Thyra de Jongh

A systematic review of the evidence on integration of targeted health interventions into health systems

A longstanding debate on health systems organization relates to benefits of integrating health programmes that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration arguing the relative merits of each approach. However, all too frequently these arguments have not been based on hard evidence. The presence of both integrated and non-integrated programmes in many countries suggests there may be benefits to either approach, but the relative merits of integration in various contexts and for different interventions have not been systematically analysed and documented. In this paper we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of the integration of targeted health programmes that emphasize specific interventions into critical health systems functions, (ii) how the integration or non-integration of health programmes into critical health systems functions in different contexts has influenced programme success, (iii) how contextual factors have affected the extent to which these programmes were integrated into critical health systems functions. Our analysis shows few instances where there is full integration of a health intervention or where an intervention is completely non-integrated. Instead, there exists a highly heterogeneous picture both for the nature and also for the extent of integration. Health systems combine both non-integrated and integrated interventions, but the balance of these interventions varies considerably.

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

BackgroundObjective of the study was to assess the effects of strategies to integrate targeted priority population, health and nutrition interventions into health systems on patient health outcomes and health system effectiveness and thus to compare integrated and non-integrated health programmes.MethodsSystematic review using Cochrane methodology of analysing randomised trials, controlled before-and-after and interrupted time series studies. We defined specific strategies to search PubMed, CENTRAL and the Cochrane Effective Practice and Organisation of Care Group register, considered studies published from January 1998 until September 2008, and tracked references and citations. Two reviewers independently agreed on eligibility, with an additional arbiter as needed, and extracted information on outcomes: primary (improved health, financial protection, and user satisfaction) and secondary (improved population coverage, access to health services, efficiency, and quality) using standardised, pre-piloted forms. Two reviewers in the final stage of selection jointly assessed quality of all selected studies using the GRADE criteria.ResultsOf 8,274 citations identified 12 studies met inclusion criteria. Four studies compared the benefits of Integrated Management of Childhood Illnesses in Tanzania and Bangladesh, showing improved care management and higher utilisation of health facilities at no additional cost. Eight studies focused on integrated delivery of mental health and substance abuse services in the United Kingdom and United States of America. Integrated service delivery resulted in better clinical outcomes and greater reduction of substance abuse in specific sub-groups of patients, with no significant difference found overall. Quality of care, patient satisfaction, and treatment engagement were higher in integrated delivery models.ConclusionsTargeted priority population health interventions we identified led to improved health outcomes, quality of care, patient satisfaction and access to care. Limited evidence with inconsistent findings across varied interventions in different settings means no general conclusions can be drawn on the benefits or disadvantages of integrated service delivery.

Health impact of external funding for HIV, tuberculosis and malaria: systematic review

Background Since 2002, development assistance for health has substantially increased, especially investments for HIV, tuberculosis (TB) and malaria control. We undertook a systematic review to assess and synthesize the existing evidence in the scientific literature on the health impacts of these investments. Methods and findings We systematically searched databases for peer-reviewed and grey literature, using tailored search strategies. We screened studies for study design and relevance, using predefined inclusion criteria, and selected those that enabled us to link health outcomes or impact to increased external funding. For all included studies, we recorded dataset and study characteristics, health outcomes and impacts. We analysed the data using a causal-chain framework to develop a narrative summary of the published evidence. Thirteen articles, representing 11 individual studies set in Africa and Asia reporting impacts on HIV, tuberculosis and malaria, met the inclusion criteria. Only two of these studies documented the entire causal-chain spanning from funding to programme scale-up, to outputs, outcomes and impacts. Nonetheless, overall we find a positive correlation between consecutive steps in the causal chain, suggesting that external funds for HIV, tuberculosis and malaria programmes contributed to improved health outcomes and impact. Conclusions Despite the large number of supported programmes worldwide and despite an abundance of published studies on HIV, TB and malaria control, we identified very few eligible studies that adequately demonstrated the full process by which external funding has been translated to health impact. Most of these studies did not move beyond demonstrating statistical association, as opposed to contribution or causation. We thus recommend that funding organizations and researchers increase the emphasis on ensuring data capture along the causal pathway to demonstrate effect and contribution of external financing. The findings of these comprehensive and rigorously conducted impact evaluations should also be made publicly accessible.

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.

Clearing the Global Health Fog : A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions

A longstanding debate on health systems organization relates to benefits of integrating health programs that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes This paper is organized in five chapters. This introduction is followed by the methodology chapter, which includes a brief section on the conceptual framework used to analyze the studies retrieved and the programs presented within these to map the nature and extent of integration into critical health system functions. The results chapter includes: a summary of the outcomes for each study grouped by the disease area or the clinical problem the intervention seeks to address, including the reported success; for each program, analysis and mapping of the nature and extent of integration into critical health system functions; and an analysis of how contextual factors either created opportunities for introducing or integrating a program or influenced the desirability or feasibility of program integration. The discussion chapter provides an overview of the implication of findings for policy makers, practitioners and researchers. The final chapter draws conclusions.