, there is no reduction of HIV in the
general population.
– Financing could never be enough: as progress is
made in diagnosis and treatment, new techniques,
equipment and drugs emerge in the market.
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12. Broad intersectoral action.
• Collaboration between THPC and support
groups like TAS, OASIS and others
• THACC is known for engaging the community
through the village councils in the
implementation of HIV-related projects.
• Corporate sponsorships but discrimination
happens in the workplace
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EMERGING MODELS
Three (3) Emerging Models of Integration:
1. Standalone outpatient HIV/AIDS clinic
integrated with chronic disease care (Tobago
Health Promotion Clinic)
2. Hospital-based HIV/AIDS testing and
treatment centres – adult & paediatric (San
Fernando General Hospital)
3. Satellite network of multi-tiered hospital
based and outpatient health facilities
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MODEL 1 – Stand Alone
ADVANTAGES/STRENGTHS
•By associating HIV/AIDS with other
chronic diseases, stigma and
discrimination may be minimised
•Unique branding strategy associating
comprehensive approach with quality
care
•Well-organised manual record-keeping
transitioning to a paperless information
system
•Multi-tasking of health workers
•Triaging according to purpose of visit
(counselling and testing, pick-up of ARVs,
consults, etc.) to avoid long queues and
waiting times
•Community outreach activities (home
visits) ensures good follow-up/ return
rates
GAPS/WEAKNESSES
•Weak linkage with health
centres doing counselling and
testing
•Referrals have to be made to
the Scarborough General
Hospital for treatment of
paediatric patients and to the
OB/GYN Ward for pregnant
women
•Inconspicuous location – not
all potential clients are aware
of the clinic site (Conversely,
could be an advantage too)
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MODEL 2 – Hospital Based
Testing and Treatment
ADVANTAGES/STRENGTHS
•Simulates “one-stop
shop” for services (STI,
HIV/AIDS testing,
counselling and treatment,
maternal and child care,
etc.) in a single health
facility/ compound
GAPS/WEAKNESSES
•Weak community
outreach services
•Link to family planning
services missing
•Hospital-based care is
known to be generally
more expensive than outpatient care
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MODEL 3 –
Multi-tiered Satellite Network
ADVANTAGES/STRENGTHS
•“Hand-holding” approach to
referral of patients to other
health facilities
•Assurance of a wide range of
services
•Relatively good feedback
being received from facilities
where patients were referred
to
GAPS/WEAKNESSES
•Patients being lost in the process
of referring to another health
facility
•Patients being lost to follow-up
•Longer time spent in securing
appointments and attending
clinics
•Travel and opportunity costs of
attending multiple clinic schedules
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FINANCING – Total TTD 253.5 million
1 USD = 6.29 TTD
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BENEFITS
1. Programmes – institutionalisation of PMTCT;
integration of VCT with SRH; free ARVs
2. Resources - high levels of funding for HIV/AIDS
also used for MCH, STIs and FP
3. Processes - shift from a programme approach
to institutionalisation of interventions
4. Intermediate products – build capacity of
committed health personnel
5. Outcomes – increased HIV testing among
mothers; improved efficiency in some areas;
community outreach
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TWO SCHOOLS OF THOUGHT ON
INTEGRATION:
Strengthening of services as
pre-requisite to integration
vs.
Integration as means to
improve services
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LESSONS LEARNT
Facilitating factors:
• Role of advocates and champions in the health
system
• Perception of strong political support from
government
• Health promotion (high risk groups and wider
population)
• Service delivery decentralisation (RHAs)
• Increased resources for HIV/AIDS
• Expanded role of civil society – “knowledge broker”
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LESSONS LEARNT
Hindering Factors:
• Structural and support services
– inadequate infrastructure, human resource
shortages, weak reporting and referral systems
• Socio-cultural
– breach of confidentiality, S&D, territorialism, lack of
accountability
• Policy and legal environment
– lacks policy framework for zero tolerance to S&D,
non-adherence to protocols/SOPs
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AREAS FOR IMPROVEMENT
1.
2.
3.
4.
5.
Socio-cultural
Health workforce
Service delivery
Systems interventions
Policy and legal environment
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CONCLUSIONS
• Resources for HIV/AIDS supported integration
of HIV services with other health programmes
such as Maternal and Child Health
• GHIs did not seem to have undermined
national planning and policy development
process
• Integration process aligned with national
priorities, along existing mechanisms for
coordination
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Experiences and
Lessons Learned in the
Region of the Americas:
Case Studies
Regional Advisory Meeting:
Integrated Health Services Networks
and Vertical Programs
Cusco, Peru
11 and 12 November 2009
Hernán Montenegro and Caroline Ramagem
Area of Health Systems and Services
PAHO/WHO
Integration Initiatives in LAC
Country
Initiative
Argentina
Law creating the Integrated Federal Health System
Bolivia
Municipal Intercultural Family and Community Health
Networks and Network of Services
Brazil
Better Health: The Right of All 2008-2011
Chile
Health Care Networks Based on Primary Care
El Salvador
Law creating the National Health System
Guatemala
Coordinated Health Care Model
Mexico
Functional Integration of the Health System
Peru
Guidelines for forming networks
Dominican Republic
Regional Health Services Network Model
Trinidad and Tobago
Experience of the Eastern Regional Health Authority
Uruguay
Integrated National Health System
Venezuela
Health Network of the Metropolitan District of Caracas
Summary of Case Studies
Lima Workshop, 9 November 2009
Country
Type of Case
Integrated health services networks
Integration of vertical programs (6)
(2 topical + 3 general = 5)
Brazil
• Care for women and children: “Mãe
• HIV/AIDS (National)
Curitibana” (Curitiba, Paraná)
• Urgent/emergency care (Northern
Macroregion, Minas Gerais)
Chile
Guatemala
• Ñuble Health Service
• Metropolitan Health Services
• Children: “Chile Grows With You”
(National)
• Ministry of Public Health and Social
Welfare and Guatemalan Social
Security Institute (Department of
Escuintla)
Colombia
• Tuberculosis (National)
Peru
• HIV/AIDS (National)
Dominican
Republic
• HIV/AIDS (National)
Trinidad and
Tobago
• HIV/AIDS (National)
FACILITATING FACTORS AND
BARRIERS
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FACILITATING FACTORS
• Political commitment and backing
• Availability of financial resources
• Leadership of health authorities and service
managers
• Decentralization and flexibility of local
management
• Alignment of financial and non-financial
incentives
• Culture of collaboration and teamwork
• Active participation of stakeholders
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STRUCTURAL BARRIERS
• Segmentation and weakness of health
systems
• Reforms of the 1980s and 1990s:
– Privatization of insurance
– Differentiated service portfolios
– Provider competition
– Diversification and instability of labor
regimes
– Regressive cost-recovery schemes
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STRUCTURAL BARRIERS
• Powerful opposing Interest groups:
– Specialists and super-specialists
– Private insurers and social security
– Pharmaceutical industry, supply industry,
etc.
• External financing modalities (Global Health
Initiatives)
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NON-STRUCTURAL BARRIERS
• Deficiencies in information, monitoring, and
evaluation systems
• Management weaknesses
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• Thank you!
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