Integrated Service Delivery Research Articles

Challenges of scaling-up of TB-HIV integrated service delivery in Ghana.

Integration of tuberculosis and HIV services in many resource-limited settings, including Ghana, has been far from optimal despite the existence of policy frameworks for integration. A previous study among programme managers and other stakeholders at the national level has documented tardiness in committing to the integration of services. In this paper, we aimed at unravelling pertinent challenges that confront TB-HIV integrated service delivery. Data were obtained from interviews with 31 individual health care providers operating under different models of TB-HIV service delivery. The study is framed around the Complexity Theory. We applied inductive and deductive techniques to code the data and validations were done through inter-rater mechanisms. The analysis was done with the assistance of QSR NVivo version 12. We found evidence of a convivial working relationship between TB-HIV service providers at the facility level. However, the interactions vary across models of care–the lesser the level of integration, the lesser the complexities for interactions that ensued. This had resulted in operational challenges on account of how the two-disease environment interacts with the other components of the health system. These challenges included; weak/inappropriate infrastructure, frail coordination between the two programmes and hospital administrators, under-staffing in comprehensive TB–HIV management, use of community facility under the Directly-Observed Treatment (DOT) protocols, and financial constraints. To fully appropriate the enormous benefits of TB-HIV service integration, there is a need to address these challenges.

Using a Multisectoral Approach in Tackling Child Sexual Abuse: Lessons from a Zimbabwean Case Study

Child sexual abuse is one of the prevalent social ills that affect children in Zimbabwe. In response to the problem of child sexual abuse and the need to mitigate its adverse effects, Zimbabwe established the Victim Friendly System. The Victim Friendly System is a multisectoral forum made up of social workers, medical doctors, nurses, the police force and role players within the justice system such as magistrates, prosecutors, counsellors, educationists and psychologists. These professionals offer distinctive but complementary interventions to child survivors of child sexual abuse. This paper discusses the merits and lessons gleaned from using the Victim Friendly System as a multisectoral forum to tackle child sexual abuse. In researching this phenomenon, the study adopted a qualitative approach and data were collected from 38 participants and 4 key informants selected using theoretical and purposive sampling respectively. A total of 300 court files of child sexual abuse cases were also reviewed. The findings that emerged from the study show that a multisectoral approach to dealing with child sexual abuse provides the benefit of integrated service delivery. Improved outcomes for victims of sexual abuse as well as streamlined, effective and efficient operations for organisations that form part of the Victim Friendly System were also evident. This notwithstanding, the paper also discusses some areas of concern that could potentially affect how the Victim Friendly System multisectoral arrangement works. The lessons that emerged from the study provide some insights that are useful in informing guidelines for multisectoral arrangements.

Global public health efforts to address HIV and related communicable disease syndemics.

To review recent progress in public health efforts to address HIV, and the extent to which key approaches can be applied to three key epidemics that commonly co-occur with HIV: TB, viral hepatitis, and STIs. The public health approach to tackling HIV in low-income and middle-income settings relied on standardized treatment regimens and monitoring approaches, task sharing and community involvement, and decentralized and integrated service delivery. These approaches can all be applied to three key epidemics that commonly co-occur with HIV: TB, viral hepatitis, and STIs. HIV, viral hepatitis, and STIs share common routes of infection, and HIV weakens the immune system, increasing the risk of TB. A public health approach can be applied to address these syndemics.

Exploring the foundation for Collaborative Governance to support early childhood in Nova Scotia

ABSTRACT Providing the best start for our youngest generation is a growing priority internationally. Integrated Service Delivery (ISD) offers an approach to address complex system challenges and improve access to early childhood public services for young children and their families. The purpose of this paper is to use the Integrative Framework for Collaborative Governance to reflect on the elements of collaboration that may have influenced the establishment and implementation of an early childhood ISD approach in Nova Scotia (Canada). The provision of adequate resources for partnership development, clarification of roles and formal agreements to enable commitment and the importance of building collaborative capacity among partners was found to be critical to develop a shared vision for ISD for early childhood. The Integrative Framework for Collaborative Governance provided a useful lens to consider some of the interactive components of ISD in the early childhood initiative and further, more in-depth study is warranted to determine which components are necessary for collaborative success.

A COLLABORATIVE PARTNERSHIP BETWEEN SCHOOL SOCIAL WORKERS AND EDUCATORS: A VEHICLE TO ADDRESS THE SOCIAL CONTEXTS OF LEARNERS AND QUALITY OF EDUCATION IN SOUTH AFRICA

Education is a core indicator of a society’s well-being. Globally, it is an established practice to include school social work into the education system. In South Africa, however, it is rarely integrated into the education system. This is a conceptual paper focusing on the social context of school-going children, reflecting on the existing well thought-through frameworks of psychosocial support and care and integrated service delivery of the South African Departments of Education and Social Development, and also questioning why collaboration between the Departments to implement the frameworks in the school environment appears to be a complicated and slow process.

Sustainable Undernutrition Reduction in Ethiopia (SURE): A Qualitative Study Assessing Feasibility of the Program Implementation in Basona Worana District, Ethiopia

Abstract Objectives The Ethiopian government designed the SURE program which aims to reduce the prevalence of stunting by improving complementary feeding and dietary diversity as part of its national nutrition program. This study was conducted to test the feasibility of the SURE program before its implementation. Methods A qualitative research design with purposive sampling was employed for this study. A five-day overall SURE program training was provided for 6 health extension workers (HEWs) and 10 agriculture extension workers (AEWs). Trainees completed pre-post knowledge tests. Following their training, two pairs of health and agriculture extension workers jointly conducted household visits in each of three selected kebeles (sub-unit of district) to assess needs and counsel mother-father pairs. They also facilitated women's and men's group dialogues to reinforce messages in gender-specific peer groups. Research assistants and investigators observed 12 joint household visits. To further assess the program, 24 semi-structured interviews with extension workers and mother-father pairs and 6 focus group discussions with men's and women's groups were conducted. Data were analyzed using Nvivo version 11. Results Health and agriculture extension workers gained demonstrable knowledge about infant and young child feeding and nutrition-sensitive agricultural practices following their training, but they largely failed to apply the 3A's counselling process (assess, analyze and act) and delivered inconsistent messages during the counselling visits based on observation. However, they felt that they can realistically continue to work together. Pairs of mothers and fathers visited were supportive of the joint HEWs and AEWs visits. Focus group discussants from women's groups reported that segregating the group discussions by gender was helpful to ensure their participation and expression of ideas. Conclusions The SURE training provided to HEWs and AEWs resulted in knowledge retention. The integrated service delivery model of the SURE program is well-accepted by both extension workers and mother-father pairs. Further support to build counselling skills will be needed to improve program processes and the quality of services. Funding Sources Childrens' Investment Fund Foundation (UK) funded this research. No other involvement in carrying out the research activities.

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Tuberculosis and HIV coinfection and related collaborative activities in Latin America and the Caribbean.

ABSTRACTObjective.To inform about the most recent epidemiological trends and integrated programmatic response to tuberculosis (TB) and HIV coinfection in Latin America and the Caribbean (LAC).Methods.A descriptive review analyzed the most relevant indicators on TB/HIV coinfection in 33 countries in LAC with a cross-sectional and time-trend approach. Data were obtained from publicly available databases and analyzed through simple proportions, weighted means, and risk ratios.Results.In LAC, during 2017, 80.8% of TB patients were actively screened for HIV, with a 25.6% increase between 2011 and 2017. In the same year, the proportion of TB patients with HIV-positive status was 11.2%, with a small but progressive reduction of 5% since 2011. The provision of antiretroviral therapy and anti-TB medication among TB/HIV coinfected patients for 2017 was at 60%. Only one-third of people living with HIV had access to isoniazid preventive therapy. Overall, the mortality in the TB/HIV cohort has not changed since 2012, hovering at around 20%.Conclusions.TB/HIV collaborative activities, as the backbone to address TB/HIV coinfection, are being scaled up in LAC and some indicators show a tendency toward improvement; nevertheless, our review shed light on the need to keep strengthening integration of service delivery, joint monitoring and evaluation, and data quality.

A One Health framework for integrated service delivery in Turkana County, Kenya

Pastoralists in sub-Saharan Africa have limited access to public services due to their mobile lifestyle, economic and political marginalization, and the limited health infrastructure that is common to arid and semi-arid lands (ASALs) where they primarily reside. This often results in poor health outcomes, including increased rates of maternal, neonatal, and under-5 mortality. One Health approaches that integrate human and animal health service delivery can help to improve pastoralists’ health through increased vaccine coverage and improved access to services.Kenya has institutionalized One Health at the national level; however, progress at the subnational level has been limited due to sustainability concerns, competing priorities, and insufficient coordination platforms. To address this gap, this paper presents a One Health framework (OHF) to aid in the implementation of integrated human and animal health policies in Turkana County, which can act as a model for other ASALs. Utilizing a grounded theory design, we conducted semi-structured interviews and focus group discussions with human health, animal health, and pastoralist stakeholders. Inadequate engagement with the public sector was identified as a major limitation by community members. Factors that contributed to this include distance to health facilities and restricted department capacities such as availability of vehicles, personnel, and cold chain maintenance.Our proposed OHF harnesses the existing structure of service delivery in Turkana and establishes an official coordination mechanism to implement One Health activities, through the form of mobile “One Health Huduma Centres”, offering a range of public services. This innovative framework is supported by stakeholders in Turkana and can improve service delivery constraints thereby improving the health of Turkana pastoralists.

Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi

BackgroundSeveral performance-based financing (PBF) evaluations have been undertaken in low-income countries, yet few have examined community perspectives of care amid PBF programme implementation. We assessed community members’ perspectives of Support...

Building a People-Centred Integrated Care Model in Urban China: A Qualitative Study of the Health Reform in Luohu.

Introduction:China has adopted a people-centred integrated care model to reform its severely hospital-centric and fragmented delivery system. As a template of this model in urban China, the Luohu Hospital Group has generated considerable public and academic interest to scale it up.Methods:Guided by a policy triangle framework, this qualitative study explored the context, actors, content, and process of founding the Luohu Hospital Group. Three semi-structured interviews and five focus groups were conducted among 35 key informants. Content analysis was used to analyse the data.Results:The reform in Luohu took place in a competitive health care market, based on the comprehensive health reform in Shenzhen. Under the strong leadership of the district government, the reform adopted comprehensive strategies to strengthen primary care and care coordination, improve the quality and efficiency of health care delivery, and promote population health. The reform achieved a high level of organisational integration but was still in the process of fulfilling professional and clinical integration.Conclusions and discussion:The establishment of the Luohu Hospital Group transformed the originally fragmented delivery system into a tightly integrated service delivery networks. Though valuable lessons have been generated, the reform and its impacts require ongoing monitoring.

Understanding the diversity of alliance governance in OECD healthcare settings

PurposeHealthcare alliances are a mechanism for developing collaborative and integrated care governance and service delivery arrangements. Yet is not known how widespread alliance arrangements are in Organisation for Economic Co-operation and Development (OECD) countries, how alliances function or how effective they are. The purpose of this paper is to provide an overview of alliances in OECD countries, including key areas covered and how performance is measured.Design/methodology/approachA structured narrative review of literature published between 2010 and 2018 was undertaken, focussed on OECD countries. The literature included peer-reviewed articles as well as publications from key policy analysis organisations.FindingsMany OECD countries have implemented integrated care models but only a small number had explicitly adopted health alliances that link primary and secondary providers under joint governance arrangements. Most alliances are pilot initiatives and not broadly adopted. Most had not adopted a unified performance measurement framework.Practical implicationsPolicy makers and service providers interested in joint governance arrangements that support integration must consider the range of potential options overviewed in this paper, as well as how to create supportive performance measurement frameworks.Originality/valueThis is the first narrative review of alliance arrangements in OECD countries. It provides an overview of arrangements, while illustrating that there is considerable scope for further alliance development.

Integrating services for impact and sustainability: a proof-of-concept project in KwaZulu-Natal, South Africa

Background: Integration of services in primary health care settings can provide mother/baby pairs with all required services at one visit. This study aimed to evaluate a proof of concept, quality improvement (QI) intervention to strengthen well-child service provision and integration with maternal health services in five rural clinics in KwaZulu-Natal, South Africa.Methods: Quantitative cross-sectional surveys were conducted among mothers bringing their child for well-child services, before and after implementation of the intervention. Exit interviews and reviews of the child’s Road to Health Booklet (RTHB) were conducted to determine services provided at the visit, and the time spent in the clinic was observed and recorded.Results: A total of 413 exit interviews and record reviews were conducted (123 at baseline and 290 at follow-up). At follow-up, significantly more mothers were tested for HIV during the well-child visit (9.2% vs. 22.6%; p = 0.045) and significantly more mothers received ART (3.7% vs. 35.5%; p = 0.010). However, coverage of growth-monitoring services remained low and there was no difference in infant feeding advice provided to mothers at baseline and follow-up (49.5% vs. 49.7%; p = 0.996). More mothers interacted with a registered nurse at follow-up than at baseline (35.8% vs. 80.7%; p = 0.032).Conclusions: Over the implementation period of the QI intervention, improvement was shown in coverage and quality of some maternal health and HIV services, but there was no improvement in growth monitoring. This suggests that QI has the potentialto improve integration of service delivery, but this was a small study and further research is recommended.

Customer Journey Clue-based Service Failure Prevention

Abstract Customers and their perception towards service are considered as a determinant of service failure, and so, service failure and its prevention must be looked into from the perspective of the customers. This paper presents a customer-centric service failure prevention framework, which aims to provide a holistic way of service failure prevention by integrating service delivery assessment and failure analysis from a customer perspective, encompassing failure identification, assessment and prioritization of failures as a basis for corrective actions. Customer journey, service clues, and customer oriented-FMEA are employed to develop the proposed framework. The approach was applied to an enrolment process showing that using customer journey assists in determining customer processes, needs, wants and touch points in the service, and when used together with service clues further facilitates systematic and effective unveiling of potential failures that are important to customers. Assessment of failures and its prioritization with customer perspective leads to better prioritization that is reflective of the voice of customers. The case study shows that higher risk is imposed by actions emanating from the employees, reinforcing further that service failures not only concern functionality of the service but equally important also are the encounter of customers with service employees and the environment.

Organising preventive care and support networks: a need for citizen-centred service delivery

Abstract Background There is a growing interest in providing preventive care and support services at a district level (Goodwin, 2014; Kernaghan, 2005) in a citizen-centred way, i.e., accessible, delivered seamlessly, and complying with citizens’ needs and capabilities (King & Meyer, 2006). Currently, those citizens who might need it most are not reached and services provided suffer from a lack of coherence (Kodner, 2009; Stange, 2009). This study aims to examine how local authorities organise more accessible and integrated preventive care and support services against reasonable costs at a district level. Methods An exploratory multiple case study approach was adopted. The unit of analysis was the organisation of the preventive care and support delivery process. Policy documents were analysed and 13 semi-structured interviews were conducted with professionals in four Dutch districts. Results Our findings show that three stages of the delivery process should be distinguished, as within each stage a set of specific key design decisions were taken aiming to contribute to easy access and integrated service delivery. These three stages are (a) entrance, (b) exploration of needs and capabilities, and (c) the development of care and support networks. Each case showed a unique constellation of choices on these key decisions, and explicated their motives for organising it in this way. Examples of these key decisions are: the number and location of access points, the number of different professionals involved (indicating the level of (de)coupled process), and the type of professionals involved. Conclusions The results show that different stages and design decisions could be identified across the four cases. These, as well as clear interfaces between the stages, can be regarded as a constellation of choices through which citizen-centred delivery could be enhanced. Key messages Importance of design decisions in citizen-centred delivery. Focus on multi-faceted issue of organising integration within the different stages.

Factors for self-assessment score of interprofessional team collaboration in community hospitals in Japan

ObjectiveInterprofessional collaboration is considered an important strategy in overcoming the complex issues associated with healthcare outcomes. A nationwide, community-based integrated care system developed for the care of older people in...

Collaborative Care to Improve Access and Quality in School-Based Behavioral Health.

Collaborative care (CC) is a well-established approach for the delivery of accessible behavioral health services in integrated health care settings. Substantial evidence supports its effectiveness in improving the quality and outcomes of adult services, and growing research indicates utility with child and adolescent populations. To date, studies examining CC models for youth have focused exclusively on primary-care settings. Nevertheless, as the most common integrated service delivery setting for youth, the education sector is an equally important context for improving access to behavioral health services for children and adolescents. We provide a narrative review of the literature on CC, describes the relevance of CC to schools, and details its alignment with contemporary movements in education and school-based behavioral health. Potential adaptations of the CC model for use in schools are detailed to improve: (1) behavioral health service accessibility, (2) the capacity of schools to provide behavioral health services, and (3) school service effectiveness through use of evidence-based practices. Although little research has explored the applicability of CC in the education sector, the model holds potential promise to improve the quality and efficiency of school-based behavioral health services.

Integrated Care Delivery for HIV Prevention and Treatment in Adolescent Girls and Young Women in Zambia: Protocol for a Cluster-Randomized Controlled Trial.

BackgroundAmong countries in sub-Saharan Africa, Zambia has one of the highest incidences of HIV. Adolescent girls and young women (AGYW) are a particularly affected group because of their social and economic vulnerability.ObjectiveThe goal of this study is to test a multilevel package of interventions at the community and health system levels in Zambia in order to connect AGYW with a source of regular care, which will in turn allow for sustainable, successful implementation of regular HIV testing and adherence to antiretroviral treatment.MethodsWe will adapt prior tools to create the SHIELD (Support for HIV Integrated Education, Linkages to Care, and Destigmatization) intervention to educate and empower Zambian AGYW of 10-24 years of age and their families and to create community-based youth clubs to foster peer support. We will also develop integrated wellness care clinics to offer a youth-friendly environment that provides tailored clinical services. We will perform formative research, including focus groups and in-depth interviews, among AGYW, caregivers, and stakeholders to help inform the development and tailoring of the interventions. A cluster-randomized controlled trial will be implemented in Lusaka, with six clinic catchment areas randomized into three groups: zones with integrated wellness care clinics and SHIELD intervention, zones with only SHIELD intervention, and control zones with no intervention. We will assess HIV testing among the HIV-negative or unknown (HIV-/u) cohort, and retention in care along with viral load suppression will be evaluated in the HIV-positive (HIV+) cohort. We will use in-depth interviews and surveys to collect staff and stakeholder feedback after the trial. Cost-effectiveness of the interventions and return-on-investment impacts will be quantified using a microsimulation model.ResultsInterim results are expected in 2021, and the final results are expected in 2022. If this multilevel intervention is successful in establishing a comprehensive care continuum for HIV-affected AGYW, the Zambian Ministry of Health may advocate for expansion to additional settings to support national scale-up.ConclusionsThis integrated service delivery model can also be a platform to implement additional preventive services, so HIV-/u and HIV+ AGYW can receive comprehensive, integrated services.Trial RegistrationClinicalTrials.gov NCT03995953; https://clinicaltrials.gov/ct2/show/NCT03995953 International Registered Report Identifier (IRRID)PRR1-10.2196/15314

Validation of the Rainbow Model of Integrated Care Measurement Tools (RMIC-MTs) in renal care for patient and care providers.

IntroductionIntegrated service delivery is considered to be an essential condition for improving the management and health outcomes of people with chronic kidney disease (CKD). However, research on the assessment of integrated care by patients and care providers is hindered by the absence of brief, reliable, and valid measurement tools.ObjectiveThe aim of this study was to develop survey instruments for healthcare professionals and patients based on the Rainbow Model of Integrated Care (RMIC), and to evaluate their psychometric properties.DesignThe development process was based on the US Food and Drug Administration guidelines. This included item generation from systematic reviews of existing tools and expert opinion on clarity and content validity, involving renal care providers and chronic kidney patients. A cross-sectional, multi-centre design was used to test for internal consistency and construct validity.SettingOutpatient clinics in a large renal network.ParticipantsA sample of 30.788 CKD patients, and 8.914 renal care providers.Methods and analysisBoth survey instruments were developed using previous qualitative work and published literature. A multidisciplinary expert panel assessed the face and content validity of both instruments and following a pilot study, the psychometric properties of both instruments were explored. Exploratory factor analysis with principal axis factoring and with promax rotation was used to assess the underlying dimensions of both instruments; Cronbach’s alpha was used to determine the internal constancy reliability.Results17.512 patients (response rate: 56.9%) and 8.849 care providers (response rate: 69.5%) responded to the questionnaires. Factor analysis of the patient questionnaire yielded three internally consistent (Cronbach’s alpha > 0.7) factors: person-centeredness, clinical coordination, and professional coordination. Factor analysis of the provider questionnaire produced eight internally consistent (Cronbach’s alpha > 0.7) factors: person-centeredness, community centeredness, clinical coordination, professional coordination, organisational coordination, system coordination, technical and cultural competence. As hypothesised, care coordination patient and providers scores significantly correlated with questions about quality of care, treatment involvement, reported health, clinics’ organisational readiness, and external care coordination capacity.ConclusionThis study provides evidence for the reliability and validity of the RMIC patient and provider questionnaires as generic tools to assess the experience with or perception of integrated renal care delivery. The instruments are recommended in future applications testing test-retest reliability, convergent and predictive validity, and responsiveness.

Concentration of health care providers: does it contribute to integration of service delivery?

BackgroundThe concentration of health care providers is a growing process in many countries, including Russia. There is a general expectation that larger medical entities can better promote the process of service integration.PurposeThis paper explores the impact of health provider concentration on service delivery integration through the indicators of teamwork, coordination and continuity of care in outpatient and inpatient medical facilities. These developments in Russia are compared with international experience.MethodsNational and international literature on health services concentration and integration is reviewed; statistical analysis is based on Russian national data, WHO and OECD databases; a sociological survey of Russian physicians and interviews with managers of medical facilities are used to evaluate the value of integration.ResultsThe review of international trends indicates a growing process of mergers to form large hospital and physician-hospital systems, particularly in the USA. Enhanced clinical and administrative integration is usually seen as the logical outcome of concentration. However, growing international empirical estimates demonstrate a controversial impact of concentration on quality of medical care, unit cost (per patient) and integration of care. In Russia, the establishment of consolidated health systems is coupled with an increase in the average size of hospitals, while the number of free-standing providers has substantially decreased. The effect of concentration in the country is also controversial. There is some evidence of its positive impact on restructuring service delivery and the accessibility to some services, but the surveys of physicians don’t demonstrate improvement in the organization of service delivery, nor closer links between providers. Surveys of providers don’t provide evidence of teamwork, coordination and continuity of care in consolidated settings.ConclusionThere are many deeply rooted barriers to integration in Russia, of which the most important is the lack of clear objectives of providers mergers. The major lesson learnt is that in the country with limited financial resources, decisions on provider concentration should be carefully justified with the focus on the specific integrative activities. National health policy for integration should be a major pre-condition for the positive impact of concentration on integration.