Integration has become a global trend in health care reform, and for good reason.
Many low- and middle-income country health systems struggle with enduring deficiencies, including service delivery fragmentation and duplication, low quality and continuity of care, and patient dissatisfaction. Integration – a linking of the delivery, management and organization of services at every stage of health promotion - promises to address all these issues, improving access, quality, efficiency and patient satisfaction in the process.
The goal of increased efficiency has particular urgency in light of international funding constraints and fewer national resources due to a changing global economic landscape. A case in point: Namibia, whose recent re-classification as a middle-income country by the World Bank has led many groups in the donor community to pull funds in search of alternative investment locations in lower-income countries.
In response, the country is actively assessing resource allocation at the national level, and exploring ways to make the health system function more efficiently. One approach involves decentralizing decision-making power to the regional level. Another involves integration of services within Namibia, which could allow health resources to be realigned to ensure greater impact with fewer resources. Combining these approaches, the decentralized integration of services enables the ministry of health to respond to community needs and tailor health programs with a greater degree of flexibility. Integration can focus on three areas:
Integration across disease areas
Integrating disease areas and service-specific funding streams may help care providers to treat the entire patient with both curative care for current conditions and preventive care based on risk factors. In this type of integration, the ministry of health may improve coordination within their portfolio of services, while coordinating with other health programs in the community to provide complementary care. For instance, it could incorporate diabetes and hypertension screening and health education into a program for rural distribution of HIV/AIDs treatments, taking fuller advantage of its visits to community households.
Integration between the tiers of the health system
Similarly, integration between all levels of the health system (i.e., primary, secondary and tertiary) may help improve information asymmetries. Sharing information on disease burden and community needs will enable more effective health care priority setting at the national level. This will enable more consistent monitoring and evaluation of health trends, particularly at the lowest level of the health system, eg: community health workers that are often not formally integrated with the primary tier of health care. These workers are regularly the first point of contact for community members, particularly those living in more remote locations. They can provide a temperature read for the health and well being of the entire community, and therefore may be an asset to health system priority setting when integrated appropriately.
Integration across sectors
Finally, integration across sectors can unite government ministries, civil society groups and businesses in achieving health-related objectives – even when those groups aren’t focused specifically on health care. For example, improvements in water and sanitation, education, etc. can lead to better overall community health services and personal health outcomes. By capitalizing on obvious synergies, a government can disseminate a uniform message of health promotion across regional stakeholders. For instance, the ministry of water and sanitation may help improve the quality of community water sources, while also promoting safe water use to reduce the incidence of diarrheal disease and other waterborne illnesses.
Health care for the people by the people
These three methods of integration set the foundation for the Rural Health Integrated Network (RHIN) project, a three-year initiative started in February 2012. Focused on Namibia, the project is facilitated by Geneva Global, a US-based performance philanthropy organization owned and run by a core team of regional representatives. The RHIN project seeks to create a regionally focused strategy for health systems integration that may be scaled to other regions throughout Namibia, while providing a model for global practice on rural health integration.
Not often in development practice do you see this type of consistent community-level engagement and effort to build a path forward together. The RHIN project has followed a community-based participatory collaboration model, mixing active research and evaluation with innovative prototype design and implementation. Its unique approach is the result of nurtured dialogues, direct partnerships and constant feedback between international, national, regional and district level stakeholders. Early relationships were formed not on the basis of a clear set of project objectives, but with an idea of co-creating the scope of work together and recognizing one another’s strengths.
This model requires some degree of socio-political stability and a supportive, enabling environment. National and, more importantly, regional groups had to be willing to partake in an initiative with a continually evolving vision for action in the first year. For some, this might present too much of a risk for available resources (time, money and human capital) to absorb. The RHIN group was termed a “coalition of the willing,” a group willing and able to partner to identify work that could improve the status quo. Beyond building this coalition at the community level, the initiative also sought to connect nationally situated government groups, NGOs, businesses and academic groups to improve health care integration.
The RHIN project created a platform through which individuals and organizations - with separate experiential backgrounds, resource pools and knowledge of current national activities - can converse and share best-practices. This collaborative platform has also become a means to connect regional change agents with nationally and internationally active groups that may have an interest in specific integration micro-projects. Their presence and organization acts as a level of risk assurance that investments will make the greatest use of existing synergies.
Growth of new collaboration
As a result of initial RHIN project conversations, Mister Sister is now in active conversation with regional representatives from the ministries of health and education to develop clinics in the RHIN project region of northern Namibia. (Previously featured on NextBillion, the organization is known for their innovations in health care service delivery to remote populations.) Similarly, academic partners like the prestigious executive MBA programs at the Wharton School of Business and HEC Paris are now engaged with Geneva Global to advise on micro-projects. Their collaboration includes a multi-sectoral marketing campaign and strategies to engage private businesses in collaborative health projects.
The William Davidson Institute is also involved in shaping the design of this project. The Healthcare Research Initiative at WDI has advised it on baseline research design, other service delivery innovations in emerging markets, and monitoring and evaluation plans to assess the impact of micro-projects. Over the course of the next year, we are particularly interested in examining the ways a community-based model can impact the engagement of businesses (both health-related and non-health-related) in a larger health campaign.
Laying a foundation
The valuable experience of existing stakeholders can lay the foundation for re-engineering an integrated health care delivery system that reaches remote areas and engages implementers and stakeholders at various levels of the system. The RHIN program will continue to seek solutions that reduce costs, create efficiencies and improve the quality of care. However, no single model will solve all the health problems faced by rural communities. Each will need to be adapted to meet the needs of the population.
Further practical evidence is needed to guide health systems integration and inform local best practices. In the next phase of the RHIN project, micro-projects that address community-identified needs will help to inform longer-term sustained methods for service integration. These micro-projects are still in their formative stages, but they will have the following broad focuses:
Training and accrediting home-based care providers, the frontline health care worker in the Ohangwena region
Linking schools with nearby health facilities
Identifying innovative ways to engage the business sector in community health initiatives
These projects will be monitored, and their impact in improving the integration of services and health outcomes will be evaluated. After a year of piloting, another convening of stakeholders will help refine the process to move forward. We hope that the lessons learned will provide a model that can help make effective integration of health care services a reality in Namibia and beyond. We will also explore how the time and energy spent building mutual respect and understanding really impacts community solidarity, helping to integrate multiple sectors and facilitate joint action for health.