Abstract
Introduction:Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view.Methods:27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed.Results:Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact.Discussion:This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial.
Highlights
Many countries have been implementing integrated care, the scale-up remains difficult
The barriers and facilitators identified in the interviews were classified into three kinds of factors: 1) integrated care factors; 2) health care system factors, consisting of barriers linked to health care delivery, data sharing and the health care payment system; and 3) policy factors, including fragmentation of responsibilities, participation and political culture
Interview participants used various terms, including: comprehensiveness, continuity, cooperation, accessibility and patient-centredness. Despite their use of similar and related concepts, the extent or depth of integrated care implementation that they envisioned differed. Some stakeholders expressed they were satisfied with a project promoting interprofessional cooperation, while others believed integrated care should go as far as transforming the entire health care system
Summary
Many countries have been implementing integrated care, the scale-up remains difficult. Despite global consensus on the need for integrated care [7], implementation and scale-up in many countries is constrained by various barriers and challenges [3, 8] Such barriers are linked to gaps in leadership, organizational culture, information technology, communication, capacity, resources and provider commitment [9,10,11,12,13]. There is a gap in the literature on these macrolevel factors, such as legislation and policies to support integrated care or its financing [14] Both Struijs et al [15] and Minkman [16] have urged for more research to be undertaken on macro-level contextual factors such as governance and payment models. Afterwards, the federal Minister of Health decides to accept these conventions or not
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